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| committer | nfenwick <nfenwick@pglaf.org> | 2025-01-22 23:00:59 -0800 |
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font-size:1.2em; font-weight:bold'>The Project Gutenberg eBook of Commentaries on the Surgery of the War, by G. J. Guthrie</div> -<div style='display:block; margin:1em 0'> -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online -at <a href="https://www.gutenberg.org">www.gutenberg.org</a>. If you -are not located in the United States, you will have to check the laws of the -country where you are located before using this eBook. -</div> - -<p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em'>Title: Commentaries on the Surgery of the War</p> -<p style='display:block; margin-left:2em; text-indent:0; margin-top:0; margin-bottom:1em;'>in Portugal, Spain, France, and the Netherlands</p> -<div style='display:table; margin-bottom:1em;'> -<div style='display:table-row'> - <div style='display:table-cell; padding-right:0.5em'>Author:</div> - <div style='display:table-cell'>G. J. Guthrie</div> -</div> -</div> -<div style='display:block; margin:1em 0'>Release Date: June 15, 2021 [eBook #65622]</div> -<div style='display:block; margin:1em 0'>Language: English</div> -<div style='display:table; margin-bottom:1em;'> - <div style='display:table-row'> - <div style='display:table-cell; padding-right:0.5em; white-space:nowrap;'>Produced by:</div> - <div style='display:table-cell'>Brian Coe, SF2001, and the Online Distributed Proofreading Team at https://www.pgdp.net (This book was produced from images made available by the HathiTrust Digital Library.)</div> - </div> -</div> -<div style='margin-top:2em; margin-bottom:4em'>*** START OF THE PROJECT GUTENBERG EBOOK COMMENTARIES ON THE SURGERY OF THE WAR ***</div> - -<div class="chapter"> - <div class="figcenter illowp100" id="i_cover" style="max-width: 30em;"> - <img class="w100" src="images/cover.jpg" alt="Cover" /> - </div> -</div> - -<p><span class="pagenum"><a name="Page_1" id="Page_1">[1]</a></span> -</p> - -<div class="page-in-box"> -<h1>COMMENTARIES<br /> -<small><span class="allsmcap">ON THE</span></small><br /> -<span class="gesperrt"><span class="smcap"><big>Surgery of the War</big></span></span></h1> - -<p class="center">IN PORTUGAL, SPAIN, FRANCE, AND<br /> -THE NETHERLANDS,<br /> -<br /> -FROM THE BATTLE OF ROLIÇA, IN 1808, TO THAT OF -WATERLOO, IN 1815;<br /> -<br /> -WITH ADDITIONS RELATING TO THOSE IN THE CRIMEA IN -1854-1855. -<br /> -<small><span class="allsmcap">SHOWING</span></small> -<br /> -<span class="allsmcap">THE IMPROVEMENTS MADE DURING AND SINCE THAT PERIOD IN THE -GREAT ART AND SCIENCE OF SURGERY ON ALL THE -SUBJECTS TO WHICH THEY RELATE.</span><br /> -<br /> -REVISED TO OCTOBER, 1855.<br /> -<br /> -<big><span class="gesperrt">BY G. J. GUTHRIE, F.R.S.</span></big></p> - -<hr class="r5" /> -<p class="center">SIXTH EDITION.</p> -<hr class="r5" /> - -<p class="center">PHILADELPHIA:<br /> -<span class="gesperrt">J. B. LIPPINCOTT & CO.</span><br /> -1862. -</p> -</div> - -<p><span class="pagenum"><a name="Page_3" id="Page_3">[3]</a></span> -</p><hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -</div> - -<p class="center">TO<br /> -<span class="smcap">The Right Honorable</span><br /> -<span class="smcap"><span class="gesperrt">The Lord Panmure</span></span>,<br /> -<span class="allsmcap">SECRETARY OF STATE FOR THE WAR DEPARTMENT,<br /> -ETC. ETC. ETC.</span>, -</p> - -<p class="center">THESE COMMENTARIES<br /> -<br /> -ARE, BY PERMISSION,<br /> -INSCRIBED,<br /> -BY HIS LORDSHIP’S VERY OBEDIENT<br /> -AND FAITHFUL SERVANT,</p> - -<p class="right">G. J. GUTHRIE. -</p> - -<p><span class="pagenum"><a name="Page_5" id="Page_5">[5]</a></span> -</p> -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="PREFACE_TO_THE_FIFTH_EDITION">PREFACE TO THE FIFTH EDITION.</h2> -</div> - -<p>Twenty months have elapsed since the Introductory -Lecture was published in <span class="smcap">The Lancet</span>; 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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_6" id="Page_6">[6]</a></span> -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 -<span class="pagenum"><a name="Page_7" id="Page_7">[7]</a></span> -parts; and my second and extended Course was recognized -by the Council of the Royal College of Surgeons -as one of General Surgery.</p> - -<p>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 -at<span class="pagenum"><a name="Page_8" id="Page_8">[8]</a></span>tending -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.</p> - -<p> -<span style="margin-left: 2em;"><span class="smcap">4 Berkeley Street, Berkeley Square</span>,</span><br /> -<span style="margin-left: 4em;">June 21, 1853.</span><br /> -</p> - -<hr class="chap x-ebookmaker-drop" /> -<p><span class="pagenum"><a name="Page_9" id="Page_9">[9]</a></span></p> -<div class="chapter"> -<h2 class="nobreak" id="PREFACE_TO_THE_SIXTH_EDITION">PREFACE TO THE SIXTH EDITION.</h2> -</div> -<hr /> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_10" id="Page_10">[10]</a></span> -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.</p> - -<p>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.</p> - -<p> -<span style="margin-left: 2em;"><span class="smcap">4 Berkeley Street, Berkeley Square</span>,</span><br /> -<span style="margin-left: 4em;">October 7, 1855.</span><br /> -</p> - -<hr class="chap x-ebookmaker-drop" /> -<p><span class="pagenum"><a name="Page_11" id="Page_11">[11]</a></span> -</p> -<div class="chapter"> -<h2 class="nobreak" id="CONTENTS">CONTENTS.</h2> -</div> -<hr /> - -<table summary="TOC"> -<tbody> - -<tr><td class="tocheading">LECTURE I.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td><td class="tocpage">pp. 25‑39</td></tr> - -<tr><td class="tocheading">LECTURE II.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td><td class="tocpage">pp. 39‑51</td></tr> - -<tr><td class="tocheading"><span class="pagenum"><a name="Page_12" id="Page_12">[12]</a></span>LECTURE III.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td><td class="tocpage">pp. 51‑73</td></tr> - -<tr><td class="tocheading">LECTURE IV.</td></tr> -<tr><td class="toctext"><a href="#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. <span class="smcap">Amputation at the hip-joint</span>; 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; -pro</a><span class="pagenum"><a name="Page_13" id="Page_13">[13]</a></span><a href="#LECTURE_IV">trusion -of bone after the operation; exfoliation from badly sawing -or splitting the bone, or unduly separating the periosteum. Bulbous -enlargement of the divided nerve.</a></td><td class="tocpage"> pp. 73‑89</td></tr> - -<tr><td class="tocheading">LECTURE V.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td><td class="tocpage"> pp. 90‑120</td></tr> - -<tr><td class="tocheading">LECTURE VI.</td></tr> -<tr><td class="toctext"><a href="#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;</a> -<span class="pagenum"><a name="Page_14" id="Page_14">[14]</a></span> -<a href="#LECTURE_VI">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.</a></td> -<td class="tocpage">pp. 120‑141.</td></tr> - -<tr><td class="tocheading">LECTURE VII.</td></tr> -<tr><td class="toctext"><a href="#LECTURE_VII"> -Secondary amputations not so successful after injuries as after -incurable disease; circumstances under which the operation is</a> -<span class="pagenum"><a name="Page_15" id="Page_15">[15]</a></span> -<a href="#LECTURE_VII"> -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. <span class="smcap">Compound -Fractures</span>: 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.</a></td> -<td class="tocpage">pp. 141‑162</td></tr> - -<tr><td class="tocheading">LECTURE VIII.</td></tr> -<tr><td class="toctext"><a href="#LECTURE_VIII"> -<span class="smcap">Hospital Gangrene</span>: its synonyms; may be caused by the use of -charpie, instruments, bandages, etc., which have been previously</a> -<span class="pagenum"><a name="Page_16" id="Page_16">[16]</a></span> -<a href="#LECTURE_VIII">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. <span class="smcap">Conclusions</span>: -Return of the number of cases in the hospital stations in the Peninsula -during the last six months of 1813.</a></td> -<td class="tocpage">pp. 163‑175</td></tr> - -<tr><td class="tocheading">LECTURE IX.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 176‑187</td></tr> - -<tr><td class="tocheading"> -<span class="pagenum"><a name="Page_17" id="Page_17">[17]</a></span> -LECTURE X.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td><td class="tocpage"> pp. 187‑208</td></tr> - -<tr><td class="tocheading">LECTURE XI.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 208‑226</td></tr> - -<tr><td class="tocheading">LECTURE XII.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td><td class="tocpage"> pp. 226‑240</td></tr> - -<tr><td class="tocheading">LECTURE XIII.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td><td class="tocpage"> pp. 241‑250</td></tr> - -<tr><td class="tocheading"> -<span class="pagenum"><a name="Page_18" id="Page_18">[18]</a></span> -LECTURE XIV.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 250‑269</td></tr> - -<tr><td class="tocheading">LECTURE XV.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td><td class="tocpage"> pp. 270‑283</td></tr> - -<tr><td class="tocheading">LECTURE XVI.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 283‑302</td></tr> - -<tr><td class="tocheading">LECTURE XVII.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 302‑321</td></tr> - -<tr><td class="tocheading"> -<span class="pagenum"><a name="Page_19" id="Page_19">[19]</a></span> -LECTURE XVIII.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 321‑340</td></tr> - -<tr><td class="tocheading">LECTURE XIX.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 340‑364</td></tr> - -<tr><td class="tocheading">LECTURE XX.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 364‑381</td></tr> - -<tr><td class="tocheading">LECTURE XXI.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 382‑414</td></tr> - -<tr><td class="tocheading"> -<span class="pagenum"><a name="Page_20" id="Page_20">[20]</a></span> -LECTURE XXII.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 414‑425</td></tr> - -<tr><td class="tocheading">LECTURE XXIII.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 426‑442</td></tr> - -<tr><td class="tocheading">LECTURE XXIV.</td></tr> -<tr><td class="toctext"><a href="#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</a> -<span class="pagenum"><a name="Page_21" id="Page_21">[21]</a></span> -<a href="#LECTURE_XXIV"> -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.</a></td> -<td class="tocpage"> pp. 442‑456</td></tr> - -<tr><td class="tocheading">LECTURE XXV.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 456‑472</td></tr> - -<tr><td class="tocheading">LECTURE XXVI.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 473‑482</td></tr> - -<tr><td class="tocheading"><span class="pagenum"> -<a name="Page_22" id="Page_22">[22]</a></span> -LECTURE XXVII.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 482‑508</td></tr> - -<tr><td class="tocheading">LECTURE XXVIII.</td></tr> -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 508‑525</td></tr> - -<tr><td class="tocheading">LECTURE XXIX.</td></tr> -<tr><td class="toctext"><a href="#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.</a> -<span class="pagenum"><a name="Page_23" id="Page_23">[23]</a></span> -<a href="#LECTURE_XXIX"> -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.</a></td> -<td class="tocpage">pp. 525‑540</td></tr> - -<tr><td class="tocheading">LECTURE XXX.</td></tr> - -<tr><td class="toctext"><a href="#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.</a></td> -<td class="tocpage">pp. 541‑559</td></tr> - -<tr><td class="tocheading">ADDENDA. <br /> -<small>REPORTS FROM THE CRIMEA</small>.</td></tr> - -<tr><td class="toctext"><a href="#ADDENDA"> -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</a> -<span class="pagenum"><a name="Page_24" id="Page_24">[24]</a></span> -<a href="#ADDENDA"> -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.</a></td><td class="tocpage"> pp. 561‑586</td></tr> - -<tr><td class="tocheading">REMARKS.</td></tr> -<tr><td><a href="#REMARKS"> -<span class="smcap">Surgical Commentaries on the preceding Cases</span>: 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 <span class="smcap">Addenda</span> desired.</a></td> -<td class="tocpage">pp. 586‑590</td> -</tr> - -<tr><td class="tocheading"></td></tr> -<tr> -<td><a href="#INDEX">Index.</a></td> -<td class="tocpage">pp. 591‑608</td> -</tr> - -<tr><td class="tocheading"></td></tr> -<tr> -<td><a href="#INDEX_OF_CASES">Index of Cases.</a></td> -<td class="tocpage">pp. 608‑614</td> -</tr> - -<tr><td class="tocheading"></td></tr> -<tr> -<td><a href="#MEDICAL_WORKS">Medical Works</a></td> -<td class="tocpage">pp. 615‑624</td> -</tr> - -</tbody> -</table> - -<hr class="chap x-ebookmaker-drop" /> -<p><span class="pagenum"><a name="Page_25" id="Page_25">[25]</a></span></p> - -<div class="chapter"> -<h2 class="nobreak" id="COMMENTARIES">COMMENTARIES<br /> -<small><span class="allsmcap">ON</span></small><br /> -<span class="gesperrt">SURGERY</span>. -</h2> -</div> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_I">LECTURE I.</h2> -</div> - -<p class="h2sub">ON GUNSHOT WOUNDS, ETC.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -precau<span class="pagenum"><a name="Page_26" id="Page_26">[26]</a></span>tionary -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.</p> - -<p>4. Secondary hemorrhage of any importance from small -vessels does not <i>often</i> 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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_27" id="Page_27">[27]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_28" id="Page_28">[28]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_29" id="Page_29">[29]</a></span> -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.</p> - -<p>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 <i>cover-slut</i>.</p> - -<p>14. Many simple flesh wounds are cured in four weeks; -the greater part in six. Fresh air and cold water are -essen<span class="pagenum"><a name="Page_30" id="Page_30">[30]</a></span>tial. -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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_31" id="Page_31">[31]</a></span> -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_32" id="Page_32">[32]</a></span> -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_33" id="Page_33">[33]</a></span> -piece of shell was lodged, and kept op considerable irritation -until it was removed. The man recovered.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Suppose a man be brought for assistance with a wound -<span class="pagenum"><a name="Page_34" id="Page_34">[34]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_35" id="Page_35">[35]</a></span> -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.</p> - -<p><span class="pagenum"><a name="Page_36" id="Page_36">[36]</a></span> -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.</p> - -<p>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.<a id="FNanchor_1" href="#Footnote_1" class="fnanchor">[1]</a></p> - -<div class="footnote"> - -<p><a id="Footnote_1" href="#FNanchor_1" class="label">[1]</a> -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.</p> - -</div> - -<p>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 -<span class="pagenum"><a name="Page_37" id="Page_37">[37]</a></span> -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.</p> - -<p>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 -inflamma<span class="pagenum"><a name="Page_38" id="Page_38">[38]</a></span>tion, -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.</p> - -<p>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, <i>et prirent la fuite</i>. -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 -<span class="pagenum"><a name="Page_39" id="Page_39">[39]</a></span> -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.”</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_II">LECTURE II.</h2> -</div> - -<p class="h2sub">ON INFLAMMATION, MORTIFICATION, ETC.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_40" id="Page_40">[40]</a></span> -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.</p> - -<p>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.</p> - -<p>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. -<span class="pagenum"><a name="Page_41" id="Page_41">[41]</a></span> -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.</p> - -<p>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:—</p> - -<p>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 -<span class="pagenum"><a name="Page_42" id="Page_42">[42]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>idiopathic</i> or <i>constitutional</i> -and that which is <i>local</i>; and has not existed long -enough to implicate the system at large, or to become -<i>constitutional</i>. Idiopathic or constitutional mortification, -sphacelus or gangrene, may be <i>humid</i> or <i>dry</i>. <i>Humid</i>, -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 <i>traumatic</i>, which explains nothing but the fact of -its following an injury.</p> - -<p><i>Local</i> 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.</p> - -<p><span class="pagenum"><a name="Page_43" id="Page_43">[43]</a></span> -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_44" id="Page_44">[44]</a></span> -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.</p> - -<p>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 <i>constitutional</i> and <i>local</i> 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.</p> - -<p><span class="pagenum"><a name="Page_45" id="Page_45">[45]</a></span> -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 <i>tallow candle</i>, and soon the appearance of <i>mottled -soap</i>. 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.</p> - -<p>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 -<span class="pagenum"><a name="Page_46" id="Page_46">[46]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>31. Mortification after the sudden application of intense -cold or heat is to be treated on similar principles.</p> - -<p>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, -<span class="pagenum"><a name="Page_47" id="Page_47">[47]</a></span> -which are harmless when applied to another and a healthy -part.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>36. Wounds or injuries of nerves, which do not entirely -divide the trunk, or a principal branch given off from a -<span class="pagenum"><a name="Page_48" id="Page_48">[48]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_49" id="Page_49">[49]</a></span> -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.”</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_50" id="Page_50">[50]</a></span> -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.</p> - -<p>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 <i>aconitine</i>, -carefully prepared, in the proportion of one grain to a -<span class="pagenum"><a name="Page_51" id="Page_51">[51]</a></span> -drachm of lard, at which strength it will sometimes irritate -almost to vesication, as well as allay pain.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_III">LECTURE III.</h2> -</div> - -<p class="h2sub">AMPUTATIONS, ETC.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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?</p> - -<p>45. In order to answer this question distinctly, it should -be considered with reference to distinct places of injury:—</p> - -<p>1st. When injuries require amputation of the arm below -<span class="pagenum"><a name="Page_52" id="Page_52">[52]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>upper third of the thigh</i>.</p> - -<p>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 -<span class="pagenum"><a name="Page_53" id="Page_53">[53]</a></span> -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.</p> - -<p>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 <i>Belleisle</i>, 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.</p> - -<p>“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 <span class="allsmcap">A.M.</span>, 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 -<span class="pagenum"><a name="Page_54" id="Page_54">[54]</a></span> -use of stimulants, till the system had in some degree recovered -its equilibrium. Such was the case at five <span class="allsmcap">P.M.</span>, 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.</p> - -<p>“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.”—<i>Case by Dr. -Dane, Surgeon to the Forces.</i></p> - -<p>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.”</p> - -<p>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.</p> - -<p>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 -admin<span class="pagenum"><a name="Page_55" id="Page_55">[55]</a></span>istration -of stimulants may render the operation less immediately -dangerous. In the latter, they will be beneficial, and -may save life.</p> - -<p>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.</p> - -<p>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:—</p> - -<p>“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.</p> - -<p>“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.</p> - -<p>“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 -respira<span class="pagenum"><a name="Page_56" id="Page_56">[56]</a></span>tion. -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.</p> - -<p>“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.</p> - -<p>“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 -<span class="pagenum"><a name="Page_57" id="Page_57">[57]</a></span> -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.</p> - -<p>“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.</p> - -<p>“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.</p> - -<p>“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.</p> - -<p>“If the vapor of chloroform be sufficiently diluted with -air, it is practically impossible that any accident, really due -<span class="pagenum"><a name="Page_58" id="Page_58">[58]</a></span> -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.”</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_59" id="Page_59">[59]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>54. The advantageous results of <i>primary</i> amputations, -or those done within the first twenty-four, or at most forty-eight -hours, over <i>secondary</i> 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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_60" id="Page_60">[60]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -atten<span class="pagenum"><a name="Page_61" id="Page_61">[61]</a></span>tion -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.</p> - -<p>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.</p> - -<p>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. -<span class="pagenum"><a name="Page_62" id="Page_62">[62]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_63" id="Page_63">[63]</a></span> -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.</p> - -<p>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.</p> - -<p>61. The practical points are, to draw blood with caution, -on the <i>accession</i> 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, -<span class="pagenum"><a name="Page_64" id="Page_64">[64]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The following case is so highly instructive on all points, -that it is transcribed from the <i>London Medical and Physical -Journal</i> for 1826:—</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_65" id="Page_65">[65]</a></span> -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.</p> - -<p>October 1st.—Better in all respects, but looking irritable -and ill; no pain anywhere; no sickness; appetite good; -pulse still quick.</p> - -<p>8th.—Two ligatures have come away; the wound looks -well; the edges have nearly healed; eats meat, and with a -good appetite.</p> - -<p>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.</p> - -<p>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.</p> - -<p>17th.—The symptoms continued nearly the same during -the week, the sickness of stomach and purging of bilious -matter abating at intervals.</p> - -<p>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.</p> - -<p>25th.—During these five days it was interesting to see -the patient eat, and desire solid food, and, in her extremely -<span class="pagenum"><a name="Page_66" id="Page_66">[66]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_67" id="Page_67">[67]</a></span> -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:—</p> - -<p>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.</p> - -<p>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, -<span class="pagenum"><a name="Page_68" id="Page_68">[68]</a></span> -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_69" id="Page_69">[69]</a></span> -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.</p> - -<p>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 <span class="allsmcap">P.M.</span>, six days after the amputation.</p> - -<p>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 -<span class="pagenum"><a name="Page_70" id="Page_70">[70]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>Medical and Chirurgical -Transactions</i>, 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 -<span class="pagenum"><a name="Page_71" id="Page_71">[71]</a></span> -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;<a id="FNanchor_2" href="#Footnote_2" class="fnanchor">[2]</a> -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.</p> - -<div class="footnote"> - -<p><a id="Footnote_2" href="#FNanchor_2" class="label">[2]</a> -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.</p> - -</div> - -<p>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.</p> - -<p>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; -<span class="pagenum"><a name="Page_72" id="Page_72">[72]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<i>across</i> the great pectoral muscle, when the artery may be -readily exposed, and a ligature placed upon it without difficulty -anywhere below the clavicle.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_73" id="Page_73">[73]</a></span> -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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_IV">LECTURE IV.</h2> -</div> - -<p class="h2sub">APHORISMS FOR AMPUTATIONS, ETC.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>ne plus ultra</i> of -<span class="pagenum"><a name="Page_74" id="Page_74">[74]</a></span> -operative boldness and dexterity, much after the fashion of -the young lady <i>pianistes</i>, who do not consider themselves -in any way advanced on the road to perfection until they -can play at least the overture to <i>Guillaume Tell</i>, if not the -<i>Galop Chromatique</i> of Listz, nearly as well as the composer -himself.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_75" id="Page_75">[75]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_76" id="Page_76">[76]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_77" id="Page_77">[77]</a></span> -by sutures or plasters being removed, the parts being simply -approximated to each other. Attention should be paid to -the directions in aphorism 61.</p> - -<h3 class="center">AMPUTATION AT THE HIP-JOINT.</h3> - -<p>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 <i>only -man</i> 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.</p> - -<p>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, -<span class="pagenum"><a name="Page_78" id="Page_78">[78]</a></span> -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.</p> - -<p>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 -<i>vice versa</i>, 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -instruc<span class="pagenum"><a name="Page_79" id="Page_79">[79]</a></span>tions -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_80" id="Page_80">[80]</a></span> -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.</p> - -<p>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.</p> - -<p>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, -<span class="pagenum"><a name="Page_81" id="Page_81">[81]</a></span> -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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_82" id="Page_82">[82]</a></span> -</p> - -<div class="figcenter illowp86" id="FIG1" style="max-width: 35em;"> - <div class="caption"><p class="center"><span class="smcap">Fig. 1.</span></p></div> - <img class="w100" src="images/i-fig1.jpg" - alt="Illustration of where to cut for amputation of hip-joint." /> - -<div class="caption"> - -<p class="center"><i>Amputation of the Hip-joint as performed by</i> <span class="smcap">Mr. Brownrigg</span>.</p> - -<p class="center">(Upper figure.)</p> - -<p class="left"><i>a</i> <i>a</i> <i>a</i>, anterior flap in dotted lines;<br /> -<i>c</i>, thumb compressing the artery on the pubis;<br /> -<i>d</i>, fingers introduced under the flap;<br /> -<i>e</i>, the straight knife, entrance and exit of. -</p> - -<p class="center">(Lower figure.)</p> - -<p class="center"><i>Flap Amputation as performed by</i> <span class="smcap">Mr. Luke</span>, <i>on the lower half of the thigh</i>.</p> - -<p> -<i>A</i>, middle of the outside of the thigh and point of entrance of knife;<br /> -<i>B</i>, under part;<br /> -<i>C</i>, upper part;<br /> -<i>A</i> to <i>E</i>, the under flap;<br /> -<i>G</i> to <i>F</i>, dotted line of upper flap, beginning short of commencement of under flap. -</p> -</div> -</div> - -<p>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.</p> -<p><span class="pagenum"><a name="Page_83" id="Page_83">[83]</a></span> -</p> - -<div class="figcenter illowp74" id="FIG2" style="max-width: 35em;"> - <div class="caption"><p class="center"><span class="smcap">Fig. 2.</span></p></div> - <img class="w100" src="images/i-fig2.jpg" - alt="Illustration of where to cut and how to sew together for amputation of hip-joint." /> - <div class="caption"> - -<p class="center"><span class="smcap">Mr. Guthrie’s operation.</span></p> - -<p>Left side—<br /> -<i>a</i>, anterior superior spine of ilium; <br /> -<i>b</i>, commencement of anterior incision, continued by the black line; <br /> -<i>c</i>, the posterior incision joining the anterior one. -</p> - -<p class="center">(Second figure.)</p> - -<p><i>b</i> <i>c</i>, line of incision marked by three sutures.</p> -</div> -</div> - -<p>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, -<span class="pagenum"><a name="Page_84" id="Page_84">[84]</a></span> -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 -<span class="pagenum"><a name="Page_85" id="Page_85">[85]</a></span> -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_86" id="Page_86">[86]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -ampu<span class="pagenum"><a name="Page_87" id="Page_87">[87]</a></span>tation. -The point of the knife should be entered <i>mid</i>-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 -<span class="pagenum"><a name="Page_88" id="Page_88">[88]</a></span> -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 -<i>whole surfaces</i> 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.</p> - -<p><span class="pagenum"><a name="Page_89" id="Page_89">[89]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> -<p><span class="pagenum"><a name="Page_90" id="Page_90">[90]</a></span> -</p><hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_V">LECTURE V.</h2> -</div> - -<p class="h2sub">REMOVAL OF THE HEAD OF THE FEMUR, ETC.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_91" id="Page_91">[91]</a></span> -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.</p> - -<p>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.</p> - -<p>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. -<span class="pagenum"><a name="Page_92" id="Page_92">[92]</a></span> -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. (<i>Aph. 118.</i>)</p> - -<p>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 -<span class="pagenum"><a name="Page_93" id="Page_93">[93]</a></span> -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_94" id="Page_94">[94]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_95" id="Page_95">[95]</a></span> -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_96" id="Page_96">[96]</a></span> -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 -<span class="pagenum"><a name="Page_97" id="Page_97">[97]</a></span> -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.</p> - -<p>89. <i>Excision</i> 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:—</p> - -<p>“In my first case, the incisions were in this form <span class="sans-serif"><b>H</b></span>, 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.”</p> - -<p>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 -<span class="pagenum"><a name="Page_98" id="Page_98">[98]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_99" id="Page_99">[99]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_100" id="Page_100">[100]</a></span> -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<span class="pagenum"><a name="Page_101" id="Page_101">[101]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_102" id="Page_102">[102]</a></span> -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.</p> - -<div class="figcenter illowp100" id="i-102" style="max-width: 30em;"> - <img class="w100" src="images/i-102.jpg" alt="Illustration showing where to make incisions on leg." /> - <div class="caption"> -<p> -<i>A.</i> The mid-point between <i>B</i> and <i>C</i>, at which the knife is introduced for carrying it across the limb.<br /> -<i>A</i> to <i>D</i>. The course of the incision to form the posterior flap, <i>E</i>.<br /> -<i>F</i> to <i>g</i>. The course of the incision to form the anterior flap. -</p> -</div> -</div> - -<p>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 -<span class="pagenum"><a name="Page_103" id="Page_103">[103]</a></span> -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.</p> - -<h3 class="center">EXCISION OF THE ANKLE-JOINT.</h3> - -<div class="figright illowp50" id="i-103" style="max-width: 20em;"> - <img class="w100" src="images/i-103.jpg" alt="Illustration of lower leg showing where to make an incision." /> -</div> - -<p>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 -<span class="pagenum"><a name="Page_104" id="Page_104">[104]</a></span> -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.</p> - -<h3 class="center">REMOVAL OF THE OS CALCIS.</h3> - -<p>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.</p> - -<p>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.</p> - -<p>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:—</p> - -<p><span class="pagenum"><a name="Page_105" id="Page_105">[105]</a></span> -“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 <i>exactly -opposite</i> its commencement. The extremities of the incision -thus formed are then joined by another passing in front of -the joint.</p> - -<div class="figcenter illowp100" id="i-105" style="max-width: 35em;"> - <img class="w100" src="images/i-105.jpg" alt="Illustration of foot showing where to make incisions." /> -</div> - -<p>“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 -<span class="pagenum"><a name="Page_106" id="Page_106">[106]</a></span> -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.</p> - -<p>“The advantages which I originally anticipated from this -operation were—<i>first</i>, the formation of a more useful support -for the body than could be obtained from any form of -amputation of the leg; and, <i>secondly</i>, 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.”</p> - -<p>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:—</p> - -<p>“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 car<span class="pagenum"><a name="Page_107" id="Page_107">[107]</a></span>ried -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.”</p> - -<p>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.</p> - -<p>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 <i>acute</i> form, -certainly irremediable by any operation or medicine at pres<span class="pagenum"><a name="Page_108" id="Page_108">[108]</a></span>ent -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.</p> - -<p>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 ad<span class="pagenum"><a name="Page_109" id="Page_109">[109]</a></span>herent; -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.</p> - -<p>“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.”</p> - -<p>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.</p> - -<div class="figcenter illowp83" id="i-110" style="max-width: 35em;"> - <img class="w100" src="images/i-110.jpg" alt="Ankle joint." /> - <div class="caption"> -<p>1. Astragalus. -<br />2. Os calcis. -<br />3. The ball. -<br />4. Ligament descending from the tibia, torn by the ball. -<br />5. Tendons of tibialis anticus and flexor communis cut across by the ball. -<br />6. The other end of the same tendons. -<br />7. The posterior tibial artery dividing into two branches. -<br />8. The posterior tibial nerve. -<br />9. The tendon of the flexor proprius pollicis. -</p> -</div> -</div> - -<p>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 -<span class="pagenum"><a name="Page_110" id="Page_110">[110]</a></span> -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 -<span class="pagenum"><a name="Page_111" id="Page_111">[111]</a></span> -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.</p> - -<div class="figcenter illowp50" id="i-111" style="max-width: 25em;"> - <img class="w100" src="images/i-111.jpg" alt="Forceps." /> -</div> - -<p>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 -<span class="pagenum"><a name="Page_112" id="Page_112">[112]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_113" id="Page_113">[113]</a></span> -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_114" id="Page_114">[114]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_115" id="Page_115">[115]</a></span> -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.</p> - -<p>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:—</p> - -<p>“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 -<span class="pagenum"><a name="Page_116" id="Page_116">[116]</a></span> -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. Dur<span class="pagenum"><a name="Page_117" id="Page_117">[117]</a></span>ing -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.</p> - -<div class="figcenter illowp88" id="i-116-upper" style="max-width: 35em;"> - <img class="w100" src="images/i-116-upper.jpg" alt="Ankle joint with marks for three incisions." /> - <div class="caption"><p>The incisions above described are here marked out on a healthy foot.</p></div> -</div> - -<div class="figcenter illowp100" id="i-116-lower" style="max-width: 35em;"> - <img class="w100" src="images/i-116-lower.jpg" alt="Bones of ankle joint with two marks showing where to cut." /> - <div class="caption"><p>The skeleton of the foot will at the same time show the amount of bone -removed.</p></div> -</div> - -<div class="figcenter illowp50" id="i-117" style="max-width: 35em;"> - <img class="w100" src="images/i-117.jpg" alt="Exterion left and right view of ankle after operation is complete." /> - <div class="caption"><p>These drawings exhibit the present condition of both sides of the foot—the -amount of deformity is less than might have been expected.</p></div> -</div> - -<p>“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 open<span class="pagenum"><a name="Page_118" id="Page_118">[118]</a></span>ing. -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.”</p> - -<p>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.</p> - -<p>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 con<span class="pagenum"><a name="Page_119" id="Page_119">[119]</a></span>tinued -round the injured part so as to meet the lower end -near the articulation of the bone with the tarsus, and <i>vice -versa</i>. 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.</p> - -<div class="figcenter illowp94" id="i-119-left" style="max-width: 35em;"> - <img class="w100" src="images/i-119.jpg" - alt="Shows amputation above knee with prosthetic and - two styles of amputation below the knee with prosthetic." /> - <div class="caption"> - -<p class="center"><i>Amputation above Knee.</i></p> - -<p> -<i>a</i>, wooden bucket for stump;<br /> -<i>b</i>, pin to attach foot;<br /> -<i>c</i>, the rolling foot;<br /> -<i>d</i>, straps of attachment to body. -</p> - -<p class="center"><i>Amputation below Knee, No. 1.</i></p> - -<p> -<i>a</i>, wooden shape to receive knee;<br /> -<i>b</i>, pin;<br /> -<i>c</i>, rolling foot;<br /> -<i>d</i>, <i>e</i>, straps of attachment. -</p> - -<p class="center"><i>Amputation below Knee, No. 2.</i></p> - -<p> -<i>a</i>, wooden bucket to receive the whole of stump;<br /> -<i>b</i>, fixture to foot;<br /> -<i>c</i>, rolling foot;<br /> -<i>d</i>, straps for knee. -</p> -</div> -</div> - -<p>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<span class="pagenum"><a name="Page_120" id="Page_120">[120]</a></span> -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.</p> - -<p>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 <i>series of levers</i>, each successive point -of it being a <i>fulcrum</i>. The precaution should be taken to -have the aperture at <i>a</i>, fig. 2, for the insertion of the pin, -made square, to prevent its turning when in use.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_VI">LECTURE VI.</h2> -</div> - -<p class="h2sub">PRIMARY AMPUTATION, ETC.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_121" id="Page_121">[121]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_122" id="Page_122">[122]</a></span> -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.</p> - -<p>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.</p> - -<p>109. <i>Amputation at the shoulder-joint</i> is an operation of<span class="pagenum"><a name="Page_123" id="Page_123">[123]</a></span> -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, <i>ce roy si vaillant</i>, 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.</p> - -<p>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, -<span class="pagenum"><a name="Page_124" id="Page_124">[124]</a></span> -they may be included in or adhere to the cicatrix, and cause, -during a long life, much distressing pain to the sufferer.</p> - -<p>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 <i>secondary</i> 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 <i>all</i> the directions usually given for rotation of the arm -inward and outward during the operation are <i>unnecessary -cruelties</i> 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.</p> - -<p>112. <i>Operation by two flaps, external and internal.</i>—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 -<span class="pagenum"><a name="Page_125" id="Page_125">[125]</a></span> -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.</p> - -<p>113. <i>The operation by one</i>, 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.</p> - -<p>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 -<span class="pagenum"><a name="Page_126" id="Page_126">[126]</a></span> -infra-spinatus, teres minor, and sub-scapularis are also cut -through in part, if not entirely. The upper and posterior -flap is thus completed.</p> - -<p>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.</p> - -<p>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.</p> - -<p>115. <i>Amputation of the arm immediately below the tuberosities -of the humerus</i> 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.</p> - -<p>116. <i>Excision of the head of the humerus.</i>—The point -governing the modus operandi of this operation is, and -<span class="pagenum"><a name="Page_127" id="Page_127">[127]</a></span> -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 <i>short</i> 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.</p> - -<p>In cases of <i>recent</i> 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.</p> - -<p>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 -<span class="pagenum"><a name="Page_128" id="Page_128">[128]</a></span> -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:—</p> - -<div class="figcenter illowp78" id="i-128" style="max-width: 25em;"> - <img class="w100" src="images/i-128.jpg" alt="Head of humerus." /> - <div class="caption"> -<p> -<i>a.</i> The head of the humerus sawn off below the tuberosities.<br /> -<i>b.</i> The ball.<br /> -<i>c c.</i> Fractures of the head of the bone. -</p> -</div> -</div> - -<p>“Pulse soft, 120. He passed a rather restless night, -although he had another opiate at one <span class="allsmcap">A.M.</span>, 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<span class="pagenum"><a name="Page_129" id="Page_129">[129]</a></span> -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 <span class="allsmcap">A.M.</span></p> - -<p>“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.</p> - -<p>“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<span class="pagenum"><a name="Page_130" id="Page_130">[130]</a></span> -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.”</p> - -<p>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, (<i>if it will rotate</i>,) 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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_131" id="Page_131">[131]</a></span> -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.</p> - -<p>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:—</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_132" id="Page_132">[132]</a></span> -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.</p> - -<p>General Lord Seaton suffered from a nearly similar wound, -at the taking of Ciudad Rodrigo, and recovered with a good -use of his arm.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_133" id="Page_133">[133]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Bring opposite the incision, by rotating the arm, first the -great tuberosity, then the smaller one, in order to divide the<span class="pagenum"><a name="Page_134" id="Page_134">[134]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>across</i> 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.</p> - -<p>120. <i>Amputation of the arm</i> 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: -<span class="pagenum"><a name="Page_135" id="Page_135">[135]</a></span> -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.</p> - -<p>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.</p> - -<p>122. <i>Excision of the elbow-joint.</i>—An incised wound -of moderate extent into the elbow-joint, cutting off with it<span class="pagenum"><a name="Page_136" id="Page_136">[136]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <b>H</b>. 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<span class="pagenum"><a name="Page_137" id="Page_137">[137]</a></span> -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.</p> - -<p>123. <i>Amputation of the elbow-joint</i> 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.</p> - -<p>124. <i>Amputation of the forearm</i> 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.</p> - -<p>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<span class="pagenum"><a name="Page_138" id="Page_138">[138]</a></span> -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.</p> - -<p>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.</p> - -<p>125. When the operation is to be performed above the -middle of the arm, it may be done by the <i>circular</i> incision.</p> - -<p>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.</p> - -<p>126. <i>Amputation at the wrist</i>, or the joint of the radius -and ulna with the first row of the bones of the carpus, has<span class="pagenum"><a name="Page_139" id="Page_139">[139]</a></span> -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.</p> - -<p>127. <i>In all injuries of the hand</i>, 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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_140" id="Page_140">[140]</a></span> -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.</p> - -<p>129. <i>The phalanges</i> 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.</p> - -<p>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.</p> - -<p>M. Langenbeck has also removed the metacarpal bone of<span class="pagenum"><a name="Page_141" id="Page_141">[141]</a></span> -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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_VII">LECTURE VII.</h2> -</div> - -<p class="h2sub">SECONDARY AMPUTATIONS, ETC.</p> - -<p>130. <i>Secondary amputations</i>, 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.</p> - -<p>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<span class="pagenum"><a name="Page_142" id="Page_142">[142]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 per<span class="pagenum"><a name="Page_143" id="Page_143">[143]</a></span>pendicularly, -whereby the <i>side</i> 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_144" id="Page_144">[144]</a></span> -ceased, and the parts can be freed from the coagulated blood, -and brought together.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_145" id="Page_145">[145]</a></span> -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.</p> - -<h3 class="center">ON COMPOUND FRACTURES.</h3> - -<p>141. A fracture of a bone, however <i>simple</i> it may be in -its nature, is said to be <i>compound</i> 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 <i>comminuted</i> when the bone is -crushed, as by a heavy wheel passing over it. It may still, -however, be a <i>simple</i> 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.</p> - -<p>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.</p> - -<p>143. It is not so with the thigh. After the battle of -Toulouse, forty-three of the best of the fractures of the<span class="pagenum"><a name="Page_146" id="Page_146">[146]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_147" id="Page_147">[147]</a></span> -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.</p> - -<p>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 <i>élite</i> 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.</p> - -<p>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<span class="pagenum"><a name="Page_148" id="Page_148">[148]</a></span> -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.</p> - -<p>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 <i>one</i>, 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<span class="pagenum"><a name="Page_149" id="Page_149">[149]</a></span> -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.</p> - -<p>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.”</p> - -<p>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<span class="pagenum"><a name="Page_150" id="Page_150">[150]</a></span> -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.</p> - -<p>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.</p> - -<p>The bone may be fractured in a case of this kind transversely, -and will require only the simplest treatment in an -almost similar manner.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_151" id="Page_151">[151]</a></span> -knee-joint, an attempt ought always to be made to save the -limb.</p> - -<p>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<span class="pagenum"><a name="Page_152" id="Page_152">[152]</a></span> -commenced, any handling or examination of the limb, however -gently made, gives great pain.</p> - -<p>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.</p> - -<p>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. Thom<span class="pagenum"><a name="Page_153" id="Page_153">[153]</a></span>son, -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_154" id="Page_154">[154]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_155" id="Page_155">[155]</a></span> -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.<a id="FNanchor_3" href="#Footnote_3" class="fnanchor">[3]</a> -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.</p> - -<div class="footnote"> - -<p><a id="Footnote_3" href="#FNanchor_3" class="label">[3]</a> 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.</p> - -</div> -<p><span class="pagenum"><a name="Page_156" id="Page_156">[156]</a></span> -</p> - -<div class="figcenter illowp100" id="i-155" style="max-width: 40em;"> - <img class="w100" src="images/i-155.jpg" alt="Apparatus to support lower leg." /> -</div> - -<p>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.</p> - -<p>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.</p> - -<p>Solid splints, and a firmly-fixed cradle, under which the -leg may hang, may be said to be the <i>sine qua non</i> of the -treatment of a gunshot fracture of the leg. The French in -the Crimea have an apparatus called a <span class="allsmcap">GOUTTIÈRE</span>, to be -hereafter noticed.</p> - -<p>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.</p> - -<p>159. The <i>arm</i>, 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<span class="pagenum"><a name="Page_157" id="Page_157">[157]</a></span> -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.</p> - -<p>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 -<i>nothing is gained beyond what is cut</i>, 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_158" id="Page_158">[158]</a></span> -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.</p> - -<div class="blockquot"> - -<p>No. 1.—<span class="smcap">Return of Surgical Cases</span> <i>treated and</i> <span class="smcap">Capital Operations</span> -<i>performed in the General Hospital at Toulouse, from April 10th to -June 28th, 1814.</i></p> - -</div> - -<table class="autotable" summary="Return of Surgical Cases"> -<thead> -<tr> -<td class="tdc bordr bordb"><span class="allsmcap">DISEASES AND<br /> STATE OF WOUNDS.</span></td> -<td class="tdc bordr bordb">Total<br />treated.</td> -<td class="tdc bordr bordb">Died.</td> -<td class="tdc bordr bordb">Dis-<br />charged<br />to duty.</td> -<td class="tdc bordr bordb">Transferred<br />to<br />Bourdeaux.</td> -<td class="tdc bordr bordb">Proportion of<br />death to the<br />number treated.</td> -</tr> -</thead> -<tbody> -<tr> -<td class="tdl bordr">Head</td> -<td class="tdr bordr"> 95</td> -<td class="tdr bordr"> 17</td> -<td class="tdr bordr"> 25</td> -<td class="tdr bordr"> 53</td> -<td class="tdl bordr">1 in 5-10/17</td> -</tr> -<tr> -<td class="tdl bordr">Chest</td> -<td class="tdr bordr"> 96</td> -<td class="tdr bordr"> 35</td> -<td class="tdr bordr"> 14</td> -<td class="tdr bordr"> 47</td> -<td class="tdl bordr">1 in 2-35/96</td> -</tr> -<tr> -<td class="tdl bordr">Abdomen</td> -<td class="tdr bordr"> 104</td> -<td class="tdr bordr"> 24</td> -<td class="tdr bordr"> 21</td> -<td class="tdr bordr"> 59</td> -<td class="tdl bordr">1 in 4-1/3</td> -</tr> -<tr> -<td class="tdl bordr">Super’r extrem’s</td> -<td class="tdr bordr"> 304</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 96</td> -<td class="tdr bordr"> 205</td> -<td class="tdl bordr">1 in 101</td> -</tr> -<tr> -<td class="tdl bordr">Inferior ditto</td> -<td class="tdr bordr"> 498</td> -<td class="tdr bordr"> 21</td> -<td class="tdr bordr"> 150</td> -<td class="tdr bordr"> 327</td> -<td class="tdl bordr">1 in 23-5/7</td> -</tr> -<tr> -<td class="tdl bordr">Comp’d fractures</td> -<td class="tdr bordr"> 78</td> -<td class="tdr bordr"> 29</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 49</td> -<td class="tdl bordr">1 in 2-20/29</td> -</tr> -<tr> -<td class="tdl bordr">Wounds of spine</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdl bordr">1 in 1</td> -</tr> -<tr> -<td class="tdl bordr">Wounds of joints</td> -<td class="tdr bordr"> 16</td> -<td class="tdr bordr"> 4</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 12</td> -<td class="tdl bordr">1 in 4</td> -</tr> -<tr> -<td class="tdl bordr">Amputations—</td> -<td class="tdr bordr " /> -<td class="tdr bordr " /> -<td class="tdr bordr " /> -<td class="tdr bordr " /> -<td class="tdr bordr " /> -</tr> -<tr> -<td class="tdr bordr tightpad"></td> -<td class="tdr bordr tightpad" /> -<td class="tdr bordr tightpad" /> -<td class="tdr bordr tightpad" /> -<td class="tdr bordr tightpad" /> -<td class="tdr bordr tightpad" /> -</tr> -<tr> -<td class="tdr bordr tightpad">Arm 7}<br />Leg and thigh 41}</td> -<td class="tdr bordr tightpad"> 48</td> -<td class="tdr bordr tightpad"> 10</td> -<td class="tdr bordr tightpad"> ...</td> -<td class="tdr bordr tightpad"> 38</td> -<td class="tdl bordr tightpad">1 in 5-1/3</td> -</tr> -<tr> -<td class="tdr bordr "> Total</td> -<td class="tdr bordr bordt"> 1242</td> -<td class="tdr bordr bordt"> 146</td> -<td class="tdr bordr bordt"> 306</td> -<td class="tdr bordr bordt"> 790</td> -<td class="tdl bordr bordt">1 in 8-128/145</td> -</tr> -</tbody> -</table> - -<p>Wounded officers 117, not included, making a total of -1359, among whom thirteen cases of tetanus occurred, all -of which proved fatal.</p> - -<div class="blockquot"> - -<p class="center">No. 2.—<span class="smcap">Officers.</span></p> - -</div> - -<table class="autotable" summary="Officers."> -<tr> -<td class="tdl bordr bordb"><span class="allsmcap">NATURE Of<br />WOUNDS.</span></td> -<td class="tdc bordr bordb">Admitted.</td> -<td class="tdc bordr bordb">Dis-<br />charged.</td> -<td class="tdc bordr bordb">Sent <br />to <br />Bordeaux.</td> -<td class="tdc bordr bordb"> Died. </td> -<td class="tdc bordr bordb">Remaining.</td> -</tr> -<tr> -<td class="tdl bordr">Head</td> -<td class="tdr bordr">6</td> -<td class="tdr bordr">4</td> -<td class="tdr bordr">1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">1</td> -</tr> -<tr> -<td class="tdl bordr">Chest</td> -<td class="tdr bordr">10</td> -<td class="tdr bordr">2</td> -<td class="tdr bordr">2</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">6</td> -</tr> -<tr> -<td class="tdl bordr">Abdomen</td> -<td class="tdr bordr">1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">1</td> -</tr> -<tr> -<td class="tdl bordr">Sup’r extremities</td> -<td class="tdr bordr">33</td> -<td class="tdr bordr">9</td> -<td class="tdr bordr">15</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">9</td> -</tr> -<tr> -<td class="tdl bordr">Inferior ditto</td> -<td class="tdr bordr">49</td> -<td class="tdr bordr">12</td> -<td class="tdr bordr">21</td> -<td class="tdr bordr">1</td> -<td class="tdr bordr">15</td> -</tr> -<tr> -<td class="tdl bordr">Comp’d fractures</td> -<td class="tdr bordr">7</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">1</td> -<td class="tdr bordr">2</td> -<td class="tdr bordr">4</td> -</tr> -<tr> -<td class="tdl bordr">Slight wounds</td> -<td class="tdr bordr">11</td> -<td class="tdr bordr">7</td> -<td class="tdr bordr">2</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">2</td> -</tr> -<tr> -<td class="tdr bordr"> Total</td> -<td class="tdr bordr bordt"> 117</td> -<td class="tdr bordr bordt"> 34</td> -<td class="tdr bordr bordt"> 42</td> -<td class="tdr bordr bordt"> 3</td> -<td class="tdr bordr bordt"> 38</td> -</tr> -</table> - -<p><span class="pagenum"><a name="Page_159" id="Page_159">[159]</a></span> -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.</p> - -<div class="blockquot"> - -<p>No. 3.—<span class="smcap">Return</span> <i>of</i> <span class="smcap">Capital Operations</span> <i>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.</i></p> -</div> - -<table class="autotable" summary="Return of Capital Operations"> -<tr> -<td class="tdc bordr bordb"><span class="allsmcap">STATIONS.</span></td> -<td class="tdc bordr bordb"><span class="allsmcap">OPERATIONS.</span></td> -<td class="tdc bordr bordb">No.<br />operated<br />upon.</td> -<td class="tdc bordr bordb">Died.</td> -<td class="tdc bordr bordb">Dis-<br />charged<br />cured.</td> -<td class="tdc bordr bordb">Under<br />treat-<br />ment.</td> -<td class="tdc bordr bordb"><span class="allsmcap">REMARKS.</span></td> -</tr> -<tr> - -<td class="tdl bordr"><span class="smcap">Vittoria</span></td> -<td class="tdl bordr">Shoulder-<br />joint</td> -<td class="tdr bordr"> 13</td> -<td class="tdr bordr"> 10</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"></td> -</tr> -<tr> - -<td class="tdr bordr"></td> -<td class="tdl bordr">Upper<br />extremities</td> -<td class="tdr bordr">108</td> -<td class="tdr bordr">58</td> -<td class="tdr bordr">40</td> -<td class="tdr bordr">10</td> -<td class="tdr bordr"></td> -</tr> -<tr> -<td class="tdr bordr"></td> -<td class="tdl bordr">Lower<br />ditto</td> -<td class="tdr bordr"> 148</td> -<td class="tdr bordr"> 95</td> -<td class="tdr bordr"> 38</td> -<td class="tdr bordr"> 15</td> -<td class="tdr bordr"></td> -</tr> -<tr> -<td class="tdr bordr"></td> -<td class="tdl bordr">Trepan</td> -<td class="tdr bordr">3</td> -<td class="tdr bordr">3</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -</tr> -<tr> -<td class="tdl bordr"><span class="smcap">Santander</span></td> -<td class="tdl bordr">Upper<br />extremities</td> -<td class="tdr bordr"> 22</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"> 8</td> -<td class="tdr bordr"> 9</td> -<td class="tdr bordr"></td> -</tr> -<tr> -<td class="tdr bordr"></td> -<td class="tdl bordr">Lower<br />ditto</td> -<td class="tdr bordr"> 23</td> -<td class="tdr bordr"> 9</td> -<td class="tdr bordr"> 6</td> -<td class="tdr bordr"> 8</td> -<td class="tdr bordr"></td> -</tr> - -<tr> -<td class="tdl bordr"><span class="smcap">Bilbao</span></td> -<td class="tdl bordr">Shoulder-<br />joint</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdl bordr" rowspan="4">{The great<br /> - {number<br /> - {of amputations at<br /> - {this station<br /> - {was in part<br /> - {occasioned by<br /> - {hospital<br /> - {gangrene.</td> -</tr> - -<tr> -<td class="tdr bordr"></td> -<td class="tdl bordr">Upper<br />extremities</td> -<td class="tdr bordr"> 146</td> -<td class="tdr bordr"> 48</td> -<td class="tdr bordr"> 46</td> -<td class="tdr bordr"> 52</td> -</tr> -<tr> -<td class="tdr bordr"></td> -<td class="tdl bordr">Lower<br />ditto</td> -<td class="tdr bordr"> 68</td> -<td class="tdr bordr"> 36</td> -<td class="tdr bordr"> 16</td> -<td class="tdr bordr"> 16</td> -</tr> -<tr> -<td class="tdr bordr"></td> -<td class="tdl bordr">Aneurism</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> - -</tr> -<tr> -<td class="tdl bordr"><span class="smcap">Passages</span></td> -<td class="tdl bordr">Shoulder-<br />joint</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"></td> -</tr> - -<tr> -<td class="tdr bordr"></td> -<td class="tdl bordr">Upper<br />extremities</td> -<td class="tdr bordr"> 11</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 7</td> -<td class="tdr bordr"></td> -</tr> - -<tr> -<td class="tdr bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 14</td> -<td class="tdr bordr"> 6</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"></td> -</tr> - -<tr> -<td class="tdr bordr"></td> -<td class="tdl bordr">Trepan</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -</tr> -<tr> - -<td class="tdr bordr"></td> -<td class="tdl bordr">Aneurism</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -</tr> -<tr> - -<td class="tdl bordr"><span class="smcap">Vera</span></td> -<td class="tdl bordr">Upper<br />extremities</td> -<td class="tdr bordr"> 12</td> -<td class="tdr bordr"> 4</td> -<td class="tdr bordr"> 8</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -</tr> -<tr> - -<td class="tdr bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -</tr> -<tr> - -<td class="tdr bordr"></td> -<td class="tdl bordr bordb">Total</td> -<td class="tdr bordr bordb bordt"> 584</td> -<td class="tdr bordr bordb bordt"> 287</td> -<td class="tdr bordr bordb bordt"> 173</td> -<td class="tdr bordr bordb bordt"> 124</td> -<td class="tdr bordr "></td> -</tr> -<tr> - -<td class="tdl bordr" colspan="2"><span class="smcap">Recapitulation</span>:—</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -</tr> -<tr> -<td class="tdr bordl "></td> -<td class="tdl bordr">Shoulder-<br />joint</td> -<td class="tdr bordr"> 19</td> -<td class="tdr bordr"> 15</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"></td> -</tr> - -<tr> -<td class="tdr bordl "></td> -<td class="tdl bordr">Upper<br />extremities</td> -<td class="tdr bordr"> 299</td> -<td class="tdr bordr"> 116</td> -<td class="tdr bordr"> 105</td> -<td class="tdr bordr"> 78</td> -<td class="tdr bordr"></td> -</tr> -<tr> -<td class="tdr bordl "></td> -<td class="tdl bordr"> Lower<br />ditto</td> -<td class="tdr bordr"> 258</td> -<td class="tdr bordr"> 149</td> -<td class="tdr bordr"> 65</td> -<td class="tdr bordr"> 44</td> -<td class="tdr bordr"></td> -</tr> -<tr> -<td class="tdr bordl"></td> -<td class="tdl bordr">Trepan</td> -<td class="tdr bordr">6</td> -<td class="tdr bordr">5</td> -<td class="tdr bordr">1</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -</tr> -<tr> -<td class="tdr bordl"></td> -<td class="tdl bordr"> Aneurism</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -</tr> -</table> - - -<p>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.</p> - -<div class="blockquot"> - -<p><span class="pagenum"><a name="Page_160" id="Page_160">[160]</a></span> -No. 4.—<span class="smcap">Capital Operations</span> <i>performed in the Field with Divisions -of the Army during the same period</i>.</p> - -<table class="autotable" summary="Capitol Operations"> -<tr> -<td class="tdl bordr bordb"><span class="allsmcap">DIVISIONS.</span></td> -<td class="tdl bordr bordb"><span class="allsmcap">OPERATIONS.</span></td> -<td class="tdc bordr bordb">Number<br />operated<br />upon.</td> -<td class="tdc bordr bordb">Died.</td> -<td class="tdc bordr bordb">Dis-<br />charged<br />cured.</td> -<td class="tdc bordr bordb">Under<br />treatment.</td> -<td class="tdc bordr bordb">Tetanus<br />occurred.</td> -<td class="tdc bordr bordb" colspan="2"> REMARKS.</td> -</tr> -<tr> -<td class="tdl bordr">Cavalry</td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdl"></td> -<td class="tdl bordr"></td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdl "></td> -<td class="tdl bordr"></td> -</tr> -<tr> -<td class="tdl bordr">First<br />division</td> -<td class="tdl bordr">Shoulder-joint</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr "> 1</td> -<td class="tdl bordr" rowspan="3">Sent to<br />General<br />Hospital.</td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 14</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordl "> 5</td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 10</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordl "> 6</td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Trepan</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdl bordr"></td> -<td class="tdl "></td> -<td class="tdl "></td> -</tr> -<tr> -<td class="tdl bordr">Second</td> -<td class="tdl bordr">Shoulder-joint</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"></td> -<td class="tdl bordr"></td> -<td class="tdl"></td> -<td class="tdl bordr"></td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 16</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"> 6</td> -<td class="tdr bordr"> ...</td> -<td class="tdr "> 5</td> -<td class="tdl bordr" rowspan="2">Sent to<br />General<br />Hospital.</td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 21</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 6</td> -<td class="tdr bordr"> 7</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordl "> 5</td> - -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Aneurism</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdl bordr"></td> -<td class="tdl "></td> -<td class="tdl bordr "></td> -</tr> -<tr> -<td class="tdl bordr">Third</td> -<td class="tdl bordr">Shoulder-joint</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdl bordr"></td> -<td class="tdl "></td> -<td class="tdl bordr"></td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 17</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 15</td> -<td class="tdl bordr"></td> -<td class="tdl "></td> -<td class="tdl bordr"></td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 10</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> 8</td> -<td class="tdl bordr"></td> -<td class="tdl "></td> -<td class="tdl bordr"></td> -</tr> -<tr> -<td class="tdl bordr">Fourth</td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 10</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 10</td> -<td class="tdr bordr"></td> -<td class="tdl bordr"></td> -<td class="tdl "></td> -<td class="tdl bordr"></td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 20</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 20</td> -<td class="tdr bordr"></td> -<td class="tdl bordr"></td> -<td class="tdl "></td> -<td class="tdl bordr"></td> -</tr> -<tr> -<td class="tdl bordr">Fifth</td> -<td class="tdl bordr">Shoulder-joint</td> -<td class="tdr bordr"> 12</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 8</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> ...</td> -<td class="tdr "> 2</td> -<td class="tdl bordr" rowspan="3">Sent to<br />General<br />Hospital.</td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 57</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 36</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> ...</td> -<td class="tdr ">18</td> - -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 41</td> -<td class="tdr bordr"> 10</td> -<td class="tdr bordr"> 13</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordl ">16</td> - -</tr> -<tr> -<td class="tdl bordr">Sixth</td> -<td class="tdl bordr">Shoulder-joint</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdl bordr"></td> -<td class="tdl "></td> -<td class="tdl "></td> - -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 7</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr "> 2</td> -<td class="tdl bordr" rowspan="2">Sent to<br />General<br />Hospital.</td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 6</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordl "> 1</td> - -</tr> -<tr> -<td class="tdl bordr">Seventh</td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 18</td> -<td class="tdr bordr"> ··</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> ...</td> -<td class="tdr ">14</td> -<td class="tdl bordr " rowspan="2">Sent to<br />General<br />Hospital.</td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 9</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> ...</td> -<td class="tdr "> 7</td> - -</tr> -<tr> -<td class="tdl bordr">Light<br />division</td> -<td class="tdl bordr">Shoulder-joint</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdl " colspan="2" rowspan="4">The whole of these<br />cases sent to the<br />General Hospital;<br />results not known<br />at the division.</td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 21</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> - -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordr"> 8</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> - -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdl bordr">Trepan</td> -<td class="tdr bordr"> 4</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> - -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdr bordr bordb "> Total</td> -<td class="tdr bordr bordb bordt"> 317</td> -<td class="tdr bordr bordb bordt"> 27</td> -<td class="tdr bordr bordb bordt"> 118</td> -<td class="tdr bordr bordb bordt"> 55</td> -<td class="tdr bordr bordb bordt"> 1</td> -<td class="tdl "></td> -<td class="tdl "></td> -</tr> -<tr> -<td class="tdl bordr" colspan="2"><span class="smcap">Recapitulation</span>:—</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdl bordr"></td> -<td class="tdl"></td> -<td class="tdl "></td> -</tr> -<tr> -<td class="tdl bordl"></td> -<td class="tdl bordr">Shoulder-joint</td> -<td class="tdr bordr"> 19</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 11</td> -<td class="tdr bordr"> 3</td> -<td class="tdr bordr"> ...</td> -<td class="tdr "> 4</td> -<td class="tdl " rowspan="4">Sent to<br />General<br />Hospital.</td> - -</tr> -<tr> -<td class="tdl bordl"></td> -<td class="tdl bordr">Upper extremities</td> -<td class="tdr bordr"> 163</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"> 64</td> -<td class="tdr bordr"> 29</td> -<td class="tdr bordr"> ...</td> -<td class="tdr">65</td> - -</tr> -<tr> -<td class="tdl bordl"></td> -<td class="tdl bordr">Lower ditto</td> -<td class="tdr bordl bordr"> 128</td> -<td class="tdr bordl bordr"> 19</td> -<td class="tdr bordl bordr"> 43</td> -<td class="tdr bordl bordr"> 22</td> -<td class="tdr bordl bordr"> ...</td> -<td class="tdr bordl">44</td> - -</tr> -<tr> -<td class="tdl bordl"></td> -<td class="tdl bordr">Trepan</td> -<td class="tdr bordr"> 6</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr"> 4</td> - -</tr> -<tr> -<td class="tdl bordl"></td> -<td class="tdl bordr">Aneurism</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> ...</td> -<td class="tdl"></td> -<td class="tdl bordr"></td> -</tr> -</table> -</div> - -<p><span class="pagenum"><a name="Page_161" id="Page_161">[161]</a></span> -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.</p> - -<p>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.</p> - -<div class="blockquot"> - -<p><span class="pagenum"><a name="Page_162" id="Page_162">[162]</a></span> -No. 5.—<span class="smcap">Return</span> <i>of</i> <span class="smcap">Capital Operations</span>, <i>Primary and Secondary, performed in the British General Hospitals, -Brussels, or brought in from the Field between 16th June and 31st July, 1815</i>.</p> - -</div> - -<table class="autotable" summary="Return of Capital Operations"> -<tr> -<td class="tdl" colspan="14"><span class="allsmcap">OPERATIONS.</span></td> -</tr> -<tr> -<td ></td> -<td class="bordl" colspan="13">General total.</td> -</tr> -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" colspan="12">Primary operations.</td> -</tr> -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="11">Died.</td> -</tr> -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="10">Remaining.</td> -</tr> -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="9">Proportion of deaths<br />to operations.</td> -</tr> - -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="8">Secondary operations.</td> -</tr> - -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="7">Died.</td> -</tr> - -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="6">Remaining.</td> -</tr> -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="5">Proportion of deaths<br />to operations.</td> -</tr> -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="4">Total remaining.</td> -</tr> - -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="3">Of these<br />doubtful.</td> -</tr> - -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdl bordl" colspan="2">Transferred to<br />Antwerp.</td> -</tr> -<tr> -<td /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="bordl" /> -<td class="tdc bordl"><span class="allsmcap">REMARKS.</span></td> -</tr> - -<tr> -<td class="tdl bordr bordt">Shoulder-<br /> joint</td> -<td class="tdr bordr bordt"> 8</td> -<td class="tdr bordr bordt"> 6</td> -<td class="tdr bordr bordt"> 1</td> -<td class="tdr bordr bordt"> 5</td> -<td class="tdr bordr bordt"> 1 to 6</td> -<td class="tdr bordr bordt"> 12</td> -<td class="tdr bordr bordt"> 6</td> -<td class="tdr bordr bordt"> 6</td> -<td class="tdr bordr bordt"> 1 to 2</td> -<td class="tdr bordr bordt"> 11</td> -<td class="tdr bordr bordt"></td> -<td class="tdr bordr bordt"></td> -<td class="tdl bordr bordt"></td> -</tr> -<tr> -<td class="tdl bordr">Hip-joint</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">... ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">... ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdl ">A French<br />soldier,<br />who<br />recovered.</td> -</tr> -<tr> -<td class="tdl bordr">Thigh</td> -<td class="tdr bordr"> 148</td> -<td class="tdr bordr"> 54</td> -<td class="tdr bordr"> 19</td> -<td class="tdr bordr"> 35</td> -<td class="tdr bordr"> 1 to 3</td> -<td class="tdr bordr"> 94</td> -<td class="tdr bordr"> 43</td> -<td class="tdr bordr"> 51</td> -<td class="tdr bordr"> 1 to 2</td> -<td class="tdr bordr"> 86</td> -<td class="tdr bordr"> 9</td> -<td class="tdr bordr"> 4</td> -<td class="tdl"></td> -</tr> -<tr> -<td class="tdl bordr">Leg</td> -<td class="tdr bordr"> 93</td> -<td class="tdr bordr"> 43</td> -<td class="tdr bordr"> 7</td> -<td class="tdr bordr"> 26</td> -<td class="tdr bordr"> 1 to 6</td> -<td class="tdr bordr"> 50</td> -<td class="tdr bordr"> 16</td> -<td class="tdr bordr"> 34</td> -<td class="tdr bordr"> 1 to 3</td> -<td class="tdr bordr"> 60</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr"> 4</td> -<td class="tdl"></td> -</tr> -<tr> -<td class="tdl bordr">Arm</td> -<td class="tdr bordr"> 72</td> -<td class="tdr bordr"> 21</td> -<td class="tdr bordr"> 4</td> -<td class="tdr bordr"> 17</td> -<td class="tdr bordr"> 1 to 5</td> -<td class="tdr bordr"> 51</td> -<td class="tdr bordr"> 13</td> -<td class="tdr bordr"> 38</td> -<td class="tdr bordr"> 1 to 4</td> -<td class="tdr bordr"> 55</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr"> 6</td> -<td class="tdl"></td> -</tr> -<tr> -<td class="tdl bordr">Forearm</td> -<td class="tdr bordr"> 39</td> -<td class="tdr bordr"> 22</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 21</td> -<td class="tdr bordr"> 1 to 22</td> -<td class="tdr bordr"> 17</td> -<td class="tdr bordr"> 5</td> -<td class="tdr bordr"> 12</td> -<td class="tdr bordr"> 1 to 3</td> -<td class="tdr bordr"> 33</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr"> 3</td> -<td class="tdl"></td> -</tr> -<tr> -<td class="tdl bordr">Carotid<br /> artery<br /> tied</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">... ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">... ...</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdl"></td> -</tr> -<tr> -<td class="tdl bordr">Trephine</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">... ...</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr"> 1 to 2</td> -<td class="tdr bordr"> 1</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr"> 1</td> -<td class="tdl"></td> -</tr> -<tr> -<td class="tdl bordr">Total</td> -<td class="tdr bordr bordt"> 374</td> -<td class="tdr bordr bordt"> 146</td> -<td class="tdr bordr bordt"> 32</td> -<td class="tdr bordr bordt"> 104</td> -<td class="tdr bordr bordt">... ...</td> -<td class="tdr bordr bordt"> 228</td> -<td class="tdr bordr bordt"> 84</td> -<td class="tdr bordr bordt"> 144</td> -<td class="tdr bordr bordt">... ...</td> -<td class="tdr bordr bordt"> 248</td> -<td class="tdr bordr bordt"> 9</td> -<td class="tdr bordr bordt"> 18</td> -<td class="tdl"></td> -</tr> -</table> - - - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<p><span class="pagenum"><a name="Page_163" id="Page_163">[163]</a></span></p> -<h2 class="nobreak" id="LECTURE_VIII">LECTURE VIII.</h2> -</div> - -<p class="h2sub">CHARACTERS OF HOSPITAL GANGRENE.</p> - -<p>164. This most destructive disease owes its names of hospital -gangrene, phagedena, gangrenosa, <i>pourriture d’hôpital</i>, -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<span class="pagenum"><a name="Page_164" id="Page_164">[164]</a></span> -destructive applications, may be considered to be infectious -as well as contagious.</p> - -<p>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.</p> - -<p>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:—</p> - -<p>“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<span class="pagenum"><a name="Page_165" id="Page_165">[165]</a></span> -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.”</p> - -<p>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:—</p> - -<p>“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.”</p> - -<p>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<span class="pagenum"><a name="Page_166" id="Page_166">[166]</a></span> -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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_167" id="Page_167">[167]</a></span> -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.</p> - -<p>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.</p> - -<p>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,<span class="pagenum"><a name="Page_168" id="Page_168">[168]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_169" id="Page_169">[169]</a></span> -subsiding at Bilbao when the treatment he introduced proved -so effectual.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_170" id="Page_170">[170]</a></span> -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.”</p> - -<p>Dr. Walker, who served at Bilbao at the same time, concludes -an able report in the following terms:—</p> - -<p>“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.”</p> - -<p>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<span class="pagenum"><a name="Page_171" id="Page_171">[171]</a></span> -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.</p> - -<p>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, <i>Inspecteur -au Service de Santé</i>, 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.</p> - -<p>171. In India, Mr. Taylor, late surgeon 29th Regiment, -now a deputy inspector-general in the medical department in -the Crimea, reports:—</p> - -<p>“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.</p> - -<p>“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<span class="pagenum"><a name="Page_172" id="Page_172">[172]</a></span> -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.</p> - -<p>“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.</p> - -<p>“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.</p> - -<p>“In no case that came under my observation did the gan<span class="pagenum"><a name="Page_173" id="Page_173">[173]</a></span>grene -directly prove fatal, though in many cases it contributed -largely in bringing about an unfavorable termination.”</p> - -<p>172. <i>Conclusions.</i> First.—Hospital gangrene never -occurs in isolated cases of wounds.</p> - -<p>Second.—It originates only in badly-ventilated hospitals, -crowded with wounded men, among and around whom cleanliness -has not been too well observed.</p> - -<p>Third.—It is a morbid poison, remarkably contagious, and -is infectious through the medium of the atmosphere applied -to the wound or ulcer.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Sixth.—In crowded hospitals the constitutional symptoms -have been sometimes observed to precede, and frequently to -accompany, the appearance of the local disease.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Tenth.—The local disease is to be arrested by the appli<span class="pagenum"><a name="Page_174" id="Page_174">[174]</a></span>cation -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Fifteenth.—The essential preventive measures are separation, -cleanliness, and exposure to the open air,—the first -<span class="pagenum"><a name="Page_175" id="Page_175">[175]</a></span> -steps toward that cure which cauterization will afterward in -general accomplish.</p> - -<p>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.</p> - -<p>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.</p> - -<div class="blockquot"> - -<p><span class="smcap">Return</span> <i>of the</i> <span class="smcap">Number of Cases</span> <i>of</i> <span class="smcap">Hospital Gangrene</span> <i>which have -appeared at the Hospital Stations in the Peninsula between 21st June -and 24th December, 1813</i>.</p> -</div> - -<table class="autotable" summary=""> -<tr> -<td class="tdc bordb bordr"> <span class="allsmcap">STATIONS.</span></td> -<td class="tdc bordb bordr"> No. of<br />cases<br />occurred.</td> -<td class="tdc bordb bordr">Discharged<br />cured.</td> -<td class="tdc bordb bordr"> Died.</td> -<td class="tdc bordb bordr"> Under<br />treatment.</td> -<td class="tdc bordb bordr">No.<br />operated<br />upon.</td> -<td class="tdc bordb bordr"> <span class="allsmcap">REMARKS.</span></td> -</tr> -<tr> -<td class="tdl bordr"> Santander</td> -<td class="tdr bordr"> 160</td> -<td class="tdr bordr"> 72</td> -<td class="tdr bordr"> 85</td> -<td class="tdr bordr"> 53</td> -<td class="tdr bordr"> 25</td> -<td class="tdl bordr" rowspan="2">{Most of these<br />{cases were sent<br />{from Vittoria.</td> -</tr> -<tr> -<td class="tdl bordr"> Bilbao</td> -<td class="tdr bordr"> 972</td> -<td class="tdr bordr"> 557</td> -<td class="tdr bordr"> 387</td> -<td class="tdr bordr"> 28</td> -<td class="tdr bordr"> 183</td> -</tr> -<tr> -<td class="tdl bordr"> Vittoria</td> -<td class="tdr bordr"> 441</td> -<td class="tdr bordr"> 349</td> -<td class="tdr bordr"> 88</td> -<td class="tdr bordr"> 4</td> -<td class="tdr bordr"> 74</td> -<td class="tdl bordr"></td> -</tr> -<tr> -<td class="tdl bordr"> Passages</td> -<td class="tdr bordr"> 41</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"> 2</td> -<td class="tdr bordr"></td> -<td class="tdr bordr"></td> -<td class="tdl bordr">{Thirty-seven<br />{transferred<br />{to Santander.</td> -</tr> -<tr> -<td class="tdl bordr">Vera</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdr bordr">...</td> -<td class="tdl">{Vera, being almost<br />{on the field<br />{of battle,<br />{had no case.</td> -</tr> -<tr> -<td class="tdl bordr"></td> -<td class="tdr bordt bordr"> 1614</td> -<td class="tdr bordt bordr"> 980</td> -<td class="tdr bordt bordr"> 512</td> -<td class="tdr bordt bordr"> 85</td> -<td class="tdr bordt bordr"> 282</td> -<td class="tdl"></td> -</tr> -</table> - -<p><span class="pagenum"><a name="Page_176" id="Page_176">[176]</a></span> -</p> -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_IX">LECTURE IX.</h2> -</div> - -<p class="h2sub">ON WOUNDS OF ARTERIES, ETC.</p> - -<div class="figcenter illowp100" id="i-176" style="max-width: 30em;"> - <img class="w100" src="images/i-176.jpg" alt="Cross section of artery." /> -</div> - -<p>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 <i>inner</i> or old -serous coat is shown to be separable into <i>two</i>: the epithelial, -marked 1, and the fenestrated, marked 2. The <i>middle</i> coat -is also separated into <i>two</i>: the inner, or <i>muscular</i>, marked -3, and the outer, or <i>elastic</i>, marked 4. The <i>outer</i> coat is -divisible also into two layers, the <i>inner</i>, marked 5, and the -<i>outer</i>, 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 -<span class="pagenum"><a name="Page_177" id="Page_177">[177]</a></span> -the general composition of a large artery, each particular -structure remaining to be examined.</p> - -<div class="figcenter illowp100" id="i-177" style="max-width: 30em;"> - <div class="caption center"> - <p>No. 1.</p> - </div> - <img class="w100" src="images/i-177.jpg" alt="Cross section of edge of large artery." /> - -<p class="center">OLD.      MIDDLE.      YOUNG.</p> - -</div> - -<p>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 <i>epithelium</i>, a name given to it by -Ruysch, from the delicate layer of epidermis investing the -female nipple, έπι, upon, θηλή, <i>a nipple</i>. The epithelium of -the human body is divided into three kinds by microscopists—the -<i>tesselated</i>, <i>pavement</i>, or <i>scaly</i>; the <i>cylindrical</i>, or -<i>conical</i>; and the <i>spheroidal</i>, or <i>glandular</i>. 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 -<span class="pagenum"><a name="Page_178" id="Page_178">[178]</a></span> -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 <i>conjunctiva</i> of the eye; the pharynx -and œsophagus; the vagina and cervix uteri; the entrance -of the female urethra, and the serous membranes.</p> - -<p>The <i>conical</i> 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.</p> - -<p>The <i>spheroidal</i> or <i>glandular</i> 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.</p> - -<p>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 <i>palpebral</i> conjunctiva, -as opposed to the tesselated on the eyeball; the ventricles -of the brain; the posterior half of the uterus, and the -Fallopian tubes.</p> - -<p>The epithelium is placed upon the second layer of the -internal coat, which, from certain appearances of apertures -or windows, has been called the <i>perforated</i> or <i>fenestrated</i> -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 -<span class="pagenum"><a name="Page_179" id="Page_179">[179]</a></span> -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.</p> - -<div class="figcenter illowp97" id="i-179" style="max-width: 30em;"> - <div class="caption"><p class="center">No. 2.</p></div> - <img class="w100" src="images/i-179.jpg" alt="Epithelium." /> - -</div> - -<p>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 <i>two</i> 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 -<span class="pagenum"><a name="Page_180" id="Page_180">[180]</a></span> -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 <i>protein</i>, 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 -(<i>fibrin</i> and <i>albumen</i>) and of sulpho-protein <i>casein</i> 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.</p> - -<p>“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.</p> - -<p>“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.</p> - -<p>“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.”</p> - -<p>In diagram No. 3, fig. 3, the organic or <i>involuntary</i> -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 -<span class="pagenum"><a name="Page_181" id="Page_181">[181]</a></span> -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.</p> - -<div class="figcenter illowp55" id="i-181" style="max-width: 30em;"> - <div class="caption"><p class="center">No. 3.</p></div> - <img class="w100" src="images/i-no3.jpg" alt="Four types of muscular fibers of the intenstine." /> - -</div> - -<div class="figright illowp55" id="i-no4" style="max-width: 20em;"> - <div class="caption"><p class="center">No. 4.</p></div> - <img class="w100" src="images/i-no4.jpg" alt="" /> -</div> - -<p>The <i>involuntary</i> -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.</p> - -<p>The <i>voluntary</i> -muscular fibers differ -from the <i>involuntary</i>, -in having cylindrical -fibers of much -larger size, with transverse -and longitudinal<span class="pagenum"><a name="Page_182" id="Page_182">[182]</a></span> -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.</p> - -<p>The <i>outer</i> or <i>elastic</i> layer of the ancient <i>middle</i> 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.</p> - -<p>The <i>external</i> coat of an artery, divided also into <i>two</i> -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, <i>white</i> in color and <i>in</i>elastic -in structure, arranged in various directions; the <i>inner</i> -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 -<span class="pagenum"><a name="Page_183" id="Page_183">[183]</a></span> -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 <i>b</i>, diagram 5.</p> - -<div class="figcenter illowp90" id="i-no5" style="max-width: 35em;"> - <div class="caption"><p class="center">No. 5.</p></div> - <img class="w100" src="images/i-no5.jpg" alt="Diagrams of fibers in artery wall." /> -<div class="caption"> -<p> -<i>a.</i> Yellow elastic fibers.<br /> -<i>b.</i> White inelastic fibers.<br /> -<i>c.</i> Nuclei.<br /> -<i>d.</i> Fiber, with nucleus. -</p> -</div> -</div> - -<p>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 <i>internal</i> coat -in all is frequently seen puckered in a longitudinal direction.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<i>cyto</i>-blastema or <i>formative substance</i> 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 -sur<span class="pagenum"><a name="Page_184" id="Page_184">[184]</a></span>face -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>When an aneurismal limb has been injected, on which an -<span class="pagenum"><a name="Page_185" id="Page_185">[185]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_186" id="Page_186">[186]</a></span> -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 <i>dark or venous</i>. 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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_187" id="Page_187">[187]</a></span> -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.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_X">LECTURE X.</h2> -</div> - -<p class="h2sub">PROPER TREATMENT OF WOUNDED ARTERIES, ETC.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_188" id="Page_188">[188]</a></span> -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.</p> - -<p>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.</p> - -<p>181. The Hunterian theory implies:—</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_189" id="Page_189">[189]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>accident</i>, not -of principle.</p> - -<p>182. The essential features of the theory opposed to Mr. -Hunter, with respect to wounded arteries, and called mine, -are:—</p> - -<p>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 -<span class="pagenum"><a name="Page_190" id="Page_190">[190]</a></span> -obliteration of its canal, and the consequent suppression of -hemorrhage.</p> - -<p>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.</p> - -<p>3d. That this freedom of circulation is less in the <i>lower</i> -than in the <i>upper</i> extremity, under all circumstances.</p> - -<p>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.</p> - -<p>5th. That mortification of the hand and arm rarely -follows the application of a ligature to the artery of the -<i>upper</i> extremity in any part of its course, however near the -heart.</p> - -<p>6th. That when the collateral vessels are capable of carrying -on the circulation through the lower extremity, the -<i>lower</i> end of the divided artery bleeds <i>dark</i> or <i>venous</i>-colored -blood, while its <i>upper</i> end bleeds <i>scarlet</i> or <i>arterial</i>-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.</p> - -<p>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 <i>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</i>.</p> - -<p>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. -<span class="pagenum"><a name="Page_191" id="Page_191">[191]</a></span> -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 <i>no aneurismal sac</i> to receive and retain it, the patient -bleeds perhaps to death, unless surgery come to his assistance.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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:—</p> - -<p>1. That no operation ought to be performed on a wounded -artery unless it bleed.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_192" id="Page_192">[192]</a></span> -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 <i>bouchon</i> of the French.</p> - -<p>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 -<i>upper</i>, although not from the <i>lower</i> end of the vessel; but -then it is of <i>venous</i> and not of <i>arterial</i> 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 <i>upper</i> end of the -divided artery, but from the <i>lower</i>, and from <i>mortification -of the foot</i>.</p> - -<p>The <i>upper</i> end of an artery retracts on being divided, and -this retraction is accompanied by a contraction of the cut -<span class="pagenum"><a name="Page_193" id="Page_193">[193]</a></span> -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.</p> - -<p>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 <i>lower</i> end of a divided artery is neither -so perfect nor so permanent as at its <i>upper</i> 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 <i>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</i>.</p> - -<p>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 -<span class="pagenum"><a name="Page_194" id="Page_194">[194]</a></span> -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 <i>upper</i> divided end of the -vessel, which will generally be able to resist this impulse, -while the <i>lower</i> 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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_195" id="Page_195">[195]</a></span> -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.</p> - -<div class="figcenter illowp55" id="i-195" style="max-width: 25em;"> - <img class="w100" src="images/i-195.jpg" alt="Axillary artery, vein, and nerves." /> - <div class="caption"> -<p> -1. Axillary artery.<br /> -2. Axillary vein.<br /> -3, 3. Branches of axillary plexus of nerves.<br /> -4. Curved, pointed and plugged ends of the artery and vein. -</p> - -<div class="blockquot"> - -<p>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.</p> -</div> -</div> -</div> - -<p>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 -<span class="pagenum"><a name="Page_196" id="Page_196">[196]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_197" id="Page_197">[197]</a></span> -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 <i>upper</i>, 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 <i>lower</i> 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.</p> - -<p>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.</p> - -<p><i>Remarks.</i>—A simple incision to expose the wounded -artery, and placing two ligatures upon it, would have saved -this man his arm and his life.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_198" id="Page_198">[198]</a></span> -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.</p> - -<p>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.</p> - -<p><i>Remarks.</i>—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.</p> - -<p>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 -<span class="pagenum"><a name="Page_199" id="Page_199">[199]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_200" id="Page_200">[200]</a></span> -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.</p> - -<p>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 -communi<span class="pagenum"><a name="Page_201" id="Page_201">[201]</a></span>cated -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>On the 24th he died.</p> - -<p>On examining the amputated limb, the popliteal nerve -was found untouched, the ball having passed on the inside; -<span class="pagenum"><a name="Page_202" id="Page_202">[202]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_203" id="Page_203">[203]</a></span> -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 <i>below -the knee</i>.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_204" id="Page_204">[204]</a></span> -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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_205" id="Page_205">[205]</a></span> -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 -<span class="pagenum"><a name="Page_206" id="Page_206">[206]</a></span> -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.</p> - -<p>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. <i>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</i>—two great facts the practice of the Peninsular war led -me to declare, and which ought no longer to be doubted.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_207" id="Page_207">[207]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_208" id="Page_208">[208]</a></span> -as the extremity of a nerve, or a slip of ligament which is -not sufficiently compressed in the noose of the ligature.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XI">LECTURE XI.</h2> -</div> - -<p class="h2sub">THE FEMORAL ARTERY, ETC.</p> - -<p>189. When the femoral artery is <i>cut across</i> 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.</p> - -<p>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 -<span class="pagenum"><a name="Page_209" id="Page_209">[209]</a></span> -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.</p> - -<p>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 <i>Aph.</i> 413.)</p> - -<p>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 -<span class="pagenum"><a name="Page_210" id="Page_210">[210]</a></span> -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.</p> - -<p>190. A <i>small puncture</i> 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 <i>larger puncture</i>, 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_211" id="Page_211">[211]</a></span> -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.</p> - -<p>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 <i>smaller wound</i> 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.</p> - -<p>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 -<span class="pagenum"><a name="Page_212" id="Page_212">[212]</a></span> -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.</p> - -<p>191. When a large artery, such as the brachial, is cut -<i>transversely</i> 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.</p> - -<p>When an artery of this size is <i>completely divided</i>, 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.</p> - -<p><span class="pagenum"><a name="Page_213" id="Page_213">[213]</a></span> -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.</p> - -<p>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.</p> - -<p>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 gradu<span class="pagenum"><a name="Page_214" id="Page_214">[214]</a></span>ally -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.</p> - -<p>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,<span class="pagenum"><a name="Page_215" id="Page_215">[215]</a></span> -and the operation to be performed for their cure; and the -surgeon may not overlook these facts.</p> - -<p>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 <i>dissected</i>, 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.</p> - -<p>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.</p> - -<p>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:—</p> - -<p>John Wilson, of the 23d Regiment, was wounded at the<span class="pagenum"><a name="Page_216" id="Page_216">[216]</a></span> -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. <i>Absolute rest</i> was enjoined. -The hemorrhage at last ceased without further interference, -and the man recovered.</p> - -<p>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<span class="pagenum"><a name="Page_217" id="Page_217">[217]</a></span> -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_218" id="Page_218">[218]</a></span> -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.</p> - -<p>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.</p> - -<p>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 in<span class="pagenum"><a name="Page_219" id="Page_219">[219]</a></span>tense. -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.</p> - -<p><i>Remarks.</i>—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.</p> - -<p>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.</p> - -<p>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,<span class="pagenum"><a name="Page_220" id="Page_220">[220]</a></span> -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<span class="pagenum"><a name="Page_221" id="Page_221">[221]</a></span> -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 <span class="allsmcap">P.M.</span> he became -more easy, and expressed an opinion that he should “do -well;” but in little more than half an hour he expired.</p> - -<p><i>Examination after death.</i>—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<span class="pagenum"><a name="Page_222" id="Page_222">[222]</a></span> -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.</p> - -<p><i>Remarks.</i>—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 <i>one</i> doctor, or an old woman, and -a little cold water, in 1812, and did die of <i>seven</i> 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 <i>experimentum crucis</i> of -principles.</p> - -<p>The <i>first error</i> 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<span class="pagenum"><a name="Page_223" id="Page_223">[223]</a></span> -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 -<i>first</i> and fundamental error, as fatal as erroneous.</p> - -<p>The <i>second</i> error consisted in the belief, <i>contrary to all -experience</i>, 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.</p> - -<p>The <i>first two errors</i>, or defects of principles, gave rise to -the <i>third</i>, 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.</p> - -<p>The <i>fourth</i> 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<span class="pagenum"><a name="Page_224" id="Page_224">[224]</a></span> -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 <i>whizzing sound or thrill</i> -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.”</p> - -<p>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? <i>It has always been so</i>; the reason, -however specious, is not valid, and cannot be admitted.</p> - -<p>The <i>fifth</i> 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? <i>They could not do it</i>—<i>they -have rarely done it</i> 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 ex<span class="pagenum"><a name="Page_225" id="Page_225">[225]</a></span>posed, -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.</p> - -<p>The <i>sixth</i> 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.</p> - -<p>If the femoral artery had been <i>wounded</i>, as was supposed -in this case, but not completely <i>divided</i>, it <i>must</i> and <i>would</i> -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.</p> - -<p>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.</p> - -<p>The <i>seventh</i> 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<span class="pagenum"><a name="Page_226" id="Page_226">[226]</a></span> -Peninsula, “<i>not to perform an operation on an artery -until it bleed</i>.”</p> - -<p>194. When a wound occurs in the thigh, implicating the -femoral artery or its branches, and the bleeding cannot be -<i>restrained</i> 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 <i>impracticability</i> -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.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XII">LECTURE XII.</h2> -</div> - -<p class="h2sub">MORTIFICATION, ETC.</p> - -<p>195. The gangrene, mortification, or sphacelus, consequent -on a wound of the main artery of the lower extremity, -is, in the first instance, <i>local</i> and <i>dry</i>, unless putrefaction be -induced by heat. (See <i>Aphorism</i> 28.) The following case -is a good example of this and of all the other points laid -down as principles or facts:—</p> - -<p>A gentleman received an injury in the upper part of the<span class="pagenum"><a name="Page_227" id="Page_227">[227]</a></span> -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 <i>tallowy-white</i> and <i>mottled</i> 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.</p> - -<p>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 <i>Aphorism</i> 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<span class="pagenum"><a name="Page_228" id="Page_228">[228]</a></span> -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.</p> - -<p>In a case of the kind in which the artery was wounded at -the <i>lower</i> part of the thigh instead of the <i>upper</i>, 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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_229" id="Page_229">[229]</a></span> -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 pre<span class="pagenum"><a name="Page_230" id="Page_230">[230]</a></span>vented; -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.</p> - -<p>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.</p> - -<p>197. The following cases may be considered conclusive:—</p> - -<p>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 -<span class="pagenum"><a name="Page_231" id="Page_231">[231]</a></span> -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.</p> - -<p><i>Remarks.</i>—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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_232" id="Page_232">[232]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_233" id="Page_233">[233]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_234" id="Page_234">[234]</a></span> -additions to surgery for which science is indebted to the -Peninsular war.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_235" id="Page_235">[235]</a></span> -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, -(<i>Anglice</i>, 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.</p> - -<p>199. The principles laid down for the treatment of -wounded arteries in the <i>lower</i> extremity are equally to be -observed with respect to those of the <i>upper</i>. 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.</p> - -<p>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 -<i>absolute rest</i> having been carefully observed.</p> - -<p>201. The necessity for an aneurismal sac below the<span class="pagenum"><a name="Page_236" id="Page_236">[236]</a></span> -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:—</p> - -<p>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, <i>but not -extending to the branch above or below it</i>. 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. <i>Between the opening and the ligature</i>, -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_237" id="Page_237">[237]</a></span> -impropriety of placing a ligature on the subclavian artery -above the clavicle, for a wound of the artery below it.</p> - -<p>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.</p> - -<p>202. In all those cases in which it has been supposed -necessary to place a ligature on the artery above the clavicle, -after a <i>failure</i> in the attempt to find the artery below it, -the failure has occurred from <i>the error committed</i> in not -dividing the integuments and great pectoral muscle <i>directly -across</i> 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 -<span class="pagenum"><a name="Page_238" id="Page_238">[238]</a></span> -which is attended with little risk, compared with that which -destroys one man for every one it saves.</p> - -<p>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.</p> - -<p>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.</p> - -<p>205. When an aneurismal tumor forms <i>some time</i> 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_239" id="Page_239">[239]</a></span> -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, <span class="allsmcap">NEAR</span> 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 -<span class="pagenum"><a name="Page_240" id="Page_240">[240]</a></span> -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 <i>rest</i> 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.</p> - -<p>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.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<p><span class="pagenum"><a name="Page_241" id="Page_241">[241]</a></span></p> -<h2 class="nobreak" id="LECTURE_XIII"> -LECTURE XIII.</h2> -</div> - -<p class="h2sub">WOUNDS OF THE ARTERIES, ETC.</p> - -<p>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.</p> - -<p>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 <i>external</i> -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.</p> - -<p><span class="pagenum"><a name="Page_242" id="Page_242">[242]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_243" id="Page_243">[243]</a></span> -days, and had large doses of opium; she improved considerably -under this treatment, and the inflammation was -very moderate.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_244" id="Page_244">[244]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_245" id="Page_245">[245]</a></span> -be obliterated for some distance above and below the parts -injured.</p> - -<p>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.</p> - -<p>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>I am willing, for -the present</i>, 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<span class="pagenum"><a name="Page_246" id="Page_246">[246]</a></span> -the two operations are essentially distinct. The operation -of Anel for <i>aneurism</i> of the popliteal artery would be destructive; -the operation of Hunter for <i>a wound</i> of the -popliteal artery would be equally so.</p> - -<p>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 <i>impracticable</i> to -tie the artery at the wounded part, and the primitive trunk -must therefore be secured.</p> - -<p>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 <i>must</i> 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?</p> - -<p>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; <i>but this is not admissible in the present day</i>.” -Operating for a tumor on the left temple, which he consid<span class="pagenum"><a name="Page_247" id="Page_247">[247]</a></span>ered -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.</p> - -<p>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 sur<span class="pagenum"><a name="Page_248" id="Page_248">[248]</a></span>geon’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.</p> - -<p>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.</p> - -<p>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:—</p> - -<p>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<span class="pagenum"><a name="Page_249" id="Page_249">[249]</a></span> -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.</p> - -<p>217. The nearest successful case to the operation thus -recommended was performed by Dr. Keith, of Aberdeen.</p> - -<p>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<span class="pagenum"><a name="Page_250" id="Page_250">[250]</a></span> -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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XIV">LECTURE XIV.</h2> -</div> - -<p class="h2sub">LIGATURE OF THE COMMON ILIAC ARTERY, ETC.</p> - -<p>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.</p> - -<p>The length of the two common iliac arteries varies according -to the stature of the patient, and the place at which the<span class="pagenum"><a name="Page_251" id="Page_251">[251]</a></span> -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<span class="pagenum"><a name="Page_252" id="Page_252">[252]</a></span> -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.</p> - -<p>The <i>common trunk</i> of the iliac arteries and the <i>aorta -itself</i> 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<span class="pagenum"><a name="Page_253" id="Page_253">[253]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_254" id="Page_254">[254]</a></span> -the body, which would lead to the under edge of the psoas -muscle instead of the upper surface, and thus render the -operation embarrassing.</p> - -<p>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.</p> - -<p>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 ex<span class="pagenum"><a name="Page_255" id="Page_255">[255]</a></span>panded -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.</p> - -<p>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.</p> - -<p>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.<span class="pagenum"><a name="Page_256" id="Page_256">[256]</a></span> -The food should be liquid, and inflammation should be -subdued by leeches, general bleeding, fomentations, and -opium.</p> - -<p>219. The <i>aorta</i> 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.</p> - -<p>220. If the <i>internal iliac</i> 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,<span class="pagenum"><a name="Page_257" id="Page_257">[257]</a></span> -and, if there be sufficient space, they should be kept out of -the way, and guarded by the finger of an assistant.</p> - -<p>221. The <i>external iliac</i> 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.</p> - -<p>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<span class="pagenum"><a name="Page_258" id="Page_258">[258]</a></span> -best mode of proceeding when the aneurismal swelling in the -groin has encroached on Poupart’s ligament.</p> - -<p>Another method has been recommended by Sir Astley -Cooper, which is perhaps more followed where there is little -doubt of the artery being sound.</p> - -<p>“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.”</p> - -<p>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<span class="pagenum"><a name="Page_259" id="Page_259">[259]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_260" id="Page_260">[260]</a></span> -wound being always the best guide; care should be taken -in every instance to include nothing in the ligature but the -artery.</p> - -<p>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.</p> - -<p>According to the principles laid down in this work, two -errors were committed in this case. The first, in tying the -gluteal artery <i>as it emerged from the pelvis</i>. The second, -in tying the internal iliac, which was unnecessary. The -bleeding which caused this operation to be resorted to is -described <i>as a welling up of the vital fluid</i>, as returning -<i>slowly and sluggishly</i>; 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.</p> - -<p>The operations were highly honorable to the gentlemen -concerned, as proving their anatomical knowledge. The -principle on which they acted I presume to condemn.</p> - -<p>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<span class="pagenum"><a name="Page_261" id="Page_261">[261]</a></span> -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 <i>directly</i> 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.<span class="pagenum"><a name="Page_262" id="Page_262">[262]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_263" id="Page_263">[263]</a></span> -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.</p> - -<p>225. The operation for popliteal aneurism lower down in -the thigh is to be done in the following manner:—</p> - -<p>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<span class="pagenum"><a name="Page_264" id="Page_264">[264]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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;<span class="pagenum"><a name="Page_265" id="Page_265">[265]</a></span> -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.</p> - -<p>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.</p> - -<p>“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<span class="pagenum"><a name="Page_266" id="Page_266">[266]</a></span> -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.”</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_267" id="Page_267">[267]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_268" id="Page_268">[268]</a></span> -the bleeding point is perceived, when a ligature above and -another below the wound should be placed upon the artery.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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, can<span class="pagenum"><a name="Page_269" id="Page_269">[269]</a></span>not -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> -<p><span class="pagenum"><a name="Page_270" id="Page_270">[270]</a></span> -</p> -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XV">LECTURE XV.</h2> -</div> - -<p class="h2sub">THE COMMON CAROTID ARTERY, ETC.</p> - -<p>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<span class="pagenum"><a name="Page_271" id="Page_271">[271]</a></span> -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.</p> - -<p>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,<span class="pagenum"><a name="Page_272" id="Page_272">[272]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>uninjured</i> vessel, whichever of the two it<span class="pagenum"><a name="Page_273" id="Page_273">[273]</a></span> -might be, a third ligature should be placed on it above -the bifurcation.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_274" id="Page_274">[274]</a></span> -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.</p> - -<p>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,<span class="pagenum"><a name="Page_275" id="Page_275">[275]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_276" id="Page_276">[276]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>235. The subclavian artery has been frequently tied above -the clavicle, <i>external</i> 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,<span class="pagenum"><a name="Page_277" id="Page_277">[277]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_278" id="Page_278">[278]</a></span> -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.</p> - -<p>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.</p> - -<p>236. When the axillary artery is to be tied for a <i>wound</i> -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.</p> - -<p>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<span class="pagenum"><a name="Page_279" id="Page_279">[279]</a></span> -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.</p> - -<p>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,<span class="pagenum"><a name="Page_280" id="Page_280">[280]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_281" id="Page_281">[281]</a></span> -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. (<i>Aph.</i> 184, page 192.)</p> - -<p>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.</p> - -<p>240. To tie the ulnar artery in the <i>middle third</i> 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.</p> - -<p>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<span class="pagenum"><a name="Page_282" id="Page_282">[282]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The radial artery, on giving off the superficialis volæ to<span class="pagenum"><a name="Page_283" id="Page_283">[283]</a></span> -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 -<i>under</i> 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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XVI">LECTURE XVI.</h2> -</div> - -<p class="h2sub">INJURIES OF THE BRAIN.</p> - -<p>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<span class="pagenum"><a name="Page_284" id="Page_284">[284]</a></span> -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<span class="pagenum"><a name="Page_285" id="Page_285">[285]</a></span> -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.</p> - -<p>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.</p> - -<p>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.<span class="pagenum"><a name="Page_286" id="Page_286">[286]</a></span></p> - -<p>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.</p> - -<p>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. <i>Incident</i> nerves arise from the skin and certain -mucous membranes, and convey impressions from them to -the spinal marrow. <i>Reflex</i> 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<span class="pagenum"><a name="Page_287" id="Page_287">[287]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_288" id="Page_288">[288]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_289" id="Page_289">[289]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_290" id="Page_290">[290]</a></span> -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. Pre<span class="pagenum"><a name="Page_291" id="Page_291">[291]</a></span>viously -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.</p> - -<p>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.</p> - -<p>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 <i>assoupissement</i>,<span class="pagenum"><a name="Page_292" id="Page_292">[292]</a></span> -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<span class="pagenum"><a name="Page_293" id="Page_293">[293]</a></span> -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.</p> - -<p>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.</p> - -<p>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 fol<span class="pagenum"><a name="Page_294" id="Page_294">[294]</a></span>lowed -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>A laboring man, thirty years of age, fell from a height<span class="pagenum"><a name="Page_295" id="Page_295">[295]</a></span> -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 <i>convulsive</i> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_296" id="Page_296">[296]</a></span> -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:—</p> - -<p>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.</p> - -<p>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 ob<span class="pagenum"><a name="Page_297" id="Page_297">[297]</a></span>ject -could have been attained; of this the following case is -a good instance:—</p> - -<p>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.</p> - -<p>250. It sometimes happens that congestion precedes inflammation -to such an extent as to give rise to stupefaction -and symptoms of compression.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_298" id="Page_298">[298]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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:—</p> - -<p>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,<span class="pagenum"><a name="Page_299" id="Page_299">[299]</a></span> -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.</p> - -<p>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.</p> - -<p>251. Mania sometimes supervenes on concussion, as the<span class="pagenum"><a name="Page_300" id="Page_300">[300]</a></span> -inflammatory symptoms subside. It is best treated by the -different preparations of opium.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_301" id="Page_301">[301]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_302" id="Page_302">[302]</a></span> -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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XVII">LECTURE XVII.</h2> -</div> - -<p class="h2sub">WOUNDS OF THE HEAD.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_303" id="Page_303">[303]</a></span> -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.</p> - -<p>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 -<span class="allsmcap">LEVEL</span>; 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<span class="pagenum"><a name="Page_304" id="Page_304">[304]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_305" id="Page_305">[305]</a></span> -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<span class="pagenum"><a name="Page_306" id="Page_306">[306]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Burdach found, in 268 cases of lesion of one side of the -brain, that 10 presented paralysis on both sides of the body,<span class="pagenum"><a name="Page_307" id="Page_307">[307]</a></span> -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.</p> - -<p>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.</p> - -<p>256. Convulsive actions of the muscles, or positive con<span class="pagenum"><a name="Page_308" id="Page_308">[308]</a></span>vulsive -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<span class="pagenum"><a name="Page_309" id="Page_309">[309]</a></span> -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.</p> - -<p>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:—</p> - -<p>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 <i>left</i> 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 <i>right</i> arm -and <i>right</i> 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 any<span class="pagenum"><a name="Page_310" id="Page_310">[310]</a></span>thing -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.</p> - -<p>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 <i>both</i> -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.</p> - -<p>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<span class="pagenum"><a name="Page_311" id="Page_311">[311]</a></span> -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.</p> - -<p>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.</p> - -<p>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:—</p> - -<p>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,<span class="pagenum"><a name="Page_312" id="Page_312">[312]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_313" id="Page_313">[313]</a></span> -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 <i>usually</i> 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.</p> - -<p>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<span class="pagenum"><a name="Page_314" id="Page_314">[314]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_315" id="Page_315">[315]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_316" id="Page_316">[316]</a></span> -no blood beneath the dura mater. The convolutions of the -brain were depressed and flattened by the pressure.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The rule in surgery, to remove the bone in such cases, is -absolute.</p> - -<p>261. Fractures of the skull are stated, from almost the -earliest records of surgery, to occur on one <i>side</i> of the head -in consequence of blows received on the <i>other</i>. 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.</p> - -<p><span class="pagenum"><a name="Page_317" id="Page_317">[317]</a></span> -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.</p> - -<p>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.</p> - -<p>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 six<span class="pagenum"><a name="Page_318" id="Page_318">[318]</a></span>teen -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><i>Sectio cadaveris.</i>—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 -<span class="pagenum"><a name="Page_319" id="Page_319">[319]</a></span> -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.</p> - -<p>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 <span class="allsmcap">RIGHT</span> 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 <span class="allsmcap">RIGHT</span> 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<span class="pagenum"><a name="Page_320" id="Page_320">[320]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_321" id="Page_321">[321]</a></span> -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.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XVIII">LECTURE XVIII.</h2> -</div> - -<p class="h2sub">INJURIES OF THE HEAD.</p> - -<p>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.</p> - -<p>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.”</p> - -<p>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<span class="pagenum"><a name="Page_322" id="Page_322">[322]</a></span> -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.</p> - -<p>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.</p> - -<p>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 <i>slight detachment</i> 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.</p> - -<p>263. Severe effects do not always take place in such cases<span class="pagenum"><a name="Page_323" id="Page_323">[323]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>On visiting her <i>an hour</i> 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<span class="pagenum"><a name="Page_324" id="Page_324">[324]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_325" id="Page_325">[325]</a></span> -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.</p> - -<p>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.</p> - -<p>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,<span class="pagenum"><a name="Page_326" id="Page_326">[326]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_327" id="Page_327">[327]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_328" id="Page_328">[328]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_329" id="Page_329">[329]</a></span> -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.</p> - -<p>269. There is an essential difference between a depression -of the skull in a <span class="allsmcap">CHILD</span> and in an <span class="allsmcap">ADULT</span>. 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<span class="pagenum"><a name="Page_330" id="Page_330">[330]</a></span> -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.</p> - -<p>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.</p> - -<p>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 <i>marked</i> -depression is known to have occurred in an <span class="allsmcap">ADULT</span>, it is good -practice to ascertain the nature and extent of the depression. -It is imperatively necessary if accompanied by symptoms of -compression.</p> - -<p>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<span class="pagenum"><a name="Page_331" id="Page_331">[331]</a></span> -a result is not likely to be obtained, the practice recommended -appears to be the best.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The following cases are illustrative of many important -points:—</p> - -<p>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.</p> - -<p>June 19th. The ball was found to have passed obliquely<span class="pagenum"><a name="Page_332" id="Page_332">[332]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>In the following case the ball could not perhaps have -been removed in the first instance with propriety; it might,<span class="pagenum"><a name="Page_333" id="Page_333">[333]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_334" id="Page_334">[334]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>George Mills, an artillery driver, aged twenty-eight, was<span class="pagenum"><a name="Page_335" id="Page_335">[335]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_336" id="Page_336">[336]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_337" id="Page_337">[337]</a></span> -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.</p> - -<p>These different cases stand out in bold relief as eminently -successful and opposed to those said to have been equally so -under <i>la chirurgie expectante</i>. 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.</p> - -<p>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 <i>under the -adult age</i>; 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.</p> - -<p>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,<span class="pagenum"><a name="Page_338" id="Page_338">[338]</a></span> -the opening must be enlarged to enable it to be withdrawn -without further laceration.</p> - -<p>274. Depressed portions of bone, accompanied by fracture -at the <i>back</i> 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.</p> - -<p>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.</p> - -<p>A gentleman received a blow on the side of the head, -which knocked him down and deprived him of his senses,<span class="pagenum"><a name="Page_339" id="Page_339">[339]</a></span> -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.</p> - -<p>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.</p> - -<p>275. When a severe blow, accompanied by a shock, as -from a fall, has been received on the head, and the skull is<span class="pagenum"><a name="Page_340" id="Page_340">[340]</a></span> -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 <i>trémoussement</i> 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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XIX">LECTURE XIX.</h2> -</div> - -<p class="h2sub">TUMORS OF THE SCALP, ETC.</p> - -<p>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<span class="pagenum"><a name="Page_341" id="Page_341">[341]</a></span> -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 -<i>immediately</i> 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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_342" id="Page_342">[342]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_343" id="Page_343">[343]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>A. Monro, of the 42d Regiment, was wounded on the 10th -of April, at Toulouse, by a musket-ball, which fractured the<span class="pagenum"><a name="Page_344" id="Page_344">[344]</a></span> -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 cov<span class="pagenum"><a name="Page_345" id="Page_345">[345]</a></span>ered -with matter, to their great surprise and satisfaction at -the accuracy of the diagnosis.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 en<span class="pagenum"><a name="Page_346" id="Page_346">[346]</a></span>sued -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_347" id="Page_347">[347]</a></span> -bone from its outer surface, unless the mischief should have -implicated the parts beneath.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_348" id="Page_348">[348]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_349" id="Page_349">[349]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_350" id="Page_350">[350]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_351" id="Page_351">[351]</a></span> -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.</p> - -<p>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.</p> - -<p>A wound of the longitudinal or lateral sinuses, allowing a<span class="pagenum"><a name="Page_352" id="Page_352">[352]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>In the second kind of protrusion, or that which usually -although not necessarily takes place when the first or active<span class="pagenum"><a name="Page_353" id="Page_353">[353]</a></span> -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.</p> - -<p>There were three cases of recovery from a protrusion of -the brain after the battle of Toulouse.</p> - -<p>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.</p> - -<p>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.<span class="pagenum"><a name="Page_354" id="Page_354">[354]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_355" id="Page_355">[355]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>In the fatal cases, paralysis, accompanied by stupor and -other symptoms of compression of the brain, invariably -supervened before death.</p> - -<p>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 de<span class="pagenum"><a name="Page_356" id="Page_356">[356]</a></span>gree -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.</p> - -<p>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.</p> - -<p>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.)</p> - -<p>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<span class="pagenum"><a name="Page_357" id="Page_357">[357]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_358" id="Page_358">[358]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_359" id="Page_359">[359]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_360" id="Page_360">[360]</a></span> -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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_361" id="Page_361">[361]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>A German dragoon was brought to me in front of Ma<span class="pagenum"><a name="Page_362" id="Page_362">[362]</a></span>drid, -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_363" id="Page_363">[363]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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, sup<span class="pagenum"><a name="Page_364" id="Page_364">[364]</a></span>puration -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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XX">LECTURE XX.</h2> -</div> - -<p class="h2sub">WOUNDS OF THE CHEST.</p> - -<p>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.</p> - -<p>296. <i>Incised</i> or <i>punctured wounds</i>, from swords, lances, -bayonets, or knives, require a treatment <i>essentially distinct</i> -on many points from that of <i>gunshot</i> 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.</p> - -<p>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 -<i>pleuritis</i>, or of the substance of the lung, termed <i>pneumonia</i>, -or of both, constituting what has been named <i>pleuro-pneumonia</i>; -but many severe blows on the chest are not -followed by such serious consequences.</p> - -<p>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<span class="pagenum"><a name="Page_365" id="Page_365">[365]</a></span> -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.</p> - -<p>A soldier was struck on the hill of Talavera,<a id="FNanchor_4" href="#Footnote_4" class="fnanchor">[4]</a> 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.</p> - -<div class="footnote"> - -<p><a id="Footnote_4" href="#FNanchor_4" class="label">[4]</a> The Duke of Wellington received a blow from a spent ball at the -same time, near the left clavicle.</p> - -</div> - -<p>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.<span class="pagenum"><a name="Page_366" id="Page_366">[366]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_367" id="Page_367">[367]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>vesicular</i> or <i>respiratory -murmur</i>, 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<span class="pagenum"><a name="Page_368" id="Page_368">[368]</a></span> -adults, <i>puerile respiration</i>, as opposed to their ordinary, or -what in old persons may be called <i>senile</i>. It is more marked -during inspiration.</p> - -<p>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 <i>bronchial or tubular respiration</i>. 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 <i>tracheal</i> -respiration. On listening over the trachea during speaking, -the voice sounds as if it were passing into the ear, and the -words are distinct—<i>tracheophony</i>. 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 <i>pectoriloquy</i>, 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 <i>natural</i> sound -in an <i>unnatural</i> position. The essential difference between -<i>bronchophony</i> and <i>tracheophony</i> 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.</p> - -<p>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<span class="pagenum"><a name="Page_369" id="Page_369">[369]</a></span> -effusion into the cavity, or condensation of the lung, has -taken place to a considerable extent.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 elas<span class="pagenum"><a name="Page_370" id="Page_370">[370]</a></span>ticity -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 <i>ascending</i> and <i>descending</i> -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.</p> - -<p>300. When inflammation of the pleura takes place, the -gliding motion is not effected silently, but with a peculiar -noise, called by the French <i>frottement</i>. 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—<i>rhonchus crepitans</i>. Hence the great -value of auscultation.</p> - -<p>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.</p> - -<p>Acute idiopathic inflammation of the pleura usually com<span class="pagenum"><a name="Page_371" id="Page_371">[371]</a></span>mences -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 <i>point de côté</i> 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.</p> - -<p>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.</p> - -<p>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 <i>decubitus</i>, 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.</p> - -<p>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<span class="pagenum"><a name="Page_372" id="Page_372">[372]</a></span> -symptoms dependent on the degree to which the effusion has -taken place; <i>this</i> 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.</p> - -<p>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 <i>puerile</i>.</p> - -<p>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 <i>bronchial</i> 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 <i>bronchophony</i>.</p> - -<p><span class="pagenum"><a name="Page_373" id="Page_373">[373]</a></span> -In pleuritic effusion, the voice, when carefully examined, -sometimes obtains a character not previously noticed, but of -comparatively little importance, called <i>œgophony</i>, 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.</p> - -<p>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,<span class="pagenum"><a name="Page_374" id="Page_374">[374]</a></span> -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.</p> - -<p>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.</p> - -<p>The <i>cough</i> 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 <i>crachat</i> 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 hepatiza<span class="pagenum"><a name="Page_375" id="Page_375">[375]</a></span>tion, -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.</p> - -<p>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.</p> - -<p>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 parch<span class="pagenum"><a name="Page_376" id="Page_376">[376]</a></span>ment; -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 <i>bronchial respiration</i>, 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 -<i>bronchophony</i>, a correct knowledge of which can only be -acquired by repeated observation.</p> - -<p>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.</p> - -<p>When the vesicular murmur cannot be heard, when the -<i>rhonchus</i> or <i>crepitating râle</i> 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.</p> - -<p>302. The effects of inflammation of the pleura are well<span class="pagenum"><a name="Page_377" id="Page_377">[377]</a></span> -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,<span class="pagenum"><a name="Page_378" id="Page_378">[378]</a></span> -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.</p> - -<p>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.</p> - -<p>303. After a time, and particularly in wounds of the<span class="pagenum"><a name="Page_379" id="Page_379">[379]</a></span> -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.</p> - -<p>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.</p> - -<p>304. The changes which take place in the structure of -the lung in pneumonia are three in number: 1. Engorge<span class="pagenum"><a name="Page_380" id="Page_380">[380]</a></span>ment. -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_381" id="Page_381">[381]</a></span> -shows merely that a thoroughly well-loaded lung ceases to -be permeable to air until a part of the load shall have been -displaced.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.<span class="pagenum"><a name="Page_382" id="Page_382">[382]</a></span></p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XXI">LECTURE XXI.</h2> -</div> - -<p class="h2sub">GENERAL BLOOD-LETTING, ETC.</p> - -<p>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 <i>injuries</i>, 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 <i>young</i> and <i>healthy</i> 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<span class="pagenum"><a name="Page_383" id="Page_383">[383]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_384" id="Page_384">[384]</a></span> -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 <i>healthy</i> 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 <span class="allsmcap">THE FORCE OF THE HEART</span> 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,<span class="pagenum"><a name="Page_385" id="Page_385">[385]</a></span> -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.</p> - -<p>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.</p> - -<p>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.”</p> - -<p>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.</p> - -<p>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,<span class="pagenum"><a name="Page_386" id="Page_386">[386]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_387" id="Page_387">[387]</a></span> -or three times a day, with better effect than smaller ones -more frequently repeated; but this has not been made -manifest.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_388" id="Page_388">[388]</a></span> -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 <i>gastro-enterite</i> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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,<span class="pagenum"><a name="Page_389" id="Page_389">[389]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_390" id="Page_390">[390]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>313. Empyema, <i>from</i> εν, <i>in</i>, <i>and</i> πυον, <i>pus</i>,—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 inter<span class="pagenum"><a name="Page_391" id="Page_391">[391]</a></span>nally, -or some communication with the atmosphere has taken -place by an external opening.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_392" id="Page_392">[392]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_393" id="Page_393">[393]</a></span> -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.</p> - -<p>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.</p> - -<p><i>Treatment.</i>—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<span class="pagenum"><a name="Page_394" id="Page_394">[394]</a></span> -surface often do good. When these means fail, the operation -must be resorted to.</p> - -<p>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.</p> - -<p>317. The place of election, in England, for a <i>puncture</i>, -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 inter<span class="pagenum"><a name="Page_395" id="Page_395">[395]</a></span>costal -muscles, by which the operator might be inconvenienced.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_396" id="Page_396">[396]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_397" id="Page_397">[397]</a></span> -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.</p> - -<p>319. In all cases of <i>serous</i> effusion, there can be little -doubt that the fluid should be wholly evacuated and the -wound closed. When the fluid is <i>purulent</i>, 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.</p> - -<p>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.</p> - -<p>The propriety of injecting stimulating or even simple fluids<span class="pagenum"><a name="Page_398" id="Page_398">[398]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_399" id="Page_399">[399]</a></span> -effected even then, if the piece of carious rib had not been -discovered and removed.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_400" id="Page_400">[400]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_401" id="Page_401">[401]</a></span>-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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_402" id="Page_402">[402]</a></span> -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.</p> - -<p>320. <i>Pneumothorax</i> 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.</p> - -<p><i>Percussion</i>, 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. <i>Auscultation</i>, in addition to<span class="pagenum"><a name="Page_403" id="Page_403">[403]</a></span> -the absence of respiration, when the chest is fully expanded, -discovers no respiratory murmur; but a peculiar sound called -<i>tintement métallique</i>, 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.</p> - -<p>“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 <i>right</i> emitted an extremely dull sound; the -<i>left</i> 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 <i>right</i> side; metallic -tinkling distinct in the <i>left</i>; 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.</p> - -<p>“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<span class="pagenum"><a name="Page_404" id="Page_404">[404]</a></span> -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.”</p> - -<p>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 <i>passed a probe to the extent of -four inches</i> 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.</p> - -<p>October 15th.—He suffered from a violent paroxysm of<span class="pagenum"><a name="Page_405" id="Page_405">[405]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>16th.—Since the last report he has been slowly sinking— -<span class="pagenum"><a name="Page_406" id="Page_406">[406]</a></span> -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.</p> - -<div class="figleft illowp55" id="i-406" style="max-width: 20em;"> - <img class="w100" src="images/i-406.jpg" alt="Section of lung with spine and ribs shown." /> - <div class="caption"> -<p> -<i>A.</i> Section of the lung, made vertically.<br /> -<i>B.</i> Section of the abscess communicating by the sinus, -<i>C</i>, with the circumscribed cavity, -<i>D</i>, in which the bullet had been -lodged after its entrance by the sinus, <i>E</i>.<br /> -<i>F.</i> The sinus by which the ball had -passed into the pleural cavity, <i>G</i>.<br /> -Opposite the 7th and 8th ribs the lung is -quite adherent.<br /> -<i>H.</i> The ball. -</p> -</div> -</div> - -<p><i>Sectio cadaveris.</i>—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<span class="pagenum"><a name="Page_407" id="Page_407">[407]</a></span> -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.</p> - -<p>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.</p> - -<p>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 <span class="allsmcap">P.M.</span>: On the dyspnœa return<span class="pagenum"><a name="Page_408" id="Page_408">[408]</a></span>ing -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.</p> - -<p>15th.—Eight <span class="allsmcap">A.M.</span>: 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 -<span class="allsmcap">P.M.</span>: 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.</p> - -<p>16th.—Eight <span class="allsmcap">A.M.</span>: 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.</p> - -<p>17th.—Eight <span class="allsmcap">A.M.</span>: 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.</p> - -<p>18th.—Eight <span class="allsmcap">A.M.</span>: 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.</p> - -<p>19th.—Eight <span class="allsmcap">A.M.</span>: 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.</p> - -<p>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<span class="pagenum"><a name="Page_409" id="Page_409">[409]</a></span> -by <i>air</i>; bowels open.—Ten at night: Calomel, and forty -minims of the solution of opium.</p> - -<p>21st.—Eight <span class="allsmcap">A.M.</span>: 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 <span class="allsmcap">P.M.</span>: Restless, -but better; senna and sulphate of magnesia mixture.—Eight -<span class="allsmcap">P.M.</span>: Oppressed; pulse 120; twelve leeches; calomel, -and thirty minims of the solution of opium, at night.</p> - -<p>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.</p> - -<p>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, -<span class="allsmcap">A.M.</span>, 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 <i>tintement métallique</i> -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 <span class="allsmcap">P.M.</span>, 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.</p> - -<p>March 17th.—Better; pulse 100; bowels open; cough<span class="pagenum"><a name="Page_410" id="Page_410">[410]</a></span> -easier; expectorates freely a <i>rouillée</i>, or reddish muco-purulent -matter.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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, <i>Vesicular</i> and <i>Interlobular</i>—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.</p> - -<p>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<span class="pagenum"><a name="Page_411" id="Page_411">[411]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 ex<span class="pagenum"><a name="Page_412" id="Page_412">[412]</a></span>treme -cases even by incisions; but these are things more -often spoken of and written about than practiced, or than -are even necessary.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_413" id="Page_413">[413]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The incisions (the “<i>taillades</i>” 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.</p> - -<p>The advantages to be derived from auscultation in these -cases are evident. Its value has been sufficiently shown, and<span class="pagenum"><a name="Page_414" id="Page_414">[414]</a></span> -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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XXII">LECTURE XXII.</h2> -</div> - -<p class="h2sub">SIMPLE INJURIES OF THE CHEST, ETC.</p> - -<p>325. The most <i>simple injury</i>, 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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_415" id="Page_415">[415]</a></span> -instances apparently miraculous, were in others quite as -unfortunate.</p> - -<p>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.</p> - -<p>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.</p> - -<p>327. <i>Incised</i> 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<span class="pagenum"><a name="Page_416" id="Page_416">[416]</a></span> -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.</p> - -<p>In a <i>simple</i> 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.</p> - -<p>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<span class="pagenum"><a name="Page_417" id="Page_417">[417]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_418" id="Page_418">[418]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_419" id="Page_419">[419]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_420" id="Page_420">[420]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_421" id="Page_421">[421]</a></span> -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.</p> - -<p>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.</p> - -<p>332. <i>The important question of hemorrhage</i>, 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 com<span class="pagenum"><a name="Page_422" id="Page_422">[422]</a></span>pressed -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_423" id="Page_423">[423]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_424" id="Page_424">[424]</a></span> -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.</p> - -<p>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, (<i>violet très éclairci</i>.) -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.</p> - -<p>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:—</p> - -<p><i>a.</i> All <i>incised</i> or <i>punctured wounds</i> 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 <i>incised</i> -wounds capable of being united by suture in the manner -directed.</p> - -<p><i>b.</i> 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<span class="pagenum"><a name="Page_425" id="Page_425">[425]</a></span> -wound should be thought preferable, which will not be the -case unless it should be low in the chest.</p> - -<p><i>c.</i> 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.</p> - -<p><i>d.</i> 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.</p> - -<p><i>e.</i> 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.</p> - -<p><i>f.</i> 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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<p><span class="pagenum"><a name="Page_426" id="Page_426">[426]</a></span></p> -<h2 class="nobreak" id="LECTURE_XXIII"> -LECTURE XXIII.</h2> -</div> - -<p class="h2sub">WOUNDS OF THE CHEST, ETC.</p> - -<p>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.</p> - -<p>336. When a musket-ball fairly passes through the cavity<span class="pagenum"><a name="Page_427" id="Page_427">[427]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>337. An enlargement of the wound, the “<i>debridement</i>” -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<span class="pagenum"><a name="Page_428" id="Page_428">[428]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_429" id="Page_429">[429]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_430" id="Page_430">[430]</a></span> -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.</p> - -<p>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.<span class="pagenum"><a name="Page_431" id="Page_431">[431]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_432" id="Page_432">[432]</a></span> -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.</p> - -<p><i>Case of Major-General Broke, by himself.</i>—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 <span class="allsmcap">P.M.</span> 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.</p> - -<p class="right"><span class="smcap">H. G. Broke</span>, - <i>Major-General</i>. -<span class="pagenum"><a name="Page_433" id="Page_433">[433]</a></span></p> - -<p>He is now, in 1855, in perfect health, the respiratory murmur -being free all over the chest.</p> - -<p>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 “<i>cut in two</i>.”</p> - -<p>On immediate examination there was no other opening to -be found but the <i>one</i> where the ball had entered; nor were -the medical officers able to feel the ball anywhere under the -skin or under the muscles.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.)</p> - -<p>15th inst., nine <span class="allsmcap">A.M.</span>: 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.</p> - -<p>Nine <span class="allsmcap">P.M.</span>: Deputy-Inspector Thomson and Staff-Surgeon -Maling examined the wound. Mr. Maling introduced his<span class="pagenum"><a name="Page_434" id="Page_434">[434]</a></span> -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.</p> - -<p>Midnight: The blood last taken is very buffy; and there -has again been an <i>immense discharge</i> 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.</p> - -<p><i>Mem.</i>—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 <i>general treatment</i>, he was -bled <i>seven times</i> between the evening of the 27th of February -and the morning of the 2d of March, the <i>cough</i>, <i>expectoration</i>, -<i>breathing</i>, <i>pain</i>, <i>etc.</i> being much relieved by -each bleeding.</p> - -<p class="right"> -<span class="smcap">A. Hair</span>, M.D. -</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_435" id="Page_435">[435]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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. <i>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.</i> 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 -<span class="pagenum"><a name="Page_436" id="Page_436">[436]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_437" id="Page_437">[437]</a></span> -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.</p> - -<p>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.</p> - -<p>Corporal Dunleary, of the 69th Regiment, was wounded -on the 16th of June, 1815, at Quatre Bras, by a musket-ball, -<span class="pagenum"><a name="Page_438" id="Page_438">[438]</a></span> -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.</p> - -<p>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.</p> - -<p>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 after<span class="pagenum"><a name="Page_439" id="Page_439">[439]</a></span>ward, -suffering little or no inconvenience from his chest, -when I last saw him.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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, -<span class="pagenum"><a name="Page_440" id="Page_440">[440]</a></span> -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.</p> - -<p><i>Case of Lieutenant-Colonel Dumaresq, aid-de-camp to -Lord Strafford, by himself.</i>—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, -<span class="pagenum"><a name="Page_441" id="Page_441">[441]</a></span> -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.</p> - -<p>N.B.—Up to this period, the 2d of July, the devil a bit -have I eaten.</p> - -<div class="poetry-container"> -<div class="poetry"> - <div class="stanza"> - <div class="verse indent0">While with fat mutton-chops, and nice loins of veal,</div> - <div class="verse indent0">You stuff your d—d guts, your hearts are all steel.</div> - <div class="verse indent0">Oh! ye doctors and potecaries, you’ll all go to hell,</div> - <div class="verse indent0">For cheating our poor tripes of their daily meal.</div> - <div class="verse right"><span class="smcap">H. Dumaresq.</span></div> - </div> -</div> -</div> - -<p>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.</p> - -<p>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.</p> - -<p>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 re<span class="pagenum"><a name="Page_442" id="Page_442">[442]</a></span>covered -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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XXIV">LECTURE XXIV.</h2> -</div> - -<p class="h2sub">Appearances After Death, Etc.</p> - -<p>343. The appearances after death differ materially even -in apparently similar wounds.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_443" id="Page_443">[443]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>passed between the base of the lung and the -diaphragm</i>, 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<span class="pagenum"><a name="Page_444" id="Page_444">[444]</a></span> -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<span class="pagenum"><a name="Page_445" id="Page_445">[445]</a></span> -amount of many ounces; its loss appeared to have been the -immediate cause of death.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_446" id="Page_446">[446]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_447" id="Page_447">[447]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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,<span class="pagenum"><a name="Page_448" id="Page_448">[448]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_449" id="Page_449">[449]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 in<span class="pagenum"><a name="Page_450" id="Page_450">[450]</a></span>flicted, -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.</p> - -<p>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,<span class="pagenum"><a name="Page_451" id="Page_451">[451]</a></span> -was secreted. From this time he gradually recovered, and -was sent to England, cured, in November.</p> - -<p>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.</p> - -<p>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 <i>sonde à dard</i>, 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.</p> - -<p>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<span class="pagenum"><a name="Page_452" id="Page_452">[452]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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:—</p> - -<p>348.—1. That a trocar and canula pushed in between the<span class="pagenum"><a name="Page_453" id="Page_453">[453]</a></span> -eleventh and twelfth ribs, in a diagonal direction upward, on -a line with the angle of the ribs generally, will in the <i>dead -body</i> invariably enter the cavity of the chest without injuring -the diaphragm.</p> - -<p>2. That the same operation performed on the <i>living body</i> -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.</p> - -<p>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 -<i>false ligamentum arcuatum</i>, (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.</p> - -<p>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<span class="pagenum"><a name="Page_454" id="Page_454">[454]</a></span>-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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>On removing the integuments of the back, covering the -muscles and the lower ribs, the broad expanse of the <i>latissimus -dorsi</i> 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 <i>serratus -posticus inferior</i> 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.</p> - -<p>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<span class="pagenum"><a name="Page_455" id="Page_455">[455]</a></span> -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 <i>erector spinæ</i> or the <i>sacro-spinal</i> 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.</p> - -<p>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.</p> - -<p>349. <i>Operation.</i>—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<span class="pagenum"><a name="Page_456" id="Page_456">[456]</a></span> -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, <i>at the moment of inspiration</i>, 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.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XXV">LECTURE XXV.</h2> -</div> - -<p class="h2sub">HERNIA OF THE LUNG, ETC.</p> - -<p>350. <i>Hernia of the lung</i>, 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 mus<span class="pagenum"><a name="Page_457" id="Page_457">[457]</a></span>cles -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 <span class="allsmcap">EXPIRATION</span> 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.</p> - -<p>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<span class="pagenum"><a name="Page_458" id="Page_458">[458]</a></span> -the patients. It is rare, however, to see a protrusion of the -lung after a gunshot wound.</p> - -<p>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.</p> - -<p>351. <i>Wounds of the diaphragm</i> 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_459" id="Page_459">[459]</a></span> -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.</p> - -<p>Oct. 1st.—Accession of symptoms as yesterday, relieved -by bleeding in a similar manner; bowels open.</p> - -<p>3d.—The inflammatory symptoms recurred this morning, -and were again removed by the abstraction of sixteen ounces -of blood. Beef-tea.</p> - -<p>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.</p> - -<p>6th and 7th.—Much the same; pulse always quick, with -much general irritability.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 re<span class="pagenum"><a name="Page_460" id="Page_460">[460]</a></span>moved -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The wound in this instance was through <i>muscular</i>, not -tendinous parts. The preparation is in the museum at Chatham, -No. 63, Class 6.</p> - -<p>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<span class="pagenum"><a name="Page_461" id="Page_461">[461]</a></span> -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.</p> - -<p>James Wilkie, 12th Light Dragoons, aged thirty-four, was -suddenly attacked, at four <span class="allsmcap">P.M.</span> 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 <span class="allsmcap">P.M.</span> 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.</p> - -<p>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.</p> - -<p><i>Appearances on dissection.</i>—On opening the abdomen,<span class="pagenum"><a name="Page_462" id="Page_462">[462]</a></span> -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.</p> - -<p>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.</p> - -<p>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 in<span class="pagenum"><a name="Page_463" id="Page_463">[463]</a></span>carceration -may take place for a length of time before strangulation -occurs from some sudden and distending impulse -giving rise to it.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_464" id="Page_464">[464]</a></span> -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.</p> - -<p>354. <i>Wounds of the heart</i> 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.</p> - -<p>355. <i>Auscultation</i> and <i>percussion</i>, 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.</p> - -<p>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<span class="pagenum"><a name="Page_465" id="Page_465">[465]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.”</p> - -<p>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<span class="pagenum"><a name="Page_466" id="Page_466">[466]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 “<i>frottement</i>” of the French) in -particular stages of disease.</p> - -<p>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<span class="pagenum"><a name="Page_467" id="Page_467">[467]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_468" id="Page_468">[468]</a></span> -effused and attached portions of lymph from rolling against -each other.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_469" id="Page_469">[469]</a></span> -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.</p> - -<p>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.</p> - -<p>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:—</p> - -<p>“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.”</p> - -<p>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<span class="pagenum"><a name="Page_470" id="Page_470">[470]</a></span> -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.</p> - -<p>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.</p> - -<p>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.<span class="pagenum"><a name="Page_471" id="Page_471">[471]</a></span></p> - -<p>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.</p> - -<div class="figcenter illowp75" id="i-471" style="max-width: 35em;"> - <img class="w100" src="images/i-471.jpg" alt="Heart." /> - <div class="caption"> - -<p> -<i>a</i>, right ventricle; -<br /><i>b</i>, left ditto; -<br /><i>c</i>, right auricle; -<br /><i>d</i>, left ditto; -<br /><i>e</i>, aorta; -<br /><i>f</i>, pulmonary artery; -<br /><i>g</i>, coronary ditto; -<br /><i>h</i>, a portion of the cartilages of the ribs seen on the inside; -<br /><i>i</i>, a portion of the diaphragm; -<br /><i>k</i>, the pericardium. -</p> - -<p>1, a portion of the pericardium reflected to show abnormal adhesions to the surface of the heart; -<br />2, aperture of wound through the diaphragm and the pericardium; -<br />3, pendulous slice off the substance of the right ventricle; -<br />4, puckered cicatrix of the wound of the ventricle. -</p> -</div> -</div> - -<p>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.</p> - -<p>That persons may die from the shock of a blow on the<span class="pagenum"><a name="Page_472" id="Page_472">[472]</a></span> -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.</p> - -<p>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.</p> - -<p><i>Lacerations and ruptures of the heart</i> have frequently -taken place from blows or other serious contusions.</p> - -<p>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.<span class="pagenum"><a name="Page_473" id="Page_473">[473]</a></span></p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XXVI">LECTURE XXVI.</h2> -</div> - -<p class="h2sub">WOUNDS OF THE INTERNAL MAMMARY ARTERY, ETC.</p> - -<p>362. <i>Wounds of the internal mammary and intercostal -arteries</i> 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.</p> - -<p>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,<span class="pagenum"><a name="Page_474" id="Page_474">[474]</a></span> -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.</p> - -<p>363. The <i>intercostal artery</i>, 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_475" id="Page_475">[475]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>364. <i>Wounds of the neck</i> 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 -<i>first</i> 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<span class="pagenum"><a name="Page_476" id="Page_476">[476]</a></span> -trachea be cut across, a stitch will be necessary to keep the -ends in contact. The <i>second</i> is, to keep the divided parts -in contact afterward, by position and bandage, but not <i>by -suture</i>. 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.</p> - -<p>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.</p> - -<p>365. <i>Wounds of the face</i> 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<span class="pagenum"><a name="Page_477" id="Page_477">[477]</a></span> -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.</p> - -<p>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.</p> - -<p>366. <i>Wounds of the eye</i> from small shot are remediable -when these small bodies lodge in the cornea or sclerotica, -whence they may be removed by any sharp-pointed instru<span class="pagenum"><a name="Page_478" id="Page_478">[478]</a></span>ment. -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.</p> - -<p>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.</p> - -<p>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.<span class="pagenum"><a name="Page_479" id="Page_479">[479]</a></span> -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.</p> - -<p>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.</p> - -<p>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, for<span class="pagenum"><a name="Page_480" id="Page_480">[480]</a></span>ward -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_481" id="Page_481">[481]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_482" id="Page_482">[482]</a></span> -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.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XXVII">LECTURE XXVII.</h2> -</div> - -<p class="h2sub">STRUCTURE OF AN INTESTINE, ETC.</p> - -<p>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<span class="pagenum"><a name="Page_483" id="Page_483">[483]</a></span> -coat in man has a peculiarity not observable in animals, of -ledges or shelves projecting into its cavity.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 <i>basement</i> or <i>germinal membrane</i>, -forming a sheath or case, inclosing within it an artery, a -vein, a capillary plexus, and an absorbent vessel termed <i>lacteal</i>. -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<span class="pagenum"><a name="Page_484" id="Page_484">[484]</a></span> -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.</p> - -<p>The office of the epithelium of the villi has been stated to -be <i>protective</i>, that of the follicles to be <i>secretive</i>. 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 -<i>protective</i>, and that which lines the follicles and may be -termed <i>secretive</i>, each column having a nucleus situated at -some part of it, and bulging out that part.</p> - -<p>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<span class="pagenum"><a name="Page_485" id="Page_485">[485]</a></span> -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.</p> - -<p>The minute vesicles above noticed fulfill the important office -of absorption, by drawing into their cavities through their -walls, by a process called <i>endosmosis</i>, 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.</p> - -<p>The <i>débris</i> 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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_486" id="Page_486">[486]</a></span> -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.</p> - -<p>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.</p> - -<p>The <i>glands of Brunner</i> 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.</p> - -<p>The <i>agminated</i> glands of <i>Grew</i> and <i>Peyer</i>, 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, <i>naked</i>. -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,<span class="pagenum"><a name="Page_487" id="Page_487">[487]</a></span> -and when injected the parts around are more vascular, the -ulcerated portion being less so than usual.</p> - -<p>The <i>solitary</i> 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.</p> - -<p>The sub-mucous areolar tissue—the tunica nervosa of -Haller, the <i>fibrous lamella</i> 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.</p> - -<p>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 <i>involuntary</i> -or unstriped kind, as opposed to the <i>voluntary</i> or striped, -which are of large size, and characterized by striæ running -transversely and longitudinally.</p> - -<p>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.</p> - -<p>The peritoneal coat is formed of the white fibers, under a<span class="pagenum"><a name="Page_488" id="Page_488">[488]</a></span> -structureless or basement membrane, covered by tesselated -epithelium, constituting a serous and secreting membrane.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_489" id="Page_489">[489]</a></span> -was greater than the apparent injury would seem to have -warranted.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_490" id="Page_490">[490]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_491" id="Page_491">[491]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_492" id="Page_492">[492]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>If the injury should not destroy the patient, but prove<span class="pagenum"><a name="Page_493" id="Page_493">[493]</a></span> -sufficient to give rise, after several weeks, to effusion into -the cavity, the fluid should be evacuated by the trocar.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_494" id="Page_494">[494]</a></span> -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.</p> - -<p><span class="pagenum"><a name="Page_495" id="Page_495">[495]</a></span> -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<span class="pagenum"><a name="Page_496" id="Page_496">[496]</a></span> -arrangements being made by bedsteads of a proper construction, -or by other simple means which are sufficiently -well known.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_497" id="Page_497">[497]</a></span> -advantage, calomel, antimony, and opium will render essential, -nay, most important, service.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>22d.—No evacuation since the 20th; pulse rather full; -bleeding to twenty-two ounces; sulphate of magnesia, one -ounce. Seven o’clock <span class="allsmcap">A.M.</span>: Medicine operated three or -four times; feels no pain in passing water.</p> - -<p>23d.—Has passed a good night; wounds dressed; is allowed -a small proportion of bread with his tea.</p> - -<p><span class="pagenum"><a name="Page_498" id="Page_498">[498]</a></span> -28th.—So far recovered as to be able to be removed to -Elvas.<a id="FNanchor_5" href="#Footnote_5" class="fnanchor">[5]</a></p> - -<p>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.</p> - -<div class="footnote"> - -<p><a id="Footnote_5" href="#FNanchor_5" class="label">[5]</a> He marched with his regiment, in the summer, to Valladolid, and -was drowned in the Douro.—G. J. G.</p> - -</div> - -<p>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.</p> - -<p>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 ex<span class="pagenum"><a name="Page_499" id="Page_499">[499]</a></span>tension -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.</p> - -<p>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<span class="pagenum"><a name="Page_500" id="Page_500">[500]</a></span> -layers of muscular or tendinous fibers, these may be carefully -divided.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_501" id="Page_501">[501]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.”</p> - -<p>387. When a portion of intestine is protruded without<span class="pagenum"><a name="Page_502" id="Page_502">[502]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_503" id="Page_503">[503]</a></span> -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.</p> - -<p>Madame Doucet was applied to a hundred years ago, by a<span class="pagenum"><a name="Page_504" id="Page_504">[504]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_505" id="Page_505">[505]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_506" id="Page_506">[506]</a></span> -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.</p> - -<p>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.”</p> - -<p>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<span class="pagenum"><a name="Page_507" id="Page_507">[507]</a></span> -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.</p> - -<p>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.</p> - -<p>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, <i>Disputat. Anatom.</i>, vol. vi., -<i>Observ. Med. Miscel.</i>, 18.) Since his time, many of the most<span class="pagenum"><a name="Page_508" id="Page_508">[508]</a></span> -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.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XXVIII">LECTURE XXVIII.</h2> -</div> - -<p class="h2sub">TREATMENT OF INCISED WOUNDS, ETC.</p> - -<p>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 pur<span class="pagenum"><a name="Page_509" id="Page_509">[509]</a></span>pose -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.</p> - -<p>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.</p> - -<p>When the intestine is more largely injured in a longitudinal -or transverse direction, or is completely divided as far<span class="pagenum"><a name="Page_510" id="Page_510">[510]</a></span> -as or beyond the mesentery, the continuous suture is absolutely -necessary.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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,<span class="pagenum"><a name="Page_511" id="Page_511">[511]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_512" id="Page_512">[512]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_513" id="Page_513">[513]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_514" id="Page_514">[514]</a></span> -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 <i>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</i>. 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.</p> - -<p class="right"><span class="smcap">A. Maclean</span>, M.D., late Surgeon, 76th Regiment. -</p> - -<hr class="tb" /> - -<p>Cases of extravasation or of effusion, terminating by the -formation of a sac, pouch, reservoir, or <i>foyer</i> 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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_515" id="Page_515">[515]</a></span> -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 (<i>débridant la -plaie</i>) 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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>The following cases of the survivors of hundreds who<span class="pagenum"><a name="Page_516" id="Page_516">[516]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>“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.</p> - -<p>“I reached the field hospital shortly afterward, when the -protrusion was returned without enlarging the orifice, and -<i>no</i> 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 <i>only</i> time -I was bled. In the morning I found the bed saturated with<span class="pagenum"><a name="Page_517" id="Page_517">[517]</a></span> -blood, which had trickled through to the floor, and had -escaped from the wound behind.</p> - -<p>“Before a month had elapsed I and all the wounded were -removed to Elvas on <i>bullock-cars</i>, and a desperate journey -it was.</p> - -<p>“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.</p> - -<p>“I arrived in England in June, and in September went to -Brighton. Soon afterward I felt terrible pains in the <i>right</i> -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.</p> - -<p>“I now gradually recovered my health, and in the spring -of 1815, accompanied the 10th Hussars to Belgium, and -served at Waterloo.</p> - -<p>“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.”</p> - -<p>John Richardson, of the 1st Royal Dragoons, was wounded<span class="pagenum"><a name="Page_518" id="Page_518">[518]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>24th.—Feels considerable relief from the tension of the -abdomen having subsided; threw up his tea and a quantity -of clotted blood this morning.</p> - -<p>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.</p> - -<p>30th.—Vomiting in the night, mixed with blood; tea, etc. -remain on the stomach this morning; pulse 108.</p> - -<p>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.</p> - -<p>20th.—The wound perfectly healed; is cleaning his accoutrements, -boots, etc. Was discharged on the 28th of -July, perfectly recovered.</p> - -<p>Owen M’Caffrey, aged thirty-three, first battalion 95th<span class="pagenum"><a name="Page_519" id="Page_519">[519]</a></span> -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, <i>the adherence of the two surfaces -of the peritoneum</i> preventing any, even the smallest portion, -getting into the cavity of the abdomen.</p> - -<p>26th.—The high inflammatory action having been reduced, -milk, rice, and sugar, and the farinaceous part of the -potato were allowed.</p> - -<p>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.</p> - -<p>7th.—Strength slowly but gradually returning. The action -of the large intestines is daily kept up by stimulating injections.</p> - -<p>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.</p> - -<p>28th.—Still improving; ultimately recovered.</p> - -<p>The situation of the ball was never ascertained.</p> - -<p>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<span class="pagenum"><a name="Page_520" id="Page_520">[520]</a></span> -lessened; the man was much reduced, but otherwise in good -health, and was sent to France from Brussels, nearly well.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_521" id="Page_521">[521]</a></span> -vomiting of bilious matter. Two small doses of castor-oil -had been exhibited.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>18th.—Diarrhœa and tenesmus troublesome during the -night; <i>ball voided with the feces at six</i> <span class="allsmcap">A.M.</span>; it is somewhat -flattened, as if from impinging on a stone; has felt -easy since. Continue antiphlogistic regimen.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>11th.—Suspect he has been rather irregular in diet.<span class="pagenum"><a name="Page_522" id="Page_522">[522]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>16th. Eight <span class="allsmcap">A.M.</span>—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 <span class="allsmcap">P.M.</span>—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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 im<span class="pagenum"><a name="Page_523" id="Page_523">[523]</a></span>mediately, -and as much blood taken as his strength would -permit; foot-bath repeated in the evening.</p> - -<p>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.</p> - -<p>28th.—In a fair way of recovery; was discharged for -England in June, with little or no complaint.</p> - -<p class="right"> -<span class="smcap">John Murray</span>, Surgeon to the Forces. -</p> - -<hr class="tb" /> -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_524" id="Page_524">[524]</a></span> -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.</p> - -<p>The two following very interesting cases of abdominal -injury having been received while these pages were passing -through the press, are here inserted:—</p> - -<p>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.</p> - -<p class="right"> -<span class="smcap">T. Alexander</span>, Deputy Inspector-General. -</p> -<p><span style="margin-left: 2em;"><i>5th August, 1855.</i></span><br /> -</p> - -<hr class="tb" /> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_525" id="Page_525">[525]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p class="right"> -<span class="smcap">Rt. De Lisle</span>, Surgeon,<br /> -4th K. O. Regiment.</p> -<p> -<span style="margin-left: 1em;"><i>Camp before Sebastopol, August 8th, 1855.</i></span><br /> -</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="LECTURE_XXIX">LECTURE XXIX.</h2> -</div> - -<p class="h2sub">ABNORMAL OR ARTIFICIAL ANUS, ETC.</p> - -<p>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.</p> - -<p>When an intestine has lost a more or less considerable<span class="pagenum"><a name="Page_526" id="Page_526">[526]</a></span> -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 <i>eperon</i> or <i>promontoire</i>, 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.</p> - -<p>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 <i>eperon</i> 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,<span class="pagenum"><a name="Page_527" id="Page_527">[527]</a></span> -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 <i>entonnoir</i>, <i>infundibulum</i>, -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.</p> - -<p>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.</p> - -<p>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 <i>eperon</i>, 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 sur<span class="pagenum"><a name="Page_528" id="Page_528">[528]</a></span>rounding -them. The inflammation, however, did not always -stop at the adhesive stage, and death has been the result as -well as a successful cure.</p> - -<p>404. Mr. Trant has invented an instrument he calls a -propeller, for pressing back the eperon, an account of which -is given in the <i>Dublin Medical Press</i>, 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 <i>eperon</i> 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 <i>eperon</i> 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.</p> - -<p>405. <i>Wounds and injuries of the liver</i>, whether incised -or penetrating, occurring from blows or from musket-balls, -are very serious, although not <i>necessarily</i> 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<span class="pagenum"><a name="Page_529" id="Page_529">[529]</a></span> -from the twelfth or fourteenth day after the primary symptoms -have in some measure subsided.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_530" id="Page_530">[530]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_531" id="Page_531">[531]</a></span> -was repeated the next day. The bilious discharge ceased in -the middle of August, and on the 2d of September he was -discharged convalescent.</p> - -<p>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.</p> - -<p>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 <i>very -largely</i> 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 -<i>very few</i> 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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_532" id="Page_532">[532]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_533" id="Page_533">[533]</a></span> -wounded through the liver, to whom little subsequent inconvenience -was occasioned.</p> - -<p>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 ‘<i>London Medical Gazette</i>’ 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.</p> - -<p>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.</p> - -<p>407. <i>Wounds of the stomach</i> 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 mis<span class="pagenum"><a name="Page_534" id="Page_534">[534]</a></span>chief, -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_535" id="Page_535">[535]</a></span> -attend to such recommendations, and to the after-treatment -these cases require.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_536" id="Page_536">[536]</a></span> -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.</p> - -<p>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.</p> - -<p>410. <i>Injuries of the spleen</i> 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<span class="pagenum"><a name="Page_537" id="Page_537">[537]</a></span> -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.</p> - -<p>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.</p> - -<p>411. <i>Wounds affecting the kidney</i> 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<span class="pagenum"><a name="Page_538" id="Page_538">[538]</a></span> -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.</p> - -<p>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,<span class="pagenum"><a name="Page_539" id="Page_539">[539]</a></span> -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.</p> - -<p>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.</p> - -<p>412. <i>Wounds of the spermatic cord</i> are of infrequent -occurrence, and rarely lead to fatal, although often to -inconvenient consequences.</p> - -<p>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.<span class="pagenum"><a name="Page_540" id="Page_540">[540]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<p><span class="pagenum"><a name="Page_541" id="Page_541">[541]</a></span></p> -<h2 class="nobreak" id="LECTURE_XXX">LECTURE XXX.</h2> -</div> - -<p class="h2sub">WOUNDS OF THE PELVIS, ETC.</p> - -<p>413. <i>Wounds of the pelvis</i> 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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_542" id="Page_542">[542]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_543" id="Page_543">[543]</a></span> -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.</p> - -<p>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.</p> - -<p>A soldier, of the Fourth Division of Infantry, was wounded -at the battle of Salamanca by a musket-ball, which entered<span class="pagenum"><a name="Page_544" id="Page_544">[544]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>414. I have removed balls on different occasions which<span class="pagenum"><a name="Page_545" id="Page_545">[545]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_546" id="Page_546">[546]</a></span> -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 <span class="allsmcap">P.M.</span>, 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 <span class="allsmcap">P.M.</span>, 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.</p> - -<p>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 <span class="allsmcap">P.M.</span>—Pulse 96; -bowels open, with discharge of blood; symptoms generally -relieved. Tincture of opium, twelve drops at night.</p> - -<p>8th.—Slept better; less pain; paralysis continues. In -the evening symptoms aggravated; lost twelve ounces of -blood; enema, etc. repeated; pulse 120.</p> - -<p>9th, 10th, 11th, 12th.—Pulse 96; bowels open; urine -bloody; is generally better.</p> - -<p>15th.—Wound of exit healed; urine bloody; bowels open. -Chicken-broth for the first time.</p> - -<p>20th.—The opening of entrance having nearly closed was -enlarged, and a free exit allowed for the matter.</p> - -<p>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.</p> - -<p>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.</p> - -<p>415. The general opinion which formerly prevailed, that -<i>wounds of the bladder</i>, by musket-balls, were for the most<span class="pagenum"><a name="Page_547" id="Page_547">[547]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_548" id="Page_548">[548]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_549" id="Page_549">[549]</a></span> -in the prostate, it must be removed by an operation in the -perineum.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_550" id="Page_550">[550]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_551" id="Page_551">[551]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>11th.—All the painful sensations much relieved; abdomen<span class="pagenum"><a name="Page_552" id="Page_552">[552]</a></span> -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.</p> - -<p>15th.—Complains of severe pain in the spermatic cord; -discharge from groin more offensive; wound filled with large -maggots; bowels open.</p> - -<p>19th.—Wound of groin looks clean; a small piece of -bone discharged by the urethra, and a piece of cloth extracted -from the groin.</p> - -<p>24th.—A small piece of bone extracted from the groin.</p> - -<p>August 5th.—Passes a good deal of pus and urine by the -urethra.</p> - -<p>29th.—Posterior wound much inflamed and very painful -upon pressure. A poultice to be frequently applied.</p> - -<p>Sept. 1st.—An abscess has burst; a piece of cloth has -been extracted; urine and pus are discharged by both -wounds.</p> - -<p>12th.—Doing well; wounds closing.</p> - -<p>16th.—Bladder resuming its power; discharge of matter -from groin very trivial.</p> - -<p>Oct. 4th.—Posterior wound closed.</p> - -<p>30th.—Wound of groin closed; urine, passed by the natural -passage, mixed with pus.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_553" id="Page_553">[553]</a></span> -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.</p> - -<p>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<span class="pagenum"><a name="Page_554" id="Page_554">[554]</a></span> -service of the East India Company, whose name I have not -been able to learn.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_555" id="Page_555">[555]</a></span> -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.</p> - -<p>420. The <i>rectum</i> 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.</p> - -<p>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.</p> - -<hr class="r5" /> - -<h3 class="center">CONCLUSIONS.</h3> - -<p>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<span class="pagenum"><a name="Page_556" id="Page_556">[556]</a></span> -abstraction of blood, and by the early use of retaining bandages.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>5. As the muscular parts rarely unite in the first instance -after being divided, sutures should never be introduced into -these structures.</p> - -<p>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.</p> - -<p>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.</p> - -<p>8. Purgatives should be eschewed in the early part of the -treatment of penetrating wounds of the abdomen. Enemata -are to be preferred.</p> - -<p>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.</p> - -<p>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, <i>Aph.</i> 391.</p> - -<p>11. The position of the patient should be inclined toward -the wounded side, to allow the omentum or intestine being<span class="pagenum"><a name="Page_557" id="Page_557">[557]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>20. In all cases in which a catheter cannot be introduced, -in consequence of the back part of the urethra or the neck<span class="pagenum"><a name="Page_558" id="Page_558">[558]</a></span> -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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_559" id="Page_559">[559]</a></span> -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.</p> - -<p>423. These commentaries are restricted to those points -which constitute, in a great degree, what the French call -<i>la haute chirurgie</i>. 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.</p> - -<p><span class="pagenum"><a name="Page_560" id="Page_560">[560]</a></span></p> -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<p><span class="pagenum"><a name="Page_561" id="Page_561">[561]</a></span></p> -<h2 class="nobreak" id="ADDENDA">ADDENDA.</h2> -</div> -<hr class="r5" /> -<p>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:—</p> - -<p>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.</p> - -<p>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:—</p> - -<p>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 lacer<span class="pagenum"><a name="Page_562" id="Page_562">[562]</a></span>ated -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.</p> - -<p>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 <i>Aphor.</i> 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.</p> - -<p>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 conse<span class="pagenum"><a name="Page_563" id="Page_563">[563]</a></span>quence -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.</p> - -<p>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 -<span class="pagenum"><a name="Page_564" id="Page_564">[564]</a></span> -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.</p> - -<p>“The Russian died on the 22d of October, ‘from great -debility and extensive sloughing.’</p> - -<p>“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.</p> - -<p>“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.”</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_565" id="Page_565">[565]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Diet was very generous.</p> - -<p class="right"> -J. C. O’LEARY,<br /> -<i>Surgeon, 68th Light Infantry</i>. -</p> - -<p>Camp, 4th Division, Crimea, Sept. 14, 1855.</p> - -<p>The bones removed are in the museum of the Royal College -of Surgeons.</p> - -<hr class="tb" /> -<p>The fourth case is given at length by Staff-Surgeon Crerar, -as follows:—</p> - -<p>Private William Smith, First Battalion First Royals, was -brought to hospital from the Greenhill trenches, in front of -Sebastopol, about twelve <span class="allsmcap">P.M.</span>, 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. -<span class="pagenum"><a name="Page_566" id="Page_566">[566]</a></span> -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.</p> - -<p>At twelve <span class="allsmcap">A.M.</span>, two hours after the operation on the 7th -instant, his pulse being rather feeble, he was ordered some -wine and water.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_567" id="Page_567">[567]</a></span> -Vespere.—Has been very cheerful all day; limb has retracted -about another half inch; pulse 112.</p> - -<p>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.</p> - -<p>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.</p> - -<p>11th.—Slept soundly all night; when I visited him, at -six <span class="allsmcap">A.M.</span>, he had just awoke; pulse 115, soft; appears contented -and comfortable.</p> - -<p>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 <span class="allsmcap">P.M.</span></p> - -<p>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.</p> - -<p>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 <span class="allsmcap">P.M.</span>, a -pint of chicken-broth, with bread, and a second glass of wine. -The morphia draught as usual.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_568" id="Page_568">[568]</a></span> -effervescing draughts of bicarbonate of potassa and citric acid -three times a day; to continue simple water dressing.</p> - -<p>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.</p> - -<p>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.</p> - -<p>Vespere.—Felt a good deal exhausted to-day from the -heat, which was very great—ninety-two degrees.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>18th.—Very much worse this morning; had a rigor about -ten <span class="allsmcap">A.M.</span> yesterday; features now sharpened and pinched; -tongue dry and brown; pulse thready, about 125.</p> - -<p>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.</p> - -<p>19th.—When I visited him at six <span class="allsmcap">A.M.</span> 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.</p> - -<p>Vespere.—No change to report.</p> - -<p><span class="pagenum"><a name="Page_569" id="Page_569">[569]</a></span> -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.</p> - -<p>Vespere.—Has been very uneasy all day; skin hot; tongue -dry.</p> - -<p>21st, six <span class="allsmcap">A.M.</span>—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 <span class="allsmcap">A.M.</span>: 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 <span class="allsmcap">P.M.</span></p> - -<p>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.</p> - -<p>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.</p> - -<p class="right"> -J. CRERAR, <i>Surgeon</i>, <i>68th Regiment</i>.<br /> -</p> - -<p><small>Camp before Sebastopol, 24th August.</small></p> - -<p>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.</p> - -<hr class="tb" /> - -<p>The fifth, by Dr. Hyde, ended fatally on the sixth day.</p> - -<p><span class="pagenum"><a name="Page_570" id="Page_570">[570]</a></span> -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.</p> - -<p>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.</p> - -<p>Operation performed about one <span class="allsmcap">P.M.</span> 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.</p> - -<p>10th.—Passed a good night; slept pretty well; pulse -106, soft; skin cool; in good spirits.</p> - -<p><span class="pagenum"><a name="Page_571" id="Page_571">[571]</a></span> -11th.—Slept some hours; pulse 106, soft; bowels open; -tongue furred, but moist. Wound dressed and looking well; -some healthy discharge.</p> - -<p>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.</p> - -<p>14th.—Died at six this morning.</p> - -<p>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.</p> - -<p class="right"> -GEO. HYDE, M.D., <i>Staff-Surgeon</i>. -</p> - -<hr class="tb" /> -<p>The sixth, by Staff-Surgeon Coombe, also ended fatally.</p> - -<p>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.</p> - -<p class="right"> -W. H. McANDREW, M.D.,<br /> -<i>Surgeon, 57th Regiment</i>. -</p> - -<p><small>Camp, Sebastopol, Sept. 14th, 1855.</small></p> - -<p>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.</p> - -<p class="right"> -W. H. McANDREW, M. D.,<br /> -Surgeon, 57th Regiment. -</p> - -<p><small>Camp, Sebastopol, Sept. 14th, 1855.</small></p> - -<hr class="tb" /> -<p>The following case of wound of the larynx is instructive:—</p> - -<p>Lieutenant Charles H. Evans, 55th Regiment, aged nine<span class="pagenum"><a name="Page_572" id="Page_572">[572]</a></span>teen -years, was wounded on the evening of the 5th of August, -1855, about eleven o’clock <span class="allsmcap">P.M.</span>, 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.</p> - -<p>About seven o’clock <span class="allsmcap">P.M.</span> 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.</p> - -<p>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.</p> - -<p class="right"> -ARCHD. GORDON. M.D.,<br /> -<i>Staff-Surgeon, 1st Class, in Med. Charge, 2d Division</i>. -</p> - -<p><small>Camp before Sebastopol, September 3, 1855.</small></p> - -<p>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.”</p> - -<hr class="tb" /> -<p><span class="pagenum"><a name="Page_573" id="Page_573">[573]</a></span> -The following cases, one of wound of the profunda femoris, -the other of the popliteal, deserve attention:—</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>On the evening of the 20th, this restlessness increased; -delirium set in, and early in the morning of the 22d he died.</p> - -<p><span class="pagenum"><a name="Page_574" id="Page_574">[574]</a></span> -The limb was examined after death, when the following -appearances presented:—</p> - -<p>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.</p> - -<p>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.</p> - -<p class="right"> -R. V. DE LISLE,<br /> -<i>Surgeon, 4th King’s Own Regiment</i>. -</p> - -<p><small>Camp before Sebastopol, Sept. 14, 1855.</small></p> - -<hr class="tb" /> -<p>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.</p> - -<p>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.</p> - -<p>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<span class="pagenum"><a name="Page_575" id="Page_575">[575]</a></span> -of morphia ʒj was prescribed without any effect. (ʒj contains -1 gr.) The dose was gradually increased to ʒij of the -solution.</p> - -<p>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.</p> - -<p>20th.—Continues much the same, with slight twitchings -of the face.</p> - -<p>25th.—Has been unconscious for three days. Now complains -of intense pain in the back and violent cold perspiration.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>20th.—Sensation much improved in both legs, and motion -increasing in the right leg.</p> - -<p>25th.—Convulsive movements all over the body, resulting<span class="pagenum"><a name="Page_576" id="Page_576">[576]</a></span> -from the use of the strychnine. Lower extremities decidedly -improved both in motion and sensation.</p> - -<p>June 1st.—Maintains his improved condition. Recommenced -the strychnine to-day, without any marked effect at -the moment.</p> - -<p>10th.—Violent tetanic spasms followed the employment -of the remedy, producing considerable increase of motion in -both extremities. The paroxysms <i>usually</i> continue about -fifteen minutes, when the muscular system resumes its ordinary -appearance.</p> - -<p>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.</p> - -<p>July 1st.—General health excellent.</p> - -<p>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.</p> - -<p>August 1st.—No change worthy of note.</p> - -<p>14th.—Discharged to Chatham.</p> - -<p class="right"> -T. H. BURGESS, M.D.,<br /> -<i>Military Hospital, Portsmouth</i>. -</p> - -<hr class="tb" /> -<p>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:—</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_577" id="Page_577">[577]</a></span> -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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_578" id="Page_578">[578]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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 -<span class="pagenum"><a name="Page_579" id="Page_579">[579]</a></span> -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.</p> - -<p>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.</p> - -<p>He may now be said to be convalescent.</p> - -<hr class="tb" /> - -<p>John Shehan, aged nineteen, 57th Regiment, was wounded -in the left thigh before the Redan, on the 18th of June. He -<span class="pagenum"><a name="Page_580" id="Page_580">[580]</a></span> -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 (<i>vide</i> 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 <i>a peculiar pathological state in which all -the vital organs remain sound, but the vis vitæ is remarkably -reduced below par</i>. 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.</p> - -<p class="right"> -R. D. LYONS,<br /> -<i>Pathologist to the Army in the East</i>. -</p> - -<p><small>Camp before Sebastopol, August 30, 1855.</small></p> -<hr class="tb" /> -<p>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 -<span class="pagenum"><a name="Page_581" id="Page_581">[581]</a></span> -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.</p> - -<p class="right"> -DAVID MILROY, M.D.,<br /> -<i>Assistant-Surgeon, 30th Regiment</i>.<br /> -</p> - -<p><small>Camp, Second Division, Heights of Sebastopol, -Sept. 5, 1855.</small></p> - -<hr class="tb" /> -<p>J. Maguire, 31st Regiment, aged twenty, wounded in the -advanced trenches.</p> - -<p>July 12, five <span class="allsmcap">A.M.</span>—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.</p> - -<p>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.</p> - -<p>August 19th.—This patient was discharged from the -regimental hospital, to general hospital, Balaklava. The -<span class="pagenum"><a name="Page_582" id="Page_582">[582]</a></span> -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.</p> - -<p class="right"> -THOMAS J. ATKINSON,<br /> -<i>Assistant-Surgeon, 31st Reg. in Med. Charge</i>. -</p> - -<p><small>Camp before Sebastopol, Sept. 1, 1855.</small></p> - -<hr class="tb" /> -<p>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.</p> - -<p class="right"> -J. E. SCOTT, M.D., <i>Surgeon, 41st Regiment</i>. -</p> - -<p><small>August 31st, 1855.</small></p> - -<hr class="tb" /> -<p>Private Jesse Lockhurst, 31st Regiment, aged twenty-six, -was wounded in the advanced trenches, 17th of August, -1855.</p> - -<p>August 17th.—Six o’clock <span class="allsmcap">A.M.</span>, 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 -<span class="pagenum"><a name="Page_583" id="Page_583">[583]</a></span> -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.</p> - -<p>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.</p> - -<p>September 1st.—He has just been discharged to general -hospital, Balaklava, from the regimental hospital.</p> - -<p class="right"> -THOS. J. ATKINSON, <i>Assistant-Surgeon</i>,<br /> -<i>31st Regiment, in Med. Charge</i>. -</p> - -<p><small>Camp before Sebastopol, September 1, 1855.</small></p> - -<hr class="tb" /> -<p>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 -<span class="pagenum"><a name="Page_584" id="Page_584">[584]</a></span> -ball could be found, it was supposed to have passed out at -the opening of entrance.</p> - -<p>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.</p> - -<p>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.</p> - -<p class="right"> -R. V. DE LISLE,<br /> -<i>Surgeon, 14th King’s Own Regiment</i>.<br /> -</p> - -<p><small>Camp, Sept. 10.</small></p> - -<hr class="tb" /> -<p>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.</p> - -<p class="right"> -W. P. WARD,<br /> -<i>Surgeon, 17th Regiment</i>.<br /> -</p> - -<hr class="tb" /> -<p>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.</p> - -<p>A director was passed along the track of the wound, and -<span class="pagenum"><a name="Page_585" id="Page_585">[585]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p class="right"> -FREDERIC WALL,<br /> -<i>Surgeon, 38th Regiment</i>. -</p> - -<p><small>Camp before Sebastopol, Sept. 20, 1855.</small></p> - -<hr class="tb" /> -<p>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 -ad<span class="pagenum"><a name="Page_586" id="Page_586">[586]</a></span>vance -of the depressed piece of bone, being the boundary of -an opening into the cerebral substance.</p> - -<p>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.</p> - -<p>The portion of bone implicated in this injury has been -preserved.</p> - -<p class="right"> -THOMAS LONGMORE,<br /> -<i>Surgeon, 19th Regiment</i>.<br /> -</p> - -<p><small>Camp before Sebastopol.</small></p> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="REMARKS">REMARKS.</h2> -</div> - -<p>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.</p> - -<p><span class="pagenum"><a name="Page_587" id="Page_587">[587]</a></span> -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.)</p> - -<p>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.</p> - -<p>The Russians, at the commencement of the siege of -Sebas<span class="pagenum"><a name="Page_588" id="Page_588">[588]</a></span>topol, -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>In performing the operation for the excision of portions -of the extremities of bones, a chain saw is a most desirable -<span class="pagenum"><a name="Page_589" id="Page_589">[589]</a></span> -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 <i>three</i> -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.</p> - -<p>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 <i>sine qua non</i> 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.</p> - -<p><span class="pagenum"><a name="Page_590" id="Page_590">[590]</a></span> -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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.</p> - -<p>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.”</p> - -<p>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.</p> - -<p><i>October 18, 1855.</i></p> - -<hr class="chap x-ebookmaker-drop" /> -<p><span class="pagenum"><a name="Page_591" id="Page_591">[591]</a></span> -</p> -<div class="chapter"> -<h2 class="nobreak" id="INDEX">INDEX.</h2> -</div> - -<ul class="index"> -<li class="ifrst">Abdomen, wounds of, <a href="#Page_488">488</a>, 649.</li> -<li class="isub1">causing abscesses in parietes of, <a href="#Page_489">489</a>.</li> -<li class="isub1">penetrating wounds of, <a href="#Page_497">497</a>.</li> -<li class="isub2">protrusion of viscera in, <a href="#Page_498">498</a>.</li> -<li class="isub3">of omentum, <a href="#Page_498">498</a>.</li> -<li class="isub3">of intestine, <a href="#Page_501">501</a>, <a href="#Page_509">509</a>.</li> -<li class="isub1">effusion of blood into, <a href="#Page_505">505</a>, <a href="#Page_510">510</a>.</li> -<li class="isub1">treatment of hemorrhage in penetrating wounds of, <a href="#Page_510">510</a>.</li> -<li class="isub1">suppuration in cavity of, <a href="#Page_511">511</a>.</li> -<li class="isub1">and pelvis, conclusions respecting wounds of, <a href="#Page_555">555</a>.</li> -<li class="isub1">right arm and thigh, extensive injury to, by a round shot, <a href="#Page_576">576</a>.</li> - -<li class="indx">Abdominal parietes, gunshot wounds of, <a href="#Page_489">489</a>.</li> -<li class="isub1">lodgment of balls in, <a href="#Page_489">489</a>.</li> -<li class="isub1">incised wounds of, <a href="#Page_490">490</a>.</li> -<li class="isub2">followed by ventral rupture, <a href="#Page_493">493</a>.</li> -<li class="isub2">on continuous suture of, <a href="#Page_493">493</a>.</li> -<li class="isub1">severe contusions of, followed by rupture of the hollow or solid viscera, <a href="#Page_491">491</a>.</li> - -<li class="indx">Abernathy’s mode of tying the external iliac, <a href="#Page_257">257</a>.</li> - -<li class="indx">Abscess of liver, consequent to injuries of the head, <a href="#Page_356">356</a>.</li> -<li class="isub1">in abdominal parietes, caused by neglected injuries, <a href="#Page_489">489</a>.</li> - -<li class="indx">Acids, mineral, use of, in sloughing wounds, <a href="#Page_70">70</a>, <a href="#Page_168">168</a>.</li> -<li class="isub2">in hospital gangrene, <a href="#Page_70">70</a>, <a href="#Page_168">168</a>.</li> - -<li class="indx"><i>Addenda</i>, commentaries on the cases in, <a href="#Page_586">586</a>.</li> - -<li class="indx">Alexander, Deputy Inspector-General, on amputations, while under the influence of chloroform, <a href="#Page_563">563</a>.</li> - -<li class="indx">Amaurosis from balls passing behind the eyes, <a href="#Page_478">478</a>.</li> - -<li class="indx">Amputation,</li> -<li class="isub1">primary, not required in gunshot wounds of the upper extremity, <a href="#Page_120">120</a>.</li> -<li class="isub1">aphorisms on, <a href="#Page_73">73</a>.</li> -<li class="isub1">at the ankle-joint, Mr. Syme’s operation for, <a href="#Page_105">105</a>.</li> -<li class="isub1">of the arm below the tuberosities, <a href="#Page_126">126</a>.</li> -<li class="isub2">by the circular incision, <a href="#Page_134">134</a>.</li> -<li class="isub2">by Mr. Luke’s operation by two flaps, <a href="#Page_135">135</a>.</li> -<li class="isub1">primary, of the arm, <a href="#Page_120">120</a>.</li> -<li class="isub1">at the elbow-joint, <a href="#Page_137">137</a>.</li> -<li class="isub1">place of election for, in local mortification of a limb, <a href="#Page_46">46</a>.</li> -<li class="isub1">of the fingers, <a href="#Page_139">139</a>.</li> - -<li class="isub1"><span class="pagenum"><a name="Page_592" id="Page_592">[592]</a></span> -of the foot, <a href="#Page_114">114</a>.</li> -<li class="isub2">by Roux’s plan, <a href="#Page_108">108</a>.</li> -<li class="isub1">of the forearm, <a href="#Page_137">137</a>.</li> -<li class="isub2">by the flap operation, <a href="#Page_137">137</a>.</li> -<li class="isub2">by the circular incision, <a href="#Page_138">138</a>.</li> -<li class="isub1">for gunshot wounds of the femur, <a href="#Page_145">145</a>.</li> -<li class="isub1">at the hip-joint, <a href="#Page_77">77</a>, <a href="#Page_92">92</a>, <a href="#Page_562">562</a>, <a href="#Page_563">563</a>, <a href="#Page_586">586</a>.</li> -<li class="isub2">Mr. Guthrie’s mode of operating in, <a href="#Page_79">79</a>, <a href="#Page_83">83</a>.</li> -<li class="isub2">Professor Langenbeck’s, <a href="#Page_80">80</a>.</li> -<li class="isub2">Mr. Brownrigg’s, <a href="#Page_82">82</a>.</li> -<li class="isub2">under chloroform, <a href="#Page_564">564</a>.</li> -<li class="isub1">immediate, question as to, <a href="#Page_51">51</a>.</li> -<li class="isub2">cases for, <a href="#Page_150">150</a>.</li> -<li class="isub1">of the leg, <a href="#Page_99">99</a>.</li> -<li class="isub2">by the circular incision, <a href="#Page_99">99</a>.</li> -<li class="isub2">by Mr. Luke’s flap operation, <a href="#Page_101">101</a>.</li> -<li class="isub2">immediately below the tuberosity of the tibia, <a href="#Page_102">102</a>.</li> -<li class="isub1">of the metacarpal bones, <a href="#Page_139">139</a>.</li> -<li class="isub1">of a metatarsal bone, <a href="#Page_118">118</a>.</li> -<li class="isub1">in cases of mortification from wounded arteries, <a href="#Page_228">228</a>.</li> -<li class="isub1">necessity for, <a href="#Page_51">51</a>.</li> -<li class="isub1">of the phalanges, <a href="#Page_140">140</a>.</li> -<li class="isub1">primary and secondary, <a href="#Page_59">59</a>.</li> -<li class="isub1">secondary, <a href="#Page_59">59</a>, <a href="#Page_141">141</a>.</li> -<li class="isub1">at the shoulder-joint, <a href="#Page_122">122</a>.</li> -<li class="isub2">by two flaps, <a href="#Page_124">124</a>.</li> -<li class="isub2">by one flap, <a href="#Page_125">125</a>.</li> -<li class="isub2">by Lisfranc’s operation, <a href="#Page_125">125</a>.</li> -<li class="isub1">at the tarsus, <a href="#Page_112">112</a>.</li> -<li class="isub1">of the thigh, by the circular incision, <a href="#Page_83">83</a>.</li> -<li class="isub2">by Mr. Luke’s flap operation, <a href="#Page_86">86</a>.</li> -<li class="isub1">at the wrist, <a href="#Page_138">138</a>.</li> -<li class="isub1">under the influence of chloroform, in the Crimea, <a href="#Page_561">561</a>.</li> -<li class="isub2">case of death from, <a href="#Page_561">561</a>.</li> -<li class="isub2">Deputy Inspector-General Taylor on, <a href="#Page_562">562</a>.</li> -<li class="isub2">Deputy Inspector-General Alexander on, <a href="#Page_563">563</a>.</li> - -<li class="indx">Ankle-joint, excision of, <a href="#Page_103">103</a>.</li> -<li class="isub1">Mr. Syme’s amputation at, <a href="#Page_105">105</a>.</li> - -<li class="indx">Aneurism of the arch of the aorta, <a href="#Page_276">276</a>.</li> -<li class="isub1">formation of, after wound of artery, <a href="#Page_212">212</a>.</li> -<li class="isub2">Hunterian theory respecting, <a href="#Page_188">188</a>.</li> -<li class="isub1">popliteal, operation for, <a href="#Page_263">263</a>.</li> -<li class="isub1">traumatic, formation of, <a href="#Page_214">214</a>.</li> - -<li class="indx">Aneurismal swelling after deep wound of an artery, <a href="#Page_212">212</a>.</li> - -<li class="indx">Anus, artificial, <a href="#Page_525">525</a>.</li> -<li class="isub2">operation for the formation of, in the loins, <a href="#Page_558">558</a>.</li> -<li class="isub2">Desault’s operation for, <a href="#Page_527">527</a>.</li> -<li class="isub2">Dupuytren’s forceps for, <a href="#Page_527">527</a>.</li> -<li class="isub2">Mr. Trant’s forceps for, <a href="#Page_528">528</a>.</li> - -<li class="indx">Aorta, ligature of, <a href="#Page_250">250</a>, <a href="#Page_252">252</a>, <a href="#Page_256">256</a>.</li> -<li class="isub1">aneurism of the arch of, <a href="#Page_276">276</a>.</li> - -<li class="indx">Arachnoid and dura mater, wounds of, <a href="#Page_345">345</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_593" id="Page_593">[593]</a></span> -Arm, amputation of, below the tuberosities, <a href="#Page_126">126</a>.</li> -<li class="isub2">primary, <a href="#Page_120">120</a>.</li> -<li class="isub2">by the circular incision, <a href="#Page_134">134</a>.</li> -<li class="isub2">by Mr. Luke’s double flap operation, <a href="#Page_135">135</a>.</li> -<li class="isub1">gunshot fracture of, <a href="#Page_121">121</a>, <a href="#Page_156">156</a>.</li> -<li class="isub1">wounds of the arteries of, <a href="#Page_238">238</a>.</li> -<li class="isub1">thigh and abdomen, extensive injury to, <a href="#Page_576">576</a>.</li> - -<li class="indx">Arsenic, local use of, in hospital gangrene, <a href="#Page_169">169</a>.</li> - -<li class="indx">Arteries, wounded, the Hunterian theory inapplicable in the treatment of, <a href="#Page_189">189</a>.</li> -<li class="isub2">Mr. Guthrie’s theory respecting, <a href="#Page_189">189</a>.</li> -<li class="isub2">principles of surgery relative to, <a href="#Page_191">191</a>.</li> -<li class="isub1">punctured wounds of, <a href="#Page_210">210</a>.</li> -<li class="isub2">formation of aneurism after, <a href="#Page_211">211</a>.</li> -<li class="isub1">transverse wound of, <a href="#Page_212">212</a>.</li> -<li class="isub1">complete division of, <a href="#Page_212">212</a>.</li> -<li class="isub1">large, mode of arresting hemorrhage from, <a href="#Page_234">234</a>.</li> -<li class="isub1">of arm and forearm, wounds of, <a href="#Page_238">238</a>.</li> - -<li class="indx">Artery, structure of, <a href="#Page_176">176</a>.</li> -<li class="isub1">deep wound of, forming aneurismal swelling, <a href="#Page_213">213</a>.</li> -<li class="isub1">effects of a ligature on, <a href="#Page_203">203</a>.</li> -<li class="isub1">wounded, not to be operated on, unless it bleed, <a href="#Page_215">215</a>, <a href="#Page_241">241</a>.</li> -<li class="isub2">to be tied at the seat of injury, <a href="#Page_191">191</a>, <a href="#Page_219">219</a>.</li> -<li class="isub1">main, of the lower extremity, mortification caused by a wound of, <a href="#Page_45">45</a>, <a href="#Page_226">226</a>.</li> - -<li class="indx">Artificial anus, <a href="#Page_525">525</a>.</li> -<li class="isub2">formation of, in the loins, <a href="#Page_558">558</a>.</li> -<li class="isub2">Desault’s operation for, <a href="#Page_527">527</a>.</li> -<li class="isub2">Dupuytren’s forceps for, <a href="#Page_527">527</a>.</li> -<li class="isub2">Mr. Trant’s forceps for, <a href="#Page_528">528</a>.</li> -<li class="isub1">foot, M. de Beaufoy’s, <a href="#Page_119">119</a>.</li> - -<li class="indx">Astragalus and calcis, Mr. T. Wakley’s operation for the removal of, <a href="#Page_115">115</a>.</li> -<li class="isub1">ball lodged in the, <a href="#Page_109">109</a>, <a href="#Page_590">590</a>.</li> -<li class="isub1">removal of, <a href="#Page_109">109</a>.</li> - -<li class="indx">Auscultation, value of, in injuries of the chest, <a href="#Page_367">367</a>.</li> - -<li class="indx">Axillary artery, gunshot wounds of, rarely cause mortification of the hand or fingers, <a href="#Page_46">46</a>, <a href="#Page_235">235</a>.</li> -<li class="isub1">ligature of, <a href="#Page_278">278</a>.</li> -<li class="isub1">wounds of, <a href="#Page_235">235</a>.</li> - -<li class="ifrst">Ball, lodging in the abdominal parietes, <a href="#Page_489">489</a>.</li> -<li class="isub2">in the astragalus, <a href="#Page_109">109</a>, <a href="#Page_590">590</a>.</li> -<li class="isub2">in the bladder, <a href="#Page_553">553</a>.</li> -<li class="isub3">calculus formed on, <a href="#Page_553">553</a>.</li> -<li class="isub4">operation for removal of, <a href="#Page_554">554</a>.</li> -<li class="isub2">in bone, <a href="#Page_36">36</a>, <a href="#Page_149">149</a>.</li> -<li class="isub2">in the brain, <a href="#Page_283">283</a>.</li> -<li class="isub2">behind the eye, <a href="#Page_478">478</a>.</li> -<li class="isub1">or other foreign bodies loose in the cavity of the pleura, <a href="#Page_448">448</a>.</li> -<li class="isub2">inclosed in a cyst, <a href="#Page_451">451</a>.</li> - -<li class="isub1"><span class="pagenum"><a name="Page_594" id="Page_594">[594]</a></span> -lodged in the head of the humerus, <a href="#Page_128">128</a>.</li> -<li class="isub2">in the liver, <a href="#Page_532">532</a>.</li> -<li class="isub1">orifices of entrance and exit, <a href="#Page_27">27</a>, <a href="#Page_489">489</a>.</li> -<li class="isub1">passing behind the eyes, causing amaurosis, <a href="#Page_478">478</a>.</li> -<li class="isub1">lodging in the pelvis, <a href="#Page_545">545</a>.</li> -<li class="isub1">penetrating the brain, <a href="#Page_347">347</a>.</li> -<li class="isub1">rolling on the diaphragm, <a href="#Page_451">451</a>.</li> -<li class="isub2">operation for extraction of, <a href="#Page_455">455</a>.</li> -<li class="isub1">separating the sutures of the skull, <a href="#Page_349">349</a>.</li> - -<li class="indx">Balls, relative size of those used by the Allies and by the Russians, <a href="#Page_588">588</a>.</li> -<li class="isub1">on cysts inclosing foreign bodies, in gunshot wounds of the chest, <a href="#Page_451">451</a>.</li> -<li class="isub1">operation for empyema, <a href="#Page_452">452</a>.</li> -<li class="isub1">operation for gunshot fracture of the lower jaw, <a href="#Page_480">480</a>.</li> - -<li class="indx">Baudens, M., on excision of the head of the humerus, <a href="#Page_133">133</a>.</li> - -<li class="indx">Bayonet, wounds by, <a href="#Page_37">37</a>.</li> -<li class="isub1">wounds, delusion as to, <a href="#Page_38">38</a>.</li> - -<li class="indx">Bearers for the wounded, <a href="#Page_156">156</a>.</li> - -<li class="indx">Beaufoy’s, M. de, artificial foot, <a href="#Page_119">119</a>.</li> - -<li class="indx">Bedsteads for gunshot fractures of the femur, <a href="#Page_152">152</a>.</li> - -<li class="indx">Bell, Mr. J., on emphysema in gunshot wounds of the chest, <a href="#Page_412">412</a>.</li> - -<li class="indx">Bennet, Dr. Hughes, on phlebitis, <a href="#Page_71">71</a>.</li> - -<li class="indx">Blackadder, Mr., on hospital gangrene, <a href="#Page_164">164</a>, <a href="#Page_169">169</a>.</li> - -<li class="indx">Bladder, wounds of, <a href="#Page_546">546</a>.</li> -<li class="isub1">ball in the, <a href="#Page_553">553</a>.</li> -<li class="isub1">calculus formed on, <a href="#Page_553">553</a>.</li> -<li class="isub2">operation for extraction of, <a href="#Page_554">554</a>.</li> - -<li class="indx">Blood, effusion of, into the abdomen, <a href="#Page_505">505</a>, <a href="#Page_510">510</a>.</li> - -<li class="indx">Boggie, Dr., on hospital gangrene, <a href="#Page_168">168</a>, <a href="#Page_169">169</a>.</li> - -<li class="indx">Bone, lodgment of a ball in, <a href="#Page_36">36</a>, <a href="#Page_149">149</a>.</li> -<li class="isub1">protrusion of, after amputation, <a href="#Page_89">89</a>.</li> -<li class="isub1">exfoliation of, after amputation, <a href="#Page_89">89</a>.</li> - -<li class="indx">Bones of the face, penetrating wounds of, <a href="#Page_479">479</a>.</li> - -<li class="indx">Brachial artery, ligature of, <a href="#Page_279">279</a>.</li> - -<li class="indx">Brain, balls lodging in, <a href="#Page_283">283</a>.</li> -<li class="isub1">balls penetrating into, <a href="#Page_347">347</a>.</li> -<li class="isub1">M. Burdach’s statistics of lesions of, <a href="#Page_306">306</a>.</li> -<li class="isub1">compression of, <a href="#Page_302">302</a>.</li> -<li class="isub2">paralysis caused by, <a href="#Page_305">305</a>.</li> -<li class="isub1">injuries of the head affecting the, <a href="#Page_283">283</a>.</li> -<li class="isub1">concussion of, <a href="#Page_287">287</a>.</li> -<li class="isub2">causing mania, <a href="#Page_299">299</a>.</li> -<li class="isub1">laceration of, by contre-coup, <a href="#Page_340">340</a>.</li> -<li class="isub1">motions of, <a href="#Page_303">303</a>.</li> -<li class="isub1">suppuration of the surface of, <a href="#Page_342">342</a>.</li> -<li class="isub1">wounds of, <a href="#Page_347">347</a>.</li> -<li class="isub2">causing abscess of the liver, <a href="#Page_356">356</a>.</li> - -<li class="indx">Bronchophony, <a href="#Page_372">372</a>, <a href="#Page_376">376</a>.</li> - -<li class="indx">Brow and eyelids, wounds of, <a href="#Page_477">477</a>.</li> - -<li class="indx">Brownrigg’s mode of amputating at the hip-joint, <a href="#Page_82">82</a>.</li> - -<li class="indx">Brunner, glands of, <a href="#Page_486">486</a>.</li> - -<li class="indx">Buck, Dr. Gurdon, operation for excision of the knee-joint, <a href="#Page_97">97</a>.</li> - -<li class="indx">Burdach’s statistics of lesion of the brain, <a href="#Page_306">306</a>.</li> - -<li class="ifrst"><span class="pagenum"><a name="Page_595" id="Page_595">[595]</a></span> -Calcis and astragalus, operation for the removal of, <a href="#Page_115">115</a>.</li> -<li class="isub1">removal of, <a href="#Page_104">104</a>.</li> - -<li class="indx">Calculus formed on a ball in the bladder, <a href="#Page_553">553</a>.</li> -<li class="isub1">operation for extraction of, <a href="#Page_554">554</a>.</li> - -<li class="indx">Cannon-shot, hemorrhage after the carrying away a limb by, <a href="#Page_25">25</a>.</li> -<li class="isub1">wind of, <a href="#Page_43">43</a>.</li> -<li class="isub1">causes mortification of a limb, by destroying its internal textures, <a href="#Page_43">43</a>.</li> - -<li class="indx">Carotid, common, ligature of, <a href="#Page_270">270</a>.</li> -<li class="isub2">statistics of ligature of, <a href="#Page_241">241</a>.</li> -<li class="isub1">external, ligature of, <a href="#Page_272">272</a>.</li> -<li class="isub2">the common carotid not to be tied for wounds of, <a href="#Page_242">242</a>.</li> -<li class="isub1">internal, ligature of, <a href="#Page_272">272</a>.</li> -<li class="isub2">wounds of, through the mouth, <a href="#Page_245">245</a>.</li> -<li class="isub3">operation for securing, <a href="#Page_245">245</a>, <a href="#Page_248">248</a>, <a href="#Page_272">272</a>.</li> -<li class="isub2">the primitive carotid not to be tied for wounds of, <a href="#Page_246">246</a>.</li> -<li class="isub1">primitive, not to be tied for wounds of external carotid, <a href="#Page_541">541</a>.</li> -<li class="isub2">nor for wounds of the internal carotid, <a href="#Page_246">246</a>.</li> - -<li class="indx">Cartilages, costal, fracture of, in gunshot wounds of the chest, <a href="#Page_429">429</a>.</li> - -<li class="indx">Cerebrum, fungus of, (hernia cerebri,) 352.</li> - -<li class="indx">Chain saw, utility of, <a href="#Page_588">588</a>.</li> - -<li class="indx">Chelius on suture of incised wounds of abdominal parietes, <a href="#Page_493">493</a>.</li> - -<li class="indx">Chest, wounds of, <a href="#Page_364">364</a>, <a href="#Page_590">590</a>.</li> -<li class="isub1">effusion into, <a href="#Page_371">371</a>, <a href="#Page_378">378</a>, <a href="#Page_420">420</a>.</li> -<li class="isub1">purulent effusion, etc. into, <a href="#Page_378">378</a>, <a href="#Page_390">390</a>, <a href="#Page_420">420</a>, <a href="#Page_435">435</a>.</li> -<li class="isub2">operation for, <a href="#Page_394">394</a>.</li> -<li class="isub1">non-penetrating wounds of, <a href="#Page_364">364</a>.</li> -<li class="isub1">value of auscultation in wounds of, <a href="#Page_367">367</a>.</li> -<li class="isub1">incised wounds of, <a href="#Page_364">364</a>, <a href="#Page_414">414</a>.</li> -<li class="isub1">wounds of both sides of, <a href="#Page_417">417</a>.</li> -<li class="isub1">large penetrating wounds of, the lung injured, <a href="#Page_418">418</a>.</li> -<li class="isub2">with hemorrhage into the cavity, <a href="#Page_421">421</a>.</li> -<li class="isub1">ecchymosis a sign of internal hemorrhage in penetrating wounds of, <a href="#Page_424">424</a>.</li> -<li class="isub1">conclusions respecting wounds of, <a href="#Page_424">424</a>.</li> -<li class="isub1">gunshot wounds of, <a href="#Page_426">426</a>.</li> -<li class="isub2">statistics of, <a href="#Page_426">426</a>.</li> -<li class="isub2">enlargement of, <a href="#Page_427">427</a>.</li> -<li class="isub2">fracture of the ribs in, <a href="#Page_428">428</a>.</li> -<li class="isub3">of the costal cartilages in, <a href="#Page_429">429</a>.</li> -<li class="isub2">involving the lungs, <a href="#Page_429">429</a>.</li> -<li class="isub2">removal of splinters, etc., <a href="#Page_445">445</a>.</li> -<li class="isub2">the ball loose in the cavity of the pleura, <a href="#Page_448">448</a>.</li> -<li class="isub3">rolling on the diaphragm, <a href="#Page_451">451</a>.</li> -<li class="isub3">inclosed in a cyst, <a href="#Page_451">451</a>.</li> -<li class="isub2">involving the lungs, effusion caused by, <a href="#Page_435">435</a>.</li> -<li class="isub2">formation of a dependent opening, <a href="#Page_452">452</a>.</li> -<li class="isub2">operation for the evacuation of the fluid, <a href="#Page_455">455</a>.</li> -<li class="isub2">anatomy of the parts concerned, <a href="#Page_453">453</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_596" id="Page_596">[596]</a></span> -Chloroform, use of, <a href="#Page_55">55</a>.</li> -<li class="isub1">Dr. Snow on, <a href="#Page_55">55</a>.</li> -<li class="isub1">Mr. Syme on the treatment of approaching death from, <a href="#Page_58">58</a>.</li> -<li class="isub1">amputation under the influence of, in the Crimea, <a href="#Page_561">561</a>.</li> -<li class="isub2">case of death from, <a href="#Page_561">561</a>.</li> -<li class="isub1">Deputy Inspector-General Taylor on, <a href="#Page_54">54</a>, <a href="#Page_562">562</a>.</li> -<li class="isub1">Deputy Inspector-General Alexander on, <a href="#Page_563">563</a>.</li> - -<li class="indx">Circulation, collateral, <a href="#Page_184">184</a>.</li> - -<li class="indx">Colon, Hilton’s operation for opening into, <a href="#Page_558">558</a>.</li> - -<li class="indx">Commentaries on the cases in the <i>Addenda</i>, <a href="#Page_586">586</a>.</li> - -<li class="indx">Compound fractures, <a href="#Page_145">145</a>.</li> -<li class="isub1">splints for, <a href="#Page_153">153</a>.</li> - -<li class="indx">Compression of the brain, <a href="#Page_302">302</a>.</li> -<li class="isub2">convulsions caused by, <a href="#Page_307">307</a>.</li> -<li class="isub2">paralysis caused by, <a href="#Page_305">305</a>.</li> -<li class="isub1">in hemorrhage from wounds of the hand, <a href="#Page_238">238</a>.</li> - -<li class="indx">Conclusions respecting wounds of the chest, <a href="#Page_424">424</a>.</li> -<li class="isub1">abdomen and pelvis, <a href="#Page_555">555</a>.</li> - -<li class="isub1">hospital gangrene, <a href="#Page_173">173</a>.</li> - -<li class="indx">Concussion of the brain, <a href="#Page_287">287</a>.</li> -<li class="isub1">causing mania, <a href="#Page_299">299</a>.</li> - -<li class="indx">Contre-coup, fracture of the skull by, <a href="#Page_316">316</a>.</li> -<li class="isub1">laceration of the brain by, <a href="#Page_340">340</a>.</li> - -<li class="indx">Contusions, severe, of abdomen, followed by rupture of the hollow or solid viscera, <a href="#Page_490">490</a>.</li> - -<li class="indx">Convulsions caused by compression of the brain, <a href="#Page_307">307</a>.</li> - -<li class="indx">Cooper, Sir A., mode of tying the external iliac, <a href="#Page_258">258</a>.</li> - -<li class="indx">Cranium, fracture of the base of, <a href="#Page_317">317</a>.</li> - -<li class="indx">Crepitating râle, or rhonchus, <a href="#Page_375">375</a>.</li> - -<li class="ifrst">Delpech on hospital gangrene, <a href="#Page_165">165</a>, <a href="#Page_166">166</a>, <a href="#Page_167">167</a>.</li> - -<li class="indx">Deposits, purulent, <a href="#Page_61">61</a>, <a href="#Page_68">68</a>.</li> - -<li class="indx">Depression of the skull, <a href="#Page_329">329</a>.</li> -<li class="isub1">of the back of the skull, with fracture, <a href="#Page_338">338</a>.</li> - -<li class="indx">Desault’s operation for artificial anus, <a href="#Page_527">527</a>.</li> - -<li class="indx">Diaphragm, ball rolling on the, <a href="#Page_451">451</a>.</li> -<li class="isub1">operation for the extraction of, <a href="#Page_455">455</a>.</li> -<li class="isub1">wounds of, <a href="#Page_458">458</a>.</li> -<li class="isub2">may cause internal hernia, <a href="#Page_463">463</a>.</li> - -<li class="indx">Dupuytren’s forceps for artificial anus, <a href="#Page_527">527</a>.</li> - -<li class="indx">Dura mater, incision of, <a href="#Page_343">343</a>.</li> -<li class="isub1">removal of blood from the surface of, <a href="#Page_360">360</a>.</li> -<li class="isub1">suppuration on the surface of, <a href="#Page_342">342</a>.</li> -<li class="isub1">wounds of, <a href="#Page_345">345</a>.</li> - -<li class="ifrst">Ecchymosis, a sign of hemorrhage into the chest, <a href="#Page_424">424</a>.</li> - -<li class="indx">Effusion, purulent, in penetrating wounds of the chest, <a href="#Page_420">420</a>, <a href="#Page_435">435</a>.</li> - -<li class="indx">Elbow-joint, amputation at, <a href="#Page_137">137</a>.</li> -<li class="isub1">excision of, <a href="#Page_135">135</a>, <a href="#Page_580">580</a>.</li> - -<li class="indx">Emphysema, <a href="#Page_410">410</a>.</li> -<li class="isub1">Mr. J. Bell on, in gunshot wounds of the chest, <a href="#Page_412">412</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_597" id="Page_597">[597]</a></span> -Empyema, <a href="#Page_390">390</a>, <a href="#Page_436">436</a>.</li> -<li class="isub1">operation for, <a href="#Page_394">394</a>, <a href="#Page_455">455</a>.</li> -<li class="isub2">M. Baudens on, <a href="#Page_452">452</a>.</li> -<li class="isub1">necessity for depending opening in, <a href="#Page_452">452</a>.</li> -<li class="isub1">Mr. Quekett’s experiments on the anatomy of the parts engaged in, <a href="#Page_452">452</a>.</li> -<li class="isub1">operation for, by incision, <a href="#Page_455">455</a>.</li> - -<li class="indx">Endocardial sound of the heart, <a href="#Page_466">466</a>.</li> - -<li class="indx">Epigastric artery, ligature of, <a href="#Page_510">510</a>.</li> - -<li class="indx">Erysipelas phlegmonodes, <a href="#Page_40">40</a>.</li> -<li class="isub1">improvement in the treatment of, <a href="#Page_41">41</a>.</li> -<li class="isub1">of the scrotum, <a href="#Page_42">42</a>.</li> -<li class="isub1">of the scalp, <a href="#Page_359">359</a>, <a href="#Page_363">363</a>.</li> - -<li class="indx">Excision of the ankle-joint, <a href="#Page_103">103</a>.</li> -<li class="isub1">calcis, <a href="#Page_104">104</a>.</li> -<li class="isub1">calcis and astragalus, <a href="#Page_115">115</a>.</li> - -<li class="isub1">elbow-joint, <a href="#Page_135">135</a>, <a href="#Page_580">580</a>.</li> -<li class="isub2">with injury to left hip, <a href="#Page_581">581</a>.</li> -<li class="isub1">head of the femur, <a href="#Page_90">90</a>, <a href="#Page_150">150</a>, <a href="#Page_564">564</a>, <a href="#Page_587">587</a>.</li> -<li class="isub2">in gunshot wounds of, <a href="#Page_150">150</a>.</li> -<li class="isub1">of the head, neck, and great trochanter of the femur, <a href="#Page_564">564</a>.</li> -<li class="isub1">of the head of the humerus, <a href="#Page_126">126</a>, <a href="#Page_571">571</a>, <a href="#Page_590">590</a>.</li> -<li class="isub2">Langenbeck’s operation for, <a href="#Page_130">130</a>.</li> -<li class="isub2">M. Baudens on, <a href="#Page_133">133</a>.</li> -<li class="isub1">of the knee-joint, <a href="#Page_97">97</a>.</li> -<li class="isub2">Mr. Jones’s mode of operating, <a href="#Page_97">97</a>, <a href="#Page_98">98</a>.</li> -<li class="isub2">Dr. Gurdon Buck’s operation for, <a href="#Page_97">97</a>.</li> -<li class="isub1">metacarpal bone of thumb, <a href="#Page_140">140</a>.</li> -<li class="isub1">phalangeal joints, Langenbeck’s operation for, <a href="#Page_140">140</a>.</li> - -<li class="indx">Excito-motory system of Dr. Marshall Hall, <a href="#Page_286">286</a>.</li> - -<li class="indx">Exfoliation of bone after amputation, <a href="#Page_89">89</a>.</li> - -<li class="indx">Exocardial sound of the heart, <a href="#Page_466">466</a>.</li> - -<li class="indx">Expiration, <a href="#Page_369">369</a>.</li> - -<li class="indx">Extraction of the ball in gunshot wounds, <a href="#Page_32">32</a>.</li> - -<li class="indx">Extremities, upper, gunshot wounds of, <a href="#Page_20">20</a>.</li> - -<li class="indx">Eye, ball lodged behind, <a href="#Page_478">478</a>.</li> -<li class="isub1">wounds of, <a href="#Page_477">477</a>.</li> - -<li class="indx">Eyelids and brow, wounds of, <a href="#Page_477">477</a>.</li> - -<li class="ifrst">Face, wounds of, <a href="#Page_476">476</a>.</li> -<li class="isub1">penetrating wounds of the bones of, <a href="#Page_479">479</a>.</li> - -<li class="indx">Femoral artery, gunshot wound of, a cause of local mortification, <a href="#Page_45">45</a>, <a href="#Page_226">226</a>.</li> -<li class="isub1">laceration of, <a href="#Page_208">208</a>.</li> -<li class="isub1">ligature of, <a href="#Page_260">260</a>.</li> -<li class="isub1">superficial ligature of, <a href="#Page_262">262</a>.</li> -<li class="isub1">and vein, injuries of, may cause gangrene, <a href="#Page_45">45</a>.</li> - -<li class="indx">Femur, removal of the head of, <a href="#Page_90">90</a>, <a href="#Page_150">150</a>, <a href="#Page_564">564</a>, <a href="#Page_587">587</a>.</li> -<li class="isub1">gunshot wounds of, <a href="#Page_145">145</a>, <a href="#Page_579">579</a>, <a href="#Page_587">587</a>.</li> -<li class="isub2">secondary amputation in, <a href="#Page_145">145</a>.</li> -<li class="isub2">of the head and neck of, <a href="#Page_150">150</a>.</li> -<li class="isub2">bedsteads for, <a href="#Page_152">152</a>.</li> - -<li class="indx">Fingers, amputation of, <a href="#Page_139">139</a>.</li> -<li class="isub1">mortification of, rarely caused by wound of axillary artery, <a href="#Page_46">46</a>.</li> - -<li class="indx">Fissure of the skull, <a href="#Page_311">311</a>.</li> - -<li class="indx">Foot, gunshot wounds of, <a href="#Page_107">107</a>, <a href="#Page_112">112</a>.</li> -<li class="isub1">amputation of, <a href="#Page_114">114</a>.</li> - -<li class="isub1"><span class="pagenum"><a name="Page_598" id="Page_598">[598]</a></span> -amputation of, by Roux’s plan, <a href="#Page_108">108</a>.</li> -<li class="isub2">at the ankle-joint, Mr. Syme’s operation for, <a href="#Page_105">105</a>.</li> -<li class="isub1">artificial, M. de Beaufoy’s, <a href="#Page_119">119</a>.</li> - -<li class="indx">Forearm, gunshot wounds of, <a href="#Page_137">137</a>.</li> -<li class="isub1">amputation of, <a href="#Page_137">137</a>.</li> -<li class="isub2">by flap operation, <a href="#Page_137">137</a>.</li> -<li class="isub2">by circular incision, <a href="#Page_138">138</a>.</li> -<li class="isub1">wounds of arteries of, <a href="#Page_238">238</a>.</li> - -<li class="indx">Forehead, gunshot wounds of, causing loss of sight, <a href="#Page_350">350</a>.</li> - -<li class="indx">Foreign body, lodgment of in a nerve, <a href="#Page_47">47</a>.</li> - -<li class="indx">Fowler’s solution of arsenic, in hospital gangrene, <a href="#Page_169">169</a>.</li> - -<li class="indx">Fractures, compound, <a href="#Page_145">145</a>.</li> -<li class="isub1">splints for, <a href="#Page_153">153</a>.</li> - -<li class="indx">Fracture, gunshot, of the leg, <a href="#Page_154">154</a>, <a href="#Page_588">588</a>.</li> -<li class="isub3">Mr. Luke’s apparatus for, <a href="#Page_154">154</a>.</li> -<li class="isub2">of the head of the femur, <a href="#Page_150">150</a>.</li> -<li class="isub2">of the upper extremities, <a href="#Page_120">120</a>.</li> -<li class="isub2">of the shoulder-joint, <a href="#Page_120">120</a>.</li> -<li class="isub2">of the elbow-joint, <a href="#Page_136">136</a>.</li> -<li class="isub2">of the arm, <a href="#Page_121">121</a>, <a href="#Page_156">156</a>.</li> -<li class="isub2">of the skull, <a href="#Page_311">311</a>.</li> -<li class="isub1">of the skull by contre-coup, <a href="#Page_316">316</a>.</li> -<li class="isub1">of the base of the cranium, <a href="#Page_317">317</a>.</li> -<li class="isub1">of the inner table of the skull, <a href="#Page_321">321</a>, <a href="#Page_324">324</a>, <a href="#Page_328">328</a>.</li> -<li class="isub1">with depression at the back part of the skull, <a href="#Page_338">338</a>.</li> -<li class="isub1">of the superior maxillary bone, <a href="#Page_582">582</a>.</li> -<li class="isub1">of the ribs in gunshot wounds of the chest, <a href="#Page_429">429</a>.</li> -<li class="isub1">of costal cartilages, ditto, <a href="#Page_429">429</a>.</li> - -<li class="indx">Frontal sinuses, gunshot wound of, <a href="#Page_350">350</a>.</li> - -<li class="indx">Fungus, or hernia cerebri, <a href="#Page_352">352</a>.</li> - -<li class="ifrst">Gall-bladder, gunshot wounds of, <a href="#Page_530">530</a>.</li> - -<li class="indx">Gangrene, hospital, <a href="#Page_163">163</a>.</li> -<li class="isub2">Fowler’s solution of arsenic in, <a href="#Page_169">169</a>.</li> -<li class="isub2">mineral acids in the treatment of, <a href="#Page_70">70</a>, <a href="#Page_168">168</a>.</li> -<li class="isub2">sloughing or pulpous form of, <a href="#Page_166">166</a>.</li> -<li class="isub2">conclusions respecting, <a href="#Page_173">173</a>.</li> -<li class="isub1">local and dry, from wound of the main artery of the lower extremity, <a href="#Page_44">44</a>, <a href="#Page_226">226</a>.</li> -<li class="isub1">traumatic, <a href="#Page_42">42</a>.</li> - -<li class="indx">Glands of Brunner, Grew, and Peyer, <a href="#Page_486">486</a>.</li> -<li class="isub1">solitary, <a href="#Page_487">487</a>.</li> - -<li class="indx">Gluteal artery, ligature of, <a href="#Page_259">259</a>.</li> - -<li class="indx">Goyraud’s operation for ligature of the internal mammary, <a href="#Page_473">473</a>.</li> - -<li class="indx">Grew, glands of, <a href="#Page_486">486</a>.</li> - -<li class="indx">Gross’s experiments on intestine, <a href="#Page_506">506</a>.</li> - -<li class="indx">Gunshot fractures of the upper extremities, <a href="#Page_120">120</a>.</li> -<li class="isub2">lower ditto, <a href="#Page_154">154</a>.</li> -<li class="isub1">wounds of axillary artery, rarely cause mortification of hand or fingers, <a href="#Page_46">46</a>, <a href="#Page_285">285</a>.</li> -<li class="isub2">extraction of the ball in, <a href="#Page_32">32</a>.</li> -<li class="isub2">of the foot, <a href="#Page_107">107</a>, <a href="#Page_112">112</a>.</li> - -<li class="isub3"><span class="pagenum"><a name="Page_599" id="Page_599">[599]</a></span> -knee-joint, <a href="#Page_94">94</a>, <a href="#Page_574">574</a>.</li> -<li class="isub3">shoulder-joint, <a href="#Page_120">120</a>.</li> -<li class="isub3">arm, <a href="#Page_121">121</a>, <a href="#Page_156">156</a>.</li> -<li class="isub3">elbow-joint, <a href="#Page_136">136</a>.</li> -<li class="isub3">forearm, <a href="#Page_137">137</a>.</li> -<li class="isub3">hand, <a href="#Page_139">139</a>.</li> -<li class="isub3">femur, <a href="#Page_145">145</a>, <a href="#Page_579">579</a>, <a href="#Page_587">587</a>.</li> -<li class="isub4">head and neck of, <a href="#Page_150">150</a>.</li> -<li class="isub3">face, <a href="#Page_479">479</a>.</li> -<li class="isub3">leg, <a href="#Page_154">154</a>, <a href="#Page_588">588</a>.</li> -<li class="isub3">lower jaw, <a href="#Page_480">480</a>.</li> -<li class="isub3">skull, <a href="#Page_346">346</a>, <a href="#Page_584">584</a>.</li> -<li class="isub3">frontal sinuses, <a href="#Page_350">350</a>.</li> -<li class="isub3">forehead, causing loss of sight, <a href="#Page_353">353</a>.</li> -<li class="isub3">orbit, <a href="#Page_350">350</a>, <a href="#Page_583">583</a>.</li> -<li class="isub3">superior maxillary bone, etc., <a href="#Page_582">582</a>.</li> -<li class="isub3">chest, <a href="#Page_426">426</a>.</li> -<li class="isub4">statistics of, <a href="#Page_426">426</a>.</li> -<li class="isub3">fracture of the ribs in, <a href="#Page_428">428</a>.</li> -<li class="isub4">costal cartilages in, <a href="#Page_429">429</a>.</li> -<li class="isub4">involving the lungs, <a href="#Page_429">429</a>.</li> -<li class="isub3">heart, <a href="#Page_468">468</a>.</li> -<li class="isub3">abdominal parietes, <a href="#Page_489">489</a>.</li> -<li class="isub3">intestine, <a href="#Page_515">515</a>.</li> -<li class="isub3">liver, <a href="#Page_528">528</a>.</li> -<li class="isub3">gall-bladder, <a href="#Page_530">530</a>.</li> -<li class="isub3">stomach, <a href="#Page_535">535</a>.</li> -<li class="isub3">spleen, <a href="#Page_536">536</a>.</li> -<li class="isub3">kidney, <a href="#Page_538">538</a>.</li> -<li class="isub3">spermatic cord and testicle, <a href="#Page_539">539</a>.</li> -<li class="isub3">penis, <a href="#Page_540">540</a>.</li> -<li class="isub3">pelvis, <a href="#Page_541">541</a>.</li> -<li class="isub3">bladder, <a href="#Page_546">546</a>.</li> -<li class="isub3">rectum, <a href="#Page_555">555</a>.</li> -<li class="isub3">inflammation consequent on, <a href="#Page_30">30</a>.</li> - -<li class="indx">Guthrie, Mr., mode of amputating at the hip-joint, <a href="#Page_79">79</a>, <a href="#Page_83">83</a>.</li> -<li class="isub1">theory respecting wounded arteries, <a href="#Page_189">189</a>.</li> - -<li class="ifrst">Hall, Dr. Marshall, excito-motory system of, <a href="#Page_286">286</a>.</li> - -<li class="indx">Hand, gunshot wounds of, <a href="#Page_139">139</a>.</li> -<li class="isub1">mortification of, rarely caused by wound of the axillary artery, <a href="#Page_46">46</a>, <a href="#Page_235">235</a>.</li> -<li class="isub1">compression in wounds of, <a href="#Page_238">238</a>.</li> - -<li class="indx">Head, injuries of, <a href="#Page_283">283</a>.</li> -<li class="isub1">affecting the brain, <a href="#Page_283">283</a>.</li> -<li class="isub1">causing abscess of the liver, <a href="#Page_356">356</a>.</li> -<li class="isub2">mania, <a href="#Page_299">299</a>.</li> - -<li class="indx">Heart, sounds of, <a href="#Page_465">465</a>.</li> -<li class="isub1">relative position of, <a href="#Page_464">464</a>.</li> -<li class="isub1">wounds of, <a href="#Page_464">464</a>.</li> -<li class="isub2">recovery after, <a href="#Page_464">464</a>, <a href="#Page_468">468</a>.</li> -<li class="isub1">insensibility of, <a href="#Page_471">471</a>.</li> -<li class="isub1">laceration and rupture of, <a href="#Page_472">472</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_600" id="Page_600">[600]</a></span> -Hernia cerebri, <a href="#Page_352">352</a>.</li> -<li class="isub1">of the lung, <a href="#Page_456">456</a>.</li> -<li class="isub1">of the stomach or bowels into the chest, after wounds of the diaphragm, <a href="#Page_463">463</a>.</li> - -<li class="indx">Hevin on the swallowing of knives, <a href="#Page_535">535</a>.</li> - -<li class="indx">Hilton’s operation for opening into the colon, <a href="#Page_558">558</a>.</li> - -<li class="indx">Hip-joint, amputation at, <a href="#Page_77">77</a>, <a href="#Page_92">92</a>, <a href="#Page_562">562</a>, <a href="#Page_563">563</a>, <a href="#Page_586">586</a>.</li> -<li class="isub2">Mr. Guthrie’s operation for, <a href="#Page_79">79</a>, <a href="#Page_83">83</a>.</li> -<li class="isub2">Langenbeck’s, <a href="#Page_80">80</a>.</li> -<li class="isub2">Mr. Brownrigg’s, <a href="#Page_82">82</a>.</li> -<li class="isub1">injury to, with excision of elbow-joint, <a href="#Page_581">581</a>.</li> - -<li class="indx">Hemorrhage after a gunshot wound, <a href="#Page_25">25</a>.</li> -<li class="isub1">secondary, <a href="#Page_208">208</a>.</li> -<li class="isub2">from the intercostal artery, <a href="#Page_474">474</a>.</li> -<li class="isub1">after the carrying away a limb by cannon-shot, <a href="#Page_25">25</a>.</li> -<li class="isub1">from sloughing stumps, <a href="#Page_71">71</a>.</li> -<li class="isub1">means used by nature for the suppression of, <a href="#Page_187">187</a>, <a href="#Page_191">191</a>.</li> -<li class="isub1">from large arteries, mode of arresting, <a href="#Page_234">234</a>.</li> -<li class="isub1">from wounds in the hand, compression in, <a href="#Page_288">288</a>.</li> -<li class="isub1">in penetrating wounds of the chest, <a href="#Page_421">421</a>.</li> -<li class="isub1">in wounds of the heart, <a href="#Page_468">468</a>.</li> -<li class="isub1">in penetrating wounds of the abdomen, <a href="#Page_510">510</a>.</li> - -<li class="indx">Hospital gangrene, <a href="#Page_163">163</a>.</li> -<li class="isub1">Deputy Inspector-General Taylor on, <a href="#Page_171">171</a>.</li> -<li class="isub1">Dr. Tice on, <a href="#Page_165">165</a>.</li> -<li class="isub1">M. Delpech on, <a href="#Page_165">165</a>, <a href="#Page_166">166</a>, <a href="#Page_167">167</a>.</li> -<li class="isub1">Mr. Blackadder on, <a href="#Page_164">164</a>, <a href="#Page_169">169</a>.</li> -<li class="isub1">Dr. Boggie on, <a href="#Page_168">168</a>, <a href="#Page_169">169</a>.</li> -<li class="isub1">Dr. Walker on, <a href="#Page_170">170</a>.</li> -<li class="isub1">mineral acids in the treatment of, <a href="#Page_70">70</a>, <a href="#Page_168">168</a>.</li> -<li class="isub1">use of Fowler’s solution of arsenic in, <a href="#Page_169">169</a>.</li> -<li class="isub1">sloughing or pulpous form of, <a href="#Page_166">166</a>.</li> -<li class="isub1">conclusions respecting, <a href="#Page_173">173</a>.</li> -<li class="isub1">hospital returns respecting, <a href="#Page_175">175</a>.</li> - -<li class="indx">Hospital, statistics of operations, <a href="#Page_158">158</a>.</li> - -<li class="indx">Hughes, Dr., on pneumothorax, <a href="#Page_396">396</a>.</li> - -<li class="indx">Humerus, amputation of, below the tuberosities, <a href="#Page_127">127</a>.</li> -<li class="isub1">excision of the head of, <a href="#Page_126">126</a>, <a href="#Page_571">571</a>.</li> -<li class="isub2">by Langenbeck’s operation, <a href="#Page_130">130</a>.</li> -<li class="isub2">M. Baudens on, <a href="#Page_133">133</a>.</li> -<li class="isub1">ball lodged in the head of, <a href="#Page_128">128</a>.</li> -<li class="isub1">amputation of, by the circular incision, <a href="#Page_134">134</a>.</li> -<li class="isub2">Mr. Luke’s, by two flaps, <a href="#Page_135">135</a>.</li> -<li class="isub1">gunshot fracture of, <a href="#Page_156">156</a>.</li> - -<li class="indx">Hunter, John, on inflammation of the veins, <a href="#Page_70">70</a>.</li> - -<li class="indx">Hunterian theory of aneurism, <a href="#Page_188">188</a>.</li> -<li class="isub1">inapplicable to the treatment of wounded arteries, <a href="#Page_189">189</a>.</li> - -<li class="ifrst">Iliac, external, ligature of, <a href="#Page_257">257</a>.</li> -<li class="isub1">internal, ligature of, <a href="#Page_256">256</a>.</li> - -<li class="indx">Iliacs, common, relative situation of, <a href="#Page_251">251</a>.</li> -<li class="isub1">ligature of, <a href="#Page_252">252</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_601" id="Page_601">[601]</a></span> -Immediate amputation, question as to, <a href="#Page_51">51</a>.</li> -<li class="isub2">cases for, <a href="#Page_150">150</a>.</li> -<li class="isub1">tumors of the scalp, <a href="#Page_340">340</a>.</li> - -<li class="indx">Incisions, use of, in erysipelas phlegmonodes, <a href="#Page_40">40</a>.</li> - -<li class="indx">Inflammation consequent on gunshot wound, <a href="#Page_30">30</a>.</li> -<li class="isub1">acute idiopathic, of the pleura, <a href="#Page_370">370</a>, <a href="#Page_376">376</a>.</li> -<li class="isub2">of the lungs, <a href="#Page_373">373</a>, <a href="#Page_380">380</a>.</li> -<li class="isub1">typhoid, of the lungs, <a href="#Page_388">388</a>.</li> -<li class="isub2">of the pleura, <a href="#Page_390">390</a>.</li> - -<li class="indx">Innominata, ligature of, <a href="#Page_273">273</a>.</li> - -<li class="indx">Inspiration, <a href="#Page_368">368</a>.</li> - -<li class="indx">Intercostal artery, wounds of, <a href="#Page_474">474</a>.</li> - -<li class="indx">Internal carotid, wounds of, through the mouth, <a href="#Page_245">245</a>.</li> -<li class="isub2">operation for, <a href="#Page_245">245</a>, <a href="#Page_248">248</a>, <a href="#Page_272">272</a>.</li> -<li class="isub1">mammary artery, wounds of, <a href="#Page_473">473</a>.</li> -<li class="isub1">strangulated hernia, after a wound of the diaphragm, <a href="#Page_463">463</a>.</li> - -<li class="indx">Intestine, structure of, <a href="#Page_482">482</a>.</li> -<li class="isub1">rupture of, <a href="#Page_491">491</a>.</li> -<li class="isub1">protrusion of, in penetrating wounds of abdomen, <a href="#Page_501">501</a>, <a href="#Page_509">509</a>.</li> -<li class="isub1">wounds of, <a href="#Page_504">504</a>, <a href="#Page_508">508</a>.</li> -<li class="isub2">punctured, <a href="#Page_504">504</a>, <a href="#Page_509">509</a>.</li> -<li class="isub2">Travers and Gross’s experiments on, <a href="#Page_506">506</a>.</li> -<li class="isub1">divided, treatment of, <a href="#Page_507">507</a>.</li> -<li class="isub2">Ramdohr on, <a href="#Page_507">507</a>.</li> -<li class="isub1">wounded, application of continuous suture to, <a href="#Page_508">508</a>.</li> -<li class="isub1">gunshot wounds of, <a href="#Page_515">515</a>.</li> - -<li class="ifrst">Jaw, lower, wounds of, <a href="#Page_480">480</a>.</li> -<li class="isub2">Baudens’s operation for, <a href="#Page_480">480</a>.</li> -<li class="isub1">upper, wounds of, <a href="#Page_479">479</a>.</li> - -<li class="indx">Jones’s mode of excising the knee-joint, <a href="#Page_97">97</a>, <a href="#Page_98">98</a>.</li> - -<li class="ifrst">Knee-joint, gunshot wounds of, with fracture of the bones, <a href="#Page_94">94</a>.</li> -<li class="isub1">excision of, <a href="#Page_97">97</a>.</li> -<li class="isub2">Jones’s operation for, <a href="#Page_97">97</a>, <a href="#Page_98">98</a>.</li> -<li class="isub2">Dr. Gurdon Buck’s operation for, <a href="#Page_97">97</a>.</li> -<li class="isub1">loss of, by a round shot, <a href="#Page_574">574</a>.</li> - -<li class="indx">Kidney, wounds of, <a href="#Page_537">537</a>.</li> - -<li class="indx">Knives, etc. in the stomach, <a href="#Page_535">535</a>.</li> -<li class="isub1">operation for their removal, <a href="#Page_536">536</a>.</li> - -<li class="ifrst">Laceration of the femoral artery, <a href="#Page_208">208</a>.</li> -<li class="isub1">brain by contre-coup, <a href="#Page_340">340</a>.</li> -<li class="isub1">and rupture of the heart, <a href="#Page_472">472</a>.</li> - -<li class="indx">Langenbeck’s mode of amputating at the hip-joint, <a href="#Page_80">80</a>.</li> -<li class="isub1">excision of the head of the humerus, <a href="#Page_130">130</a>.</li> -<li class="isub2">phalangeal joints, <a href="#Page_140">140</a>.</li> -<li class="isub2">metacarpal bone of thumb, <a href="#Page_141">141</a>.</li> - -<li class="indx">Larrey’s operation for opening the pericardium, <a href="#Page_469">469</a>.</li> -<li class="isub1">ligature of the femoral artery, prior to amputation at the hip-joint, <a href="#Page_79">79</a>.</li> - -<li class="indx">Lateral sinus, wounds of, <a href="#Page_351">351</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_602" id="Page_602">[602]</a></span> -Larynx, wound of, <a href="#Page_571">571</a>.</li> - -<li class="indx">Lee, Mr. Henry, on phlebitis, <a href="#Page_70">70</a>.</li> - -<li class="indx">Leg, gunshot fractures of, <a href="#Page_154">154</a>, <a href="#Page_588">588</a>.</li> -<li class="isub1">amputation of, <a href="#Page_99">99</a>.</li> -<li class="isub2">by the circular incision, <a href="#Page_99">99</a>.</li> -<li class="isub2">by Luke’s flap operation, <a href="#Page_101">101</a>.</li> -<li class="isub2">immediately below the tuberosity of the tibia, <a href="#Page_102">102</a>.</li> -<li class="isub1">apparatus for compound fracture of, <a href="#Page_154">154</a>.</li> -<li class="isub2">for slinging, when broken, <a href="#Page_589">589</a>.</li> - -<li class="indx">Ligature on an artery, effects of, <a href="#Page_203">203</a>.</li> -<li class="isub1">size of, etc., <a href="#Page_207">207</a>.</li> -<li class="isub1">one, utterly insufficient to control hemorrhage from a wounded artery, <a href="#Page_245">245</a>.</li> - -<li class="indx">Lisfranc’s amputation at the shoulder-joint, <a href="#Page_125">125</a>.</li> - -<li class="indx">Liver, abscess of, consequent to injuries of the head, <a href="#Page_356">356</a>.</li> -<li class="isub1">wounds and injuries of, <a href="#Page_528">528</a>.</li> -<li class="isub1">removal of portions of, <a href="#Page_533">533</a>.</li> -<li class="isub1">lodgment of balls in, <a href="#Page_532">532</a>.</li> - -<li class="indx">Longitudinal sinus, wounds of, <a href="#Page_351">351</a>.</li> - -<li class="indx">Luke’s flap amputation of the thigh, <a href="#Page_86">86</a>.</li> -<li class="isub2">leg, <a href="#Page_101">101</a>.</li> -<li class="isub2">arm, <a href="#Page_135">135</a>.</li> -<li class="isub1">apparatus for compound fracture of the leg, <a href="#Page_154">154</a>.</li> - -<li class="indx">Lung, hernia of, <a href="#Page_456">456</a>.</li> - -<li class="indx">Lungs, acute inflammation of, <a href="#Page_373">373</a>, <a href="#Page_380">380</a>.</li> -<li class="isub2">morbid changes caused by, <a href="#Page_380">380</a>.</li> -<li class="isub1">typhoid inflammation of, <a href="#Page_388">388</a>.</li> -<li class="isub1">gunshot wounds of, <a href="#Page_413">413</a>.</li> -<li class="isub1">removal of splinters from, <a href="#Page_445">445</a>.</li> - -<li class="ifrst">Machine for raising wounded soldiers in bed, <a href="#Page_589">589</a>.</li> - -<li class="indx">Mammary, internal, wounds of, <a href="#Page_473">473</a>.</li> -<li class="isub1">Goyraud’s operation for ligature of, <a href="#Page_473">473</a>.</li> - -<li class="indx">Mania caused by concussion of the brain, <a href="#Page_299">299</a>.</li> - -<li class="indx">Maxillary bone, superior, gunshot fracture of, <a href="#Page_582">582</a>.</li> - -<li class="indx">Membrane, mucous, of the stomach, <a href="#Page_485">485</a>.</li> - -<li class="indx">Meningeal artery, middle, injury of, <a href="#Page_314">314</a>.</li> - -<li class="indx">Metacarpal bone of thumb, excision of, <a href="#Page_140">140</a>.</li> -<li class="isub1">bones, amputation of, <a href="#Page_139">139</a>.</li> - -<li class="indx">Metatarsal bone, amputation of, <a href="#Page_118">118</a>.</li> - -<li class="indx">Mineral acids, use of, in hospital gangrene, etc., <a href="#Page_70">70</a>, <a href="#Page_168">168</a>.</li> - -<li class="indx">Mortification, <a href="#Page_42">42</a>.</li> -<li class="isub1">from wind of cannon-shot, not admitted, <a href="#Page_43">43</a>.</li> -<li class="isub1">from extensive injuries from large shot, etc., <a href="#Page_44">44</a>.</li> -<li class="isub1">from gunshot wound of main artery of a limb, <a href="#Page_45">45</a>, <a href="#Page_226">226</a>.</li> -<li class="isub1">of hand and fingers, rarely caused by wound of the axillary artery, <a href="#Page_46">46</a>, <a href="#Page_235">235</a>.</li> -<li class="isub1">from cold, <a href="#Page_46">46</a>.</li> - -<li class="indx">Motions of the brain, <a href="#Page_303">303</a>.</li> - -<li class="indx">Mouth, wound of the internal carotid through, <a href="#Page_245">245</a>.</li> -<li class="isub1">operation for, <a href="#Page_245">245</a>, <a href="#Page_248">248</a>, <a href="#Page_272">272</a>.</li> - -<li class="indx">Mucous membrane of the stomach, <a href="#Page_485">485</a>.</li> - -<li class="indx">Musket-ball wounds. See <i>gunshot wounds</i>.</li> - -<li class="ifrst"><span class="pagenum"><a name="Page_603" id="Page_603">[603]</a></span> -Neck, wounds of, <a href="#Page_242">242</a>, <a href="#Page_475">475</a>.</li> -<li class="isub1">Velpeau on wounded arteries of, <a href="#Page_246">246</a>.</li> - -<li class="indx">Nerve, consequences of the section of, <a href="#Page_47">47</a>.</li> -<li class="isub1">lodgment of a foreign body in, <a href="#Page_47">47</a>.</li> -<li class="isub1">enlargement, of extremity of, after amputation, <a href="#Page_89">89</a>.</li> -<li class="isub1">consequences of incomplete section of, <a href="#Page_47">47</a>.</li> - -<li class="indx">Nose, wounds of, <a href="#Page_477">477</a>.</li> - -<li class="ifrst">Occiput, depression and fracture of, <a href="#Page_338">338</a>.</li> - -<li class="indx">Œgophony, <a href="#Page_373">373</a>.</li> - -<li class="indx">Ollivier on lacerations and ruptures of the heart, <a href="#Page_472">472</a>.</li> - -<li class="indx">Omentum, protrusion of, in penetrating wounds of abdomen, <a href="#Page_498">498</a>.</li> - -<li class="indx">Operations, hospital statistics of, <a href="#Page_158">158</a>.</li> - -<li class="indx">Orbit, wounds of, <a href="#Page_350">350</a>, <a href="#Page_583">583</a>.</li> - -<li class="indx">Os calcis, removal of, <a href="#Page_104">104</a>.</li> - -<li class="ifrst">Patella, compound gunshot fractures of, <a href="#Page_95">95</a>.</li> - -<li class="indx">Paracentesis thoracis, <a href="#Page_394">394</a>, <a href="#Page_455">455</a>.</li> - -<li class="indx">Paralysis, the result of compression of the brain, <a href="#Page_305">305</a>.</li> - -<li class="indx">Parotid gland, wounds of, <a href="#Page_479">479</a>.</li> -<li class="isub1">and duct, wounds of, <a href="#Page_479">479</a>.</li> - -<li class="indx">Pelvis, wounds of, <a href="#Page_541">541</a>.</li> -<li class="isub1">balls lodging in, <a href="#Page_545">545</a>.</li> -<li class="isub1">and abdomen, conclusions respecting wounds of, <a href="#Page_555">555</a>.</li> - -<li class="indx">Penis, wounds of, <a href="#Page_540">540</a>.</li> - -<li class="indx">Pericardium, Larrey’s operation for opening, <a href="#Page_469">469</a>.</li> -<li class="isub1">Skielderup’s ditto, <a href="#Page_469">469</a>.</li> - -<li class="indx">Peroneal artery, ligature of, <a href="#Page_266">266</a>.</li> - -<li class="indx">Peyer, glands of, <a href="#Page_486">486</a>.</li> - -<li class="indx">Phagedena gangrenosa, <a href="#Page_163">163</a>.</li> - -<li class="indx">Phalangeal joints, excision of, <a href="#Page_140">140</a>.</li> - -<li class="indx">Phalanges, amputation of, <a href="#Page_140">140</a>.</li> - -<li class="indx">Phlebitis, <a href="#Page_60">60</a>, <a href="#Page_62">62</a>, <a href="#Page_63">63</a>.</li> -<li class="isub1">Mr. Hunter on, <a href="#Page_70">70</a>.</li> -<li class="isub1">Mr. Henry Lee on, <a href="#Page_70">70</a>.</li> -<li class="isub1">Dr. Hughes Bennett on, <a href="#Page_71">71</a>.</li> - -<li class="indx">Plantar artery, external, ligature of, <a href="#Page_267">267</a>.</li> - -<li class="indx">Pleura, acute idiopathic inflammation of, <a href="#Page_370">370</a>, <a href="#Page_376">376</a>.</li> -<li class="isub1">typhoid ditto, <a href="#Page_390">390</a>.</li> -<li class="isub1">effusion into the cavity of, <a href="#Page_371">371</a>, <a href="#Page_378">378</a>, <a href="#Page_420">420</a>.</li> -<li class="isub1">purulent ditto, <a href="#Page_379">379</a>, <a href="#Page_390">390</a>.</li> -<li class="isub2">operation for, <a href="#Page_393">393</a>.</li> -<li class="isub1">balls or other foreign bodies loose in the cavity of, <a href="#Page_418">418</a>.</li> - -<li class="indx">Pneumonia, <a href="#Page_373">373</a>, <a href="#Page_379">379</a>.</li> -<li class="isub1">morbid changes caused by, <a href="#Page_380">380</a>.</li> -<li class="isub1">typhoid, <a href="#Page_388">388</a>.</li> - -<li class="indx">Pneumothorax, <a href="#Page_396">396</a>, <a href="#Page_402">402</a>.</li> -<li class="isub1">Dr. Hughes on, <a href="#Page_396">396</a>.</li> - -<li class="indx">Popliteal aneurism, operation for, <a href="#Page_263">263</a>.</li> -<li class="isub1">artery, not to be tied, unless wounded and bleeding, <a href="#Page_265">265</a>.</li> -<li class="isub2">wound of, <a href="#Page_573">573</a>.</li> - -<li class="indx">Pourriture d’hôpital, <a href="#Page_163">163</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_604" id="Page_604">[604]</a></span> -Primary amputation, advantages of, <a href="#Page_59">59</a>.</li> - -<li class="isub1">not required in gunshot wounds of the upper extremity, <a href="#Page_120">120</a>.</li> - -<li class="indx">Profunda femoris, ligature of, <a href="#Page_261">261</a>.</li> -<li class="isub1">wound of, <a href="#Page_573">573</a>.</li> - -<li class="indx">Protrusion of bone after amputation, <a href="#Page_89">89</a>.</li> -<li class="isub1">of the brain, <a href="#Page_352">352</a>.</li> - -<li class="indx">Pulpous form of hospital gangrene, <a href="#Page_166">166</a>.</li> - -<li class="indx">Purulent deposits, <a href="#Page_61">61</a>, <a href="#Page_68">68</a>.</li> - -<li class="ifrst">Quekett, Mr., experiments on the anatomy of the parts engaged in empyema, and the operation by incision, <a href="#Page_452">452</a>.</li> -<li class="isub1">on the structure of the agminated glands of Grew and Peyer, <a href="#Page_486">486</a>.</li> - -<li class="ifrst">Radial artery, wound of, <a href="#Page_238">238</a>.</li> -<li class="isub1">ligature of, <a href="#Page_282">282</a>.</li> -<li class="isub1">wound of, in the hand, <a href="#Page_238">238</a>.</li> -<li class="isub2">operation for, <a href="#Page_282">282</a>.</li> - -<li class="indx">Ramdohr on the treatment of divided intestine, <a href="#Page_507">507</a>.</li> - -<li class="indx">Ravaton on protrusion of omentum in penetrating wounds of abdomen, <a href="#Page_501">501</a>.</li> - -<li class="indx">Rectum, wounds of, <a href="#Page_555">555</a>.</li> - -<li class="indx">Removal of the head of the femur, <a href="#Page_90">90</a>.</li> -<li class="isub2">and neck of, in gunshot wounds of, <a href="#Page_150">150</a>.</li> -<li class="isub1">os calcis, <a href="#Page_104">104</a>.</li> -<li class="isub1">astragalus and calcis, <a href="#Page_115">115</a>.</li> - -<li class="indx">Respiration, the four movements of, <a href="#Page_285">285</a>.</li> -<li class="isub1">distinction of sounds during, <a href="#Page_367">367</a>.</li> - -<li class="indx">Respiratory murmur, <a href="#Page_367">367</a>.</li> - -<li class="indx">Rhoncus crepitans, <a href="#Page_370">370</a>, <a href="#Page_375">375</a>.</li> - -<li class="indx">Ribs, fracture of, in gunshot wounds of the chest, <a href="#Page_428">428</a>.</li> -<li class="isub1">the cartilages of, <a href="#Page_429">429</a>.</li> - -<li class="indx">Roux’s amputation of the foot, <a href="#Page_108">108</a>.</li> - -<li class="indx">Rupture of the heart, <a href="#Page_472">472</a>.</li> -<li class="isub1">ventral, <a href="#Page_488">488</a>, <a href="#Page_493">493</a>.</li> -<li class="isub1">of intestine, by violence, <a href="#Page_491">491</a>.</li> -<li class="isub1">of the solid viscera, by violence, <a href="#Page_493">493</a>.</li> - -<li class="ifrst">Scalp, immediate and secondary tumors of, <a href="#Page_341">341</a>.</li> -<li class="isub1">wounds of, <a href="#Page_361">361</a>.</li> -<li class="isub1">erysipelas of, <a href="#Page_359">359</a>, <a href="#Page_363">363</a>.</li> - -<li class="indx">Sciatic artery, ligature of, <a href="#Page_259">259</a>.</li> - -<li class="indx">Scrotum, erysipelas phlegmonodes of, <a href="#Page_42">42</a>.</li> - -<li class="indx">Secondary amputations, <a href="#Page_59">59</a>, <a href="#Page_141">141</a>.</li> -<li class="isub2">in gunshot wounds of the femur, <a href="#Page_145">145</a>.</li> -<li class="isub1">hemorrhage, <a href="#Page_208">208</a>.</li> -<li class="isub1">tumors of the scalp, <a href="#Page_341">341</a>.</li> - -<li class="indx">Shock or constitutional alarm, <a href="#Page_26">26</a>.</li> - -<li class="indx">Shoulder-joint, gunshot wounds of, <a href="#Page_120">120</a>.</li> -<li class="isub1">amputation at, <a href="#Page_122">122</a>.</li> - -<li class="indx">Sight, loss of, from a musket-ball traversing the forehead, <a href="#Page_350">350</a>.</li> - -<li class="indx"> -Sinuses, frontal, gunshot injury to, <a href="#Page_350">350</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_605" id="Page_605">[605]</a></span> -Sinuses, longitudinal and lateral, wounds of, <a href="#Page_351">351</a>.</li> - -<li class="indx">Skielderup’s operation for opening the pericardium, <a href="#Page_469">469</a>.</li> - -<li class="indx">Skull, simple fissure or fracture of, <a href="#Page_311">311</a>.</li> -<li class="isub1">fracture of, by contre-coup, <a href="#Page_316">316</a>.</li> -<li class="isub2">the inner table of, <a href="#Page_321">321</a>, <a href="#Page_324">324</a>, <a href="#Page_328">328</a>.</li> -<li class="isub1">depression of, <a href="#Page_329">329</a>.</li> -<li class="isub2">and fracture of back part of, <a href="#Page_338">338</a>.</li> -<li class="isub1">gunshot wounds of, <a href="#Page_346">346</a>, <a href="#Page_584">584</a>.</li> -<li class="isub1">balls separating the sutures of, <a href="#Page_349">349</a>.</li> -<li class="isub1">removal of a large portion of, <a href="#Page_359">359</a>.</li> - -<li class="indx">Sloughing stumps, hemorrhage from, <a href="#Page_71">71</a>.</li> -<li class="isub1">form of hospital gangrene, <a href="#Page_166">166</a>.</li> -<li class="isub1">ulcer, <a href="#Page_164">164</a>.</li> -<li class="isub1">wounds, use of mineral acids in, <a href="#Page_70">70</a>.</li> - -<li class="indx">Snow, Dr., on chloroform, <a href="#Page_55">55</a>.</li> - -<li class="indx">Solitary glands, <a href="#Page_487">487</a>.</li> - -<li class="indx">Sounds, distinction of, in respiration, <a href="#Page_367">367</a>.</li> -<li class="isub1">of the heart, <a href="#Page_465">465</a>.</li> - -<li class="indx">Spermatic cord, wounds of, <a href="#Page_539">539</a>.</li> - -<li class="indx">Sphacelus, dry, from wound of main artery of lower extremity, <a href="#Page_45">45</a>, <a href="#Page_226">226</a>.</li> - -<li class="indx">Spine, effects of strychnia in injury of, <a href="#Page_574">574</a>.</li> - -<li class="indx">Spleen, wounds and injuries of, <a href="#Page_536">536</a>.</li> -<li class="isub1">removal of, <a href="#Page_538">538</a>.</li> - -<li class="indx">Splints for fractures, <a href="#Page_153">153</a>.</li> - -<li class="indx">Splinters, removal of, from a wounded lung, <a href="#Page_445">445</a>.</li> - -<li class="indx">Statham’s operation for removal of astragalus, <a href="#Page_110">110</a>.</li> - -<li class="indx">Statistics, hospital, of operations, <a href="#Page_158">158</a>.</li> -<li class="isub1">Burdach’s, of lesions of the brain, <a href="#Page_306">306</a>.</li> -<li class="isub1">of ligature of common carotid, <a href="#Page_241">241</a>.</li> - -<li class="indx">Stomach, mucous membrane of, <a href="#Page_485">485</a>.</li> -<li class="isub1">wounds of, <a href="#Page_533">533</a>.</li> -<li class="isub1">gunshot wounds of, <a href="#Page_535">535</a>.</li> -<li class="isub1">fistulous opening in, after gunshot wounds of, <a href="#Page_535">535</a>.</li> -<li class="isub1">knives in, <a href="#Page_535">535</a>.</li> -<li class="isub2">operation for the removal of, <a href="#Page_536">536</a>.</li> - -<li class="indx">Structure of arteries, <a href="#Page_176">176</a>.</li> -<li class="isub1">of intestine, <a href="#Page_482">482</a>.</li> - -<li class="indx">Strychnia, effects of, in injury of the spine, <a href="#Page_574">574</a>.</li> - -<li class="indx">Subclavian, ligature of, <a href="#Page_274">274</a>.</li> -<li class="isub1">above the clavicle, <a href="#Page_276">276</a>.</li> - -<li class="indx">Suppuration on the surface of the dura mater and brain, <a href="#Page_342">342</a>.</li> - -<li class="indx">Suture, continuous, for wounded intestine, <a href="#Page_508">508</a>.</li> -<li class="isub1">for incised wounds in abdominal parietes, <a href="#Page_493">493</a>.</li> - -<li class="indx">Sutures of the skull, separated by a ball, <a href="#Page_349">349</a>.</li> - -<li class="indx">Syme, Mr., amputation at the ankle-joint, <a href="#Page_105">105</a>.</li> -<li class="isub1">on the treatment of approaching death from chloroform, <a href="#Page_58">58</a>.</li> - -<li class="ifrst">Tarsus, amputation at, <a href="#Page_112">112</a>.</li> - -<li class="indx"> -Taylor, Deputy Inspector-General, on hospital gangrene, <a href="#Page_171">171</a>.</li> -<li class="isub1">on amputations under chloroform, <a href="#Page_54">54</a>, <a href="#Page_562">562</a>.</li> -<li class="isub1">on wound of the larynx, <a href="#Page_572">572</a>.</li> - -<li class="isub1"><span class="pagenum"><a name="Page_606" id="Page_606">[606]</a></span> -on the privations endured by the British soldiery in the Crimea, and their effects, <a href="#Page_562">562</a>.</li> - -<li class="indx">Testicle, removal of, after a wound, <a href="#Page_539">539</a>.</li> - -<li class="indx">Thigh, amputation of, by the circular incision, <a href="#Page_83">83</a>.</li> -<li class="isub2">by Luke’s flap operation, <a href="#Page_86">86</a>.</li> -<li class="isub1">arm and abdomen, extensive injury to, <a href="#Page_576">576</a>.</li> -<li class="isub1">gunshot fractures of, <a href="#Page_579">579</a>, <a href="#Page_587">587</a>.</li> - -<li class="indx">Thumb, excision of metacarpal bone of, <a href="#Page_140">140</a>.</li> - -<li class="indx">Tibia, amputation of the leg below the tuberosity of, <a href="#Page_102">102</a>.</li> - -<li class="indx">Tibial artery, anterior, ligature of, <a href="#Page_268">268</a>.</li> -<li class="isub1">posterior, ditto, <a href="#Page_266">266</a>.</li> - -<li class="indx">Tice, Dr., on hospital gangrene, <a href="#Page_165">165</a>.</li> - -<li class="indx">Tongue, wounds of, <a href="#Page_481">481</a>.</li> - -<li class="indx">Trant’s forceps for artificial anus, <a href="#Page_528">528</a>.</li> - -<li class="indx">Traumatic aneurism, formation of, <a href="#Page_214">214</a>.</li> -<li class="isub1">gangrene, <a href="#Page_42">42</a>.</li> - -<li class="indx">Travers’s experiments on intestine, <a href="#Page_506">506</a>.</li> - -<li class="indx">Trephine not applicable in simple fracture of the skull, without depression, <a href="#Page_312">312</a>.</li> -<li class="isub1">manner of applying, <a href="#Page_358">358</a>.</li> -<li class="isub1">use of, at different periods, <a href="#Page_327">327</a>.</li> -<li class="isub1">frequent application of, <a href="#Page_359">359</a>.</li> - -<li class="indx">Trochanter, head and neck of the femur, excision of, <a href="#Page_564">564</a>.</li> - -<li class="indx">Tumors, immediate and secondary, of the scalp, <a href="#Page_341">341</a>.</li> - -<li class="indx">Typhoid pleuritis, <a href="#Page_390">390</a>.</li> -<li class="isub1">pneumonia, <a href="#Page_388">388</a>.</li> - -<li class="ifrst">Ulnar artery, ligature of, <a href="#Page_281">281</a>.</li> -<li class="isub1">wound of, <a href="#Page_238">238</a>, <a href="#Page_281">281</a>.</li> - -<li class="ifrst">Valvulæ conniventes, <a href="#Page_483">483</a>.</li> - -<li class="indx">Veins, inflammation of, <a href="#Page_60">60</a>, <a href="#Page_62">62</a>.</li> -<li class="isub1">Mr. Hunter on, <a href="#Page_70">70</a>.</li> -<li class="isub1">Mr. Henry Lee on, <a href="#Page_70">70</a>.</li> -<li class="isub1">Dr. Hughes Bennett on, <a href="#Page_71">71</a>.</li> - -<li class="indx">Velpeau on wounded arteries of the neck, <a href="#Page_246">246</a>.</li> - -<li class="indx">Ventral rupture, <a href="#Page_488">488</a>, <a href="#Page_493">493</a>.</li> - -<li class="indx">Vertebral artery, wounds of, <a href="#Page_242">242</a>.</li> -<li class="isub1">ligature of, <a href="#Page_248">248</a>.</li> - -<li class="indx">Vesicular, or respiratory murmur, <a href="#Page_367">367</a>.</li> - -<li class="indx">Viscera, rupture of, <a href="#Page_491">491</a>.</li> -<li class="isub1">protrusion of, in penetrating wounds of the abdomen, <a href="#Page_498">498</a>.</li> - -<li class="ifrst">Wakley, Mr. T., removal of os calcis and astragalus, <a href="#Page_115">115</a>.</li> - -<li class="indx">Walker, Dr., on hospital gangrene, <a href="#Page_170">170</a>.</li> - -<li class="indx">Wounded, bearers for the, <a href="#Page_156">156</a>.</li> - -<li class="indx">Wound by a musket-ball, <a href="#Page_25">25</a>.</li> -<li class="isub1">shock or alarm after, <a href="#Page_26">26</a>.</li> - -<li class="indx">Wounds of entrance and exit, made by a musket-ball, <a href="#Page_27">27</a>, <a href="#Page_489">489</a>.</li> -<li class="isub1">from flattened balls, pieces of shell, etc., <a href="#Page_28">28</a>.</li> -<li class="isub1">gunshot, formation of sinuses in, <a href="#Page_31">31</a>.</li> -<li class="isub1">extraction of ball and other foreign substances, <a href="#Page_32">32</a>.</li> - -<li class="isub1"><span class="pagenum"><a name="Page_607" id="Page_607">[607]</a></span> -gunshot, the bone struck or penetrated, not broken, the ball lodging, <a href="#Page_36">36</a>.</li> -<li class="isub1">of the skull, <a href="#Page_346">346</a>, <a href="#Page_584">584</a>.</li> -<li class="isub1">of the forehead, causing loss of sight, <a href="#Page_350">350</a>.</li> -<li class="isub1">of the frontal sinuses, <a href="#Page_350">350</a>.</li> -<li class="isub1">by a bayonet thrust, <a href="#Page_37">37</a>.</li> -<li class="isub1">of the neck, with hemorrhage, <a href="#Page_242">242</a>, <a href="#Page_475">475</a>.</li> -<li class="isub1">of the larynx, <a href="#Page_571">571</a>.</li> -<li class="isub2">Deputy Inspector-General Taylor on, <a href="#Page_572">572</a>.</li> -<li class="isub1">of the orbit, <a href="#Page_350">350</a>, <a href="#Page_583">583</a>.</li> -<li class="isub1">of the longitudinal or lateral sinus, <a href="#Page_351">351</a>.</li> -<li class="isub1">of the arm, <a href="#Page_121">121</a>, <a href="#Page_156">156</a>.</li> -<li class="isub1">of the forearm, <a href="#Page_137">137</a>.</li> -<li class="isub1">of the profunda femoris, <a href="#Page_573">573</a>.</li> -<li class="isub1">of the popliteal artery, <a href="#Page_573">573</a>.</li> -<li class="isub1">of the abdomen, <a href="#Page_488">488</a>.</li> -<li class="isub2">causing abscess in paries of, <a href="#Page_489">489</a>.</li> -<li class="isub1">gunshot ditto, <a href="#Page_489">489</a>, <a href="#Page_515">515</a>.</li> -<li class="isub1">incised ditto, <a href="#Page_490">490</a>.</li> -<li class="isub2">followed by ventral rupture, <a href="#Page_493">493</a>.</li> -<li class="isub1">penetrating, <a href="#Page_497">497</a>.</li> -<li class="isub2">followed by protrusion of viscera, <a href="#Page_498">498</a>.</li> -<li class="isub3">of omentum, <a href="#Page_498">498</a>.</li> -<li class="isub3">of intestine, <a href="#Page_504">504</a>, <a href="#Page_508">508</a>.</li> -<li class="isub1">punctured ditto, <a href="#Page_504">504</a>, <a href="#Page_509">509</a>.</li> -<li class="isub1">of the chest, <a href="#Page_364">364</a>.</li> -<li class="isub2">non-penetrating, <a href="#Page_364">364</a>.</li> -<li class="isub2">incised, <a href="#Page_364">364</a>, <a href="#Page_414">414</a>.</li> -<li class="isub1">of both sides of the chest, <a href="#Page_417">417</a>.</li> -<li class="isub1">large, penetrating, of the chest, the lung being injured, <a href="#Page_418">418</a>.</li> -<li class="isub1">of the chest, conclusions respecting, <a href="#Page_424">424</a>.</li> -<li class="isub1">gunshot of the chest, <a href="#Page_426">426</a>.</li> -<li class="isub3">statistics of, <a href="#Page_426">426</a>.</li> -<li class="isub2">fracture of the ribs in, <a href="#Page_428">428</a>.</li> -<li class="isub3">costal cartilages in, <a href="#Page_429">429</a>.</li> -<li class="isub2">of the lung, <a href="#Page_429">429</a>.</li> -<li class="isub3">diaphragm, <a href="#Page_458">458</a>.</li> -<li class="isub3">heart, <a href="#Page_464">464</a>.</li> -<li class="isub3">internal mammary and intercostal arteries, <a href="#Page_473">473</a>.</li> -<li class="isub3">face, <a href="#Page_476">476</a>.</li> -<li class="isub3">eyelids and brow, <a href="#Page_477">477</a>.</li> -<li class="isub3">eye, <a href="#Page_477">477</a>.</li> -<li class="isub3">nose and ear, <a href="#Page_477">477</a>.</li> -<li class="isub2">penetrating, of the bones of the face, <a href="#Page_479">479</a>.</li> -<li class="isub2">of the parotid gland and duct, <a href="#Page_479">479</a>.</li> -<li class="isub3">upper jaw, <a href="#Page_479">479</a>.</li> -<li class="isub3">lower jaw, <a href="#Page_480">480</a>.</li> -<li class="isub1">of the head and neck of femur, <a href="#Page_150">150</a>.</li> -<li class="isub1">of the knee-joint, gunshot, <a href="#Page_94">94</a>.</li> -<li class="isub1">of the patella, ditto, <a href="#Page_95">95</a>.</li> -<li class="isub1">of the leg, <a href="#Page_154">154</a>.</li> -<li class="isub1">of the foot, <a href="#Page_107">107</a>.</li> - -<li class="isub1"><span class="pagenum"><a name="Page_608" id="Page_608">[608]</a></span> -of the tongue, <a href="#Page_481">481</a>.</li> -<li class="isub1">of the liver, <a href="#Page_528">528</a>.</li> -<li class="isub1">of the gall-bladder, <a href="#Page_530">530</a>.</li> -<li class="isub1">of the stomach, <a href="#Page_533">533</a>.</li> -<li class="isub1">of the stomach, gunshot, <a href="#Page_535">535</a>.</li> -<li class="isub1">of the spleen, <a href="#Page_536">536</a>.</li> -<li class="isub1">of the kidney, <a href="#Page_538">538</a>.</li> -<li class="isub1">of the spermatic cord and testicle, <a href="#Page_539">539</a>.</li> -<li class="isub1">of the penis, <a href="#Page_540">540</a>.</li> -<li class="isub1">of the pelvis, <a href="#Page_541">541</a>.</li> -<li class="isub1">gunshot, of the bladder, <a href="#Page_546">546</a>.</li> -<li class="isub1">of the rectum, <a href="#Page_555">555</a>.</li> -<li class="isub1">of the abdomen and pelvis, conclusions respecting, <a href="#Page_555">555</a>.</li> - -<li class="indx">Wrist, amputation at, <a href="#Page_138">138</a>.</li> -</ul> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="nobreak" id="INDEX_OF_CASES">INDEX OF CASES.</h2> -</div> - -<ul class="index"> -<li class="ifrst">A soldier, wounded in the thigh, the ball passing between the femoral artery and vein, <a href="#Page_26">26</a>.</li> - -<li class="indx">Generals Sir Lowry Cole, Sir E. Packenham, and Colonel Duckworth; injuries to arteries, <a href="#Page_26">26</a>.</li> - -<li class="indx">Colonel Sir W. Myers and General Sir R. Crawford, illustrating the shock of a severe wound, <a href="#Page_26">26</a>, <a href="#Page_27">27</a>.</li> - -<li class="indx">Colonel Ross; musket-shot wound of arm: gradual descent of the ball to the elbow, <a href="#Page_36">36</a>.</li> - -<li class="indx">Erysipelas phlegmonodes of the left arm, treated by incisions, <a href="#Page_41">41</a>.</li> - -<li class="indx">Local mortification of a leg struck by a cannon-shot, the internal textures being destroyed, <a href="#Page_43">43</a>.</li> - -<li class="indx">Section of the brachial plexus of nerves by a gunshot wound, causing paralysis, complicated by gunshot wound of the knee-joint, requiring secondary amputation, <a href="#Page_47">47</a>.</li> - -<li class="indx">Sir James Kempt; injury to a nerve, <a href="#Page_48">48</a>.</li> - -<li class="indx">Admiral Sir Philip Broke; wound of skull, with paralysis, <a href="#Page_48">48</a>.</li> - -<li class="indx">Brigade-Major Bissett; gunshot wound, injuring the left great sciatic nerve, perineum, and rectum, <a href="#Page_49">49</a>.</li> - -<li class="indx">Mr. Wrottesley, of the Engineers; right thigh shattered by a cannon-shot, etc., <a href="#Page_53">53</a>.</li> - -<li class="indx">An East Indian; severe wound of left thigh from the explosion of his gun; amputation, death, <a href="#Page_53">53</a>.</li> - -<li class="indx">A soldier of the siege train before Sebastopol; the left thigh nearly carried off by a cannot-shot, <a href="#Page_54">54</a>.</li> - -<li class="indx">Purulent deposit, after amputation, <a href="#Page_61">61</a>.</li> - -<li class="indx">Phlebitis, <a href="#Page_64">64</a>.</li> - -<li class="indx">Jane Strangemore; amputation of limb for white-swelling of the knee-joint; fatal phlebitis, <a href="#Page_64">64</a>.</li> - -<li class="indx">Endemic fever, after secondary amputation, with subacute pneumonia, <a href="#Page_67">67</a>, <a href="#Page_68">68</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_609" id="Page_609">[609]</a></span> -Sloughing of a spear-wound of the arm, <a href="#Page_69">69</a>.</li> - -<li class="indx">Captain Flack; cannon-shot wound of left thigh, <a href="#Page_77">77</a>.</li> - -<li class="indx">Excision of the head and neck of the femur, <a href="#Page_94">94</a>.</li> - -<li class="indx">Colonel Donnellan; musket-shot wound of knee-joint, <a href="#Page_96">96</a>.</li> - -<li class="indx">Excision of knee-joint, by Dr. Gurdon Buck, <a href="#Page_97">97</a>.</li> -<li class="isub1">by Mr. Jones of Jersey, <a href="#Page_97">97</a>, <a href="#Page_98">98</a>.</li> - -<li class="indx">Amputation of the foot, by Roux’s operation, <a href="#Page_108">108</a>.</li> - -<li class="indx">Ball lodged in the astragalus, <a href="#Page_110">110</a>.</li> - -<li class="indx">Excision of the astragalus and calcis, <a href="#Page_115">115</a>.</li> -<li class="isub1">head of the humerus, a musket-ball having lodged in the bone, <a href="#Page_128">128</a>, <a href="#Page_131">131</a>.</li> - -<li class="indx">Gunshot wounds of the shoulder-joint, <a href="#Page_131">131</a>, <a href="#Page_132">132</a>.</li> - -<li class="indx">Lieutenant Timbrell; gunshot fracture of both thighs; recovery without amputation, <a href="#Page_149">149</a>.</li> - -<li class="indx">Illustrative of the means used by nature for the suppression of hemorrhage, <a href="#Page_194">194</a>.</li> - -<li class="indx">Illustrative of gunshot wounds of the femoral artery, <a href="#Page_196">196</a>, <a href="#Page_208">208</a>.</li> - -<li class="indx">Ligature of the right common iliac artery, for supposed gluteal aneurism, <a href="#Page_206">206</a>.</li> - -<li class="indx">Punctured wounds of arteries, <a href="#Page_210">210</a>.</li> - -<li class="indx">Colonel Fane; wound of carotid by an arrow; formation of an aneurism, <a href="#Page_211">211</a>.</li> - -<li class="indx">Scythe wound of the femoral artery, <a href="#Page_213">213</a>.</li> - -<li class="indx">Wound of femoral artery with a pen-knife; closure of wound; formation of traumatic aneurism, <a href="#Page_215">215</a>.</li> - -<li class="indx">Gunshot wound of the thigh; severe hemorrhage finally arrested without ligature of the artery, <a href="#Page_216">216</a>.</li> - -<li class="indx">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, <a href="#Page_218">218</a>.</li> - -<li class="indx">Duckshot wound of thigh; closure of wound; aneurismal swelling punctured; hemorrhage; ligature of femoral high up; death, <a href="#Page_218">218</a>.</li> - -<li class="indx">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, <a href="#Page_219">219</a>.</li> - -<li class="indx">Dry gangrene, from injury to the main artery of the lower extremity, <a href="#Page_227">227</a>.</li> -<li class="isub1">following an injury to the popliteal space; large incision in the calf, evacuating a quantity of coagulated blood; subsequent separation of the limb, <a href="#Page_228">228</a>.</li> - -<li class="indx">Gunshot wound of the posterior tibial artery; secondary hemorrhage and traumatic aneurism; ligature of the femoral artery, renewal of the hemorrhage, amputation, death, <a href="#Page_230">230</a>.</li> -<li class="isub1">of the peroneal artery, hemorrhage and formation of an aneurism; ligature of the wounded vessel; recovery, <a href="#Page_231">231</a>.</li> - -<li class="indx">Axillary aneurism from a bruise; ligature of the subclavian; rupture of the sac; death, <a href="#Page_236">236</a>.</li> - -<li class="indx">Shell injury; amputation of right leg and arm; secondary hemorrhage; ligature of the subclavian near the seat of the bleeding, <a href="#Page_237">237</a>.</li> - -<li class="indx">Wounds of the vertebral artery, recorded by Breschet, Chiari, Ramaglia, and Maisonneuve, <a href="#Page_242">242</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_610" id="Page_610">[610]</a></span> -Wound of the external carotid during an operation; utter insufficiency of one ligature, <a href="#Page_244">244</a>, <a href="#Page_245">245</a>.</li> - -<li class="indx">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, <a href="#Page_247">247</a>.</li> - -<li class="indx">Wound of internal carotid through the mouth; successful ligature of the vessel, <a href="#Page_249">249</a>.</li> - -<li class="indx">Ligature of the common iliac artery, <a href="#Page_252">252</a>.</li> - -<li class="indx">Wound of the gluteal artery; ligature of that artery and of the internal iliac; death, <a href="#Page_260">260</a>.</li> - -<li class="indx">Wound of the popliteal artery by a mortising chisel; secondary hemorrhage; ligature of the femoral unsuccessful; cure by ligature of the popliteal, <a href="#Page_265">265</a>.</li> - -<li class="indx">Balls lodging in the brain, <a href="#Page_284">284</a>.</li> - -<li class="indx">Concussion in a child, <a href="#Page_289">289</a>.</li> - -<li class="indx">Coup-de-soleil, <a href="#Page_293">293</a>.</li> - -<li class="indx">Concussion of the brain, passing into excitement, etc., <a href="#Page_294">294</a>.</li> - -<li class="indx">Gouty inflammation, transferred to the brain, <a href="#Page_296">296</a>.</li> - -<li class="indx">Illustrative of the treatment of concussion, <a href="#Page_297">297</a>.</li> - -<li class="indx">Concussion, complicated by the symptoms of compression, <a href="#Page_298">298</a>.</li> -<li class="isub1">followed by mania, <a href="#Page_300">300</a>.</li> - -<li class="indx">Illustrative of the after-effects of concussion, <a href="#Page_301">301</a>.</li> - -<li class="indx">Fatal paralysis, caused by compression of the brain, <a href="#Page_307">307</a>.</li> - -<li class="indx">Illustrative of the different forms of paralysis following compression or irritation of the brain, <a href="#Page_309">309</a>.</li> - -<li class="indx">Fracture of the skull without depression, <a href="#Page_311">311</a>.</li> - -<li class="indx">Fracture of the skull, with injury to the middle meningeal artery, <a href="#Page_315">315</a>.</li> - -<li class="indx">Fracture of the base of the cranium, <a href="#Page_317">317</a>.</li> - -<li class="indx">Fracture of the inner table of the skull, without injury to the outer plate of bone, <a href="#Page_322">322</a>.</li> - -<li class="indx">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, <a href="#Page_323">323</a>.</li> - -<li class="indx">Illustrative of a peculiar fracture of the inner table of the skull, with a cutting instrument, <a href="#Page_325">325</a>.</li> - -<li class="indx">Gunshot wounds of the skull and brain, the ball lodging, <a href="#Page_331">331</a>, <a href="#Page_343">343</a>, <a href="#Page_348">348</a>.</li> - -<li class="indx">Injury to the head from a fall; large abstraction of blood, <a href="#Page_334">334</a>.</li> - -<li class="indx">Comminuted fracture of the skull, by a piece of shell, <a href="#Page_336">336</a>.</li> - -<li class="indx">Injury to the head, the symptoms of concussion and compression being combined, <a href="#Page_338">338</a>.</li> - -<li class="indx">Gunshot fracture of the left parietal, with suppuration on the surface of, and in the substance of the brain, <a href="#Page_343">343</a>.</li> - -<li class="indx">Gunshot wound of the skull, the breech-pin of the gun lodging in the brain, <a href="#Page_348">348</a>.</li> - -<li class="indx">Separation of the sagittal suture by a fall, consequent to a gunshot wound of the body, <a href="#Page_349">349</a>.</li> - -<li class="indx">Gunshot injury to the frontal sinuses, <a href="#Page_350">350</a>.</li> - -<li class="indx">Wounds of the orbit, <a href="#Page_351">351</a>.</li> - -<li class="indx">Fungus cerebri, <a href="#Page_353">353</a>.</li> - -<li class="indx">Major D.; gunshot wound of the forehead; incomplete recovery, <a href="#Page_357">357</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_611" id="Page_611">[611]</a></span> -Loss of a large portion of the skull; reported by Dr. Drummond, <a href="#Page_359">359</a>.</li> - -<li class="indx">Cannon-shot wound of the head and face, <a href="#Page_361">361</a>.</li> - -<li class="indx">Wound of scalp and parietal bone, <a href="#Page_362">362</a>.</li> - -<li class="indx">Non-penetrating wounds of the chest, <a href="#Page_365">365</a>.</li> - -<li class="indx">Acute pneumonia and pleurisy, <a href="#Page_383">383</a>.</li> - -<li class="indx">Dr. Wendelstadt; empyema, <a href="#Page_398">398</a>.</li> - -<li class="indx">Mr. Winter; gunshot wound of the chest, followed by empyema, <a href="#Page_399">399</a>.</li> - -<li class="indx">Lance and musket-shot wounds of the chest, causing empyema, <a href="#Page_399">399</a>.</li> - -<li class="indx">Mr. Cornish; pneumothorax and phthisis, <a href="#Page_403">403</a>.</li> - -<li class="indx">Pistol shot wound of the chest, with pneumothorax and empyema, <a href="#Page_404">404</a>.</li> - -<li class="indx">Lord Beaumont, <a href="#Page_407">407</a>.</li> - -<li class="indx">Sword wound of the chest, with emphysema, <a href="#Page_412">412</a>.</li> - -<li class="indx">Wounds of both sides of the chest, <a href="#Page_417">417</a>.</li> - -<li class="indx">Penetrating wounds of the chest, the lung being injured, <a href="#Page_418">418</a>.</li> - -<li class="indx">Sword wounds of the chest, <a href="#Page_420">420</a>.</li> - -<li class="indx">Penetrating wounds of the chest, with internal hemorrhage, <a href="#Page_423">423</a>.</li> - -<li class="indx">Fracture of rib, in gunshot wound of chest, <a href="#Page_428">428</a>, <a href="#Page_447">447</a>.</li> - -<li class="indx">General Sir Lowry Cole; gunshot wound of the lung, <a href="#Page_430">430</a>.</li> - -<li class="indx">Illustrative of gunshot wounds of the lungs, <a href="#Page_431">431</a>.</li> - -<li class="indx">General Sir A. Barnard, <a href="#Page_431">431</a>.</li> - -<li class="indx">Major-General Broke, <a href="#Page_432">432</a>.</li> - -<li class="indx">The Duke of Richmond, <a href="#Page_433">433</a>.</li> - -<li class="indx">Mrs. M., <a href="#Page_435">435</a>.</li> - -<li class="indx">Sir C. B.; effusion, <a href="#Page_436">436</a>.</li> - -<li class="indx">Gunshot wounds of the lungs, with fracture of ribs, effusion, etc., <a href="#Page_436">436</a>.</li> - -<li class="indx">Lieut.-Col. Dumaresq, <a href="#Page_440">440</a>.</li> - -<li class="indx">A two-pound shot passing through the right side of the chest, <a href="#Page_441">441</a>.</li> - -<li class="indx">Post-mortem appearances in gunshot wounds of the chest, <a href="#Page_442">442</a>.</li> - -<li class="indx">Mr. Drummond, <a href="#Page_443">443</a>.</li> - -<li class="indx">Gunshot wound of the lung; extensive enlargement of the wound; removal of splinters and of a piece of cloth, <a href="#Page_446">446</a>.</li> - -<li class="indx">Gunshot wound of the lung, remaining fistulous; death from pneumonia seven months afterward, <a href="#Page_447">447</a>.</li> - -<li class="indx">Gunshot wounds of the chest, the ball or other foreign body being loose in the cavity of the pleura, <a href="#Page_448">448</a>.</li> - -<li class="indx">Major-General Sir R. Crawford, <a href="#Page_449">449</a>.</li> - -<li class="indx">Gunshot wounds of the chest, the ball or other foreign body being inclosed in a cyst, <a href="#Page_451">451</a>.</li> - -<li class="indx">Wounds of the diaphragm, <a href="#Page_458">458</a>.</li> - -<li class="indx">Captain Prevost, <a href="#Page_458">458</a>.</li> - -<li class="indx">The Duc de Berri, <a href="#Page_469">469</a>.</li> - -<li class="indx">Lance wound of the heart and diaphragm, <a href="#Page_470">470</a>.</li> - -<li class="indx">Latour d’Auvergne, premier grenadier de France, <a href="#Page_472">472</a>.</li> - -<li class="indx">General Sir G. Walker; gunshot wound of the chest; secondary hemorrhage from the intercostal artery, <a href="#Page_474">474</a>.</li> - -<li class="indx">Gunshot wound of the chest, with rapidly fatal hemorrhage from a wounded intercostal artery, <a href="#Page_475">475</a>.</li> - -<li class="indx">Gunshot wounds of the neck, <a href="#Page_476">476</a>.</li> - -<li class="indx">General Sir E. Packenham; twice shot through the neck, on different occasions, <a href="#Page_476">476</a>.</li> - -<li class="indx"><span class="pagenum"><a name="Page_612" id="Page_612">[612]</a></span> -Lieut.-General Sir A. Leith; amaurosis from a sword wound in the forehead, <a href="#Page_478">478</a>.</li> - -<li class="indx">General Sir Colin Halkett; gunshot wounds of the neck, thigh, and face, <a href="#Page_479">479</a>.</li> - -<li class="indx">Gunshot fracture of the lower jaw, <a href="#Page_480">480</a>.</li> - -<li class="indx">Colonel Carleton; gunshot fracture of the lower jaw, <a href="#Page_481">481</a>.</li> - -<li class="indx">Captain Fritz; bursting of his gun; lodgment of the iron breech in the forehead; its descent through the nares into the mouth, <a href="#Page_482">482</a>.</li> - -<li class="indx">Ventral rupture, the result of severe bruises or other injuries to the abdominal parietes, <a href="#Page_488">488</a>.</li> - -<li class="indx">Severe and extensive wound of abdominal parietes from a musket-shot; exposure of the peritoneum, healing by granulations, <a href="#Page_489">489</a>.</li> - -<li class="indx">General Sir John Elley; sabre wound of abdomen, involving the stomach, and followed by a small hernia, <a href="#Page_490">490</a>.</li> - -<li class="indx">Rupture of intestine from external injury, <a href="#Page_491">491</a>.</li> - -<li class="indx">Rupture of kidney and injury to the spine from a cannon-shot, <a href="#Page_492">492</a>.</li> - -<li class="indx">Fatal inflammation of omentum, intestines, and peritoneum, with effusion, from a severe bruise inflicted by a ricochet cannon-shot, <a href="#Page_492">492</a>.</li> - -<li class="indx">Penetrating wound of abdomen by a ramrod, <a href="#Page_497">497</a>.</li> - -<li class="indx">Penetrating wounds of abdomen, with protrusion of omentum, <a href="#Page_500">500</a>.</li> - -<li class="indx">with protrusion of intestine, <a href="#Page_502">502</a>.</li> - -<li class="indx">Penetrating wound of abdomen, with formation of abscess, <a href="#Page_505">505</a>.</li> - -<li class="indx">Sabre wounds of the abdomen, with extensive hemorrhage, <a href="#Page_510">510</a>.</li> - -<li class="indx">Sabre wound of abdomen, with suppuration in the cavity, reported by Ravaton, <a href="#Page_512">512</a>.</li> - -<li class="indx">Strangulated inguinal hernia; operation; sloughing of the intestine, etc., <a href="#Page_512">512</a>.</li> - -<li class="indx">Gunshot wounds of abdomen, with protrusion or injury of intestine, <a href="#Page_516">516</a>.</li> - -<li class="indx">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, <a href="#Page_524">524</a>.</li> - -<li class="indx">Lieut.-General Sir S. Barns; gunshot wound of the liver, <a href="#Page_529">529</a>.</li> - -<li class="indx">Gunshot wounds of the liver and gall-bladder, <a href="#Page_530">530</a>.</li> - -<li class="indx">In which portions of the liver have been removed, <a href="#Page_533">533</a>.</li> - -<li class="indx">In which a pig’s tail was thrust up the rectum, <a href="#Page_535">535</a>.</li> - -<li class="indx">In which the spleen was removed, <a href="#Page_537">537</a>.</li> - -<li class="indx">Wounds of the kidney, <a href="#Page_538">538</a>.</li> - -<li class="indx">Medullary sarcoma of the right testicle, involving the lumbar glands, ending fatally, caused by a gunshot wound of the testis, <a href="#Page_540">540</a>.</li> - -<li class="indx">Gunshot wound of the penis, <a href="#Page_540">540</a>.</li> - -<li class="indx">Pistol-shot wound in the last dorsal or upper lumbar vertebra, causing complete paraplegia, <a href="#Page_541">541</a>.</li> - -<li class="indx">Gunshot wounds of the pelvis, <a href="#Page_542">542</a>.</li> - -<li class="indx">The late Colonel Wade; gunshot wound, the ball passing through the ilium; lodgment of the ball for thirty-five years, <a href="#Page_542">542</a>.</li> - -<li class="indx">The late General Sir Hercules Packenham, G.C.B.; musket-shot wound of the pelvis, lodgment of the ball, <a href="#Page_542">542</a>.</li> - -<li class="indx">Colonel Sir J. M. Wilson; three musket-shot wounds of the left hip, one passing upward through the ilium, and lodging against or in<span class="pagenum"><a name="Page_613" id="Page_613">[613]</a></span> the spine, causing paralysis of the left lower extremity, etc.; lodgment of the ball, <a href="#Page_543">543</a>.</li> - -<li class="indx">Gunshot wound of the external and common iliac arteries, <a href="#Page_544">544</a>.</li> -<li class="isub1">of the pelvis, the ball lodging, extracted on the forty-fifth day after the wound; reported by La Motte, <a href="#Page_545">545</a>.</li> - -<li class="indx">Captain Campbell; pistol-shot wound of abdomen; injury to spine, <a href="#Page_545">545</a>.</li> - -<li class="indx">Gunshot wounds of the bladder, <a href="#Page_549">549</a>.</li> - -<li class="indx">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, <a href="#Page_551">551</a>.</li> - -<li class="indx">Calculus formed around the ball in the bladder, <a href="#Page_552">552</a>.</li> - -<li class="indx">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, <a href="#Page_554">554</a>.</li> - -<li class="indx">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, <a href="#Page_555">555</a>.</li> - -<li class="indx">Gunshot wounds of the rectum, <a href="#Page_555">555</a>.</li> -</ul> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<h2 class="center">CASES IN THE ADDENDA.</h2> -</div> - -<ul class="index"> -<li class="ifrst">Amputation of finger; death caused by exhibition of chloroform, <a href="#Page_561">561</a>.</li> - -<li class="indx">Successful amputation of the arm at the shoulder-joint, and of the thigh in the lowest third, without chloroform, <a href="#Page_561">561</a>.</li> - -<li class="indx">Amputations while under the influence of chloroform, reported by Deputy Inspector-General Alexander, <a href="#Page_563">563</a>.</li> - -<li class="indx">Sir T. Trowbridge; amputation of both feet under chloroform, <a href="#Page_563">563</a>.</li> - -<li class="indx">Amputations at the hip-joint under chloroform, <a href="#Page_564">564</a>.</li> - -<li class="indx">Excision of the head, neck, and great trochanter of the femur, reported by Mr. O’Leary, <a href="#Page_564">564</a>.</li> -<li class="isub1">reported by Staff-Surgeon Crerar, <a href="#Page_565">565</a>.</li> -<li class="isub1">reported by Dr. Hyde, <a href="#Page_570">570</a>.</li> - -<li class="indx">Excision of the head of the humerus, reported by Dr. M’Andrew, <a href="#Page_571">571</a>.</li> - -<li class="indx">Lieut. Evans; fatal case of wound of the larynx; reported by Dr. Gordon, <a href="#Page_571">571</a>.</li> - -<li class="indx">Wounds of the profunda femoris, and of the popliteal artery, reported by Mr. De Lisle, <a href="#Page_573">573</a>.</li> - -<li class="indx">Loss of the right leg by a round shot, <a href="#Page_574">574</a>.</li> - -<li class="indx">The effects of strychnia in injury of the spine, etc., reported by Dr. Burgess, <a href="#Page_574">574</a>.</li> - -<li class="indx">Extensive injury by a round shot to the abdomen, right arm, and thigh, reported by Dr. Rooke, of the Civil Service, <a href="#Page_576">576</a>.</li> - -<li class="indx">Gunshot fracture of the left femur, reported by Mr. Lyons, Pathologist to <span class="pagenum"><a name="Page_614" id="Page_614">[614]</a></span>the Army in the East, <a href="#Page_579">579</a>.</li> - -<li class="indx">Excision of the elbow-joint for a gunshot wound, reported by Dr. Milroy, <a href="#Page_580">580</a>.</li> -<li class="isub1">with lacerated wound of the left hip, and comminuted fracture of the ilium, reported by Mr. Atkinson, <a href="#Page_581">581</a>.</li> -<li class="isub1">for a comminuted fracture of the bones by a piece of shell, reported by Dr. Scott, <a href="#Page_582">582</a>.</li> - -<li class="indx">Grape-shot wound of the superior maxillary and malar bones, reported by Mr. Atkinson, <a href="#Page_582">582</a>.</li> - -<li class="indx">Musket-shot wound of the right temple, fracturing the supra-orbital ridge, reported by Mr. De Lisle, <a href="#Page_583">583</a>.</li> - -<li class="indx">Musket-shot fractures of the skull, reported by Mr. Ward, Mr. Wall, and Mr. Longmore, <a href="#Page_584">584</a>, <a href="#Page_585">585</a>.</li> -</ul> - -<p class="center">THE END</p> - -<hr class="chap x-ebookmaker-drop" /> - -<p><span class="pagenum"><a name="Page_615" id="Page_615">[615]</a></span></p> - -<div class="chapter"> -<h2 class="nobreak" id="MEDICAL_WORKS">MEDICAL WORKS</h2> -</div> - -<p class="center">PUBLISHED BY<br /> -<big><span class="gesperrt">J. B. LIPPINCOTT & Co.</span>,</big><br /> -<span class="gesperrt">PHILADELPHIA</span>.</p> -<hr class="r5" /> -<p class="center">Will be sent by mail, post paid, on receipt of the price by the -Publishers.</p> -<hr class="r5" /> - -<h3>Leidy’s Anatomy.</h3> - -<div class="figcenter illowp55" id="i-615-left" style="max-width: 20em;"> - <img class="w100" src="images/i-615-left.jpg" alt="" /> - <div class="caption"><p class="center">View of the Heart, with the anterior portions of the ventricles -removed.</p></div> -</div> - -<div class="figright illowp36" id="i-615-right" style="max-width: 10em;"> - <img class="w100" src="images/i-615-right.jpg" alt="" /> - <div class="caption"><p class="center">Dorsal Vertebra.</p></div> -</div> - -<p>Human Anatomy: An Elementary Text-book for Students. -By <span class="smcap">Joseph Leidy</span>, -M.D., Professor -of Anatomy in the -University of -Pennsylvania. -Elegantly illustrated -from numerous -original -drawings. One -vol. 8vo. $5.00</p> - -<p><span class="pagenum"><a name="Page_616" id="Page_616">[616]</a></span></p> - -<h3>Macleod’s Surgery of the Crimean War.</h3> - -<div class="blockquot"> - -<p>Notes on the Surgery of the War in the Crimea, with Remarks -on the Treatment of Gunshot Wounds. By <span class="smcap">George H. B. -Macleod</span>, M.D., F.R.C.S., Surgeon to the General Hospital -in Camp before Sebastopol, Lecturer on Military Surgery in -Anderson’s University, Glasgow, etc. etc. One vol. 12mo. -$1.50.</p> -</div> - -<p>SUMMARY OF CONTENTS.</p> - -<div class="blockquot"> - -<p class="hanging2">Chap. I.—The History and Physical Characters of the Crimea. The Changes -of the Seasons during the occupation by the Allies. The Natives, and -their Diseases.</p> - -<p class="hanging2">Chap. II.—Drainage of the Camp. Water Supply. Latrines. Food. Cooking. -Fuel. Clothing. Housing. Duty. Effect of all these combined -on the health and diseases of the soldiers. Hospitals. Distribution of -the Sick. Nursing, male and female. Transport.</p> - -<p class="hanging2">Chap. III.—The Campaign in Bulgaria, and its effects on the subsequent -health of the troops. The Diseases which appeared there, and during the -Flank March, as well as afterward in the Camp before Sebastopol.</p> - -<p class="hanging2">Chap. IV.—Distinction between Surgery as practiced in the Army and Civil -Life. Soldiers as patients, and the character of the Injuries to which -they are liable. Some peculiarities in the Wounds and Injuries seen -during the war.</p> - -<p class="hanging2">Chap. V.—The “Peculiarities” of Gunshot Wounds, and their General -Treatment.</p> - -<p class="hanging2">Chap. VI.—The Use of Chloroform in the Crimea. Primary and Secondary -Hemorrhage from Gunshot Wounds. Tetanus. Gangrene. Erysipelas. -Frost-bite.</p> - -<p class="hanging2">Chap. VII.—Injuries of the Head.</p> - -<p class="hanging2">Chap. VIII.—Wounds of the Face and Chest.</p> - -<p class="hanging2">Chap. IX.—Gunshot Wounds of the Abdomen and Bladder.</p> - -<p>Chap. X.—Compound Fracture of the Extremities.</p> - -<p class="hanging2">Chap. XI.—Gunshot Wounds of Joints. Excision of Joints, etc. etc.</p> - -<p class="hanging2">Chap. XII.—Amputation.</p> -</div> - -<hr class="r5" /> - -<p class="center">IN PRESS.</p> - -<h3>Principles and Practice of Surgery.</h3> - -<div class="blockquot"> - -<p class="hanging2">By <span class="smcap">Henry H. Smith</span>, M.D., Surgeon-General of the State of -Pennsylvania.</p> -</div> - -<p><span class="pagenum"><a name="Page_617" id="Page_617">[617]</a></span></p> - -<h3>Kolliker’s Anatomy.</h3> - -<div class="figright illowp50" id="i-617" style="max-width: 30em;"> - <img class="w100" src="images/i-617.jpg" alt="" /> - <div class="caption"><p class="center">Cartilage cells from a fibrous, velvety, articular cartilage of the condyle -of the femur of man, magnified 350 diameters.</p></div> -</div> - -<p>Manual of Human Microscopical Anatomy. By <span class="smcap">A. Kolliker</span>, -Professor of Anatomy -and Physiology -in Wurzburg. -Translated by <span class="smcap">Geo. -Bush</span>, F.R.S., and -<span class="smcap">Thomas Huxley</span>, -F.R.S. Edited, -with notes and additions, -by <span class="smcap">J. Da -Costa</span>, M.D. Illustrated -by 313 engravings -on wood. -One vol. 8vo. $3.75.</p> - -<div class="blockquot"> - -<p>It would be useless -for us to attempt a review -of this work, for -the text is so fully illustrated -by engravings, -and is so intimately -associated with -them, that we cannot -extract any part as a -sample of the style, -without weakening its -force, for the want of -its accompanying illustration. -The book -must be read and studied before an adequate idea can be formed of its -value and excellence. The book comes from such high authority, and is -indorsed by such competent judges, as to make it at once indispensable to -the student of microscopic anatomy. We hope it will have an extensive -circulation.—<i>Western Lancet.</i></p> - -<p>The reputation of Professor Kolliker, acquired by his former and larger -work on microscopical anatomy, will be enhanced by this text book on -Histology, for such it is destined to be pre eminently. The text is fully -illustrated by engravings, greatly adding to the value of the work, and -accompanied by explicit explanations of the figures. We commend it to -the profession, and to students especially, as worthy of their patronage.—<i>N. -Y. Medical Gazette.</i></p> -</div> - -<p><span class="pagenum"><a name="Page_618" id="Page_618">[618]</a></span></p> -<h3>Drake’s Diseases of the North American Valley.</h3> - -<div class="blockquot"> - -<p class="hanging2">A Systematic Treatise, Historical, Etiological, and Practical, -on the principal diseases of the interior valley of North -America, as they appear in the Caucasian, African, Indian, -and Esquimaux varieties of its population. By <span class="smcap">Daniel -Drake</span>, M.D. Edited by <span class="smcap">S. Hanbury Smith</span>, M.D., formerly -Professor of the Theory and Practice of Medicine in -Starling Medical College, Ohio; and <span class="smcap">Francis G. Smith</span>, -M.D., Professor of the Institute of Medicine in the medical -department of Pennsylvania College, Philadelphia. One -vol. 8vo. Sheep, $5.00.</p> -</div> - -<div class="blockquot"> - -<p>Dr. Drake’s great reputation, and his extensive practice in the western -country, gives great value and decisive authority to this treatise on the -diseases prevalent in the valley of the Mississippi. While the work is of -great interest to the general practitioner in other parts of the country, to -the Western and Southwestern members of the medical profession it will -hereafter be considered an indispensable book of reference and instruction.</p> -</div> - -<h3>Horner’s United States Dissector.</h3> - -<div class="figleft illowp50" id="i-618" style="max-width: 20em;"> - <img class="w100" src="images/i-618.jpg" alt="" /> - <div class="caption"><p>Nerves of the neck and tongue.</p></div> -</div> - -<p>The United States Dissector; or, Lessons in Practical Anatomy. -By <span class="smcap">William E. Horner</span>, -M.D., late Professor of -Anatomy in the University -of Pennsylvania. Fifth edition, -carefully revised, and entirely -remodeled. By <span class="smcap">Henry -H. Smith</span>, M.D., fellow of the -College of Physicians of Philadelphia, -etc. With one hundred -and seventy-seven new -illustrations. One vol. demi -8vo. $2.00.</p> - -<div class="blockquot"> - -<p>This is a new and revised edition -of one of the most popular works -on dissection which has ever been -published in this country. The -editor has carefully revised the -text, modified its order, added an -entire set of new illustrations, -and introduced such recent subjects as the progress of science rendered -necessary.</p> -</div> - -<p><span class="pagenum"><a name="Page_619" id="Page_619">[619]</a></span></p> -<h3>Malgaigne’s Treatise on Fractures.</h3> - -<div class="figleft illowp70" id="i-619" style="max-width: 21em;"> - <img class="w100" src="images/i-619.jpg" alt="" /> - <div class="caption"><p>Old Inter-Capsular Fracture, with considerable -shortening.</p></div> -</div> - -<p>A Treatise on Fractures. By Professor <span class="smcap">J. F. Malgaigne</span>, of -Paris. With over one hundred -Illustrations. Translated -from the French, with notes -and additions, by <span class="smcap">John H. -Packard</span>, M.D. One vol. -8vo. $4.00.</p> - -<div class="blockquot"> - -<p>Malgaigne’s Treatise has enjoyed -so wide a circulation and -such well-deserved renown, that -we must own to a feeling of surprise -at learning that before the -appearance of the present work -no attempt has been made to present -so popular an author in an -English dress. The present book, -a contribution to our literature -from America, is the work of a -gentleman whose name is not otherwise known to us, and is one which we can -conscientiously pronounce very valuable.... A very useful book indeed, -and one which we hope will have an extensive circulation.—<i>British and -Foreign Med. Chir. Review.</i></p> - -<p>Must be regarded as a monument, conspicuous and to be admired, even -among the noble monuments of the medical literature of his [the author’s] -country. As a solid, complete, substantial, highly-finished work, we know -of none that is its superior; it can, with justice, be regarded as a model in -scientific literature.—<i>North American Med. Chir. Rev.</i></p> - -<p>It affords us sincere pleasure to be able to welcome the appearance, in -an English dress, of this valuable treatise. The annotations which Dr. -Packard has appended to it are numerous, and appear to us to be of much -practical value, adapting, as they do, the treatment of fractures to the -generally received and most approved American methods.—<i>Journal of the -Medical Sciences.</i></p> -</div> - -<h3>Bernard and Robin on the Blood.</h3> - -<div class="blockquot"> - -<p class="hanging2">Notes of M. Bernard’s Lectures on the Blood, with an Appendix, -giving an account of the latest studies of M. Robin, -the celebrated microscopist. By <span class="smcap">Walter Franklin Atlee</span> -M.D. One vol. 12mo. Cloth, 75 cents.</p> -</div> - -<p><span class="pagenum"><a name="Page_620" id="Page_620">[620]</a></span></p> -<h3>Wood’s Practice of Medicine.</h3> - -<div class="blockquot"> - -<p>A Treatise on the Practice of Medicine. By <span class="smcap">Geo. B. Wood</span>, -M.D., Professor of the Theory and Practice of Medicine in -the University of Pennsylvania. Fourth edition, improved. -Two vols. 8vo. $7.00.</p> -</div> - -<div class="blockquot"> - -<p>This is far the best work on the practice of medicine in the English language, -and we recommend it strongly to the attention of our readers. It -is much fuller than Dr. Watson’s admirable lectures, while it is less lengthy -than the Library or Cyclopædia of Medicine; and it has this further advantage -over the two last-named works—that while they are far behind, it -is a fair reflex of the actual state of knowledge.—<i>London Medical Times -and Gazette.</i></p> -</div> - -<h3>Wood and Bache’s Dispensatory.</h3> - -<p>The Dispensatory of the United States: Consisting of—</p> - -<div class="blockquot"> - -<p class="hanging2">1. A treatise on Materia Medica, or the natural, commercial, -chemical, and medical history of the substances employed in -medicine, and recognized by the Pharmacopœias of the -United States and Great Britain;</p> - -<p class="hanging2">2. A treatise on Pharmacy: Comprising an account of the -preparations directed by the American and British Pharmacopœias, -and designed especially to illustrate the Pharmacopœia -of the United States; and</p> - -<p class="hanging2">3. A copious Appendix, embracing an account of all substances -not contained in the official catalogues, which are -used in medicine, or have any interest for the physician or -apothecary. By <span class="smcap">Geo. B. Wood</span>, M.D., Professor of the -Theory and Practice of Medicine in the University of Pennsylvania, -etc. etc., and <span class="smcap">Franklin Bache</span>, M.D., Professor -of Chemistry in the Jefferson Medical College of Philadelphia, -etc. etc. Eleventh edition, much enlarged. One vol. -8vo. $6.00.</p> -</div> - -<div class="blockquot"> - -<p>This work has been thoroughly revised, with many alterations and additions, -so as to bring it fully up to the level of the present state of materia -medica and pharmacy. It embraces the substance of the recently revised -United States and British Pharmacopœias, with a commentary on all that -is new in those publications. Nothing, indeed, has been omitted in the -revision which could render it worthy of the confidence it has enjoyed.</p> -</div> - -<p><span class="pagenum"><a name="Page_621" id="Page_621">[621]</a></span></p> -<h3>Wood’s Therapeutics.</h3> - -<div class="blockquot"> - -<p class="hanging2">A Treatise on Therapeutics and Pharmacology, or Materia -Medica. By <span class="smcap">Geo. B. Wood</span>, M.D., Professor of the Theory -and Practice of Medicine in the University of Pennsylvania, -Senior Physician of the Pennsylvania Hospital, -one of the authors of the United States Dispensatory, -author of a Treatise on the Practice of Medicine, etc. etc. -Two vols. 8vo. $7.00.</p> -</div> - -<div class="blockquot"> - -<p>In his preface Dr. Wood gives the following account of his opportunities -for acquiring knowledge and forming just views on the subjects embraced -in this treatise:—</p> - -<p>“Almost from the commencement of his professional life the author has -given peculiar attention to this branch of medical knowledge. For a -period of about thirty years, before 1850, when he was transferred to the -professorship which he now occupies, he was engaged in teaching materia -medica, first as a private lecturer, and afterwards successively in the Philadelphia -College of Pharmacy and the University of Pennsylvania. His -position, therefore, rendered constant investigations into the properties, -effects, and uses of remedies necessary in order at once to do justice -to his pupils and avoid discredit to himself. Most of those whom he -now addresses are probably aware that he is one of the authors of the -United States Dispensatory. To provide the original materials for his -portion of that work, and to gather from time to time the knowledge -requisite for its maintenance upon a level with the progressive condition -of medical science, unremitting diligence was essential in prosecuting inquiry -and investigation in the whole field of pharmacology. In addition -to the ordinary professional opportunities, he has for about twenty years -held the office of one of the physicians of the Pennsylvania Hospital, -which has given him facilities for testing the value of remedies greater -than any amount of private practice could afford. Few persons have had -greater advantages or stronger inducements than himself for acquiring the -knowledge requisite for the production of a work of this kind.”</p> -</div> - -<h3>Wood’s Lectures and Addresses.</h3> - -<div class="blockquot"> - -<p class="hanging2">Introductory Lectures and Addresses on Medical Subjects. -Delivered chiefly before the medical classes of the University -of Pennsylvania. By <span class="smcap">Geo. B. Wood</span>, M.D., LL.D., -President of the American Philosophical Society, Professor -of the Theory and Practice of Medicine, and of Clinical -Medicine, in the University of Pennsylvania, etc. etc. One -vol. 8vo. $1.75.</p> -</div> - -<p><span class="pagenum"><a name="Page_622" id="Page_622">[622]</a></span></p> -<h3>Eberle and Mitchell on Children.</h3> - -<div class="blockquot"> - -<p class="hanging2">A Treatise on the Diseases and Physical Education of Children. -By <span class="smcap">John Eberle</span>, M.D., late Professor of the Theory -and Practice of Medicine in Transylvania University, etc. -etc. Fourth edition, with notes and large additions by -<span class="smcap">Thomas D. Mitchell</span>, A.M., M.D., Professor of the Theory -and Practice of Medicine in the Philadelphia College of -Medicine, late Professor of Materia Medica and Therapeutics -in Transylvania University, Lecturer on Obstetrics and -the Diseases of Women and Children, etc. etc. One vol. -8vo. $2.50.</p> -</div> - -<div class="blockquot"> - -<p>Dr. Eberle’s “Treatise” has long been regarded by the medical profession -as the best and most comprehensive work on the diseases and 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.</p> -</div> - -<h3>Richardson’s Anatomy.</h3> - -<div class="figleft illowp50" id="i-622" style="max-width: 20em;"> - <img class="w100" src="images/i-622.jpg" alt="" /> - <div class="caption"><p>Veins of the head and neck.</p></div> -</div> - -<p>Elements of Human Anatomy: General, Descriptive, and -Practical. With over 400 -illustrations. By <span class="smcap">T. G. -Richardson</span>, 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.</p> - -<div class="blockquot"> - -<p>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.—<i>New Jersey Medical -Reporter.</i></p> - -<p>Our author claims for his work the -improvement of having general, de<span class="pagenum"><a name="Page_623" id="Page_623">[623]</a></span>scriptive, -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.—<i>N. Y. -Medical Times.</i></p> -</div> - -<h3>Ricord on Venereal Diseases.</h3> - -<div class="blockquot"> - -<p class="hanging2">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 <span class="smcap">Ph. Ricord</span>, M.D., Surgeon of -the Venereal Hospital of Paris, Clinical Professor of Special -Pathology. Translated from the French by <span class="smcap">A. Sidney -Doane</span>, A.M., M.D. Thirteenth edition. One vol. 8vo. -$1.50.</p> -</div> - -<div class="blockquot"> - -<p>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.</p> -</div> - -<h3>Thomson’s Domestic Medicine.</h3> - -<div class="blockquot"> - -<p class="hanging2">A Dictionary of Domestic Medicine and Household Surgery. -By <span class="smcap">Spencer Thomson</span>, M.D., L.B.C.S. Edinb. First American, -from the last London edition. Revised, with additions, -by <span class="smcap">Henry H. Smith</span>, M.D., Professor of Surgery in the -Pennsylvania University. One vol. 12mo. $1.50.</p> -</div> - -<div class="blockquot"> - -<p>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.”</p> - -<p>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.</p> -</div> - -<p><span class="pagenum"><a name="Page_624" id="Page_624">[624]</a></span></p> -<h3>Agnew’s Practical Anatomy.</h3> - -<div class="figleft illowp30" id="i-624" style="max-width: 15em;"> - <img class="w100" src="images/i-624.jpg" alt="Thigh and knee showing arteries and veins." /> -</div> - -<p>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 <span class="smcap">D. Hayes Agnew</span>, -M.D., Lecturer on Anatomy, and -Surgeon to the Philadelphia -Hospital, (Blockley.) One vol. -12mo. $1.00.</p> - -<div class="blockquot"> - -<p>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.</p> -</div> - -<h3>Acton on the Urinary Organs.</h3> - -<div class="blockquot"> - -<p class="hanging2">A Practical Treatise on Diseases of the Urinary and Generative -Organs in both Sexes. Part I.—Non-specific Disease. Part -II.—Syphilis. By <span class="smcap">William Acton</span>, 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.</p> -</div> - -<div class="blockquot"> - -<p>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.</p> -</div> - -<hr class="chap x-ebookmaker-drop" /> - -<div class="chapter"> -<div class="transnote"> -<p>Transcriber’s Notes:</p> -<p>A number of typographical errors have been corrected silently.</p> -<p>Archaic spellings have been retained.</p> -<p>Cover image is in the public domain.</p> -<p>Alt Text for images are in the public domain.</p> -<p>“Remarks” heading added to Table of Contents.</p> -<p>Index, Index of Cases, and Medical Works added to the Table of Contents.</p> -<p>Amputation of arm index to page 156 is deduced, only “ 56” was printed.</p> -<p>Index references page 649 which does not exist.</p> -</div> -</div> - -<div style='display:block; margin-top:4em'>*** END OF THE PROJECT GUTENBERG EBOOK COMMENTARIES ON THE SURGERY OF THE WAR ***</div> -<div style='text-align:left'> - -<div style='display:block; margin:1em 0'> -Updated editions will replace the previous one—the old editions will -be renamed. -</div> - -<div style='display:block; margin:1em 0'> -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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