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diff --git a/old/65622-0.txt b/old/65622-0.txt deleted file mode 100644 index 5837edc..0000000 --- a/old/65622-0.txt +++ /dev/null @@ -1,25408 +0,0 @@ -The Project Gutenberg eBook of Commentaries on the Surgery of the -War, by G. J. Guthrie - -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 -www.gutenberg.org. 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. - -Title: Commentaries on the Surgery of the War - in Portugal, Spain, France, and the Netherlands - -Author: G. J. Guthrie - -Release Date: June 15, 2021 [eBook #65622] - -Language: English - -Produced by: 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.) - -*** START OF THE PROJECT GUTENBERG EBOOK COMMENTARIES ON THE SURGERY -OF THE WAR *** - - - - - - COMMENTARIES - ON THE - SURGERY OF THE WAR - - IN PORTUGAL, SPAIN, FRANCE, AND - THE NETHERLANDS, - - FROM THE BATTLE OF ROLIÇA, IN 1808, TO THAT OF - WATERLOO, IN 1815; - - WITH ADDITIONS RELATING TO THOSE IN THE CRIMEA IN - 1854-1855. - - SHOWING - - THE IMPROVEMENTS MADE DURING AND SINCE THAT PERIOD IN THE - GREAT ART AND SCIENCE OF SURGERY ON ALL THE - SUBJECTS TO WHICH THEY RELATE. - - REVISED TO OCTOBER, 1855. - - BY G. J. GUTHRIE, F.R.S. - - SIXTH EDITION. - - PHILADELPHIA: - J. B. LIPPINCOTT & CO. - 1862. - - - - - TO - The Right Honorable - The Lord Panmure, - SECRETARY OF STATE FOR THE WAR DEPARTMENT, - ETC. ETC. ETC., - - THESE COMMENTARIES - ARE, BY PERMISSION, - INSCRIBED, - BY HIS LORDSHIP’S VERY OBEDIENT - AND FAITHFUL SERVANT, - - G. J. GUTHRIE. - - - - -PREFACE TO THE FIFTH EDITION. - - -Twenty months have elapsed since the Introductory Lecture was published -in THE LANCET; fifteen others succeeded at intervals, and fifteen -have been printed separately to complete the number of which the -present work is composed. Divested of the historical and argumentative, -as well as of much of the illustrative part, contained in the records -whence it is derived, it nevertheless occupies 585 pages--the essential -points therein being numbered from 1 to 423. - -Sir De Lacy Evans, in some observations lately made in the House of -Commons on the subject of a Professorship of Military Surgery in -London, alluded to these Lectures in the most gratifying manner; -he could not, however, state their origin, scope, or object, being -unacquainted with them. - -On the termination of the war in 1814, I expressed in print my regret -that we had not had another battle in the south of France, to enable -me to decide two or three points in surgery which were doubtful. I -was called an enthusiast, and laughed at accordingly. The battle of -Waterloo afforded the desired opportunity. Sir James M’Grigor, then -first appointed Director-General, offered to place me on full pay for -six months. This would have been destructive to my prospects in London; -I therefore offered to serve for three, which he was afraid would be -called a job, although the difference between half-pay and full was -under sixty pounds; and our amicable discussion ended by my going to -Brussels and Antwerp for five weeks as an amateur. The officers in -both places received me in a manner to which I cannot do justice. -They placed themselves and their patients at my entire disposal, and -carried into effect every suggestion. The doubts on the points alluded -to were dissipated, and the principles wanting were established. Three -of the most important cases, which had never before been seen in -London nor in Paris, were sent to the York Military Hospital, then at -Chelsea. The rank I held as a Deputy Inspector-General precluded my -being employed. It was again a matter of money. I offered to do the -duty of a staff-surgeon without pay, provided two wards were assigned -to me in which the worst cases from Brussels and Antwerp might be -collected. The offer was accepted; and for two years I did this duty, -until the hospital was broken up, and the men transferred to Chatham. -In the first year a Course of Lectures on Military Surgery was given. -The inefficiency of such a Course alone was soon seen, for Surgery -admits of no such distinctions. Injuries of the head, for instance, in -warfare, usually take place on the sides and vertex; in civil life, -more frequently at the base. They implicate each other so inseparably, -although all the symptoms are not alike or always present, that they -cannot be disconnected with propriety. This equally obtains in other -parts; and my second and extended Course was recognized by the Council -of the Royal College of Surgeons as one of General Surgery. - -When the Court of Examiners of the Royal College of Surgeons of -England--of which body I have been for more than twenty years a -humble member--confer their diploma after examination on a student, -they do not consider him to have done more than laid the foundation -for that knowledge which is to be afterward acquired by long and -patient observation. When a student in law is called to the bar, he -is not supposed to be therefore qualified to be a Queen’s counsel, -much less a judge or a chancellor. The young theologian, admitted -into deacon’s orders, is not supposed to be fitted for a bishopric. -When the young surgeon is sent, in the execution of his duties, to -distant climes, where he has few and sometimes no opportunities of -adding to the knowledge he had previously acquired, it is apt to be -impaired; and he may return to England, after an absence of several -years, less qualified, perhaps, than when he left it. To such persons -a course of instruction is invaluable. It should be open to them as -public servants gratuitously, and should be conveyed by a person -appointed and paid by the Crown. He should be styled, in my opinion, -the Military Professor of Surgery, and be capable, from his previous -experience and his civil opportunities, of teaching all things in the -principles and practice of surgery connected with his office, although -he may and should annually select his subjects. Leave of absence for -three months might be advantageously granted to officers in turn for -the purpose of attending these lectures, and the Professor should -certify as to their time having been well employed. For thirty years I -endeavored to render this service to the Army, the Navy, and the East -India Company, from the knowledge I had acquired of its importance. -To the Officers of these services my two hospitals, together with -Lectures and Demonstrations, were always open gratuitously, as a mark -of the estimation in which I held them. By the end of that period the -enthusiasm of the enthusiast who wished for another battle in 1814 -had oozed out, like the courage of Bob Acres in “The Rivals,” at the -ends of his fingers. The course of instruction was discontinued, but -not until such parts were printed, under the title of “Records of the -Surgery of the War,” as were not before the public, in order that -teachers of civil or systematic surgery should be acquainted with them. - - 4 Berkeley Street, Berkeley Square, - June 21, 1853. - - - - -PREFACE TO THE SIXTH EDITION. - - -The rapid sale of the fifth, and the demand for a sixth edition of this -work, enable me to say that the precepts inculcated in it have been -fully borne out and confirmed by the practice of the Surgeons of the -Army now in the Crimea in almost every particular. To several of these -gentlemen I desire to offer my warmest thanks for the assistance they -have afforded. Their names are given with the cases and observations -they have been so good as to send me, and a fuller “Addenda” shall be -made from time to time, as I receive further information from them, and -others who will, I hope, follow the example they have thus set. More, -however, has been done; they have performed operations of the gravest -importance at my suggestion, that had not been done before, with a -judgment and ability beyond all praise; and they have modified others -to the great advantage of those who may hereafter suffer from similar -injuries. They have thus proved that if the Administrative duties of -the Medical Department of the Army have not been free from public -animadversion, that its practical and scientific duties have merited -public approbation; which I am satisfied, from what they have already -done, they will continue to deserve. - -The precepts laid down are the result of the experience acquired in the -war in the Peninsula, from the first battle of Roliça in 1808, to the -last in Belgium, of Waterloo in 1815, which altered, nay overturned, -nearly all those which existed previously to that period, on all points -to which they relate. Points as essential in the Surgery of domestic as -in military life. They have been the means of saving the lives, and of -relieving, if not even of preventing, the miseries of thousands of our -fellow-creatures throughout the civilized world. - -I would willingly imitate the example lately indulged in, by many -of the best Parisian surgeons, of detailing circumstantially the -improvements they have made in practical and scientific surgery; -the manner in which they were at first contested, and the universal -adoption of them which has succeeded, were it not that I might run the -risk of being accused of gratifying some personal vanity, while only -desirous of drawing the attention of the public to the merits of the -men who so ably served them in the last war, nearly all of whom are no -more; and who have passed away, as I trust their successors will not, -with scarcely a single acknowledgment of their services, except the -humble tribute now offered by their companion and friend. - - 4 Berkeley Street, Berkeley Square, - October 7, 1855. - - - - -CONTENTS. - - -LECTURE I. - -A wound made by a musket-ball is essentially a contused wound; -sometimes bleeds; attended by shock and alarm, particularly when from -cannon-shot, or when vital parts are injured; secondary hemorrhage -rare. Entrance and exit of balls. Course of balls. Position. Treatment: -cold or iced water; no bandage to be applied; wax candles. Progress of -inflammation. Extraction of balls in flesh wounds; manner of doing it. -Dilatation; when proper. Bayonet wounds; delusion respecting them. pp. -25-39 - - -LECTURE II. - -Peculiar phlegmonous inflammation. Erysipelatous inflammation; -internal treatment. Erysipelas phlegmonodes, or diffused inflammation -of the areolar tissue; treatment by incision; first case treated -in England by incision; caution with respect to the scrotum. -Mortification--distinction into idiopathic or constitutional and that -which is local; humid and dry; traumatic. Local mortification from -intense heat or cold; wind of a ball; electricity; search for these -cases after the battle of Waterloo; case of recovery after amputation; -appearances on dissection. Mortification from injury of the great -vessels; appearance of the skin. Patient dies when the mortification -passes the knee. Points of practice; amputation to be performed below -the knee. Wound being on the thigh, amputation not to be done above the -knee when the line of separation has formed below it. Wounds of the -axillary not so dangerous as wounds of the femoral. Wounds of nerves; -complete division of, followed by the loss of sensation, motion, and -the power of resisting cold and heat. Cases of Sir James Kempt, of -Sir Philip Broke, and Brigade-Major Bissett. Treatment; external and -internal remedies. pp. 39-51 - - -LECTURE III. - -Necessity for immediate amputation when an extremity is so wounded -as to preclude all hope of saving it; degree of danger attending -amputations of the upper and lower extremities; the question us to -immediate amputation--of the arm, or leg below the knee; in the upper -half of the thigh. Constitutional alarm of shock from the injury. -Illustrative cases by Dr. Beith, Dr. Dane, etc. Advantages of primary -over secondary amputations; consequences of secondary amputations. -Purulent deposits; cases by Dr. Irwin, Mr. Rose, and Mr. Boutflower; -case of purulent deposit in the thyroid gland; Daniel Lynch’s case. -Inflammation of the veins; cases; two varieties of phlebitis--the -adhesive and irritative, or unhealthy; symptoms and treatment of -the unhealthy inflammation. The case of Private A. Clarke; of Jane -Strangemore; cases of endemic fever after secondary amputation ending -in sub acute inflammation of the lungs and effusion into the chest. -Employment of the sulphuric acid lotion in sloughing stumps. Writers on -purulent deposits: the author’s claims; opinions of Mr. Henry Lee and -Dr. Hughes Bennett. Hemorrhage in sloughing stumps, and its treatment; -ligature of the principal artery of the limb in such cases, and its -failure; hemorrhage after amputation at the shoulder-joint; sloughing -of the stump caused by the bad air of the hospital; hemorrhages from -irritable stumps not unfrequent in crowded hospitals; symptoms and -treatment. pp. 51-73 - - -LECTURE IV. - -Aphorisms for amputations; necessity for the operation; compression -of the femoral artery as it passes over the edge of the pubes; no -necessity for the tourniquet in great amputations; the hemorrhage -greater when a tourniquet is applied; use of the instrument after -amputation; old mode of performing circular amputations; nicking the -periosteum injurious; ligature of wounded vessels; bringing together -the integuments; dressing the stump; subsequent treatment. AMPUTATION -AT THE HIP-JOINT; injuries justifying the operation; case of Captain -Flack; wound of the principal artery, with fracture of the femur, -necessitates the operation; in malignant diseases of the femur, the -operation affords the only chance of success; amputation at the -hip-joint not to be done when the bone can be sawn through immediately -below the trochanter major, and there be sufficient flaps; mode of -operating; prior ligature of the femoral artery, by Baron Larrey; not -practiced in the British army; directions for operating; Professor -Langenbeck’s mode; Mr. Brownrigg’s; illustrative engravings; amputation -by the circular incision; secondary amputation; number of vessels to be -tied in primary and secondary operations; Mr. Luke’s amputation of the -thigh by the flap operation; protrusion of bone after the operation; -exfoliation from badly sawing or splitting the bone, or unduly -separating the periosteum. Bulbous enlargement of the divided nerve. -pp. 73-89 - - -LECTURE V. - -Removal of the head of the femur, dislocated in consequence of -strumous disease, or for fracture of the head or neck of the bone, -caused by an external wound; cases most favorable for the operation; -anatomical description of the operation; the operation on the dead -body; commencing for the removal of the head of the bone: completing, -by amputation of the thigh at the hip-joint, the injuries being such -as to require that operation; ligature of a great artery, close to a -large branch, successful; completing the operation for the removal -of the head of the femur; case of removal of the head of the femur; -wounds of the knee-joint from musket-balls, with fracture of the bones, -require immediate amputation; secondary amputation does not offer such -a chance of success; compound fractures of the patella without injury -to other bones; the joint involved; lodgment of the ball in the joint; -the ball penetrating the condyles of the femur; wound of the popliteal -artery; cases for amputation; clean incised wounds of the knee-joint; -case of Colonel Donnellan; excision of the knee-joint; formerly rarely -successful; Mr. Jones, of Jersey, mode of operating; Dr. Gurdon Buck’s -case of excision of the knee-joint, for anchylosis, following a gunshot -wound; Mr. Jones’s improvement of the operation; amputation of the -leg; by the circular incision; the flap operation, as performed by Mr. -Luke; amputation at the tuberosity of the tibia: removal of the head -of the fibula; excision of the ankle-joint; removal of the os calcis; -Mr. Syme’s amputation at the ankle-joint; sloughing of the under flap, -and its causes; gunshot wounds of the foot; wounds of the fore part of -the foot by cannon-shot, grape-shot, or musket-balls; amputation at the -tarsus of the foot, leaving the astragalus and os calcis; operation -for the removal of the astragalus and os calcis by Mr. Wakley, jun.; -necessary not to wound the anterior tibial artery; amputation of a -single metatarsal bone; M. de Beaufort’s artificial foot. pp. 90-120 - - -LECTURE VI. - -Primary amputation of the upper extremity rarely to be practiced for -musket-shot wounds, or for injuries of the soft parts; treatment of -slight gunshot wounds of the head of the humerus; a depending opening -for the exit of matter to be made, if not previously existing; the -principal points to attend to in such cases; simple incised wounds -of the joint; splintering of the head of the bone, or the passage of -a ball through it, requires its being sawn off; cases for amputation -of the arm; site of the operation, the head of the bone being -uninjured; complete shattering of the arm; complicated with more -or less severe injury of the chest or abdomen; if the latter not -likely to cause a speedy dissolution, then amputation of the arm is -to be performed; moderate hemorrhage or expectoration of blood, under -such circumstances, not absolutely fatal; destructive injuries from -rebounding or nearly spent round shot, or flat pieces of shell, without -external signs of a wound; necessity for an immediate operation in such -cases; amputation at the shoulder-joint; the fear of hemorrhage passed -away; compression of the subclavian; amputation at the shoulder-joint -for malignant disease of the bone and periosteum; the acromion and -coracoid processes should not be exposed, nor is it necessary to -deprive the glenoid cavity of its cartilage; the nerves to be cut -short, after the operation has been completed, else they may cause -distressing pain for life; primary amputation at the shoulder-joint -a very simple operation; secondary amputation much less so; general -directions prior to the operation; the operation by two flaps, external -and internal; by one, or nearly one, upper flap; Lisfranc’s operation; -modification of it by M. Baudens; difficulties of the secondary -amputation; amputation of the arm immediately below the tuberosities -of the humerus; excision of the head of the humerus; Langenbeck’s -operation; this excision not easy of execution when the head and neck -of the bone are broken from the shaft, nor in secondary operations: -not to be practiced in every instance of compound fracture of the -part; cases; injury of the head of the humerus, with much loss of the -soft parts; giving way of the axillary artery during the treatment -not a cause for amputation; the vessel to be tied above and below the -opening, and the subclavian not to be ligatured till all other means -have failed; amputation of the arm by the circular incision; cases -requiring this operation; Mr. Luke’s operation by two flaps; excision -of the elbow-joint; injuries of the joint not requiring this operation; -cases in which it is admissible; mode of operating; amputation at the -elbow-joint recommended, but not often performed; mode of operating; -supposed advantage attending the retention of the olecranon; amputation -of the forearm; seldom requisite; the flap operation preferable, -particularly near the wrist; mode of operating; the circular operation -in the middle of the forearm; amputation at the wrist; in all injuries -of the hand, requiring an operation, the thumb and one or more fingers -to be preserved, if possible; treatment of metacarpal bones fractured -by a musket-ball; of injured metacarpal bones, the fingers being -destroyed; removal of the heads of the metacarpal bones when necessary; -amputation of the phalanges; Langenbeck’s operation for excision of -the phalangeal joints; excision of the metacarpal bone of the thumb -by Langenbeck, the periosteum being separated from the bone, and left -behind in the wound. pp. 120-141. - - -LECTURE VII. - -Secondary amputations not so successful after injuries as after -incurable disease; circumstances under which the operation is -performed in military surgery, and the consequences; secondary -hemorrhage; non-union of the stump; phlebitis and sloughing of the -stump; depositions of matter in the viscera; in secondary amputations -larger flaps required, or the bone to be cut shorter; directions for -sawing the bone; larger number of arteries to be tied; torsion of -arteries; bleeding from a small branch, cut short, above the ligature; -mode of avoiding this; use of the tourniquet; and its inconveniences; -in oozing of blood, the wound not to be finally closed for some -hours; treatment in cases of non-union; cat-gut or other animal -ligatures; hemorrhage from large veins to be controlled by pressure, -not by ligatures; if the bone be too long, a piece to be sawn off; -consequences of not doing so. COMPOUND FRACTURES: definition of; -comminuted; compound fracture of the arm or leg does not necessitate -amputation; of the thigh, amputation is requisite; difficulty of -treating a gunshot fracture, with extensive splintering of the bone; -consequences of the splintering; necrosis of the bone, and formation of -sequestra; case of Lieut. Timbrell, fracture of both femurs; recovery -without amputation: lodgment of a ball in, or its passage through, a -bone, without splintering; consequences; its removal requisite when -lodged in a bone; mere grazing a bone by a ball; simple transverse -fracture of a bone by a ball; flattening of a ball; its lodgment -between the broken portions of a bone; extensive shattering of the -femur, a case for immediate amputation; gunshot fractures of head -and neck of the femur; excision of the injured portions of bone-if -the upper third, or middle of the bone, amputation necessary; in -fractures of the lower third, not communicating with the knee-joint, an -attempt is to be made to save the limb; when the femur is splintered, -if the limb is to be saved, the principal splinters to be removed; -the necessary incisions often neglected; if the splinters cannot be -got at, amputation is requisite; secondary danger from the smaller -splinters; a careful examination to be made for them when suppuration -is established, and incisions made if requisite for their removal; -consequences of their retention; proper bedsteads for the wounded -should form a part of military stores; position of the patient in -gunshot fractures of the leg or thigh; splints, and their application; -gunshot wounds of the leg; limb rarely to be amputated; removal of -splinters; position of the limb; Mr. Luke’s the best apparatus for a -compound fracture of the leg; illustrated by wood-engraving; bearers -for wounded men; gunshot wounds of the arm; more probability of saving -the limb; if an artery ulcerate, it should be tied at each end; primary -amputation in such cases rare; secondary, only for mortification, or -when the strength gives way; in incisions at a late period, the nerves -and arteries to be avoided; splints for the arm. Hospital returns. -pp. 141-162 - - -LECTURE VIII. - -HOSPITAL GANGRENE: its synonyms; may be caused by the use of charpie, -instruments, bandages, etc., which have been previously employed on -infected parts; is a highly contagious and infectious disease; its -prevalence at Leyden in 1798; if the disease be mild or chronic, wounds -on the arm may continue healthy for some days after those on the leg -are infected, but not so if the gangrene be acute; Mr. Blackadder’s -description of the disease, as it occurred in his own person, from -inoculation; M. Delpech attributed its spread in the French army to the -misfortunes and sufferings of the soldiery; Dr. Tice on the attendant -depression, apathy, and despair; description of the disease in its -most virulent and less destructive forms; characteristic signs of -the disease; the question as to its constitutional or local origin; -character of the fever; opinion of the French surgeons that the disease -was of local origin; local and constitutional treatment; use of mineral -acids at Santander in 1813; Dr. Boggie on large bleedings in the -disease at Bilbao; cases of hospital gangrene, with tetanus-bleeding -curing the one, and failing in the other; Dr. Boggie on the treatment -of phagedœna, and of inflammatory gangrene, after disorganisation; the -introduction of Fowler’s solution of arsenic, as an escharotic, by Mr. -Blackadder; dangers of that practice; Dr. Walker on hospital gangrene -at Bilbao: Delpech on phagedœnic ulcer, and its treatment; attributes -the first employment of mineral acids to the British surgeons in Spain, -and especially to Mr. Guthrie; Deputy Inspector-General Taylor on -hospital gangrene in India; considers it a local disease, to be cured -by local treatment; uses nitric acid to the circumference of the ulcer; -the burning, gnawing sensation removed by the acid; dirty fungous -growths from wounds of the hands and forearm. CONCLUSIONS: Return of -the number of cases in the hospital stations in the Peninsula during -the last six months of 1813. pp. 163-175 - - -LECTURE IX. - -On wounds of arteries, and the means adopted by nature and art for -the suppression of hemorrhage; their structure; ancient three coats -separated into six-1, the epithelial; 2, fenestrated; 8, muscular; -4, elastic; 5, elastic and areolar combined; 6, areolar. Nature of -epithelium; divided into three kinds--tesselated, cylindrical, and -spheroidal. Structure of epithelial (1) and of fenestrated coat (2); -structure of muscular (3) and elastic coat (4); structure of elastic -and areolar coats (5 and 6). Chemical composition, protein. Voluntary -and involuntary muscular fibers; difference between them. Muscular -fibers in arteries involuntary. White inelastic and elastic yellow -fibers in outer coat. Blood-vessels of arteries; nerves of. Production -of cells, nuclei, and nucleoli. Cyto-blastema or formative substance. -Collateral circulation of two kinds--by direct, large, communicating -arteries, and by the capillary vessels, both being incapable of -supporting life in the lower extremity after the receipt of a sudden -injury to the main trunk in the thigh. pp. 176-187 - - -LECTURE X. - -Proper treatment of wounded arteries due to the Peninsular war; -Hunterian theory inapplicable; opposing theory of Mr. Guthrie; means -supposed to be adopted by nature for the suppression of bleeding from -large arteries from the time of Celsus to 1811 disputed; their true -nature shown; important distinction drawn between the processes adopted -with the upper and lower ends of a divided artery; cases illustrative -of the facts stated; application of a small ligature; consequent -processes; opinions formerly entertained, erroneous; internal coagulum -not absolutely necessary; artery does not always contract up to its -next collateral branch, nor is it necessary; important case in proof; -ligatures should be small, round, and strong; undue interference to be -avoided. pp. 187-208 - - -LECTURE XI. - -Appearance of the femoral artery when torn across high up; illustrative -cases. A small puncture; illustrative cases. An artery of the size of -the brachial cut to a fourth of its circumference; when completely -divided; when wounded at some depth from the surface; course to be -pursued; illustrative case. No operation to be done on a wounded artery -unless it bleed; cases: John Wilson, Don Bernardino Garcia Alvarez, and -Captain Seton. pp. 208-226 - - -LECTURE XII. - -Mortification local and dry in the first instance. Case deserving of -great attention. Amputation not always to be had recourse to in such -cases; the case of Cook demonstrative on this point. General treatment -in such cases. Wounds of the arteries of the leg. Case of H. Vigarelie -decisive of the principle and the practice to be pursued. Remarks on -the bleeding from great arteries. The surgery of the Peninsular war in -advance of the surgery of civil life. Case of suppurating aneurism of -the axillary artery; bursting after ligature of the subclavian; wounds -of the radial in the hand. pp. 226-240 - - -LECTURE XIII. - -Primitive carotid artery not to be tied for a wound of the external or -internal carotid; danger of doing it. Wounds of the vertebral artery; -illustrative cases. Opinion of Velpean. Parisian in advance of some -London surgeons. Wound of internal carotid; case by Dr. Twitchell. -Operative process described; case by Dr. Keith. pp. 241-250 - - -LECTURE XIV. - -Ligature of the common iliac artery; abdominal hernia; ligature of the -aorta; of the internal iliac artery; of the external iliac artery--two -methods; in cases of aneurism of the gluteal or sciatic artery, the -internal iliac artery should be the vessel secured--in all cases of -wounds, the wounded artery itself; Dr. Tripler’s (U. S. army) case of -wound of the gluteal artery; unsuccessful ligature of that artery, -followed by ligature of the internal iliac, and death; errors in the -treatment of this case; ligature of the femoral artery in the groin; -compression not to be made upon it when the operation is done for -aneurism; operation for popliteal aneurism; suppression of urine; -constitutional irritation after these operations; popliteal artery only -to be tied, when wounded and bleeding; case of wound of the popliteal -by a heavy mortising chisel; secondary hemorrhage; unsuccessful -ligature of the femoral; subsequent ligature of the popliteal, followed -by cure; ligature of the posterior tibial and peroneal arteries; of the -anterior tibial artery; of the plantar arteries. pp. 250-269 - - -LECTURE XV. - -Ligature of the common carotid artery: the external; the internal; the -arteria innominata; the subclavian, the axillary, the brachial, the -ulnar, the radial, and their terminations in the palm of the hand. -pp. 270-283 - - -LECTURE XVI. - -General remarks. Balls lodged in the brain. Respiration consists of -four movements. Excito-motor system of Dr. Marshall Hall. Concussion -of the brain; symptoms of first stage; of second stage. Treatment: -blood-letting in large and small quantities; mercury; blisters on the -head, between the shoulders, and on the nape of the neck; refrigerating -lotions; ice. Supervention of mania. Effects of concussion at a later -period. Relapses from irregularities. pp. 283-302 - - -LECTURE XVII. - -Compression, meaning of. Brain compressible; motions of the brain. -Symptoms of compression. Paralysis of the opposite side to the injury; -of the same side, and of both. Convulsions. Illustrative cases of -paralysis. Fissure or fracture of the skull; treatment. Symptoms in -more serious cases. Injury to the middle meningeal artery; trephine -necessary. Fractures on one side of the skull from blows on the other. -Fractures of the base from a fall on the vertex; not always fatal. -pp. 302-321 - - -LECTURE XVIII. - -Fracture of inner table without injury to the outer, of rare -occurrence. Illustrative cases. Subsequent mischief relieved by -operation at the end of two years. Peculiar division and fracture of -inner table. Principle in surgery on this point. Illustrative cases. -Trephine less dangerous at the first than at a later period. Fragments -of bone injuring the brain to be removed; propriety of division of -scalp in an adult, to examine the state of the bone beneath. Operation -dangerous; illustrative cases. Brain bears pressure best in young -persons. Symptoms of concussion are frequently accompanied by those of -compression. Contre-coup. pp. 321-340 - - -LECTURE XIX. - -Immediate and secondary tumors of the scalp. Suppuration on the -dura mater; on the brain; elevation or rising up of the dura mater, -indicating fluid beneath. Balls penetrating the brain. Sutures -separated by musket-balls. Injury of the frontal sinuses; of the orbit -and brain. Fungus, or hernia cerebri. Presumed cause of permanent -defects. Application of trephine; abuse of. Erysipelas of the scalp. -pp. 340-364 - - -LECTURE XX. - -Wounds of the chest most dangerous. Incised wounds require a treatment -essentially distinct from those made by gunshot. Contused wounds. -Auscultation of primary importance; distinctive sounds learned from -it. Symptoms of inflammation. Serous effusion the most important -evil in wounds of the chest. Respiratory murmur; pleuritic effusion. -Symptoms of pneumonia. Pulse. Difficulty of breathing; cough; sputum. -Differences of delirium. Rhoncus crepitans. Effects of inflammation -of the pleura; thickness of pleura in or after chronic inflammation. -Changes in the lung, subsequent on pneumonia, are principally three. -pp. 364-381 - - -LECTURE XXI. - -General blood-letting in pleuritis and pneumonia; local bleeding. -Internal remedies; tartar emetic; mercury; opium; blisters. Typhoid -pneumonia; treatment. Empyema or effusion of fluids into the cavity -of the chest; symptoms of. State of lung. Auscultation; operation for -empyema; place of election. Admission of air into the chest when in a -healthy state harmless; illustrative cases. Pneumothorax, nature of, -as ascertained by auscultation. Metallic tinkling; illustrative cases; -treatment. Emphysema; nature of; treatment. pp. 382-414 - - -LECTURE XXII. - -Simple injuries to the chest from sword or knife; involving the lung; -wound not to be probed; to be closed by a continuous suture; patient to -lie on the wounded side. Treatment of incised wounds of greater extent; -not to be examined by the probe or finger; absolute quietude necessary; -to relieve the oppression in breathing; to suppress hemorrhage; closure -of the wound; secretion of fluid into the cavity; necessity for a -depending opening. Illustrative cases. Ecchymosis, pathognomonic of -blood effused into the chest. Conclusions, six in number. pp. 414-425 - - -LECTURE XXIII. - -Penetrating gunshot wounds of the chest; always dangerous; statistics -of cases after Toulouse, the Three Days in Paris in 1830, and the -battles of Waterloo and the Sutlej; appearances of the orifices of -entrance and exit; symptoms; balls passing round the chest, but not -penetrating the cavity; lodging in the sternum; enlargement of the -wound sometimes necessary for the removal of foreign bodies, or of -blood; also when the wound is too small to admit the finger-end in -order to ascertain the state of the ribs, etc.; not to be greater than -absolutely requisite; pieces of shell, of a sword or lance, broken off, -and partly lodged in the thorax, or a ball sticking firmly between two -ribs; to be carefully extracted. Gunshot fracture of a rib; removal -of splinters, and of foreign bodies; case; comminuted fracture; wound -of costal cartilage; oblique gunshot wound; the ball running round -between lung and pleura for some distance; the lung sometimes only -slightly bruised, at others distinctly grooved by the ball; a ball -fairly passing through the lung; condition of the organ; symptoms; -effusion of blood; if the lung previously adherent, the cavity of the -chest not opened by the ball, its track only communicating externally; -illustrative cases of Generals Sir Lowry Cole, Sir A. Barnard, the Duke -of Richmond, Major-General Broke, Colonel Dumaresq; condition of the -track of the ball; can be detected after death, but not so during life, -as it does not cause any disturbance of the respiration after recovery -has taken place; case of Mrs. M.; wounds of the upper part of the lung -more dangerous than those of the lower; danger from effusion where the -external wound does not communicate freely with the chest; necessity -for its removal by operation; illustrative cases. pp. 426-442 - - -LECTURE XXIV. - -Appearances after death in various instances. Cases of Mr. Drummond, -etc. Splinters of bone to be removed. M. Guerin’s case, extensive -incision for the extraction of a splinter sticking in the lung. Balls, -or other foreign bodies, loose, or rolling about on the diaphragm. -Illustrative cases. Case of General Sir Robert Crawford. Consequences -of traumatic inflammation of the chest; effusion. Presence of a ball -or other foreign body rolling on the diaphragm, to be ascertained by -means of the stethoscope. M. Baudens on the encysting of balls and -splinters of bone; on the withdrawal of fluids by a syringe. Necessity -for an operation for the removal of balls, etc.; anatomy of the parts -concerned; manner in which the operation should be performed. -pp. 442-456 - - -LECTURE XXV. - -Hernia of the lung. Wounds of the diaphragm; cases of Captain Prevost -and of others; such wounds never heal; symptoms and treatment; are -often followed by hernia; operation recommended when the hernia is -strangulated. Wounds of the heart; anatomical position of the heart; -theory of the sounds of; endocardial, exocardial sounds: symptoms when -the heart is wounded; treatment; Larrey’s operation for opening the -pericardium, in cases of hemorrhage from wounds of the heart, or of -hydrops pericardii. Skielderup’s operation; case of J. Dierking, with a -diagram; the heart insensible to the touch; death from a blow on that -organ; treatment of wounds of; laceration and ruptures of the heart. -pp. 456-472 - - -LECTURE XXVI. - -Wounds of the internal mammary artery; operation proposed by M. Goyraud -for ligature of the internal mammary artery, when wounded; wounds of -the intercostal artery; suppression of hemorrhage from; case of General -Sir G. Walker. Wounds of the neck; two principles of treatment; cases -of Captain Hall and General Sir E. Packenham. Wounds of the face; -treatment. Wounds of the eyelids; treatment. Wounds of the ball of -the eye. Wounds of the nose and ear. Gunshot wounds of the eyeball. -Musket-shot lodged behind the eye; may cause ophthalmitis; loss of -sight by musket-balls passing across the back of both orbits. Wounds of -the first branch of the fifth pair of nerves. Injuries to the bones of -the face; to the bones of the nose. Wounds of the cheek; of the parotid -gland and duct. Salivary fistula. Wounds of the lachrymal bones and -sac; lachrymal fistula; case of General Sir Colin Halkett. Wounds of -the lower jaw; treatment; M. Baudens’s cases; case of Colonel Carleton; -incised and gunshot wounds of the tongue. Case of Captain Fritz; -lodgment of the iron breech of a gun in the forehead; its descent into -the mouth, and partial protrusion through the palate. Lodgment of balls -in the forehead, etc.; their descent into the throat or soft or hard -palate. Lodgment of a ball in the maxillary sinus for months and years. -pp. 473-482 - - -LECTURE XXVII. - -Structure of an intestine; eight distinct layers. Valvulæ conniventes -peculiar to man. Nature of villi: manner of absorption. Mucous membrane -of the stomach. Glands of Brunner, Grew, and Peyer. Solitary glands. -Muscular coat of the intestine. Wounds of the abdomen affecting its -wall or paries. Illustrative cases. Entrance and exit of a ball. -Lodgment of a ball in the abdominal paries. Incised wounds of the -paries followed by suppuration. Rupture of viscera from a blow. In -incised wounds the muscular parts are not reunited; formation of an -abdominal hernia; treatment. Admission of atmospheric air a bugbear. -Penetrating wounds. Protrusion of omentum; of intestine. Illustrative -cases. Treatment of wounded intestine. Large effusions of blood into -the cavity of the abdomen. Travers’s experiments on wounded intestines. -Treatment of a divided intestine; by ligature; by continuous suture. -Ramdohr’s treatment of a completely divided intestine. Manner of making -a continuous suture. pp. 482-508 - - -LECTURE XXVIII. - -Treatment of incised wounds of the intestine of small extent; when -larger; enlargement of the external wound when necessary. Intestine or -artery injured to be secured by suture; wound to be reopened. Bleeding -from the mesenteric or epigastric artery; effusion of blood into the -cavity; to be evacuated by enlarging the wound, when in quantity; if -the effusion be a small one, the blood will coagulate, and be absorbed; -suppuration in the abdomen a consequence of the non-absorption or -non-evacuation of blood effused to a large amount; illustrative cases; -treatment. Wounds of the intestines from musket-balls. Illustrative -cases of Captain Smith, Ensign Wright, Mathews, etc. Balls passed per -anum. Remarks. Cases of gunshot wounds of the abdomen occurring during -the Crimean campaign. pp. 508-525 - - -LECTURE XXIX. - -Abnormal or artificial anus; mode of formation. Valve or septum in -the orifice of the lower end of the bowel generally present, but -occasionally wanting. Treatment by compression. Desault’s mode of -treatment; Dupuytren’s; Mr. Trant’s. Wounds and injuries of the -liver. Cases of General Sir S. Barns, Corporal Macdonald, Lieutenant -Hooper, etc. Removal of portions of the liver, the patient surviving. -Illustrative cases by Blanchard, Dieffenbach, and Dr. Macpherson. -Wounds of the stomach; treatment. Fistulous opening in that viscus. -Knife swallowing; the operation of opening the abdomen and stomach -for the removal of knives which have thus passed into that organ. -Interesting cases. Wounds and injuries of the spleen; removal of the -organ entire or in part. Treatment of incised, punctured, and gunshot -wounds of the spleen. Wounds of the kidney and ureter. Illustrative -cases. Wounds of the spermatic cord and testis; case of medullary -sarcoma of the testis and lumbar glands, following a gunshot wound of -the testicle; wounds of the penis. Illustrative case. pp. 525-540 - - -LECTURE XXX. - -Wounds of the pelvis from musket-balls; fistulous opening in -consequence. Paralysis of one or of both limbs, complete or incomplete. -Balls lodging in bone should be removed: cases of Colonel Wade, Sir -Hercules Packenham, Sir John Wilson, John Bryan, Sir E. Packenham, -etc. Case by La Motte. Captain Campbell’s case. Wounds of the bladder; -consecutive accidents; employment of the catheter and its permanent -use. Treatment of inflammatory swelling and sloughing; operations when -required; illustrative cases. Cases of balls lodging and forming the -nucleus of calculi, successfully removed. Wounds of the bladder and -rectum; operation frequently required to save life. Operation in the -back for artificial anus. Conclusions. pp. 541-559 - - -ADDENDA. - -REPORTS FROM THE CRIMEA. - -Use of chloroform in the Crimea; case of Martin Kennedy; amputation of -finger; death following the exhibition of chloroform. Mr. Hannan’s case -of double amputation without chloroform. Effects of chloroform in cases -of amputation at the hip-joint or at the upper third of the thigh; the -operations not successful. Deputy Inspector-General Taylor on the want -of success attending operations on the lower extremities in the Crimea, -and its causes; his opinion corroborated by Deputy Inspector-General -Alexander. Use of chloroform in the Light Division; Alexander’s -statistics of operations in the Light Division. Five cases of excision -of the head, neck, and trochanter of the femur; four unsuccessful; -the third, Mr. O’Leary’s, doing well at date of report. Staff-Surgeon -Crerar’s case; extensive comminuted fracture of neck, trochanter, and -shaft of the femur, by a fragment of an exploded grenade; excision of -head, neck, trochanter, and part of shaft of the bone; death on the -fifteenth day; P.M.:--the muscles infiltrated with pus; no attempt to -repair the loss; Dr. Hyde’s case; comminuted fracture of neck of and -bone of great trochanter by a grape-shot, during the attack on the -Great Redan, on the 8th of September; operation the day after; death -on the sixth day. Dr. M’Andrew’s cases of excision of the head of the -humerus; attended with success. Dr. Gordon’s case of fatal wound of -the larynx and pharynx, with fracture of the thyroid cartilage; Deputy -Inspector-General Taylor’s comments on this case; Surgeon De Lisle’s -cases of wounds of the profunda femoris and popliteal arteries; case -of loss of the right leg below the knee by a round shot; Dr. Burgess’s -case, showing the effects of strychnia in injury of the spine and -spinal cord. Dr. Rooke’s case of severe and extensive injury to the -right hand and forearm, and the right side of the abdomen, (the bowels -being exposed by the destruction of skin, muscles, and peritoneum,) -with comminuted fractures of the ilium and neck and trochanter of the -femur; recovery at the end of three months. Mr. Lyons’s fatal case of -gunshot fracture of the left femur. Dr. Milroy’s, Mr. Atkinson’s, and -Dr. Scott’s cases of excision of the elbow-joint; Mr. Atkinson’s case -of round shot fracture of the superior maxillary and the malar bones; -recovery. Mr. De Lisle’s case of musket-shot wound of the right temple; -the supra-orbitar ridge broken off. Mr. Ward’s, Mr. Wall’s, and Mr. -Longmore’s cases of gunshot fracture of the cranium, with or without -injury to the brain. pp. 561-586 - - -REMARKS. - -SURGICAL COMMENTARIES ON THE PRECEDING CASES: Amputations at the -hip-joint; excision of the head and neck of the femur; the balls used -by the Allies and by the Russians; gunshot fractures of the lower -extremities; the utility of the chain saw; the machines for moving -the wounded soldiers in bed; the apparatus for slinging a broken -leg; excision of the knee-joint; of the head of the humerus; of the -elbow-joint; the head of the humerus to be retained in the socket, when -practicable; wounds penetrating the chest and abdomen; future reports -for the ADDENDA desired. pp. 586-590 - -Index. pp. 591-608 - -Index of Cases. pp. 608-614 - -Medical Works pp. 615-624 - - - - - COMMENTARIES - ON - SURGERY. - - - - -LECTURE I. - -ON GUNSHOT WOUNDS, ETC. - - -1. A wound made by a musket-ball is essentially contused, and attended -by more or less pain, according to the sensibility of the sufferer, -and the manner in which he may be engaged at the moment of injury. A -musket-ball will often pass through a fleshy part, causing only the -sensation of a sudden and severe, although sometimes of a trifling -blow. If it merely strike the same part without rupturing the skin, the -pain is often great. Major King, of the Fusiliers, was killed at New -Orleans by a musket-ball, which struck him on the pit of the stomach, -leaving only the mark of a contusion. - -2. Wounds from musket-balls, particularly of the face, sometimes -bleed considerably at the moment of injury, and for some little time -afterward, although no large vessel shall be injured to render the -bleeding inconvenient or dangerous. The application of a tourniquet is -then seldom if ever necessary, unless a vessel of some magnitude should -be partially torn or divided. - -3. When a limb is carried away by a cannon-shot, any destructive -bleeding usually ceases with the faintness and failure of strength -subsequent on the shock, and a hemorrhage thus spontaneously suppressed -does not generally return; it is the effort of nature to save life. -The application of a tourniquet is rarely necessary, unless as a -precautionary measure, when it should be applied loosely, and the -patient, or some one else, shown how to tighten it if necessary. -A musket-ball will often pass so close to a large artery, without -injuring it, as to lead to the belief that the vessel must have receded -from the ball by its elasticity. A ball passed between the femoral -artery and vein of a soldier at Toulouse without doing more injury -than a contusion, but it gave rise to inflammation and closure of the -vessels, followed by gangrene of the extremity. General Sir Lowry -Cole was shot through the body at Salamanca, immediately below the -left clavicle; a part of the first rib came away, and the artery at -the wrist became, and remained, much diminished in size. General Sir -Edward Packenham was shot through the neck on two different occasions, -the track of each wound being apparently through the great vessels. The -first wound gave him a curve in his neck, the second made it straight. -His last unfortunate wound, at New Orleans, was directly through the -common iliac artery, and killed him on the spot. Colonel Duckworth, -of the 48th Regiment, received a ball through the edge of his leather -stock, at Albuhera, which divided the carotid artery, and killed him -almost instantaneously. - -4. Secondary hemorrhage of any importance from small vessels does not -_often_ occur. On the separation of the contused parts, or sloughs, a -little blood may be occasionally lost; but it is then generally caused -by the impatience of the surgeon, or the irregularity of the patient, -and seldom requires attention. - -5. A large artery does sometimes give way by ulceration between the -eighth and the twentieth days; but the proportion is not more than four -cases in a thousand, requiring the application of a ligature; exclusive -of those formidable injuries caused by broken bones, or the inordinate -sloughing caused by hospital gangrene, when not properly treated. - -6. A certain constitutional alarm or shock follows every serious wound, -the continuance of which excites a suspicion of its dangerous nature, -which nothing but its subsidence, and the absence of symptoms peculiar -to the internal part presumed to be injured, should remove. The -opinion given under such circumstances should be very guarded; for if -this symptom of alarm should continue, great fears may be entertained -of hidden mischief. Colonel Sir W. Myers was shot, at Albuhera, at -the head of the Fusilier Brigade, at the moment of victory, by a -musket-ball, which broke his thigh, and lodged. The continuance of -the alarm and anxiety satisfied me it had done other mischief. He -died next morning, of mortification of the intestines. General Sir -Robert Crawford was wounded at the foot of the smaller breach at the -storming of Ciudad Rodrigo, by a musket-ball, which entered the outer -and back part of the shoulder, and came out at the axilla. There was a -third wound, a small slit in the side, apparently too small to admit -a ball. The continuance of the anxiety and alarm pointed out some -hidden mischief, which I declared had taken place; and when he died his -surgeon found the ball loose in his chest. It had been rolling about on -his diaphragm. Surgery was not sufficiently advanced in those days to -point out the situation, or to authorize an attempt for the removal of -the ball. It must in future be done. - -This constitutional alarm and derangement are not always present to so -marked an extent. A soldier at Talavera was struck on the head by a -twelve-pound shot, which drove some bone into, and some brain out of -his head: he was walking about, complaining but little, immediately -after the accident, although he died subsequently. - -7. It is not always possible, from their appearance, to decide which -opening is the entrance, which the exit of an ordinary sized round -ball; or when two holes are distant from each other, to ascertain -whether they have been caused by one, or by two distinct balls. When a -ball is not impinging with much impetus, it may become a penetrating, -without being much of a contused wound, which will close in and heal -with little suppuration. If the ball do not press upon, or interfere -with some important part, the slight degree of irritation which follows -may give rise to the formation of a sac, which adheres to it and -possibly keeps it quiet for years, if not for life. - -8. The wound made by the entrance of an ordinary musket-ball is usually -circular, depressed, of a livid color, and capable of admitting the -little finger, the exit being more ragged, and not depressed. It is -sometimes little more than a small slit or rent, although at others, as -in the face or in the back of the hand, it may be much torn, giving to -an otherwise simple wound a more frightful appearance, such as is not -usually seen in the thigh, or other equally firm fleshy part. - -9. Wounds from flattened or irregular-shaped musket-balls, pieces of -shells, or other sharp-edged destructive instruments, are often very -much lacerated, and their entrance is less marked. The part thus torn -can generally be preserved, and the wound healed with comparatively -little loss of substance. - -10. When it is desirable to ascertain the exact course of a ball, and, -if possible, the internal part injured by it, the sufferer should be -placed in the position he was in when he received the injury, with -especial reference to the probable situation of the enemy, when that -will often become very intelligible which was before indistinct. My -attention was directed, after the battle of Toulouse, to a soldier, -whose foot was gangrenous without an apparent cause, he having received -merely a flesh wound in the thigh, not in the exact course of the main -artery, which, nevertheless, I said was injured. On placing the man -in the same position with regard to us, that he supposed himself to -have been in toward the enemy when wounded, the possibility of such an -injury was seen; and dissection after death proved the correctness of -the opinion. - -11. When one opening only can be seen, it is presumed the ball has -lodged; but this does not follow, although the finger of the surgeon -may pass into the wound for some distance. At the battle of Vimiera, I -pulled a piece of shirt, with a ball at the bottom of it, out of the -thigh of an officer of the 40th Regiment, into which it had gone for -at least three inches. After the battle of Toulouse, a ball, which -penetrated the surface of the chest, and passed under the pectoral -muscle for two inches, was ejected by the elasticity of the rib against -which it struck. Scarcely any inconvenience followed, and the officer -rapidly recovered. After the battle of Waterloo, I was requested to -decide whether a young officer should be allowed to die in a few days, -or to have a chance for his life by losing his leg above the knee. The -joint was open, the suppuration profuse. A large or grape-shot was -supposed to be lodged in the head of the tibia. The limb was amputated, -and he is now alive, forty years afterward, but no shot was found in -his limb. It had dropped out after doing the injury. - -12. The treatment of simple gunshot or flesh wounds should be, under -ordinary circumstances, as simple as themselves. Nothing should be -applied but a piece of linen or lint, wetted with cold water; this -may be retained by a strip of sticking-plaster, or any other thing -applicable for the purpose of keeping the injured part covered. A -compress of linen, or other similar substance, moistened with cold -or iced water when procurable, will be useful; and a few inches of a -linen bandage may be sewed on, to prevent the compress from changing -its position during sleep. When the wound becomes tender, a little -oil, lard, or simple ointment may be placed over it. A roller, as a -surgical application, is useless, if not injurious. At the first and -second battles in Portugal, every wound had a roller applied over it; -it soon became stiff, bloody, and dirty. They did no good, were for the -most part cut off with scissors, and thus rendered useless. When really -wanted, at a later period, they were not forthcoming. An advancing -army cannot, and ought not to carry casks full of rollers into the -field; and the apothecary-general had better have instead, two casks or -boxes full of good wax candles; for, although every regimental surgeon -ought to have four in his panniers, kept as carefully for emergencies -as his capital instruments, they will require from time to time to be -replaced. No roller should be more than two inches and a quarter wide, -and made of good, strong, coarse linen, very much, in fact, the reverse -of the rollers which have until lately been supplied to the army. - -13. Cold or iced water may be used as long as cold is grateful to the -sufferer. When it ceases to be so, it should be exchanged for warm, -applied in any convenient way which modern improvements have suggested, -whether by piline, gutta-percha, oiled silk, etc. An evaporating -poultice may be used in private life, but no poultices should be -permitted in a military hospital, until the principal surgeon is -satisfied they are necessary. They are generally cloaks for negligence, -and sure precursors of amputation in all serious injuries of bones and -joints. They are properly used to alleviate pain, stiffness, swelling, -the uneasiness arising from cold, and to encourage the commencing -or impeded action of the vessels toward the formation of matter. As -soon as the effect intended has been obtained, the poultice should be -abandoned, and recourse again had to water, hot or cold, with compress -and bandage. I was in the habit of calling a poultice when misapplied a -_cover-slut_. - -14. Many simple flesh wounds are cured in four weeks; the greater part -in six. Fresh air and cold water are essential. Purgatives may be -occasionally given, and abstinence is an excellent remedy. Emetics, -bleeding, and something approaching to starvation as to solids, are of -great importance if the sufferers should be irregular in their habits, -or the inflammatory symptoms run high. In weakly persons, a generous -diet with tonic remedies will be necessary. - -15. In wounds of muscular parts inflammation usually occurs from twelve -to twenty-four hours after the injury, and the vicinity of the wound -becomes more sensible to the touch, with a little swelling and increase -of discoloration. A reddish serous fluid is discharged, and the limb -becomes stiff and nearly incapable of motion, from its causing an -increase of pain. These symptoms are gradually augmented on or about -the third day; the inflammation surrounding the wound is more marked; -the discharge is altered, being thicker; the action of the absorbents -on the edges of the wound may be observed; and, on the fourth or fifth, -the line of separation between the dead and living parts will be very -evident. The wound will now discharge purulent matter mixed with other -fluids, which gradually diminish as the naturally healthy actions take -place. The inside of the wound, as the process of separation proceeds, -changes from a blackish-red color to a brownish yellow, moistened by -a little good pus. On the fifth and sixth days, the outer edge of the -separating slough is distinctly marked, and begins to be displaced; -the surrounding inflammation extends to some distance, the parts -are more painful and sensible to the touch; the discharge is more -purulent, but not great in quantity. On the eighth or ninth day, the -slough is, in most cases, separated from the edges of the track of the -ball, and hanging in the mouth of the wound, although it cannot yet be -disengaged; the discharge increases, and the wound becomes less painful -to the patient, although frequently more sensible when touched. - -If there be two openings, the exit of the ball, or the counter-opening, -is in general much the cleaner, being often in a fair granulating -state before the entrance of the ball is free from slough. If the -inflammation have been smart, the limb is at this time a little swollen -and discolored for some distance around; fibrin and serum are thrown -out into the cellular membrane, or areolar tissue, as it is now termed; -the redness diminishes; the sloughs are discharged, together with any -little extraneous substances which may be in the wound; and there is -frequently a slight bleeding, if the irritable granulations are roughly -treated. The limb on the twelfth, and even fifteenth day, retains the -appearance of yellowness and discoloration which ensues from a bruise, -and which continues a few days longer. The sloughs do not, sometimes, -separate until this period, and, in persons slow to action, not even -until a later one. The wound now contracts; the middle portion of the -track first closes, and is no longer pervious; the lower opening soon -heals, while the upper, or that usually made by the entrance of the -ball, continues to discharge for some time, and toward the end of six -weeks, or sometimes two months, finally heals with a depression and -cicatrix, marking distinctly the nature of the injury that has been -received. - -16. The state of constitution, the difficulties and distresses of -military warfare, exposure to the inclemency of the weather, the season -of the year, or the imprudence of individuals, will sometimes bring on -a train of serious symptoms, in wounds apparently of the same nature as -others in which no such evils occur. After the first two or three days, -the symptoms gradually increase, the swelling is much augmented, the -redness extends, and the pain is more severe and constant. The wound -becomes dry, stiff, with glistening edges, the general sensibility is -increased, the system sympathizes, the skin becomes hot and dry, the -tongue loaded, the head aches, the patient is restless and uneasy, -the pulse full and quick; there is fever of the inflammatory kind. -The swelling of the part increases from deposition in the areolar -tissue to a considerable extent above and below the wound, and the -inflammation, instead of being entirely superficial or confined to -the immediate track of the ball, spreads widely. The wound itself the -sufferer can hardly bear to be touched; it discharges but little, -and the sloughs separate slowly. Pus soon begins to be secreted more -copiously, not only in the track of the wound, but in the surrounding -parts; sinuses may form in the course of the muscles, or under the -fascia, and considerable surgical treatment be necessary, while the -cure is protracted from three to four, and even to six months; and is -often attended for a longer period with lameness, from contraction of -the muscles or adhesions of the areolar tissue. The parts, from having -been so long in a state of inflammation, are much weaker, and if the -injury have been in the lower extremity, the leg and foot swell on -any exertion, which cannot be performed without pain and inconvenience -for a considerable time. The treatment should be active; the patient, -if robust, ought to be bled if no endemic disease prevail, vomited, -purged, kept in the recumbent position, and cold applied so long as -it shall be found agreeable to his feelings; when that ceases to be -the case, warm fomentations ought to be resorted to, but they are to -be abandoned the instant the inflammation is subdued and suppuration -well established. The feelings of the patient will determine the -period, and it is better to begin a day too soon than one too late. -If the inflammation be superficial, leeches will not be of the same -utility as when it is deep seated; but then they must be applied in -much greater numbers than are usually recommended. The roller and -graduated compresses, or pressure made by slips of adhesive plaster -under them, are the best means of cure in the subsequent stages, with -change of air, and friction to the whole extremity, which alone, when -early and well applied, will often save months of tedious treatment. -If the limb become contracted and the cellular membrane thickened, it -is principally by friction (shampooing) that it can be restored to its -natural motion. - -17. If the ball should have penetrated without making an exit, or have -carried in with it any extraneous substances, the surgeon must, if -possible, ascertain its exact situation, and remove it and any foreign -bodies which may be lodged; indeed, if there be time, every wound -should be examined so strictly as to enable the surgeon to satisfy -himself that nothing has lodged. This is less necessary where there are -two corresponding openings evidently belonging to one shot; but it is -imperiously demanded of the surgeon, where there is one opening only, -even if that be so much lacerated as to lead to the suspicion of its -being a rent from a piece of shell; for it is by no means uncommon for -such missiles, or a grape-shot, to lodge wholly unknown to the patient, -and to be discovered by the surgeon at a subsequent period, when much -time has been lost and misery endured. A soldier during the siege of -Badajoz had the misfortune to be near a shell at the moment of its -bursting, and was so much mangled as to render it necessary to remove -one leg, an arm, and a testicle, (a part of the penis and scrotum being -lost.) In one of the flesh wounds in the back part of the thigh and -buttock a large piece of shell was lodged, and kept op considerable -irritation until it was removed. The man recovered. - -18. In examining a wound, a finger should be gently introduced, if -possible, in the course of the ball, to its utmost extent; in parts -connected with life, or liable to be seriously injured, it is the only -sound usually admissible. While this examination is taking place, the -hand of the surgeon should be carefully pressed upon the part opposite -where the ball may be expected to lie, by which means it may perhaps be -brought within reach of the finger, and for want of which precaution, -it may be missed by a very trifling distance. While the finger is in -the wound the limb may be thrown as nearly as possible into that action -which was about to be performed on the receipt of the injury, when -the contraction of the muscles and the relative change of the parts -will more readily allow the course of the ball to be followed. If this -should fail, attention should be paid to the various actions of the -limb, the attendant symptoms arising from parts affected, and what may -be called the general anatomy of the whole circle of injury. A muscle, -in the act of contraction, may oppose an obstacle to the passage of an -instrument in the direction the ball has taken, especially if it should -have passed between tendons or surfaces loosely connected by cellular -membrane; as by the side of, or between the great blood-vessels, which -by their elasticity may make way for the ball, and yet impede the -progress of a sound. When the ball is ascertained to have passed beyond -the reach of the finger, a blunt silver sound or elastic bougie may be -used, and the opposite side of the limb should be carefully examined, -and pressure made on the wounded side, when it will probably be found -more or less deeply seated. If the ball should not be discoverable by -these means, the surgeon should consider every symptom, and every part -of anatomy connected with the wound, before he decides on leaving the -ball to the operations of nature. - -19. It is unnecessary to dilate a wound without a precise object -in view, which might render an additional opening requisite. This -dilatation or opening, when made, should always be carried through -the fascia of the limb. A wound ought not to be dilated because such -operation may at a more distant period become necessary. The necessity -should first be seen, when the operation follows of course. - -Suppose a man be brought for assistance with a wound through the -thigh, in the immediate vicinity of the femoral artery, which he says -bled considerably at the moment of injury, but the hemorrhage had -ceased. Is the surgeon warranted in cutting down upon the artery, and -putting ligatures upon it on suspicion? Every man in his senses ought -to answer, No. The surgeon should take the precaution of applying a -tourniquet loosely on the limb, and of placing the man in a situation -where he can receive constant attention in case of need; but he is not -authorized to proceed to any operation, unless another bleeding should -demonstrate the injury and the necessity for suppressing it. By the -same reasoning, incisions are not to be made into the thigh on the -speculation that they may be hereafter required. If the confusion which -has enveloped this subject be removed, and bleeding arteries, broken -bones, and the lodgment of extraneous substances be admitted to be the -only legitimate causes for dilating wounds in the first instance, the -arguments in favor of primary dilatation in other cases must fall to -the ground. - -When the inflammation, pain, and fever run high, the tension of the -part being great, an incision should be made by introducing the knife -into the wound, and cutting for the space of two or three inches, -according to circumstances, in the course of the muscles, carefully -avoiding any other parts of importance. The same should be done at the -inferior or opposite opening, if mischief be seriously impending, not -so much on the principle of loosening the fascia as on that of taking -away blood from the part immediately affected, and of making a free -opening for the evacuation of the fluids about to be effused. - -It is no less an advantageous practice in the subsequent stages of -gunshot wounds, where sinuses form and are tardy in healing. A free -incision is also very often serviceable when parts are unhealthy, -although there may not be any considerable sinus. Upon the necessity of -it where bones are splintered, there is no occasion in this place to -insist. - -20. In making incisions for the removal of balls in the vicinity of -large vessels, particularly in the neck, the hand should always be -unsupported, in order to prevent an accident from any sudden movement -of the patient. This caution is the more necessary on the field of -battle, where many things may give rise to sudden alarm. At the affair -of Saca Parte, near Alfaiates, in Portugal, I stationed myself behind -a small watch-tower, and the wounded were first brought to this spot -for assistance. A howitzer had also been placed upon it, being rising -ground, and at the moment I was extracting a ball situated immediately -over the carotid artery, the gun was fired, to the inexpressible alarm -of surgeon, patient, and orderly, who bolted in all directions. From -my hand being unsupported, no mischief ensued, and the operation was -completed as soon as all had recovered their usual serenity. When a -ball is discovered on the opposite side of a limb, through which it -has nearly penetrated, but has not had sufficient power to overcome -the resistance and elasticity of the skin, it should be removed by -incision. An opening is thus obtained for the evacuation of any -matter which may be formed in the long track of such a wound, and -any other extraneous bodies are more readily extracted. When a ball -has penetrated half through the thick part of the thigh, in such a -direction that it cannot readily be removed by the opening at which -it entered; or, from the vicinity of the great vessels, it may be -considered unadvisable to cut for it in that direction; or if the -ball cannot be distinctly felt by the finger through the soft parts, -it ought not to be sought for at the moment, for an incision of -considerable extent will be required to enable the surgeon to extract -it. Much pain will be caused, and higher inflammation may follow than -would ensue if the wound were left to the efforts of nature alone, -by which, in time, the ball would in all probability be brought -much nearer to the surface, and might be more safely extracted. It -frequently happens, that after a few days or weeks, a ball will be -distinctly felt in a spot where the surgeon had before searched for it -in vain. A wound will frequently close without further trouble, the -ball remaining without inconvenience in its new situation; and the -patient not being annoyed by it, does not feel disposed to submit to -pain or inconvenience for its removal. A very strong reason for the -extraction of balls during the first period of treatment, if it can be -safely accomplished, is, that they do not always remain harmless, but -frequently give rise to distressing or harassing pains in or about the -part, which often oblige the sufferer to submit to their extraction at -a later period, when their removal is infinitely more difficult; and -may be more distressing than at the moment of injury. - -Nothing appears more simple than to cut out a ball which can be felt -at the distance of an inch, or even half an inch below the skin, but -the young surgeon often finds it more difficult than he expected, -because he makes his incision too small; and cannot at all times oppose -sufficient resistance to prevent the ball from retreating before the -effort he makes for its expulsion with the forceps or other instrument. -The ball also requires to be cleared from the surrounding cellular -substance, to a greater extent than might at first be imagined; for -all that seems to be required is, that a simple incision be made down -to the surface of it, when it will slip out, which is not usually -the case. When a ball has been lodged for years, a membranous kind -of sac is formed around it, which shuts it in as it were from all -communication with the surrounding parts. If it should become necessary -to extract a ball which has been lodged in this manner, the membranous -sac will often be found to adhere so strongly to the ball that it -cannot be got out without great difficulty, and sometimes not without -cutting out a portion of the adhering sac. - -It often occurs that a ball lodges and cannot be found, especially -where it has struck against a bone, and slanted off in a different -direction. If the ball should lodge in the cellular tissue between two -muscles, it often descends by its gravity to a considerable distance, -and excites a low degree of irritation, which slowly brings it to -the surface, or terminates in abscess. Colonel Ross, of the Rifle -Brigade, was wounded at the battle of Waterloo by a musket-ball, which -entered at the upper part of the arm and injured the bone. More than -one surgeon had pointed out the way by which it had passed under the -scapula and lodged itself in some of the muscles of the back. About -a year afterward I extracted it close to the elbow, the ball lying -at the bottom of an abscess, which was only brought near the surface -by time, by the use of flannel, and by desisting from all emollient -applications.[1] - -[Footnote 1: Various instruments have been invented for the removal -of balls which have been deeply lodged in soft parts; but little -assistance has been derived from them hitherto, although many of them -are very ingenious.] - -21. A ball will frequently strike a bone, and lodge, without causing -a fracture, although it will a fissure. It will even go through the -lower part of the thigh-bone, between or a little above the condyles, -merely splitting without separating it, and some balls have lodged in -bones for years, with little inconvenience. It should nevertheless be -a general rule not to allow a ball to remain in a bone, if it can be -removed by any reasonable operation. The rule is not entirely devoid of -exception. Lieutenant-Colonel Dumaresq, aid-de-camp to the present Lord -Strafford, was wounded at Waterloo by a ball which penetrated the right -scapula, and lodged in a rib in the axilla. The thoracic inflammation -nearly cost him his life, but he ultimately quite recovered, and died -many years afterward of apoplexy, the ball remaining enveloped in bone. - -22. When a bayonet is thrust into the body it is a punctured wound made -by direct pressure; when of little depth, much inconvenience rarely -ensues, and the part heals slowly, but surely, under the precaution of -daily pressure. A punctured wound, extending to considerable depth, -labors under disadvantages in proportion to the smallness of the -instrument, and the differences of texture through which it passes. -When the instrument is large, the opening made is in proportion, and -does not afford so great an obstacle to the discharge of the fluids -poured out or secreted as when the opening is small. Lance wounds are -therefore less dangerous than those inflicted by the bayonet. When a -small instrument passes deep through a fascia, it makes an opening in -it which is not increased by the natural retraction of parts, inasmuch -as it is not sufficiently large to admit of it; and which opening, -small as it is, may be filled or closed up by the soft cellular tissue -below, which rises into it, and forms a barrier to the discharge of any -matter which may be secreted beneath. If the instrument should have -passed into a muscle, it is evident that if that muscle were in a state -of contraction at the moment of injury, the punctured part must be -removed to a certain distance from the direct line of the wound when in -a state of relaxation, and vice versa. The matter, secreted, and more -or less in almost every instance will be secreted, cannot in either -case make its escape, and all the symptoms occur of a spontaneous -abscess deeply seated below a fascia. That inflammation should spread -in a continuous texture is not uncommon; that matter, when confined, -should give rise to great constitutional disturbance is, if possible, -less so; but that this disturbance takes place without the occurrence -of inflammation, or the formation of matter, may be doubted; and it -may be concluded that there is no peculiarity in punctured wounds that -may not be accounted for in a satisfactory manner. Serious effects have -been attributed to injuries of nerves, but without sufficient reason; -nevertheless, those who have seen locked-jaw follow a very simple -scratch of the leg from a musket-ball, more frequently than from a -greater injury, are not surprised at any symptoms of nervous agitation -that may occur after punctured wounds. As many bayonet wounds through -muscular parts heal with little trouble, it is time enough to dilate -them when assistance seems to be required. Cold water should be used at -first; care should be taken not to apply a roller or compress of any -kind over the wound; matter, when formed, should be frequently pressed -out, and, if necessary, a free exit should be made for it. - -23. A great delusion is cherished in Great Britain on the subject -of the bayonet--a sort of monomania very gratifying to the national -vanity, but not quite in accordance with matter of fact. Opposing -regiments, when formed in line, and charging with fixed bayonets, never -meet and struggle hand to hand and foot to foot, and this for the very -best possible reason, that one side turns round and runs away as soon -as the other comes close enough to do mischief; doubtless considering -that discretion is the better part of valor. Small parties of men may -have personal conflicts after an affair has been decided, or in the -subsequent scuffle if they cannot get out of the way fast enough. -The battle of Maida is usually referred to as a remarkable instance -of a bayonet fight; nevertheless, the sufferers, whether killed or -wounded, French or English, suffered from bullets, not bayonets. The -late Sir James Kempt commanded the brigade supposed to have done this -feat, but he has assured me that no charge with the bayonet took -place, the French being killed in line by the fire of musketry; a fact -which has of late received a remarkable confirmation in the published -correspondence of King Joseph Bonaparte, in which General Regnier, -writing to him on the subject, says: “The 1st and 42d Regiments charged -with the bayonet until they came within fifteen paces of the enemy, -when they turned, _et prirent la fuite_. The second line, composed of -Polish troops, had already done the same.” Wounds from bayonets were -not less rare in the Peninsular war. It may be that all those who were -bayoneted were killed, yet their bodies were seldom found. A certain -fighting regiment had the misfortune one very misty morning to have a -large number of men carried off by a charge of Polish lancers, many -being also killed. The commanding officer concluded they must be all -killed, for his men possessed exactly the same spirit as a part of the -French Imperial guard at Waterloo. “They might be killed, but they -could not by any possibility be taken prisoners.” He returned them -all dead accordingly. A few days afterward they reappeared, to the -astonishment of everybody, having been swept off by the cavalry, and -had made their escape in the retreat of the French army through the -woods. The regiment from that day obtained the ludicrous name of the -“Resurrection men.” - -The siege of Sebastopol has furnished many opportunities for partial -hand to hand bayonet contests, in which many have been killed and -wounded on all sides, but I do not learn that in any engagements which -have taken place regiments advanced against each other in line and -really crossed bayonets as a body; although the individual bravery of -smaller parties was frequently manifested there, as well as in the war -in the Peninsula. - - - - -LECTURE II. - -ON INFLAMMATION, MORTIFICATION, ETC. - - -24. In some very rare cases, an intense, deep-seated inflammation -supervenes after some days, almost suddenly and without any obvious -cause. The skin is scarcely affected, although the limb--and this -complaint has hitherto been observed only in the thigh--is swollen, and -exceedingly painful. If relief be not given, these persons die soon, -and the parts beneath the fascia lata appear after death softened, -stuffed, and gorged with blood, indicating the occurrence of an intense -degree of inflammation, only to be overcome by general blood-letting; -and especially by incisions made through the fascia from the wound, -deep into the parts, so as to relieve them by a considerable loss of -blood, and by the removal of any pressure which the fascia might cause -on the swollen parts beneath. - -25. Erysipelatous inflammation is marked by a rose or yellowish -redness, tending in bad constitutions to brown or even to purple, but -in all cases terminating by a defined edge on the white surrounding -skin. It frequently spreads with great rapidity, so that the limb, -and even the whole skin of the body, may be in time affected by it, -the redness subsiding and even disappearing in one part, while it -extends in another direction. When this inflammation attacks young -and otherwise healthful persons of apparently good constitution, it -should be treated by emetics, purgatives, and diaphoretics, in the -first instance, with, perhaps, in some cases, bleeding. When the habit -of body is not supposed to be healthy, bleeding is inadmissible, and -stimulating diaphoretics, combined with camphor and ammonia, will be -found more beneficial after emetics and purgatives; these remedies may -in turn be followed by quinine and the mineral acids, with the infusion -and tincture of bark. Little reliance can be placed on large doses of -cinchona in powder; they nauseate and therefore distress. - -When the inflammation extends deeper than the skin, into the areolar -or cellular tissue, it partakes more of the nature of the healthy -suppurative inflammation, commonly called phlegmonous, is accompanied -by the formation of matter, and tends to the sloughing or death of this -tissue at an early period. The redness in this case is of a brighter -color, although equally diffuse, and with a determined edge; the limb -is more swollen and tense, and soon becomes quagmiry to the touch. The -skin is then undermined, and soon loses its life, becomes ash colored -and gangrenous in spots, and separates, giving exit to the slough and -matter which now pervade the whole extremity affected. If the patient -survive, it will probably be with the loss of the whole of the skin and -the cellular substance of the limb. - -As soon as the inflamed part communicates the springy, fluctuating -sensation approaching, but not yet arrived at the quagmiry feel alluded -to, an incision should be made into it, when the areolæ or cells of -the cellular tissue will be seen of a bright leaden color, and of a -gelatinous appearance, arising from the fluid secreted into them, being -now nearly in the act of being converted into pus. The septa, dividing -the tissue into cells, have not at this period lost their life, and -the fluid hardly exudes, as it will be found to do a few hours later, -when the matter deposited has become purulent. When this change has -taken place, the patient is in danger, and if relief be not given, he -will often sink under the most marked symptoms of irritative fever of -a typhoid type. Nature herself sometimes gives the required relief by -the destruction of the superincumbent skin; but this part is tough, -offers considerable resistance, and does not readily yield until the -deep-seated fascia is implicated, and the muscular parts are about to -be laid bare. - -An incision made into the inflamed part through the cellular tissue, -down to the deep-seated fascia, which should not be divided in the -first instance, gives relief. One of four inches in length usually -admits of a separation of its edges to the amount of two inches, by -which the tension of the skin, which principally causes the mischief -which follows the inflammation, is removed. As many incisions are -required as will relieve this tension, according to the extent of the -inflammation, which is also relieved by the flow of blood, but that -requires attention, as it is often considerable, particularly if the -deep fascia be divided on which the larger vessels are found to lie. If -the necessary incisions be delayed until the quagmiry feeling is fully -established, the skin above it is generally undermined and dies. The -following case is given as the first known in London, in which long -incisions were made for the cure of this disease, and their effect in -relieving the constitutional irritation is so strongly marked as to -need no further explanation:-- - -Thomas Key, aged forty, a hard drinker, was admitted into the -Westminster Hospital, under my care, on the 21st of October, 1823, -having fallen and injured his left arm against a stool, four days -previously. On the 30th, the skin being very tense, the part springy, -and yielding the boggy feel described, pulse 120, mind wandering, -I proposed, in consultation with my colleagues, to make incisions -into the part, but which were considered to be unusual and improper. -On the 31st, the pulse being 140, and everything indicating a fatal -termination, I refrained from any further consultation, although -directed by the rules of the hospital; and, after my old Peninsular -fashion, made an incision eight inches long into the back of the arm, -and another of five on the under edge, in the line of the ulna, down to -the fascia, which was in part divided; one vessel bled freely. The next -day, November 1, the pulse was 90; the man had slept, and said he had -had a good night. The incision on the back of the arm was augmented -to eleven inches; and from that time he gradually recovered, being -snatched as it were from the jaws of death. - -This case, published at the time, has been the exemplar on which this -most successful practice has been followed throughout the civilized -world--a practice entirely due to the war in the Peninsula. - -When this kind of inflammation attacks the scrotum, which it sometimes, -although rarely, does, as a sporadic disease, independent of any -urinary affection, incisions into it should be made with great caution, -not extending beyond the discolored spots, in consequence of the loss -of blood which would ensue from the great vascularity of the part. -They should be confined to, and not extend beyond, the parts obviously -falling into a state of slough or of mortification. - -26. Mortification is the last and most fatal result of inflammation, -although it may occur as a precursor of it in the neighboring parts, -and not as a consequence. The essential distinction is, between that -which is _idiopathic_ or _constitutional_ and that which is _local_; -and has not existed long enough to implicate the system at large, or to -become _constitutional_. Idiopathic or constitutional mortification, -sphacelus or gangrene, may be _humid_ or _dry_. _Humid_, when the death -of the part has been preceded by inflammation and a great deposition -of fluid in it, followed by putrefaction and decomposition, as after -an attack of erysipelas following an injury. It may then be said to -be acute. Dry, when preceded by little or no deposition of fluid in -it, and followed by a drying, shriveling, and hardening of the part, -nearly in its natural form and shape, unless exposed to external causes -usually leading to putrefaction. The most remarkable instances have -occurred in persons suffering from typhus fever, and exposed to cold, -without sufficient covering or care. When it occurs in old persons, or -in those who have lived on diseased rye or other food, it may be called -chronic. The gangrene which follows wounds has been termed _traumatic_, -which explains nothing but the fact of its following an injury. - -_Local_ mortification may be the effect of great injury applied direct -to the part, or of an injury to the great vessels of the limb. It may -occur from intense cold freezing the part, or from intense heat burning -or destroying it. - -27. It sometimes happens that a cannon-ball strikes a limb, and without -apparently doing much injury to the skin, so completely destroys the -internal textures that gangrene takes place almost without an effort -on the part of nature to prevent it. This kind of injury was formerly -attributed to the wind of a ball; but no one who has seen noses, ears, -etc. injured or carried away, and all parts of the body grazed, without -such mischief following, can believe that either the wind, or the -electricity collected by it, can produce such effect. - -The patient is aware of having received a severe blow on the part -affected, which does not show much external sign of injury, the skin -being often apparently unhurt or only grazed; the power of moving the -part is lost, and it is insensible. The bone or bones may or may not -be broken, but in either case the sufferer, if the injury be in the -leg, is incapable of putting it to the ground. After a short time the -limb changes color in the same manner as when severely bruised, and the -necessary changes rapidly go on to gangrene. The limb swells, but not -to any extent, and more from extravasation between the muscles and the -bones than from inflammation, which, although it is attempted to be set -up, never attains to any height. The mortification which ensues tends -to a state between the humid and the dry, and rather more to the latter -than the former. These cases are not of frequent occurrence, and are -not commonly observed until after the blackness of the skin, and the -want of sensibility and motion attract attention; for the patient is -generally stupefied at first by the blow, and the part or parts about -the injury feel benumbed. I made these cases an object of particular -research after the battle of Waterloo, but could find only one among -the British wounded. The man stated that he had received a blow on the -back part of the leg, he believed from a cannon-shot, which brought him -to the ground, and stunned him considerably. On endeavoring to move, -he found himself incapable of stirring, and the sensibility and power -of motion in the limb were lost. The leg gradually changed to a black -color, in which state he was carried to Brussels. When I saw it, the -limb was black, apparently mortified, and cold to the touch; the skin -was not abraded; the leg was not so much swollen as in cases of humid -gangrene; the mortification had extended nearly as high as the knee; -there was no appearance of a line of separation; and the signs of -inflammation were so slight that amputation was performed immediately -above the knee. On dissecting the limb, I found that a considerable -extravasation of bloody fluid had taken place below the calf of the -leg, and in the cavity thus formed some ineffectual attempts at -suppuration had commenced. The periosteum was separated from the tibia -and fibula; the popliteal artery was, on examination, found closed -in the lower part of the ham by coagulated lymph, proceeding from a -rupture of the internal coat of the vessel. Two inches below this the -posterior tibial and fibular arteries were completely torn across, and -gave rise, in all probability, to the extravasation. The operation was -successful. The proper surgical practice in such cases is to amputate -as soon as the extent of the injury can be ascertained, in order -that a joint may not be lost, as the knee was in this instance. It -is hardly necessary to give a caution not to mistake a simple bruise -or ecchymosis for mortification. To prevent such an error leading to -amputation, Baron Larrey has directed an incision to be previously made -into the part, and to this there can be no objection. - -When a large shot or other solid substance has injured a limb to -such an extent only as admits of the hope of its being possible to -save it, this hope is sometimes found to be futile, at the end of -three or four days, from a failure of power, in the part below the -injury, to maintain its life for a longer time: mortification is -obviously impending. In military warfare, uncontrollable events often -render amputation unavoidable in such a case. Under more favorable -circumstances, the surgeon should be guided by the principle laid -down of _constitutional_ and _local_ mortification; and, although the -line cannot perhaps be distinctly drawn between them at the end of -three, four, or more days, it will be better to err on the side of -amputation than of delay. If the limb should be swollen or inflamed to -any distance, with some constitutional symptoms, in a doubtful habit of -body, the termination will in general be unfavorable, whichever course -be adopted, more particularly if the amputation must be done above the -knee. The consideration of the circumstances in which the patient is -placed, his age, and habit of body, should have great weight in forming -a decision in the first instance, as to the propriety of attempting -to save the limb, which ought only to be done in persons of good -constitution and apparent strength. - -28. Whenever the main artery of a limb is injured by a musket-ball, -mortification of the extremity will frequently be the result, -particularly if it be the femoral artery; it will be of certain -occurrence if both artery and vein are injured, although they may not -be either torn or divided. There may not then be such a sudden loss -of blood, in considerable quantity, as to lead to the suspicion of -the vessel being injured. The fact is known from the patient’s soon -complaining of coldness in the toes and foot, accompanied by pain, -felt especially in the back part or calf of the leg, or in the heel, -or across the instep, together with an alteration of the appearance -of the skin of the toes and instep, which, when once seen, can never -be mistaken. It assumes the color of a _tallow candle_, and soon the -appearance of _mottled soap_. Although there may be little loss of -temperature under ordinary circumstances of comfort, there is a feeling -of numbness, but it is only at a later period that the foot becomes -insensible. This change marks the extent of present mischief. The -temperature of the limb above is somewhat higher than natural, and some -slight indications of inflammatory action may be observed as high as -the ham, and the upper part of the tibia in front; it is at these parts -that the mortification usually stops when it is arrested. The general -state of the patient, during the first three or four days, is but -little affected, and there is not that appearance of countenance which -usually accompanies mortification from constitutional causes. In a day -or two more, the gangrene will frequently extend, when the limb swells, -becomes painful, and more streaked or mottled in color; the swelling -passes the knee, the thigh becomes œdematous, the patient more feverish -and anxious, then delirious, and dies. - -An extreme case will best exemplify the practice to be pursued. A -soldier is wounded by a musket-ball at the upper part of the middle -third of the thigh, and on the third day the great toe has become -of a tallowy color and has lost its life. What is to be done? Wait -with the hope that the mortification will not extend. Suppose that -the approaching mortification has not been observed until it has -invaded the instep. What is to be done? Wait, provided there are no -constitutional symptoms; but if they should present themselves, or the -discoloration of the skin should appear to spread, amputation should -be performed forthwith, for such cases rarely escape with life if it -be not done. Where in such a case should the amputation be performed? -I formerly recommended that it should be done at the part injured in -the thigh. I do not now advise it to be done there at an early period, -when the foot only is implicated; but immediately below the knee, at -that part where, if mortification ever stops and the patient survives, -it is usually arrested; for the knee is by this means saved, and the -great danger attendant on an amputation at the upper third of the thigh -is avoided. The upper part of the femoral artery, if divided, rarely -offers a secondary hemorrhage. The lower part, thus deprived by the -amputation of its reflex blood, can scarcely do so; and if it should, -the bleeding may be suppressed by a compress. The blood will be dark -colored. If the upper end should bleed, the blood will be arterial, and -by jets, and the vessel must be secured by ligature. - -29. When from some cause or other amputation has not been performed, -and the mortification has stopped below the knee, it is recommended -to amputate above the knee after a line of separation has formed -between the dead and the living parts. This should not be done. The -amputation should be performed in the dead parts, just below the line -of separation, in the most cautious and gentle manner possible, the -mortified parts which remain being allowed to separate by the efforts -of nature. A joint will be saved, and the patient have a much better -chance for life. - -30. A wound of the axillary artery rarely leads to mortification of the -fingers or hand. If it should do so, the principle of treatment should -be similar, although the saving of the elbow is not so important as -that of the knee: neither is the amputation in the axilla, below the -tuberosities of the humerus, as dangerous as that above the knee. - -31. Mortification after the sudden application of intense cold or heat -is to be treated on similar principles. - -32. When a nerve or plexus of nerves conveying sensation and motion, -and going to a part, or an extremity of the body, is divided, the part -or limb is deprived of three great qualities: motion, sensation, and -the power of resisting with effect the application of a degree of heat -or of cold, which is innocuous when applied in a similar manner to the -opposite or sound extremity. In other words, it will be scalded by hot -water and frost-bitten by iced or even cold water, which are harmless -when applied to another and a healthy part. - -An officer received, at the battle of Salamanca, two balls, one under -the left clavicle, which was supposed to have divided the brachial -plexus of nerves, as the arm dropped motionless and without sensation -to the side. The other ball passed through the knee-joint, which -suppurated. The left side of the chest became affected; he suffered -from severe cough, followed by hectic fever, and was evidently about -to sink. As a last chance, I amputated his leg above the knee, after -which he slowly recovered. Fourteen years afterward he showed me his -arm in the same state, and told me he had been indicted for a rape, but -that the magistrates, seeing the wooden leg and the useless arm, while -admitting the attempt, would not assent to the committal of the offence. - -33. When one nerve only of several going to an extremity such as the -arm and hand, is divided, the loss sustained is confined to the extreme -part more immediately supplied by the injured nerve. Thus, if the ulnar -nerve only be divided, the little finger and the adjacent side of the -ring finger suffer, perhaps in some degree the inner side of the thumb -and the adjoining fingers; if the median nerve, the thumb and other -fingers; if the radial, the back of the hand next the thumb. In some -instances there seems to be a kind of collateral communication by which -a degree of sensibility is after a time recovered. - -34. If any foreign substance should lodge in and continue to irritate -the nerve, the wounded part often becomes so extremely painful as not -to be borne; the nerve at that part forms a tumor of a most painful -character, requiring removal, or in extreme cases even the amputation -of the extremity. - -35. After an ordinary amputation, the extremity of a nerve enlarges so -as to resemble a leek, and if this should adhere to the cicatrix of -the wound, painful symptoms, referred to the toes and other parts of -the removed leg, are experienced often to an almost unbearable degree; -the end of the nerve should be removed. The pain apparently felt in -and referred to the toes is merely the effect of irritation of the -extremity of the nerve. - -36. Wounds or injuries of nerves, which do not entirely divide the -trunk, or a principal branch given off from a plexus of nerves, -may give rise to general as well as to local symptoms; that is, by -sympathy, connection, or continuity of disease, other nerves and organs -of the body are affected. This applies also to the spinal marrow, -when the injury does not destroy at once. General Sir James Kempt was -wounded at the storming of the castle of Badajoz, on the inside of -the left great toe, by a musket-ball which, from the appearance of -a slit-like opening, was supposed to have rebounded from the bone, -but was discovered a fortnight afterward flattened and lying between -it and the next toe. Inflammation had ensued, followed by great -irritability and numerous spasmodic attacks, appearing to render -locked-jaw probable. The spasms soon became general, extending from -the foot to the head, but tetanus did not take place. On his return to -England, they gradually subsided, but he did not sleep at night for a -year. After the battle of Waterloo the spasms became more frequent and -troublesome, attacking the muscles at the back of the neck and throat, -causing considerable anxiety. The attack was often traced to exposing -the foot to cold or to undue pressure, and frequently to derangement -of stomach, although he was most regular in diet. After the lapse of -six or seven years these severe symptoms subsided; but during the last -forty years of his life he suffered occasionally from them. - -Admiral Sir Philip Broke received a cut with a sword on boarding the -Chesapeake, on the left side of the back of the head, which went -through his skull, rendering the brain visible; the wound healed in -six months, although splinters of bone came away for a year. A second -cut on the right side did not penetrate the bone. After a temporary -paralysis of the right side, he recovered, with a loss of power and a -disordered sensation in the second, third, and little fingers of the -right hand, aggravated by cold weather and by mental anxiety. - -Seven years afterward, he fell from his horse, and suffered from -concussion of the brain, which added to his former sensations by -rendering the left half of his whole person incapable of resisting -cold, or of evolving heat. In a still atmosphere abroad, at 68° Fahr., -he said, “the left side requires four coatings of stout flannel, which -are augmented as the thermometer descends every two degrees and a half, -to prevent a painful sense of cold; so that when it stands at the -freezing point the quantity of clothing of the affected side becomes -extremely burdensome. When exposed to a breeze, or even in moving -against the air, one or even two oilskin coverings are necessary in -addition, to prevent a sensation of piercing cold driving through the -whole frame. Moderate horse exercise and generous diet improved the -general health; the warm bath caused a distressing effect; the shower -bath, cold or tepid, increased the paralytic affection. Frictions, -with remedies of all kinds, increased it also, and so did sponging -with vinegar and water, as well as any violent, stimulating, quick -excitement, or earnest attention to any particular subject. The Admiral -died unrelieved, twenty-six years after the receipt of the injury, of -disease of the bladder.” - -37. Brigade-Major Bissett was wounded on horseback, in the Kaffir war, -by a musket-ball, which entered on the outside of the lower part of -the left thigh, passed upward across the perineum, wounding the rectum -within the anus--from which part he lost a quantity of blood--and -came out through the pelvis on the opposite side. The course of this -ball was accounted for by the fact that he saw the Kaffir who shot -him standing some yards below him when he fired. The ball, in its -passage upward and across the thigh, injured the great sciatic nerve, -and the consequence is continued pain in the toes, instep, and foot, -with contraction of the muscles, and lameness, together with the usual -incapability of bearing heat or cold, particularly the latter, against -which he is peculiarly obliged to guard. The skin shows no sign of -discoloration or derangement. Position gives the explanation why the -ball took such a peculiar course; the symptoms show the nature of the -injury. From other effects he has perfectly recovered, but his leg is -comparatively useless, while it is a constant source of suffering. - -38. The cases related in the Lectures on wounds of arteries, of -mortification taking place in the foot and leg, after the division -of the principal artery in the thigh, show that the maintenance of -the life of a part depends on the blood. The cases now related show -that neither an injury nor the division of the principal nerve, nor, -perhaps, of all the nerves going to a part, will destroy that life. -The complete failure of the circulation, in a part such as the foot, -impairs, but does not totally destroy, the sensibility imparted by -the nerves, until after the loss of life has taken place, or until -decomposition is about to occur. An injury then to the nerve causes -great pain, not usually at the part injured, but in the extreme parts -supplied by it; some loss of the power of motion; some deprivation of -its ordinary sensibility, as shown by a feeling of numbness, and an -incapability, to a certain extent, of resisting heat or cold. When all -the nerves have been divided, the power of moving the limb is lost, as -well as its sensibility in a general sense. The temperature remains at -a natural standard under ordinary circumstances, but no extra evolution -of heat can take place by which cold is resisted, nor any absorption -of it, which perhaps renders the application of a high temperature, -particularly when combined with moisture, dangerous. The circulation -is capable of maintaining the ordinary heat of a part, although it is -deprived of the influence of the special nerves of sensation and of -motion; but a greater evolution of heat appears to depend on something -communicated by the nerves in a state of integrity. In the case of Sir -P. Broke, this something appeared to be derived from the brain, on -which part the wound was inflicted, and the transmission of which was -interrupted by the injury. The evolution of animal heat has of late -been supposed to be dependent on electricity, from the resemblance -which exists between it and the nervous power, although the attempts to -identify them have not been successful. That the evolution of heat is -the result of nervous power, appears to be indisputable; in what that -power consists, physiologists have yet to ascertain. - -39. The best means of mitigating the pain, independently of the -application of warmth--and cold rarely does good, as the sufferer soon -finds out--is by the application of stimulants to the whole of the -extremity affected, followed by narcotics. The tinctures of iodine and -lytta, the oleum terebinthinæ, the oleum tiglii or cajeputi, the liquor -ammoniæ or veratria, may be used in the form of an embrocation, of such -strength as to cause some irritation on the skin, short, however, of -producing any serious eruption. After the parts have been well rubbed, -opium, belladonna, or henbane may be applied in the form of ointment; -or the tincture of opium, henbane, or aconite may in turn be applied on -linen. Great advantage has been derived in many neuralgic pains from -the application of an ointment of _aconitine_, carefully prepared, in -the proportion of one grain to a drachm of lard, at which strength it -will sometimes irritate almost to vesication, as well as allay pain. - -When the pains return from exposure to cold, particularly in the -lower extremity, great advantage has been derived from cupping on the -loins, from purgatives, opiates, and the warm bath. Benefit has been -obtained occasionally from quinine, and from belladonna, aconite, and -stramonium, administered internally in small doses frequently repeated, -but not suffered to accumulate without purgation; as the accumulated -effects are sometimes dangerous. - - - - -LECTURE III. - -AMPUTATIONS, ETC. - - -40. When the wound of an extremity is of so serious a nature as to -preclude all hope of saving the limb by scientific treatment, it should -be amputated as soon as possible. - -41. An amputation of the upper extremity may almost always be done from -the shoulder-joint downward, without much risk to life. When necessary, -the sooner it is done the better. - -42. An amputation of any part of the lower extremity below the knee -may be done forthwith, with nearly an equal chance of freedom from -any immediate danger, as of the upper extremity at or near the -shoulder-joint. - -43. It is otherwise with amputations above the middle of the thigh, and -up to the hip-joint. They are always attended with considerable danger. - -44. There can be no doubt that if the knife of the surgeon could in all -cases follow the ball of the enemy or the wheel of a railway carriage, -and make a clean good stump, instead of leaving a contused and ragged -wound, it would be greatly to the advantage of the sufferer; but as -this cannot be, and an approach to it even can rarely take place, -the question naturally recurs,--At what distance of time, after the -receipt of the injury or accident, can the operation be performed most -advantageously for the patient? - -45. In order to answer this question distinctly, it should be -considered with reference to distinct places of injury:-- - -1st. When injuries require amputation of the arm below the -shoulder-joint, or of the leg below the knee, these operations may -be done at any time from the moment of infliction until after the -expiration of twelve or twenty-four hours, without any detriment being -sustained by the sufferer with regard to his recovery; although every -one, under such circumstances, must be desirous to have the operation -over. The surgeon having several equally serious cases of injury of -the head or trunk brought to him at the same time as two requiring -amputation of the upper extremity, may defer the latter more safely -perhaps than the assistance he is also called upon to give to the other -cases, the postponement of which may be attended with greater danger. - -2d. This state embraces those great injuries in which the shoulder is -carried away with some injury to the trunk; or the thigh is torn off -at or above its middle, rendering an amputation of the upper third, -or at the hip-joint, necessary. It is this or nearly this state which -alone implies a doubt as to the propriety of immediate amputation, and -demands further investigation. It is the state to which attention is -earnestly drawn for future observation. - -46. It has been implied, if not actually maintained, that a man could -have his thigh carried away by a cannon-shot without being fully aware -of it, or, if aware of it, that it did not cause much alarm--in fact, -that it did not materially signify as to his apprehension, whether the -ball took off his limb or the tail of his coat, or only grazed his -breeches. An instance of this kind has not fallen under my observation. - -47. A surgeon on the field of battle can rarely have a patient brought -to him, requiring amputation, under less time than from a quarter to -half an hour; a surgeon in a ship may see his patient in less than -five minutes after the receipt of the injury; and to the surgeons of -the navy we must hereafter defer for their testimony as to the absence -or presence of the constitutional alarm and shock to which I have -alluded, and to what degree they follow, immediately after the receipt -of such injury. The question must not be encumbered and mystified by -a reference to all sorts of amputations after all sorts of injuries, -but to the one especial injury, viz., that of the _upper third of the -thigh_. - -48. My experience, which may be erroneous, like everything human, -has taught me, that when a thigh is torn, or nearly torn off, by a -cannon-shot, there is always more or less loss of blood, suddenly -discharged, which soon ceases in death, or in a state approaching to -syncope. When the great artery has been torn, this fainting saves life, -for an artery of the magnitude of the common femoral does not close its -canal by retracting and contracting in the same manner as a smaller -vessel; it can only diminish it; and the formation of an external -coagulum is necessary to preserve life, which the shock, alarm, and -fainting, by taking off the force of the circulation, aid in forming; -and without which the patient would bleed to death. An amputation, in -this state of extreme depression, might destroy life, although aided by -the exhibition of chloroform. - -49. If the cannon-shot, or other instrument capable of crushing the -upper part of a thigh, should not divide the principal artery, and -the sufferer should not bleed, it is possible he may be somewhat in -the state alluded to in which the patient, for he may not be called -sufferer, is said to be just as composed as if he had only lost a -portion of his breeches. Nevertheless few have seen a man lose even -a piece of his skin and of his breeches by a cannon-shot, without -perceiving that he was indisputably frightened. Dr. Beith, surgeon -of the _Belleisle_, hospital ship, in the Baltic, informs me that -Mr. Wrottesley, of the Engineers, was struck by a cannon-shot, at -Bomarsund, on the upper part of his right thigh, which shattered it -and his hand, which was resting upon it. His leg was also broken by a -splinter from the gun which the ball had previously struck. The femoral -artery was not injured, and it was said he lost but little blood. He, -however, never rallied from the blow, but sank in twenty minutes after -he was brought to Dr. Beith. The constitutional shock and alarm were -great; countenance sunk and pallid, pulse scarcely perceptible. - -“An East Indian, twenty-two years of age, of healthy aspect, in the -month of October, 1854, when proceeding on a shooting excursion, at -Moulmein, in Burmah, was most severely wounded by the accidental -explosion of his gun, the entire charge of large shot lodging in the -center of the left thigh, and causing a bad compound fracture, with -fearful laceration of the soft parts. I was asked to see the patient -by Dr. Reynolds, the staff-surgeon of the station, at half-past seven -A.M., an hour after the injury had been inflicted, and found him -laboring under most urgent collapse and great nervous depression. It -was of course impossible to save the limb, but I suggested delay for -some hours, and the moderate use of stimulants, till the system had -in some degree recovered its equilibrium. Such was the case at five -P.M., and the flap operation was done while the man was under the -full influence of chloroform, (three drachms being required for that -purpose.) When placed in bed, he became conscious, but never rallied, -and died in half an hour. - -“Very little blood was lost during the operation, and the impression -on my mind was, that it would have been wiser to have steadily but -carefully continued the use of stimulants during the operation, and -thus have counteracted the shock of the latter following on that of the -injury, from which the system had only partially recovered.”--_Case by -Dr. Dane, Surgeon to the Forces._ - -Deputy Inspector-General Taylor informs me that “a young muscular man, -of the siege-train, had his left thigh nearly carried off at its middle -by a cannon-shot at Sebastopol. The soft parts on the inside, including -the artery, escaped laceration; the remaining soft parts and large -pieces of bone were entirely carried away, the injury extending above -the middle of the bone. The muscles on the fore part of the other thigh -were extensively laid bare and injured. The prostration was great; -pulse feeble; the man’s spirits were good, and he desired amputation -under chloroform. The left thigh was amputated at the upper third. The -chloroform, administered on a pocket-handkerchief, lightly folded, and -held over the nose and mouth, speedily took effect. I am under the -impression that the chloroform not only caused insensibility to pain, -but supported the system during the operation, although the man died an -hour after its completion. Nevertheless, I think the chloroform enabled -the man to bear the operation better than he would have done without -it.” - -This case does not quite meet my proposition as to the effect of -chloroform when the thigh has been carried off nearer the hip-joint, -with rupture of the principal artery; cases which have hitherto been -usually lost, whether amputation is performed or not. - -50. While some persons, under the loss of a thigh high up, are reduced -to a state of syncope, or nearly approaching to it, which renders them -almost or even entirely speechless, others are said to suffer extreme -pain, and earnestly entreat assistance, under which circumstances -amputation should be performed forthwith. In the former, the -administration of stimulants may render the operation less immediately -dangerous. In the latter, they will be beneficial, and may save life. - -51. Chloroform, or other similar medicaments, may produce an effect in -such cases as yet unknown. Its careful administration may not destroy -the ebbing powers of life, and may render an amputation practicable, -which could not otherwise be performed without the greatest danger. It -may be otherwise; the point, however, is to be ascertained, although in -all cases of great suffering its use should be unhesitatingly adopted. - -Much difference of opinion having taken place on the subject of -chloroform, I requested Dr. Snow, who has superintended its use in many -of our hospitals, and in almost all the cases of serious operation in -private life, to draw up his observations and opinions in the most -compendious form possible, which he has been so good as to do, in the -following terms:-- - -“Chloroform may be given with safety and advantage to every patient -who requires, and is in a condition to undergo, a surgical operation. -A state of great depression, from injury or disease, does not -contra-indicate the use of chloroform. This agent acts as a stimulant -in the first instance, increasing the strength of the pulse, and -enabling the patient, in a state of exhaustion, to go through an -operation much better than if he were conscious. - -“Persons who have died from the effects of chloroform had disease of -the heart, or of some other vital organ, but the majority had a sound -state of constitution; and it seems probable that the average health -of persons who have been the subject of accident has been at least as -good as that of those who have taken chloroform without ill effects. -From these and other considerations I am of opinion that accidents from -chloroform are to be prevented by care in its administration, and not -by the selection or rejection of cases for its employment. - -“When animals are made to breathe air containing not more than four -or five per cent. of the vapor of chloroform till death ensues, the -breathing ceases very gradually, being first rendered laborious and -then feeble, and the heart continues to beat for a minute or two after -respiration has ceased. During this interval, while the heart is still -beating, the animal can be easily restored by artificial respiration. -This mode of death from chloroform might undoubtedly take place in -the human subject, if a person were to go on giving it regardless of -the symptoms; but a careful examination of all the recorded cases of -death from this agent shows that it has not occurred in this manner. -On the contrary, the symptoms of danger have in every instance come on -suddenly, and the action of the heart has been arrested at the same -moment as the breathing, or even before it. This is precisely the way -in which the lower animals die when they are compelled to breathe air -containing eight or ten per cent. of the vapor of chloroform. It is -therefore evident that the cause of death is the inhalation of the -vapor of chloroform not sufficiently diluted with common air. - -“It requires more chloroform to suspend the functions of the ganglionic -nerves, which preside over the contractions of the heart, than to -suspend the functions of the medulla oblongata and the nerves of -respiration; but the action of the heart may be arrested by the direct -effect of this agent. Chloroform, when inhaled, is absorbed by the -blood in the lungs, passes at once to the left cavities of the heart, -and is immediately sent through the coronary arteries to every part of -that organ, in less time, probably, than it can reach the brain; or, -supposing the respiration to be suddenly arrested by the action of the -chloroform on the brain, the vapor, not being sufficiently diluted, -is present in large quantities in the lungs at the moment when the -breathing ceases; and becoming absorbed, in addition to that which was -already in the blood, has the effect of paralyzing the heart. - -“Twenty-five minims of chloroform produce only twenty-six cubic inches -of vapor, and as one hundred cubic inches of air, at 60° Fahr., will -take up fourteen cubic inches of vapor, and at 70° will take up -twenty-four cubic inches, if fully saturated, it is quite possible -that the air during inhalation may contain ten per cent. of the vapor, -if means be not taken to prevent it. Under these circumstances, -each hundred cubic inches of air would contain nearly ten minims -of chloroform, and this might be taken into the lungs at once by a -rather deep inspiration. The average quantity of chloroform present -in the blood of an adult, when sufficiently insensible for a surgical -operation, is eighteen minims, while twenty-four minims are as much as -can be present in the system at one time with safety. The absorption -of a little more than thirty minims would have the effect of causing -death, even if it were equally diffused throughout the circulation. It -must be evident, therefore, that to take ten minims of chloroform into -the lungs at one inspiration, when insensibility is almost complete, -must be attended with danger. - -“Robust persons, accustomed to hard work or violent exercise, are very -apt to become affected with rigidity of the muscles and struggling, -when nearly insensible from chloroform; and they often hold the breath -for a time, and then draw a deep inspiration. It is under these -circumstances that several of the accidents from chloroform have taken -place, and extreme care is required to give the chloroform more than -usually diluted with air, when this state of unconscious struggling and -rigidity occurs. - -“The most important point to attend to, in the exhibition of -chloroform, is to insure that the vapor shall be sufficiently diluted -with air during the whole process of inhalation. This may be effected -with a suitable apparatus and proper attention, or if an inhaler be -not at hand, the chloroform should be diluted with one or two parts -by measure of rectified alcohol. One or two drachms of this may be -placed on a hollow sponge, and repeated when required. The spirit -has the effect of limiting the quantity of chloroform which rises in -vapor, while very little of the diluent is inhaled, since, from its -lower volatility, the greater part of it remains on the sponge or -handkerchief employed to exhibit the chloroform. - -“When the chloroform vapor is so diluted that it does not constitute -more than four or five per cent. of the respired air, its effects -become developed very gradually and regularly. The suspension of the -sensibility of the conjunctiva at the border of the eyelids is the best -sign that the patient will bear the operation without flinching, and -the inhalation should immediately be left off if the breathing become -stertorous. The pulse is not a very important guide in the exhibition -of chloroform, for the two following reasons: 1st, if the vapor be -sufficiently diluted with air, the pulse cannot be seriously affected -by it; and 2d, if it be not so diluted, the pulse may cease suddenly, -without previous warning of danger. - -“If the vapor of chloroform be sufficiently diluted with air, it is -practically impossible that any accident, really due to this agent, -should occur. In case of accident, however, artificial respiration, -very promptly and efficiently performed, is the only means which -affords a prospect of restoring the patient--at all events, this is -the only means found to restore animals when it was obvious they would -not recover spontaneously. The prospect of success from artificial -respiration will depend on the greater or less extent to which the -heart is affected by the direct action of the chloroform.” - -Mr. Syme, in his “Clinical Observations,” delivered in the Royal -Infirmary in Edinburgh, recommends, in cases of approaching death -from the use of chloroform, that the tongue should be drawn forward -by means of a pair of artery forceps, by which it is presumed the -epiglottis is raised, and a greater facility afforded for the admission -of atmospheric air, the inconvenience resulting from two small holes in -the tip of the tongue being amply compensated by the preservation of -life. - -Nevertheless, I am of opinion that attention should be paid to the -pulse, and whenever it begins to fail or flutter, the inhalation of -chloroform should be arrested; for respiration and the pulse often -cease almost simultaneously, and in some instances have done so -irrecoverably. - -I formerly said that chloroform might be used with advantage in all -cases of injury requiring amputation, save one, and in that one -experience was wanting to decide the point. It is when a thigh has -been carried off by a cannon-ball, or destroyed at its upper part by -any other means, such as the wheels of a railway carriage or other -weighty machine. When the thigh is carried off by a cannon-shot, the -artery being torn across, there is so great a shock and so great a -loss of blood at the moment, followed by fainting, or such faintness -as leads to the belief that the sufferer is dying, and some do -actually die without an effort at recovery. In such a case, or in one -somewhat similar, Dr. Snow and others think chloroform would act as a -stimulus, and that it would enable the patient to bear the operation -of amputation with success, which he otherwise might not have done. It -may be so; but, as I believe nothing in surgery until fairly tried and -found to answer, I refrain, for the present, from expressing a positive -opinion, save that the trials should be made with great caution, -inasmuch as the observations which have been made in the Crimea have -not been sufficiently numerous or so decisive as to settle the point -in favor of the chloroform, although they confirm all the others to -which allusion has been made. In these cases a tourniquet cannot be -applied, and the sudden loss of blood saves the life of the sufferer -for the time, by suppressing the bleeding; which suppression, I have -long since pointed out, is effected in the artery at the groin, by the -formation of a coagulum, and not by the contraction and retraction of -the vessel into the shape of the neck of a claret bottle, which would -take place at the lower third of the same artery in the thigh under -a similar injury; in which case, also, the bleeding would cease by -the unassisted efforts of nature. If the artery, there or elsewhere, -should, on the contrary, be only partially divided, the person would -bleed to death, unless surgery of some kind should come to his aid. - -52. When the sufferer is brought to the surgeon at the end of half an -hour, having lost a limb below the thigh or shoulder by a cannon-shot, -he will often be found in a state of such great depression as to be -likely to be destroyed by the infliction of a serious and painful -operation like amputation, unless chloroform should relieve it. This -has occurred to me so often as to induce me formerly to recommend delay -for four, six, or even eight hours, if the unfortunate person did not -suffer much, and appeared likely to be revived by the proper use of -stimulants. If he should be in great pain, the limb should be removed -under chloroform. - -53. This recommendation originated from the fact that, as one seriously -wounded man has as much claim as another to the attention of the -surgeon, all could not be attended to at the same time; and the -success following the deferred cases of amputation was as great, if -not greater, than in those on which the operation was more immediately -performed. - -54. The advantageous results of _primary_ amputations, or those done -within the first twenty-four, or at most forty-eight hours, over -_secondary_ amputations, or those done at the end of several days, or -of three or four weeks, have been so firmly and fully established as no -longer to admit of dispute. - -55. When an amputation is deferred to the secondary period, a joint is -often lost. A leg which might have been cut off below the knee in the -first instance is frequently obliged to be removed above the knee when -done in the second. - -56. In the secondary period after great injuries, the areolar and -muscular textures near the part injured are often unhealthy, the -bones are in many instances inflamed internally, and their periosteal -membranes deposit on the surrounding parts so much new ossific matter -as frequently to envelop in a few days the ligatures on the vessels, -and render them immovable, necrosis of the extremity of the bone -following as a necessary consequence, thus protracting the cure for -months. - -57. Sloughing of the stump, accompanied by inflammation of the vein -or veins leading to the cava, frequently takes place. This state of -stump is often followed by purulent deposits in and upon the different -viscera, and principally in the cavities of the chest. Where febrile -diseases are endemic, they often prevail; the constitutional irritation -is great; the stumps do not unite, or, if apparently united, open out -and slough, and frequently after a few days implicate the veins. - -58. In the first edition of my work on Gunshot Wounds, and on the -great operations of Amputation, published in 1815, I said, alluding -to secondary operations: “In the most favorable state of the stump, -the diseased parts do not extend very deep; yet inflammation is -frequently communicated along the vein, which is found to contain -pus, even as far as the vena cava.” “When I have met with this -appearance, I have always considered the vessels as participating -in (not originating) the disease, which had existed some days, and -thereby more quickly destroying the patient.” I further said that -after secondary amputations, the febrile irritation, allayed by the -operation, sometimes returns, and more or less rapidly cuts off the -patient by an affection of some particular internal part or viscus, -especially of the lungs. “If it be the lungs, and they are most usually -affected, the breathing becomes uneasy; there is little pain when the -disease is compared with pneumonia or pleuritis; the cough is dry and -not very troublesome; the pulse having been frequent, there is but -little alteration; the attention of the surgeon is not sufficiently -drawn by the symptoms to the state of the organ, and in a very short -time all the symptoms are deteriorated: blisters are employed, perhaps -blood-letting, but generally in vain; and the patient dies in a few -hours, as in the last stage of inflammation of the lungs, in which -effusion or suppuration has taken place.” “My attention was drawn to -it after losing several cases in this way, as a circumstance of more -than common accident, from its having happened to a young officer to -whom I was paying considerable attention, (at Salamanca.) Since that I -had one well-marked case at Santander, of a sudden and fatal affection -of the lungs after amputation of the thigh, which was under the -immediate care of Dr. Irwin,” and of myself as the principal medical -officer. The late Mr. Rose, of the Guards, communicated a case, after -amputation of the arm, to Sir James M’Grigor, who forwarded it to me; -and my old friend, the late Mr. Boutflower, who served frequently -under me during the latter part of that war, and aided me in all my -labors and views, forwarded to me, at the same time, two cases from -Fuenterabia, which terminated fatally after amputation of the arm, -from the deposition of a considerable quantity of pus in the cavity of -the thorax. “So insidious,” he said, “was the approach of the disease, -that, except a difficulty of breathing which supervened a few hours -before death, there were no symptoms indicating the existence of such a -morbid affection.” No further notice was taken of this disease by any -one in any of the hospitals on entering France in 1813, neither at St. -Jean de Luz, nor Bayonne, nor Pau, St. Sever, Tarbès, or Orthez, until -after the battle of Toulouse, where the following cases occurred, which -I published previously to any one else in 1815. - -A soldier suffered amputation of the thigh five weeks after the injury, -in consequence of a gunshot fracture at Toulouse, he being in a very -reduced state, the discharge profuse, the pain great, hectic fever -severe. The third day after the operation, from which he scarcely -rallied, he complained of difficulty in swallowing, and pain in the -situation of the thyroid gland, which was found next morning to be -inflamed. In spite of the means employed, he died on the fourth day of -this attack, or the seventh after the amputation, in a state of great -emaciation. On dissection, the whole substance of the thyroid gland was -destroyed, a deposit of good pus occupying its place, which descended -by the sides of the trachea and œsophagus to the sternum, and had all -but found its way into the larynx, between the cricoid and thyroid -cartilages on the right side. - -Daniel Lynch, wounded through the knee-joint at the battle of -Toulouse, on the 12th of April, 1814, had his thigh amputated by -the late Mr. Boutflower, on the 8th of May. The night succeeding -the operation he passed comfortably. Next day, the 9th, the febrile -symptoms were augmented. On the 10th he was worse; pulse 150. On the -11th he was better. On the 16th he was considered to be in a state -of convalescence, and went on improving until the 22d, when fever -recurred. On the 28th his stomach became very irritable; the stump -appeared to be nearly healed, the discharge being small, and of good -quality; one ligature remained. 30th: Pulse 110; tongue of a brownish -hue. During the 31st and 1st of June he got worse, and died. The stump -appeared to have united externally, except where the ligatures came -out; but, on cutting through the line of adhesion, the muscular parts -within were evidently unhealthy; the bone was surrounded for some -distance by a case of osseous matter, including the remaining ligature, -which could not be removed by any force short of breaking it. The femur -was bare, and showed marked signs of absorption having commenced; three -inches of it must have come away if the man had lived. The extremity of -the vein was in a sloughing state. - -Having dissected the other extremity for a clinical lecture I -was occasionally in the habit of giving on particular cases, a -semi-transparent membranous bag, containing good pus, was found -accidentally on the tibialis posticus muscle. The blood in the perineal -vein outside of it was coagulated; there were little or no marks of -inflammation, and the matter appeared to have been deposited without -any. The inner side of the soleus muscle seemed simply to be discolored. - -The first edition, containing these facts, which were before unknown, -and which furnish another laurel to the surgery of the Peninsular war, -having been published before the battle of Waterloo, the opinions -and facts stated therein became matters for public discussion, and -the reports made by my friends from Brussels, Antwerp, Yarmouth, and -Colchester, confirmed all the facts, and, I may add, all the opinions -of the slightest importance. They were published in the second edition -in 1820, and again more pointedly in the third, published June 18, 1827. - -59. Forty years have passed away since I stated my opinion, that -inflammation of the veins is of two kinds--the adhesive or healthy, -from which the sufferers usually recover, as in the cases of women -laboring under the disease called phlegmasia dolens, and the -irritating or unhealthy, occurring after operations; the disease being -communicated by continuity to the vein, rather perhaps than originating -in it. I then said I did not believe that pus is carried from the -inside of the vein to the general circulation, the office of the vein -as a carrier of blood ceasing on the inflammation taking place in -its internal tissue, although I admit that the blood in a vitiated -state, from the commencing disease in the stump, or in the system, may -have for some time passed along it into the general circulation. The -inflammation thus commencing may extend upward and downward, and across -to the opposite side of the body, as I first demonstrated in 1825, in -the case of Jane Strangemore, p. 47. I never saw it actually in the -heart, the sufferers dying by the time it had reached as high as the -diaphragm, and in general before it had got so far. - -60. When a person, after undergoing amputation, is about to suffer -from unhealthy inflammation of the veins, the pulse quickens, and -continues above 90, usually rising from 100 to 130. The stomach -becomes irritable; there are frequent attacks of vomiting, generally -of a bilious character, accompanied by the usual symptoms of fever. A -few days after the commencement of the complaint, there is usually a -well-marked rigor, followed perhaps by others, but exacerbations and -remissions of fever are common. The skin gradually assumes a yellowish -tinge, the perspiration is excessive, the bowels irregular, the pulse -becomes weaker and more irritable, the emaciation is considerable, and -the patient gradually sinks; or the febrile symptoms may subside, with -the exception of the frequency of the pulse, the patient rallies a -little, but while he says he is better, and the appetite even returns, -the deterioration in appearance becomes more marked, more deathlike, -even while eating, and an accession of fever rapidly closes the scene. -The stump is often not more painful than under ordinary circumstances, -neither is there any remarkable pain or tenderness in the course of the -vessels. - -61. The practical points are, to draw blood with caution, on the -_accession_ of fever, provided a remittent or typhoid form does not -prevail; to open out the stump as soon as possible, even by a division -of the external adhesions, the inner parts being usually unsound; to -envelop it in a large warm poultice; to apply cold above, even ice if -procurable, in the course of the great vessels, and to soothe the -system by calomel, opium, and saline diaphoretic remedies, followed by -stimulants, cordials, quinine, and acids. - -Private A. Clarke, 79th Regiment, had his thigh broken by a musket-ball -a little above the knee-joint, at Waterloo, and was admitted into the -clinical ward of the York Hospital, in London, in November, 1816. The -bone being in a state of necrosis, Mr. Guthrie amputated the thigh high -up, on the 20th of January, 1817. Pulse before and after the operation -104. On the 25th, pulse 120; skin cool; tongue moist; appeared weak -and irritable. During the 26th and 27th, symptoms of low fever came -on. 28th, suffered severely from vomiting, general fever, greater -prostration of strength; stump had not united, but discharged good pus. -30th, skin assumed a yellow tinge. - -On the 1st of February, had a rigor resembling a fit of ague, and Mr. -Guthrie declared his suspicion of the formation of matter, probably in -the liver, and of inflammation of the veins of the stump. The symptoms -gradually assumed the character of typhus gravior, and on the 8th he -died. On dissection the liver was found enlarged, and weighing six -pounds; the other viscera were sound. On examining the stump an abscess -containing four ounces of good pus was found in the under part, near -the bone. The femoral vein and those going to that part of the stump -were inflamed, and contained coagulated blood, lymph, and purulent -matter, the disease extending from the femoral to the vena cava. The -rigors on the 1st February marked the formation of matter, the typhoid -symptoms its continuance, and the inflammation of the veins. Union was -discouraged from the first dressing. - -The following case is so highly instructive on all points, that it is -transcribed from the _London Medical and Physical Journal_ for 1826:-- - -Jane Strangemore, aged twenty-eight, was admitted into the Westminster -Hospital, September 24, 1823, with an elastic swelling of the whole -of the knee-joint, measuring twenty-seven inches and a half in -circumference. The thigh was amputated by Mr. Guthrie on Saturday, -the 27th, the bone being sawn through just below the trochanter. She -suffered a good deal from pain after the operation. An opiate was -administered and repeated, and she passed a good night. - -28th.--The pulse, which previous to the operation was 80, has increased -to 100; there is, however, little heat of skin, and she appears easy. -Some aperient medicine, and saline draughts to be given every four -hours. Toward the evening, she vomited a quantity of bilious matter; -pulse 120. Three grains of calomel and one of opium, followed by the -common aperient mixture, were ordered, and an enema. Equal parts of -ether and laudanum to be applied to the region of the stomach, to which -part pain was referred. - -October 1st.--Better in all respects, but looking irritable and ill; no -pain anywhere; no sickness; appetite good; pulse still quick. - -8th.--Two ligatures have come away; the wound looks well; the edges -have nearly healed; eats meat, and with a good appetite. - -9th.--Not so well; pulse 120; skin hot; feels ill; complains of pain in -the other leg and thigh, which disturbed her rest. Was well purged, and -the leg fomented; the pain was principally felt in the calf and in the -heel. - -10th.--Pulse 130; tongue furred; vomiting again of bile; the pain in -the thigh, extending upward to the groin and downward to the heel, -is intolerable, particularly in the latter part; the thigh and leg -much swelled, and tender to the touch, although without redness; the -swelling elastic, yet yielding to the pressure of the finger, but -not in any manner like an œdematous limb. Mr. Guthrie pronounced the -disease this morning to be inflammation of the veins, extending from -the opposite side; but after a careful examination, and on pressure, -no pain was felt in the course of the iliac vessels of that side, and -the stump looked well, save at one small point corresponding to the -termination of the femoral vein. - -17th.--The symptoms continued nearly the same during the week, the -sickness of stomach and purging of bilious matter abating at intervals. - -20th.--Less pain in the limb, which is swollen and tender to the touch, -the superficial veins being all very much enlarged. The groin more -swollen and tender; sickness gone, and her appetite returning; she is -allowed good nourishing simple diet. The stump has been poulticed since -the 9th, to promote suppuration. - -25th.--During these five days it was interesting to see the patient -eat, and desire solid food, and, in her extremely emaciated state, -seem to enjoy it. The bowels occasionally deranged. Pulse always from -125 to 136. Is slightly jaundiced in color, but declares that she is -better, and will get well. - -27th.--Gradually sank in the evening, and died; the limb having -everywhere diminished in size, except at the groin, where the swelling -was more circumscribed, resembling the appearance of a chronic abscess -approaching the surface. On examination after death, the termination -of the vein on the face of the stump was open, and in a sloughy -state; above that, for the distance of four inches, and as high as -Poupart’s ligament, the inside of the vein bore marks of having been -inflamed, but the inflammation seemed to have been of an adhesive -character; above that point, the inflammation appeared to have been -of an irritative or erysipelatous kind, had gone on to suppuration, -and the vein was filled with purulent matter, lymph, and blood, partly -coagulated and partly broken down. These appearances extended up the -cava as high as the diaphragm, and traces of inflammation could be -distinctly observed almost in the auricle. The disease had passed along -the right external iliac and its branches; it had descended along the -left iliac vein and its branches in the pelvis to the uterus, and along -the limb to the sole of the foot. At the left groin the iliac vein, -becoming femoral, was greatly distended with pus, apparently of good -quality, and, if the patient had lived a day or two longer, it would -have been discharged by a natural effort, as in chronic abscess; the -viscera were healthy. - -During the last days of this woman’s life, no blood was returned from -the lower half of the body, unless by the superficial veins; yet she -was comparatively easy, although of a yellow hue, emaciated to the -utmost, so as to represent a living skeleton; in this state, with a -pulse at 130, craving for and eating a whole mutton-chop and more at a -time, with the most deathlike countenance it is possible to conceive. - -These two cases mark the course, the symptoms, and the termination of -inflammation of the veins after amputation, in as clear (if not a more -clear) and distinct manner as any which have since been published, -and which they preceded; nevertheless, most authors of more modern -date overlook the first, and some appear to avoid as much as possible -noticing the second. - -62. After the battle of Waterloo, the wounded of the same regiment were -sent indiscriminately, some to Brussels, others to Antwerp. Those who -remained at Brussels suffered principally from inflammatory fever after -amputation; those at Antwerp, from the epidemic fever prevailing at the -time, beginning us an intermittent and ending often in typhus; facts of -great importance to recollect, as showing the influence of malaria. The -following are instances of endemic fever after secondary amputation, -ending in subacute inflammation of the lungs and effusion into the -chest:-- - -Charles Brown, 92d Regiment, forty years of age, at that time a healthy -man, was wounded on the 18th June by two musket-balls in the right hand -and wrist; he was admitted into the hospital at Antwerp on the 25th -June. On the 5th July, the arm was swollen above the elbow; discharge -profuse and fetid; countenance sallow and dejected; fever. 8th: Arm -amputated above the elbow. 9th, 10th, 11th: A little increase of -fever. 12th: A paroxysm of intermittent, to which he had been subject -occasionally since he had been at Walcheren. On removing the dressing, -the edges of the stump were retorted; discharge copious and fetid; -respiration hurried; thirst; skin hot and yellowish; pulse 90. 14th: -Intermittent returned; head affected in consequence of long continuance -in the hot bath. 15th: Complains to-day of fullness and pain in the -left side; pulse 100; skin of a deeper tinge of yellow; a sense of -suffocation when in the horizontal position. A blister was applied to -the whole of the side of the chest. 16th: Was delirious during the -night; vomited frequently; became insensible at the hour when the -paroxysm of intermittent fever was expected to return; and died in the -evening. On opening the chest, the lungs were found adhering to the -pleuræ costales in several places, and were hepatized; a quantity of -serum and lymph was contained in the left pleura, so as to compress -the lung, in which there was a small abscess. The liver was twice the -natural size. - -J. Lomax, of the Guards, was wounded at Waterloo, suffered amputation -of the right arm on the 23d August, and arrived at the General -Hospital, Colchester, on the 27th, in a state of high fever, and unable -to give any distinct account of himself. He had had the ague, he said, -for many days, which left him for a short time, but returned when on -board ship; on the 25th he was attacked by pain in the side, which -was very severe on the 26th, on which day a blister was applied, which -greatly relieved him. The stump had an unhealthy appearance, the edges -of the wound evincing a disposition to separate. On the 28th he was -free from pain; fever unabated, with a tendency to delirium. He sank -rapidly on the 30th, and died on the 31st, notwithstanding the use of -the most powerful stimuli. A quantity of serum was found on dissection -in the left side of the chest, and the pleura pulmonalis on each side -was covered with a thick layer of coagulable lymph. The pericardium was -distended with fluid. The liver was enormously enlarged, pushing up the -diaphragm, and displacing the lung, having in its substance a large -abscess containing at least a quart of pus. The stump did not exhibit -any peculiar appearance. - -O. Sweeney, 90th Regiment, aged nineteen, was wounded in the hand on -the 18th of June, 1815, and taken to Brussels. On the 5th of July he -left for England, and arrived at Colchester on the 14th. The wound -shortly after assumed an unhealthy appearance; hemorrhage took place, -and the arm was amputated on the 30th. The day after, he had severe -rigors for fifteen minutes, followed by fever. The next day he was -better, and appeared to be doing well until the 6th of August, when -fever recurred. Stump quite healthy in appearance. On the 7th, he was -attacked by vomiting and purging, which lasted several hours, and -reduced him much, returning at intervals until the evening of the 8th. -Small quantities of wine and opium agreed best, and a blister was -applied to the scrobiculus cordis. On the 9th, he complained of pain -and tenderness in the abdomen, which were relieved by fomentations and -an enema. The stump looked well, and discharged healthy pus in small -quantity; the ligature on the brachial artery came away. On the 10th, -his strength failed, and the tongue and teeth were covered with a dark -sordes. The adhesions of the stump appeared disposed to separate. At -night he was restless, with low delirium; and on the 11th died, with -the complete facies Hippocratica. On raising the sternum, the pleura of -the left lung was found adhering to that of the ribs, and covered by a -thick layer of coagulable lymph. The lung was highly inflamed; and on -cutting into its substance, a number of small tubercles was observed. -The pericardium and left cavity of the thorax contained more than the -usual quantity of fluid. During the progress of this case, eleven -days from the amputation no one symptom existed which could induce a -suspicion of inflammation going on in the thorax. The stump was in a -sloughing state, but the disease did not extend along the brachial -veins. - -Thomas Haynes, 23d Light Dragoons, aged nineteen, was wounded by a -spear on the back of the left forearm, at Waterloo; the wound appeared -to do well until he left Brussels for England, when it assumed an -unfavorable appearance, and on his arrival at Colchester, on the 14th -of July, it was in a sloughing state. The pain was excessive, and the -tenderness around the whole circumference of the sore was so great that -he could not suffer the slightest pressure with the finger. He was -largely bled, and a solution of sulphuric acid, one drachm to twelve -ounces of water, was applied twice a day to the whole surface, and the -whole kept wet with cold water; this treatment was continued until -the 21st, during which period he was bled five times, to about twenty -ounces each time. The acid solution was increased in strength from one -drachm to an ounce, and care was taken that the sloughing portions -only were touched with it. His health was considerably amended, and -on the whole a favorable result was expected. At two on the 22d, -however, a sudden hemorrhage took place, to the amount of three pints; -a second ensuing on the 23d, the arm was amputated. The pulse continued -quick; in other respects he was doing well, until the 25th, when some -accession of fever took place, and increased. He was bled to ten -ounces, and purged. On the 26th, the line of incision in the stump -appeared to be healed; and with the exception of the pulse at 140, he -had no unpleasant symptom on the 27th, and was free from pain of every -kind. On removing the center strap, which had been allowed to remain, -a large collection of matter of good quality issued. On the 28th, he -was much the same. On the 29th, the countenance had assumed a deathlike -paleness; pulse 120, intermitting every fifth pulsation; breathing -short and laborious, with some pain in the chest, and every symptom of -effusion having taken place. He died at two P.M., six days after the -amputation. - -The only morbid appearance found on dissection was a large quantity of -serous fluid in the pericardium, which was distended by it, and on both -sides of the chest. The heart and lungs, with their membranes, were -quite sound. On examining the stump, the sanative process was found -to have been entirely confined to the integuments. No appearance of -granulation could be perceived on the muscular surface. - -This last case is worthy of especial observation, on account of the -manner in which sulphuric acid was used for the sloughing state, from -one drachm to one ounce of the acid to twelve ounces of water, not -as something new, but as an ordinary application; and I am doubtful -whether there is any case on record of such use, anterior to it. Is the -external use of strong acids in sloughing cases also due to the war in -the Peninsula? Delpech says Yes,--a testimony I shall confirm in its -proper place. - -I have departed, in some degree, in the foregoing observations, from -the aphorismal form I had prescribed for myself in the commencement -of these Commentaries. I have done so as an act of justice to those -officers who served at Toulouse, Brussels, Antwerp, and Colchester, in -1814 and 1815, who are all now no more, and who labored hard in the -then early investigation of these different states of disease, and have -not received the reward they merited of public acknowledgment. I have -endeavored, as the late Chancellor of the Exchequer says in his life of -Lord George Bentinck, to preserve for them the chastity of their honor. - -63. Mr. Hunter, in 1793, described the appearances and the fatal -results of inflammation of the veins, as a consequence of injuries -inflicted on the surrounding parts, but I apprehend I was the first -person to point out the prevalence of this complaint after secondary -amputation, and its intimate connection with certain low inflammatory -attacks, attended by destructive purulent depositions, particularly in -the chest, and their more chronic deposit in other parts. Mr. Rose, -of the Guards, published some observations in the fourteenth volume -of the _Medical and Chirurgical Transactions_, in 1828, confirming -the remarks made by me in print thirteen years before, but without -referring to them. Mr. Arnott has an able paper on that subject in the -fifteenth volume. M. Sedillot thinks he has detected globules of pus -in different parts of the circulating system in persons who had died -of this disease. Mr. Henry Lee, 1850, one of the last English writers -on the subject, professedly doubts the accuracy of the observation; -this point remains among others for further investigation. He admits, -however, that in cases where, from long-continued disease, there have -been repeated introductions of vitiated fluids into the circulation, -the blood loses much of its coagulating power, which prevents the -admission of purulent matter by the veins, by forming coagula with it -in them, thus constituting he thinks the essential disease. When the -coagulating power of the blood is thus lost, he thinks it possible that -pus-globules may then be found circulating in it. Other late writers, -and lastly Dr. Hughes Bennett, think these diseases are dependent on -the introduction of a peculiar animal poison. Attention should be -paid by the medical officers of the public service, whenever there -is a war, to the state of the blood, and to the inner lining of the -diseased veins under the microscope;[2] and all those gentlemen, when -in London, should study its use, under Mr. Quekett, at the College of -Surgeons, to whose lectures they have the right of admission, and to -whose kindness they will all soon feel greatly indebted. I am not aware -that the writers referred to have added anything to the practical facts -I had related so long before, which is much to be regretted. It is of -little use, although it is a step in the right direction, to describe a -disease, or even to show why and wherefore it destroys, unless a means -of prevention or of cure can also be indicated. - -[Footnote 2: The India Company have supplied the principal hospital of -each presidency with one good microscope at least; one of these, with a -person who understands its use, should be attached (but is not) to the -principal hospitals during the present war in the East.] - -64. In the irritable and sloughing state of stump alluded to, -hemorrhages frequently take place from the small branches, or from the -main trunks of the arteries, in consequence of ulceration; and it is -not always easy to discover the bleeding vessel, or, when discovered, -to secure it on the face of the stump; for as the ulcerative process -has not ceased, and the end of the artery which is to be secured is not -sound, no healthy action can take place; the ligature very soon cuts -its way through, and the hemorrhage returns as violently as before, or -some other branch gives way; and under this succession of ligatures and -hemorrhages the patient dies. - -Some surgeons have, in such cases, preferred cutting down upon the -principal artery of the limb, in preference to performing another -amputation, even when it is practicable; and they have sometimes -succeeded in restraining the hemorrhage for a sufficient length -of time to allow the stump to resume a more healthy action. This -operation, although successful in some cases, will generally fail, -and particularly if absolute rest cannot be obtained, when amputation -will become necessary. The same objection of want of success may be -made to amputation; on a due comparison of the whole of the attending -circumstances, the operation of tying the artery in most cases is to be -preferred in the first instance, and if that prove unsuccessful, then -recourse is to be had to amputation; but this practice is by no means -to be followed indiscriminately. The artery ought to be secured with -reference to the mode of operating, as in aneurism, but the doctrines -of this disease are not to be applied to it, because it is still a -wounded vessel with an external opening. - -To obviate all doubts, the part from which the bleeding comes should -be well studied, and the shortest distance from the stump at which -compression on the artery commands the bleeding carefully noted; at -this spot the ligature should be applied, provided it be not within the -sphere of the inflammation of the stump. In case the hemorrhage should -only be restrained by pressure above the origin of the profunda, and -repeated attempts to secure the vessel on the surface of the stump have -failed, amputation is preferable to tying the artery in the groin, when -the strength of the patient will bear it. - -When hemorrhage takes place after amputation at or below the -shoulder-joint, it is a dangerous occurrence. An incision should then -be made through the integuments and _across_ the great pectoral muscle, -when the artery may be readily exposed, and a ligature placed upon it -without difficulty anywhere below the clavicle. - -If the state of the stump in any of these cases should appear to depend -upon the bad air of the hospital, the patient had better be exposed to -the inclemency of the weather than be allowed to remain in it. - -In crowded hospitals, hemorrhages from the face of an irritable stump -are not unfrequent, and often cause a great deal of trouble and -distress. It is not a direct bleeding from a vessel of sufficient size -to be discovered and secured by ligature, but an oozing from some -part of the exposed granulations, which are soft, pale, and flaccid. -On making pressure on them the hemorrhage ceases, but shortly after -reappears, and even becomes dangerous. This hemorrhage is usually -preceded by pain, heat, and throbbing in the surface from which it -proceeds. There is irritation of the habit generally, and a tendency to -direct debility. The proper treatment consists in the removal of the -patient to the open air, with an antiphlogistic regimen in the first -instance, followed by the use of quinine and acids; cold to the stump, -in the shape of pounded ice or iced water. Escharotic and stimulating -applications should be used with caution. If any of the styptics which -are sometimes announced as infallible could be relied upon, their -application in these cases would be most advantageous. The solution of -the perchloride of iron is the best. - - - - -LECTURE IV. - -APHORISMS FOR AMPUTATIONS, ETC. - - -65. Amputation of a limb is the last resource and the opprobrium -of surgery, as death is of the practice of physic; it being, -notwithstanding, impossible to do impossibilities, and save a limb or -a life which can no longer be preserved. Art and science at that point -cease to be useful. - -66. At the commencement of the war in the Peninsula, all surgeons -believed it to be impossible to compress in an effective manner the -artery of the thigh against the bone, as it passes over the edge of the -pubes, and that the loss of blood on its division must be so formidable -as to be murderous. This was merely a surgical delusion, which -maintained its ground in London until the end of 1815, when the French -soldier, whose thigh I had successfully taken off at the hip-joint, -after the battle of Waterloo, without first tying the femoral artery, -was shown to all disbelievers. It was the great point in advance in -English and European surgery, and one great result of the practice of -that war. - -67. This great, indeed most important fact, having been established, -the surgery of amputation was deprived of nearly all its terrors. -Confidence, and with it coolness, were obtained; and many young -surgeons diligently sought for an operation on the hip-joint as the -_ne plus ultra_ of operative boldness and dexterity, much after the -fashion of the young lady _pianistes_, who do not consider themselves -in any way advanced on the road to perfection until they can play at -least the overture to _Guillaume Tell_, if not the _Galop Chromatique_ -of Listz, nearly as well as the composer himself. - -68. As a tourniquet cannot be applied in this amputation, nor even at -that of the shoulder-joint, without doing harm, its inutility in the -greatest operations is proved; and recourse should not be had to it in -the smaller or less dangerous ones, provided sufficient assistance can -be obtained. When the surgeon has only one assistant, he should apply -a tourniquet, or even if he should have several bad ones on whom he -cannot depend. - -69. There is always more blood lost, and particularly in secondary -amputations, when a tourniquet is used than when the principal artery -is compressed by one assistant, and two others are ready to press on -the outside of the flaps, or upon the divided vessels, with the ends -of their fingers; the force necessary to prevent the passage of blood -through the common femoral, or the axillary artery, being merely that -of the finger and thumb, applied in a very gentle manner, or even of -the end of the forefinger of a competent person. I have rarely applied -a tourniquet since 1812, and few persons have done more formidable -operations under more difficult circumstances. The ancient illusion -with regard to the necessity for tourniquets in amputation must be -given up, except by incompetent persons, or by those who are fearful -and superstitious, and do not like to depart from the ways of their -forefathers. - -70. A tourniquet is useful when loosely applied after an operation, -and the attendant should be taught how to turn it, so as to suppress -any serious bleeding which may take place until the surgeon can be -procured. It may be, although it rarely is, necessary on the field of -battle. The surgeon need not, therefore, load himself or his assistant, -as formerly, with a sackful, for a thoroughly useful tourniquet can be -made in a moment with a pebble and a pocket-handkerchief, or a roller. -The great point is to know where and how to apply it. When gentlemen -called surgeons by warrant are sent to an army, as many were to that in -Spain and France, with only the knowledge of a druggist, having been -refused a commission on account of their ignorance, it is necessary -this instruction should be especially given to them; and this horrible -fact is recorded with the hope it may be useful in preventing any such -atrocious proceedings in future. Peace or humane societies, if they -cannot prevent a war, may interfere with advantage on this point, to -divest it of some of its horrors. At the battle of Inkerman, a young -officer, the son of a friend of mine, was wounded in the leg by a -musket-ball, which caused much loss of blood. A tourniquet was applied, -instead of the required operation being performed, and he was sent on -board a transport from Balaklava. The leg mortified, as a matter of -course, and was amputated. He died, an eternal disgrace to British -surgery, or rather to the nation which will not pay sufficiently able -men, and therefore employs ignorant ones--the best they can get for the -money. - -71. When circular operations were performed in the olden time, -particularly on the thigh, the skin, when divided, was dissected, and -turned up like the cuff of a coat--a painful proceeding, as unnecessary -as it was barbarous. Forty years have elapsed since I demonstrated -its absurdity, and showed that the first incision in the thigh should -include the fascia lata, any deep attachments it might have should -follow, when the parts thus divided ought to be retracted as a whole, -to form a proper covering for the stump. - -It was at the same time shown that, in whatever way, and however -clumsily and tediously, the muscles might be divided, it did not -prevent the successful result of the operation, provided the bone was -cut short, so as to form a cone, with an elongated or depressed point. - -72. The nicking of the periosteum, and pushing it upward and downward, -so as to leave a space for the saw, was at the same time forbidden, as -leading to necrosis of the part of the bone thus denuded, if unremoved -by the saw. The saw was also directed to be held perpendicularly to, -and not across, the bone, nor even diagonally to it--an apparently -trivial, but yet great improvement. The last part divided is an outer -and thin layer of hard bone, which does not so readily splinter on the -side as on the under part, by the weight of the leg. - -73. The limb to be amputated is not to be held by the assistant in the -manner described and usually shown in books: one hand ought not to be -above the knee, but below and by the side of it, the other grasping -the calf, so that the limb may be duly supported, and drawn inward or -outward, in the opposite direction to the saw, as it divides the last -layers of the bone. - -74. The common integuments of the stump should be drawn together, -in primary amputations, by sutures formed of flexible leaden wires; -by threads of silk, if leaden wires be not attainable. The vessels -which bleed should be carefully secured by single yet fine threads -of dentists’ or other strong silk, one end to be cut off in primary -amputations. In secondary amputations, when the parts are not always -sound, both ends of the ligature should be cut off, and in such cases -the edges of the wound should be brought in contact only, with a layer -of fine linen between them, without the expectation of, or the desire -for, union taking place. - -75. The removal of a limb should not occupy two minutes, but the -securing the blood-vessels should be done without reference to time; -when carefully effected, there is little fear of secondary bleeding, -and the stump should be closed at once. It has been lately recommended -not to close the stump for four, six, or eight hours after the -operation; but this is not advisable, unless the depressed state of the -patient, or other causes, should have rendered it impossible to secure, -in a proper manner, all the vessels which are likely to bleed. It will -be less painful and dangerous to delay, in such cases, than to have to -reopen the stump. - -76. When the edges of the incision have been brought together by the -hands of the assistants, and by the sutures indicated, strips of -some kind of agglutinative plaster without resin should be applied -between them, and a little wet lint over the incision, retained by two -cross-pieces of rollers, the ends of which are maintained in their -situation by another roller applied round the body and over the upper -part of the thigh, including the extremities of the two cross-pieces; -but this roller is not to be applied over the end of the stump. When -the war came well in, stump-caps, as they were called, went out, being -worse than useless. The stump should be supported on a soft pillow, so -as to be as comfortable as possible, and protected by a cradle from -accidental injury. - -If inflammation, accompanied by pain, should take place, cold or iced -water should be applied, particularly in primary amputations. In -secondary ones, warm fomentations or light warm poultices will be more -advantageous, all constriction by sutures or plasters being removed, -the parts being simply approximated to each other. Attention should be -paid to the directions in aphorism 61. - - -AMPUTATION AT THE HIP-JOINT. - -77. This amputation essentially owes its existence to the wars of the -French Revolution. M. Bourgery says Blandin performed it three times -in 1794; once successfully. Baron Larrey did it seven times during his -different campaigns, and he says one or two persons who had survived -were seen during their cure by an officer in Russian Poland, but they -never reached France. Nevertheless, I always assume that one at least -did recover, whether he was really seen or not, being a compliment and -a reward justly due to the zeal and ability of my old friend the Baron, -to whom the surgery of France is so much indebted. This operation was -first done in Spain by the late Mr. Brownrigg, at Elvas, in 1811, and -by myself after the siege of Ciudad Rodrigo, but none of our patients -ultimately recovered. I operated on a French soldier at Brussels soon -after the receipt of the injury at Waterloo; he survived; and he was -the first and the _only man_ seen for a long time afterward in either -London or Paris. The biographer of Baron Larrey says he was present -at, and advised the operation to be done; but that is an error, as the -Baron did not visit Brussels until after I had left it for Antwerp; -neither had I any knowledge of the Baron’s writings in 1811 or 1812, -when my first operation was done in Portugal. Eighteen or twenty ways -have been suggested for doing this operation, and twenty persons are -believed to have survived its performance, several of whom may be -living at the present time. - -A very extensive destruction of the soft parts, the femur remaining -entire, does not authorize the removal of the limb in the first -instance, unless the main artery be also injured. Captain Flack, of the -88th Regiment, was struck by a large cannon-shot at Ciudad Rodrigo, -on the outside and anterior part of the left thigh, which tore up and -carried away nearly all the soft parts from the groin, or bend of the -thigh, below Poupart’s ligament, to within a hand’s-breadth of the -knee. It was an awful affair. He was supposed to be dying, was returned -dead, and his commission was given to another. Left to die in the field -hospital after the town was stormed, and finding himself thus deserted -by his own friends, he claimed my aid as a stranger. I took him five -leagues to my hospital at Aldea del Obispo. The femoral artery lay bare -for the space of nearly four inches, in a channel at the bottom of the -wound; the whole, however, gradually closed in, and he recovered. - -If the injury is on the back part, a flap should be made in amputation -from the fore part. If the wound should be on the outside, the flap -is to be made from the inside, and _vice versa_, the object being to -make the stump as long as possible. A wound of the artery, accompanied -by a fracture of the femur, requires amputation, for although many -would survive either injury alone, none would, it may be apprehended, -surmount both united. - -If after a fracture in course of treatment, the principal artery should -be wounded by some accidental motion of the bone, amputation should in -general be resorted to. A ligature on the artery higher up would fail, -and the operation of seeking for both ends of the injured vessel would -cause so much mischief in an unsound part that the consequences would -in all probability be fatal. - -78. When the femur is suffering from a malignant disease, commencing -in the periosteum, or in its cancellated internal structure, I am -reluctantly obliged to say, from experience, that the removal of the -whole bone at the hip-joint offers the best, perhaps the only chance -of success. In such cases, the operator has in general the power of -selecting his mode of proceeding. - -It may be laid down as a principle in all cases of accident, whether -from shot, shell, or railway carriages, that no man should suffer -amputation at the hip-joint when the thigh-bone is entire. It should -never be done in cases of injury when the bone can be sawn through -immediately below the trochanter major, and sufficient flaps can be -preserved to close the wound thus made. An injury warranting this -operation should extend to the neck, or head of the bone, and it may -be possible, as I have proposed, even then to avoid it by removing the -broken parts. - -79. The principle being established, as a general rule in all cases of -recent injury, that the femur must be broken at least as high as the -trochanter to constitute an imperative case for this operation, the -next point of importance relates to the manner of forming the first -incisions. The instructions and recommendations to be found in books -for the performance of this operation are frequently inapplicable, and -are not to be depended upon; the errors occurring from the operation -having been considered and performed on the dead body and not on the -living; on the normal and not on the injured state of parts. Thus, -for instance, it is recommended that an assistant should rotate the -knee outward or inward, to show the head of the femur; to which -recommendation there is the insuperable objection, that no person -should suffer this operation who has a knee, or half a thigh, or even -a third of one, to move by the rotary process. Pure theorists in -surgery have decided upon having a large flap made on the fore part of -the thigh, and a smaller one behind, regardless of the fact that this -cannot be done in many cases requiring a primary operation from the -nature of the injury; although it may be done in many secondary cases, -in which this severe operation would not have been required if the limb -had been amputated in the first instance. It is the mode recommended by -Mr. Brownrigg, who in his operations, which were secondary ones, had a -choice of integument, and it is, perhaps, under these circumstances, -the best. - -Baron Larrey tied the femoral artery in the first instance, and then -made two lateral flaps; but this operation, dependent on the fear of -hemorrhage, was never performed in the British army. - -80. My first successful operation, performed in 1815, was done from -without inward, the flaps being anterior and posterior, the artery -being compressed against the pubis. - -The patient is to be laid on a low table, or other convenient thing, -in a horizontal position; an assistant, standing behind and leaning -over, compresses the external iliac artery becoming femoral, as it -passes over the edge of the pubis. The surgeon, standing on the inside, -commences his first incision some three or four inches directly below -the anterior spinous process of the ilium, carries it across the -thigh through the integuments, inward and backward, in an oblique -direction, at an equal distance from the tuberosity of the ischium -to nearly opposite the spot where the incision commenced; the end of -this incision is then to be carried upward with a gentle curve behind -the trochanter, until it meets with the commencement of the first; -the second incision being rather less than one-third the length of -the first. The integuments, including the fascia, being retracted, -the three gluteal muscles are to be cut through to the bone. The -knife being then placed close to the retracted integuments, should be -made to cut through everything on the anterior part and inside of the -thigh. The femoral or other large artery should then be drawn out by -a tenaculum or spring forceps, and tied. The capsular ligament being -well opened, and the ligamentum teres divided, the knife should be -passed behind the head of the bone thus dislocated, and made to cut its -way out, care being taken not to have too large a quantity of muscle -on the under part, or the integuments will not cover the wound, under -which circumstance a sufficient portion of muscular fiber must be cut -away. The obturatrix, gluteal, and ischiatic arteries are not to be -feared, being each readily compressed by a finger until they can be -duly secured. The capsular ligament, and as much of the ligamentous -edge of the acetabulum as can be readily cut off, should be removed. -The nerves, if long, are to be cut short. The wound is then to be -carefully cleansed, and brought together by three or more soft leaden -sutures in a line from the spine of the ilium toward the tuberosity of -the ischium. The ligatures are to be brought out between the sutures, -and some adhesive strips of plaster applied to support them. A little -wet lint is to be placed over the wound, and some well-adapted compress -under the lower flap; the whole to be retained by a soft bandage. In my -successful case there was a shot-hole in the under flap, which did good -service; and from having seen its use, I have no objection to a small -perpendicular slit being made in the lower flap, and a strip of linen -introduced to prevent adhesion. The immediate union of the flaps cannot -be expected, nor is it often to be desired. - -This mode of proceeding is more certain of making good flaps where -integuments are scarce. Where the integuments will admit of the -anterior flap being made by the sharp-pointed puncturing knife dividing -the parts after it has been passed across from without inward, there -is no objection to this proceeding, and some prefer it. I have had two -such knives added to each of the cases of instruments supplied to the -army for the purpose. - -Professor Langenbeck, when lately in London, informed me he had -performed amputation at the hip-joint several times in the Holstein -war, and he believed more than once successfully; making the anterior -flap by the pointed knife, cutting from within outward, but the -posterior one by cutting through the integuments from without inward, -as I have recommended in high amputation below the joint, in order to -make the flap of a more equal and proper thickness. One point to be -attended to is to leave as little as possible of the internal tendinous -structure of the great gluteus muscle, as it does not readily unite -with other parts; a second, not to leave too much muscle on the under -part; and a third, to remove as much as possible of the ligamentous -structure about the joint. The after-treatment will be the same as in -other formidable cases. The shock, however, of the injury, and of the -amputation, will render blood-letting unnecessary. Cordials, in small -quantities, with opiates and a good but light nourishing diet, should -be given. The wound should be wetted with cold water, and the patient -constantly watched, so that hemorrhage may be arrested if it should -take place. In an otherwise successful operation performed by Mr. C. G. -Guthrie, at the Westminster Hospital, the patient was lost on the third -day from this cause. - -Mr. Brownrigg’s operation is to be done in the following manner: The -patient is to be placed on a low table and properly secured, with -the nates projecting over its edge, the artery being compressed. The -surgeon enters the pointed knife between the spine of the ilium and -the trochanter major, and carries it across the thigh, as near as may -be to the head and neck of the femur, until the point appears on the -inside, near the scrotum, which should have been previously drawn away. -The knife is to cut slowly downward, to make a flap, under which, and -behind the knife, an assistant inserts his four fingers, in order to be -able to grasp the flap and aid in compressing the principal artery, as -the operator completes the flap, which it is intended should be a large -one, as shown in the diagram, fig. 1. - -[Illustration: Fig. 1. - -_Amputation of the Hip-joint as performed by_ Mr. Brownrigg. - -(Upper figure.) - - _a_ _a_ _a_, anterior flap in dotted lines; - _c_, thumb compressing the artery on the pubis; - _d_, fingers introduced under the flap; - _e_, the straight knife, entrance and exit of. - -(Lower figure.) - -_Flap Amputation as performed by_ Mr. Luke, _on the lower half of -the thigh_. - - _A_, middle of the outside of the thigh and point of entrance of knife; - _B_, under part; - _C_, upper part; - _A_ to _E_, the under flap; - _G_ to _F_, dotted line of upper flap, beginning short of commencement - of under flap.] - -The assistant holding up the flap, the surgeon cuts the attachment of -the gluteus medius muscle, from the upper edge of the trochanter, if it -has not been already done, opens the capsular ligament of the joint, -and divides the ligamentum teres. The head of the bone can then be -readily withdrawn from the acetabulum. The knife being placed behind -the head of the bone and the trochanter, should be carried obliquely -downward and backward, so as to form a shorter flap behind than was -made before. The amputations of the hip-joint, performed in the Crimea, -have not, I understand, been as successful as the ability with which -they were performed might have led the operators to expect. - -[Illustration: Fig. 2. - -MR. GUTHRIE’S OPERATION. - -Left side-- - - _a_, anterior superior spine of ilium; - _b_, commencement of anterior incision, continued by the black line; - _c_, the posterior incision joining the anterior one. - -(Second figure.) - - _b_ _c_, line of incision marked by three sutures.] - -81. Amputation by the circular incision is to be done in the following -manner: When a tourniquet is used, which it should not be, if the -surgeon can depend on his assistants, the pad should be firm and -narrow, and carefully held directly over the artery, while the ends of -the bandage in which it is contained are pinned together. The strap of -the tourniquet is then to be put round the limb, the instrument itself -being directly over the pad, with the screw entirely free; the strap -is then to be drawn tight and buckled on the outside, so as to prevent -its slipping, and yet not to interfere with the screw. Should the screw -require to be turned more than half its number of turns, the strap is -not sufficiently tight, or the pad has not been well applied. The -patient being placed on a table at a convenient height, the assistants -are carefully to retract the integuments upward, and put them on the -stretch downward, by which means their division is more easily and -regularly accomplished. The surgeon, standing on the outside, passes -his hand under the thigh and round above quite to the outside, and -there he begins his incision with the heel of the knife, and with a -quick, steady movement, carries it round the thigh until the circular -division of the skin, cellular membrane, and fascia has been completed. -The skin cannot be sufficiently retracted unless the fascia be divided, -and as the division of the skin is certainly the most painful part -of the operation, it ought never to be done by two incisions, when -the largest thigh can most readily and speedily be encircled by one. -If the fascia should not be completely divided by the first circular -incision, it is to be cut with the point of the knife, together with -any attachment to the bone or muscles beneath. The amputating knife -is then to be applied close to the retracted fascia and integuments, -and the outermost muscles are to be divided by a circular incision, -with any portion of the fascia that may not have equally retracted. -This incision completed, the knife is immediately to be placed close -to the edge of the muscular fibers which have retracted, and the -remainder of the soft parts divided to the bone in the same manner. -In making these two incisions, care should be taken to cut at least -half an inch on each side of the great artery by one incision, which -should be either the first or second, as may be most convenient. The -muscles attached to the bone are then to be separated with a scalpel -for about three inches in large thighs, by which means the bone will -be fairly imbedded when sawed off. The common linen retractor is next -to be placed on the limb, and the muscles steadily kept back while the -bone is sawed through. The periosteum may or may not be divided by one -circular cut of the scalpel after the retractor has been put on. The -heel of the saw is then to be applied and drawn toward the surgeon, -so as to mark the bone, in which furrow he will continue to cut with -long and steady strokes, the point of the saw slanting downward in a -perpendicular direction until the bone be nearly divided, when the saw -is to be more lightly pressed upon, to avoid splintering it, which this -manner of sawing will also tend to prevent. During this operation -the thigh should be held steadily above, and in such a manner below -that the part to be cut off does not weigh or drag on the bone above; -at the same time it must not be pressed inward or upward, or it will -prevent the motion of the saw or splinter the bone. The retractor is -then to be removed, the great artery to be pulled out by a tenaculum -passed through its sides, separated a little from its attachments, and -firmly tied with a two-threaded, strong ligature, provided dentists’ -silk be not used, and the tenaculum is not to be withdrawn until this -has been accomplished; any other vessels that show themselves may be -secured, and compression should for an instant be taken off the main -artery, when others will start. If used, the tourniquet should now be -removed, and the small remaining vessels will be discovered. If the -great vein continue to bleed after some pressure has been made upon -it, a single-threaded ligature should be put over it; but this should -not be done if it can be avoided, and only when the loss of a little -blood might be dangerous. If the cancellated part of the bone bleed -freely, the thumb of the left hand pressed steadily upon it, while the -vessels are tying, will in a short time suppress the hemorrhage. Any -inequality of bone should be removed by forceps. The ligatures should -now be shortened, one end of each thread being cut off; the stump is -to be sponged with cold water and dried, the bandage rolled steadily -down the thigh; the muscles and integuments brought forward and placed -in apposition, horizontally across the face of the stump, and retained -by leaden sutures and adhesive plasters carefully applied, from below -upward, and from above downward; the ligatures being brought out nearly -as straight as possible, in two or three places between the slips of -plaster, unless both ends have been cut short. A compress of lint is to -be placed over and under the wound, supported by two slips of bandage, -in the form of a Maltese cross, vertically and horizontally, and the -whole secured by a few more turns of the bandage. No stump-cap is to be -applied; the stump is to be raised a little on a proper pillow from the -bed, in which the patient lies on his back; and if the bone appear to -press too much against the upper flap, the body may be a little raised, -which will relieve it. - -In secondary amputation of the thigh, the integuments may not be sound, -and will not retract, in which case they must be dissected back to an -equal distance all round. If the muscles are much diminished in size, -or flabby, they should be left even longer than may appear necessary -for the formation of a good stump; and this is to be done more -especially on the under part, for the bone will frequently protrude -under these circumstances, when enough has been supposed to have been -preserved. In all these cases the bone should be shorter than usual, -and the skin should, if possible, retain its attachments to the parts -beneath. No inconvenience can ever arise from too much muscle and skin -in a circular stump; but it does sometimes from too much skin alone. - -In primary operations there will be from three to seven vessels to be -tied; in secondary ones, from ten to sixteen, and even then there may -be an oozing from the stump. In this case a little delay in searching -for the vessels is necessary; the tourniquet and all tight bandages -should be removed, and the stump well sponged with cold water before -it is dressed. A certain degree of oozing is to be expected from all -stumps, although it does not always occur: but when there is really -any hemorrhage, so that blood distills freely through the dressings, -the stump should be opened, when the bleeding vessel will generally -be discovered readily, though not visible before. A stump under these -circumstances should not be closed in the first instance; the parts -should be merely approximated until all bleeding has ceased. - -When the operation is performed near the knee, the gradual thickening -of the thigh prevents the retraction of the integuments, and has an -effect upon the vessels of the stump; both of which evils are avoided -after the circular incision has been completed, by making a cut, an -inch and a half in length, in the integuments through the fascia on -each side, in the horizontal direction in which they are recommended to -be placed, after the operation is finished; but this will very rarely -be necessary. - -82. Amputation of the thigh, by the flap operation, is best -accomplished by the method adopted by Mr. Luke, of the London Hospital, -which is as follows: The patient being placed so that the thigh -projects beyond the table, the surgeon stands with his left hand toward -the body, or on the outside when amputating the right, and on the -inside when amputating the left thigh. The knife to be used ought to be -narrow, pointed, and longer by two or three inches than the diameter -of the thigh at the place of amputation. The point of the knife -should be entered _mid_-distance between the anterior and posterior -surfaces of the thigh, which may be effected with accuracy, if the eye -is brought to a level with the thigh, when the middle point is easily -determined. The posterior flap is to be formed first, by carrying the -knife transversely through the thigh, so that its point shall come out -on the opposite side, exactly midway between the anterior and posterior -surfaces. In traversing the thigh, the knife should pass behind the -bone, and will be more or less remote from it in different individuals, -according to the greater or less development of the posterior muscles, -when, by cutting obliquely downward, to the extent of from four to six -inches, according to the thickness of the thigh, a posterior flap is -formed. The anterior flap is effected, not by making a flap, but by -commencing an incision through the integuments and muscles on the side -of the thigh opposite to the surgeon, at a little distance anterior -to the extremity of the posterior flap. This incision is made from -without inward, through the integuments, so as to form an even curve, -and without angular irregularity, over the thigh, to near the base -of the posterior flap on the side on which the surgeon stands. The -length of this flap is determined by that of the posterior. It will -therefore vary from four to six inches, as before stated; and for its -completion will require a second, or perhaps a third, application of -the knife. In the two flaps thus made, the division of almost all the -soft structures is included, a few only immediately surrounding the -bone remaining uncut. These are to be divided by a circular sweep of -the knife, at the part where it is intended to saw the bone; in this -way it is sufficiently denuded for the application of the saw. The -flaps being held back by an assistant, the bone is to be sawn through -in the usual way. In amputations of the lower part of the thigh it -usually happens that the ischiatic nerve lies upon the surface of -the posterior flap, and should be removed. It occasionally occurs, -although not frequently, that the popliteal artery is cut obliquely at -its commencement; but in amputations above the passage of the arterial -trunk through the tendon of the triceps, this does not take place, the -division of the artery being usually included in the circular sweep -made after the formation of the flaps. The divided arteries having been -carefully secured, the flaps are to be brought together and retained by -three sutures passed through the integuments at equal distances from -each other, and from the extremity or base of the flaps. It appears -to be a matter of considerable importance not only that their edges -should be kept in apposition, but that their _whole surfaces_ should -be kept in accurate contact. For this purpose, the following method of -dressing is adopted: The edges, in the intervals between the sutures, -are to be held together by strips of adhesive plaster about one inch in -breadth. A compress of lint is then to be fitted over each flap, that -upon the posterior being the larger. The compresses are to cover the -flaps only, and not to extend over the extremity of the bone, where -their pressure would probably be ill endured. The posterior compress -is made large, that it may serve as a cushion on which the thigh rests -when the patient is placed in bed. The compresses are to be retained in -position by one or two strips of plaster, and supported by a bandage -applied carefully round the stump. If this be properly accomplished, -the whole surfaces of the flaps will be kept accurately in contact -with each other, and complete union may be reasonably expected. By -securing the perfect apposition and support of the entire surfaces in -accurate contact, the disposition to the issue of blood from small -vessels is also obviated to a great extent, and it is even probable -that vessels of a larger diameter than the smallest, which would bleed -if not restrained, are, by the pressure of the opposing surface, -prevented from doing so, and the probability of secondary hemorrhage -is diminished. Experience has demonstrated the fact that primary -union of the flaps is most effectually procured in the great majority -of amputations thus treated. Indeed, non-union of the flaps is the -exception; union, the rule. In the subsequent treatment of the stump, -care must be taken to prevent an accumulation of discharge in the -tracks of the ligatures; and the dressings must be renewed according to -circumstances having reference to the quantity of discharge, and the -uneasiness of the patient. The line of division of the integuments of -the two flaps is situated, at first, in the center of the face of the -stump; but when the flaps have united, a gradual change takes place in -the position of the cicatrix: it recedes, by degrees, to the posterior -aspect of the thigh, and the bone abuts upon the anterior flap, by -which alone it is eventually covered, and the cicatrix is thus removed -from its pressure. - -83. A protrusion of bone is a disagreeable occurrence after amputation; -it will sometimes happen after sloughing of the stump, without any -fault of the operator. If, on completing the operation, it is evident -the bone cannot be well covered, a sufficient portion should be at once -sawn off, and the error remedied. - -When the bone protrudes at a subsequent period to the extent of an inch -or more, it should be removed by operation, an incision being made on, -and down to, the bone, and the saw applied where it is sound. The chain -saw, when at hand, answers well, and some should be supplied for the -use of the principal hospitals with every army. The protruded end of -bone should be held steadily by pincers, or it may be introduced into a -hollow tube, which fixes it firmly. - -When the bone has been badly sawn through, or split in the act of -dividing the last layer, or the periosteum is unduly separated, the -end will often exfoliate with the split, which may extend up for -several inches, giving rise to the formation of abscesses, causing much -suffering, and occupying a great length of time before the ring of bone -and the split portion exfoliate, and the stump becomes quite sound. -A splinter of this kind may even require to be removed at a late or -at a distant period, from the nervous irritation and suffering it may -occasion. This irritation has been often attributed to the extremity -of the principal nerve, which always enlarges, assumes a bulbous form, -and is painful on pressure, when made for the purpose, although not so -under ordinary circumstances. This enlargement never requires removal, -unless it should adhere to the cicatrix, or be the subject of disease -incidentally occasioned in it. The great sciatic nerve became early -thus enlarged in the thigh of the late Marquess of Anglesea, and was -mistaken for disease, for which he was advised to have it removed, it -being painful on pressure, and therefore the supposed cause of the -tic douloureux under which he labored. Consulted on the propriety of -this operation, his leg-maker, Mr. Pott, being present, who had also -lost a leg above the knee, I requested his lordship to squeeze Mr. -Pott’s bulbous nerve, in the same manner as the doctor had squeezed his -lordship. He did so, and Mr. Pott roared and sprang from the floor in a -manner which quite satisfied Lord Anglesea. - - - - -LECTURE V. - -REMOVAL OF THE HEAD OF THE FEMUR, ETC. - - -84. The removal of the head of the thigh-bone from its place in -the hip-joint, after it has been separated in a measure from its -attachments by disease of a scrofulous nature, is an operation which -has been several times successfully performed, and life has been -thereby preserved without much suffering or risk to the patient. In -this case, the head of the bone is found lying outside the cavity, from -which it has been drawn by the action of the muscles. A step further -must be taken, and this operation must some day be done in cases -of fracture of the head or neck of this bone caused by an external -wound--cases which have hitherto been invariably fatal, or in which -life has been preserved by amputation at the hip-joint. - -The great advance which operative surgery has made within the last -forty years, and the success which has followed the removal of the -head of the humerus, the whole of the elbow, the ankle, and even the -knee-joint, render it imperative on surgeons of ability to endeavor to -save life without the performance of so formidable an operation as that -of the removal of the whole limb, more particularly when the health -is good and the parts sound, with the exception of those immediately -injured. - -The cases which seem more particularly favorable for this operation are -those in which the head or neck of the bone is broken by a musket-ball. -Picture to yourselves a man lying with a small hole either before or -behind in the thigh, no bleeding, no pain, nothing but an inability to -move the limb, to stand upon it, and think that he must inevitably die -in a few weeks, worn out by the continued pain and suffering attendant -on the repeated formation of matter burrowing in every direction, -unless his thigh be amputated at the hip-joint, or he be relieved by -the operation which, I insist upon it, ought first to be performed. - -85. In order to do this operation with precision, the surgeon should -make himself well acquainted with the anatomy of the parts; and -as the war in the Russian Empire may offer opportunities for its -performance, a recapitulation of the essential points to be noticed -may be useful. Two limbs should be injected so as to show the great -arteries distinctly, and one should be dissected so that every part -may be brought into view at once. That being done, attention should be -directed to two points, the great trochanter and the round head of the -thigh-bone in its socket, which is directly below and a little internal -to the anterior superior spinous process of the ilium. - -When the thigh is bent in the dissected limb, the head of the bone -will be seen rolling in the socket very distinctly, and, in order to -lay it bare for removal, the muscles, etc. around it must be divided. -The first, on the anterior and outer part, is the tensor vaginæ -femoris; this should be divided; outside this the gluteus medius -must be cut, going to be inserted into the upper and outer part of -the top of the great trochanter; deeper, and between these two last, -lies the gluteus minimus, winding forward to be inserted into the -anterior portion of the same part. Now, let the great gluteus muscle -be cut through backward in a curve, and the insertions of four muscles -at one part--viz., the pit or fossa immediately behind the great -trochanter--will be brought into view: these are the pyriformis, the -gemelli, reckoned as one muscle, and the obturatores externus and -internus. They should all be cut through within half an inch from -their insertion. The square muscle lying or placed immediately below -them, and running from the ischium to the inter-trochanteric line, is -the quadratus femoris; it must be cut across. The head of the femur -will now be seen to roll in the socket on the least motion being -given to the knee. The surgeon should then open into the exposed -joint with great care, when by a gentle rotation of the knee inward -the head of the thigh-bone will be readily dislocated outward. The -ligamentum teres, or the round ligament, as it is termed, although it -is triangular at its origin, should now be divided, with as much of the -capsular ligament as may be necessary, when everything will be ready -for the application of the saw. - -Pause a moment, and view the parts before the saw is applied. Two -strong muscles are inserted into the small trochanter by a common -tendon, the iliacus internus and psoas magnus. This insertion should -remain untouched if the fracture should not extend below the little -trochanter. It is not always necessary to injure them, and they will -be of great use afterward, if the operation should prove successful. -If the neck of the bone be broken through, rotating the thigh as -directed may not assist much in dislocating its head. But then, the -separation of the fractured parts may be readily completed, and the -piece detached, when the remaining part of the head of the bone will be -more easily removed. The sawing may be accomplished with the greatest -ease by a small common saw, or by the improved chain saw, which will do -good service. The arteries to be divided are all of small size. Filled -with red injection, they are so small as scarcely to be seen; and -they could not give any trouble; for the wound is so large as to give -easy access to every part, and readily admit of any bleeding vessel -being tied without difficulty. The round ligament should be cut off -close to its origin in the acetabulum, and any portion of the capsular -ligament and cartilaginous edge of the acetabulum which can be quickly -removed with it, but no time should be unnecessarily lost in trying to -remove the cartilaginous lining of the cavity itself, which will be -gradually absorbed. The sawn end of the femur should now be brought -up into the cavity, and kept there if possible by a supporting splint -and bandage, with the hope that it may become rounded and adhere by a -newly-formed ligamentous structure, in the same manner as the end of -the humerus does to the glenoid cavity of the scapula, when similarly -treated. The edges of the wound are then to be brought in apposition, -and retained so by two or three sutures. The gluteus magnus slides -over the trochanter major, having a bursa between them, and this part -will not readily throw out granulations. The surgeon may therefore be -less solicitous about the accuracy of the apposition of the edges at -the under part, through which the discharge will more easily pass. The -outside must, however, be supported by sticking-plaster and bandage -compress, to prevent any bagging, and to keep all parts in contact. -The saving the periosteum of as much of the femur to be taken away, -as strongly recommended by MM. Flourens and Baudens in the excision -of the head of the humerus, should be attempted, although not easy of -execution. (_Aph. 118._) - -86. The surgeon should now do the operation on the undissected limb. -The first cut through the skin, integuments, and fascia lata should -be a curved one, beginning just over the inner edge of the tensor -vaginæ femoris muscle, as shown on the other leg, curving downward -and outward, so as to pass across the bone an inch at least below the -trochanter major, when it should turn upward to the extent of three -inches or more, as the size of the limb may require. This incision or -flap should, when complete, divide, in addition to the integuments, -the fascia lata, the tensor vaginæ femoris, and part of the gluteus -maximus. The flap thus formed must be raised or turned up by an -assistant, to enable the operator to get at and divide the parts below, -in the order before named. It is not necessary to stop to tie any -bleeding vessel until the operation is finished, for little or no blood -will be lost. - -Pause again. The surgeon has just done nearly the outer half of the -operation as to cutting, for removing the whole limb at the joint; -and if he should now find that the bone is so much shattered in the -shaft that he cannot hope to save the limb, there is no difficulty -in removing it. To do this, place your long knife inside the bone, -with the middle of its edge resting against the outer edge of the -iliacus and psoas muscles, and at one firm cut of a strong hand let -it cut its way inward, forming an inner flap, your assistant steadily -compressing the femoral artery against the bone above. This artery and -the great profunda will both be divided; seize them with the finger -and thumb of the left hand, and place a ligature, or assist in placing -one, on each branch with the right; or, if the trunk of the profunda -should have been cut very short, tie the main trunk of the femoral. -Let the ligature be a single thread of strong dentists’ silk, with -which I have successfully tied the common iliac, and no fear need be -entertained of its not holding fast if you tie it reasonably tight. -The idea usually entertained that a great artery cannot be closed by -the ordinary process of nature under a ligature, if a branch be given -off near it, is erroneous. I never placed reliance on this opinion -unless in the accidental circumstance of the outside of the orifice of -the branch being in contact with the ligature, the irritation caused -by which outside may not be sufficient to close the orifice within, -and the common iliac artery of one of the two cases in which I tied it -successfully (the patient dying a year afterward) may be seen in the -Museum of the College of Surgeons. It is tied about an inch from the -aorta, and was pervious on each side of the ligature, which has closed -the vessel to no greater extent than its own width, proving all the -facts I have mentioned so frequently on this subject. As to the smaller -vessels, they will give no trouble, being easily commanded, each by the -point of a finger. I have not done this operation of removing the head -and neck of the femur on a healthy living man after an accident, but -it must be done, and I am satisfied it will in the end succeed. It was -done in the 3d Division of the army in the Crimea after the engagement -of the 18th of June. The continuity of the head with the shaft was not -altogether destroyed, the fracture being principally confined to the -great trochanter and the trochanteric ridge. It was at first thought -the operation might be dispensed with, but as great irritation ensued, -with every prospect of considerable mischief, the head, neck, and both -trochanters were excised. On the 6th of July the man was doing well, -but unfortunately he was attacked by cholera three days afterward, -and died. This operation has since been done by Mr. Blenkin, of the -Grenadier Guards; the result will be stated hereafter. - -Amputation at the hip-joint should not be performed, unless the head -and neck of the thigh-bone be injured; and it ought not to be done -if they be, unless the shaft of the thigh-bone be extensively broken -also. The operation I have recommended should be its substitute, -and I hope yet to see a man walking with ease and comfort on whom -it has been performed. The recommendation thus given is the result -of the experience of former times, of the whole of the war in the -Peninsula and at Waterloo, matured by that of the last forty years -in London hospitals, and by a due consideration of the state of -surgery throughout all civilized Europe and America. Surgery is never -stationary, and surgeons of the present day must continue to show that -it is as much a science as an art. - -87. Wounds of the knee-joint from musket-balls, with fracture of -the bones composing it, require immediate amputation; for although -a limb may be sometimes saved, it cannot be called a recovery, or a -successful result, where the limb is useless, and is a constant source -of irritation and distress after several mouths of acute suffering have -been endured, to obtain even this partial relief from impending death. -For one limb thus saved, ten lives will be lost; and the sufferer is -often glad, after months and years have elapsed, to lose the limb thus -saved, more particularly when the ball has lodged in the articulating -surface of either of the bones. Amputation at a secondary period, in -these cases, does not afford half the chance of success, for many -will not survive the inflammation and the fever which will ensue. -The amputation should therefore be immediate, unless excision can be -substituted for it, and it is a point to be hereafter decided whether -excision may not almost always be so substituted when the wound is made -by a musket-ball, and the popliteal artery and nerve are not injured. - -88. Compound fractures of the patella, without injury to the other -bones, admit of delay, provided the bone be not much splintered. If -the ball should have pierced the center of the patella, and passed out -nearly in an opposite direction behind, the limb will not be saved. -If the ball have struck the patella on its edge, and gone through it -transversely, opening into the joint, it will very rarely be saved; -but if it be merely fractured, there is hope under the most rigorous -antiphlogistic treatment, and delay is proper. A ball will occasionally -penetrate the capsular ligament, and lodge in the knee-joint, with -little injury to the bones. If it cannot be extracted without opening -extensively into the cavity of the joint, and the extraction of the -ball is absolutely necessary, amputation or excision had better be -performed at first, for it will be ultimately necessary. The condyles -of the femur and the lower part of the bone being spongy, a ball may -pass through them or between them, and fall into the knee-joint, or -it may make a prominence on the side of the patella, without passing -out, or immediately interrupting the motion of the leg, for the soldier -may walk some distance afterward. The popliteal artery may also be -divided in addition, and either of these cases will render amputation -necessary, for the ball must be taken out on the fore part, and the -general inflammation of the joint will either destroy the patient -in a short time, or, after much distress and hazard, leave him no -alternative but amputation. If a ball lodge in the condyles of the -femur within the capsular ligament, and cannot be easily extracted, -excision or amputation is advisable; for the limb, if preserved, will -not be a useful one. If the ball, on the other hand, lodge without the -capsular ligament, and cannot readily be extracted, the wound should -be healed as soon as possible; and, although it may cause some little -inconvenience to the knee-joint, the limb and life of the patient -may be saved, as I have seen in many instances, when a continuance -of persevering efforts to extract the ball would have exposed both -to great danger. Many cases of wounds in the knee-joint, in which -the capsular ligament has been wounded, and the articulation opened -into without injury to the bones, do well, such as simple incised -wounds made with a clean cutting instrument. The success attending all -wounds of the knee-joint depends entirely upon absolute rest, upon -the antiphlogistic mode of treatment being rigidly enforced, on the -healthy state of the atmosphere, and on the locality being free from -endemic disease. The limb is to be placed in the straight position, a -splint to be put beneath it, in order to prevent any motion, and cold -or iced water to be applied, especially in summer, to diminish the -increasing heat. General bleeding may be had recourse to in sufficient -quantity to keep all general inflammatory action in due bounds; but -it is on local blood-letting that the surgeon must principally rely -for the prevention of inflammation. Cupping can sometimes be performed -with marked effect; but leeches are more serviceable when they can be -procured in sufficient numbers; from twenty to forty, or more, may -be applied at a time; whenever the sensation of heat is felt, and is -accompanied by pain, they should be repeated until these symptoms -subside. The necessity for the local abstraction of blood is so great -that it should never be lost sight of for a moment; for if suppuration -take place throughout the cavity of the joint, it is followed, in most -instances, by ulceration of the cartilages and caries of the bones. By -local and general bleeding, the application of cold, rigid abstinence, -and the straight position, a recovery may sometimes be effected; but -wounds of the knee-joint, however simple, should always be considered -as of a very dangerous nature, infinitely more so than those of the -shoulder, the elbow, or the ankle. When a poultice is applied to a -gunshot wound of this kind, I consider it the precursor of amputation. -Col. Donnellan, of the 48th Regiment, was wounded, at the battle of -Talavera, in the knee-joint, by a musket-ball, which gave him so little -uneasiness that he could scarcely be persuaded to proceed to the rear. -At a little distance from the fire of the enemy, we talked over the -affairs of the moment, when, tossing his leg about on his saddle, he -declared he felt no inconvenience from the wound, and would go back, as -he saw his corps was very much exposed. After he had stayed with me -a couple of hours, I persuaded him to go into the town. This injury, -although at first to all appearance so trifling, proceeded so rapidly -as to prevent any relief at last being obtained from amputation, and -caused his death in a few days. - -89. _Excision_ of the knee-joint is an operation formerly attended -with so little success that it has been but rarely performed until -lately. The result will, in all probability, be more favorable in -cases of injury from musket-balls, in which the femur and tibia have -both been much injured, without so much mischief being inflicted on -the soft parts as would have rendered amputation necessary. In such -cases, provided every accommodation, and particularly absolute rest -and good air, can be obtained for the sufferer, excision should be -attempted, in preference to the amputation recommended in 84 and 85. -Some cases of success have lately been published by Mr. Jones, of the -island of Jersey; some by Mr. Syme, Mr. Mackenzie, Dr. Gurdon Buck, -Mr. Fergusson, and others. Mr. Jones’s method of operating is here -transcribed, as sent to me by himself:-- - -“In my first case, the incisions were in this form ‘H’, two lateral, -one along each side of the joint, and a transverse one immediately over -the middle of the patella. The flaps were then dissected upward and -downward, the patella removed--and I do not see that any advantage can -be gained by keeping it, even if not diseased--the crucial and lateral -ligaments were then divided, and the joint completely opened. The leg -was afterward bent backward on the thigh, and the diseased portion of -the femur was cleared, and removed with an ordinary amputating saw. The -same method was followed with the tibia: the bones were then placed in -juxtaposition, the flaps brought together by means of a few stitches, -and the limb placed in a species of fracture-box. Water-dressing was -applied. In the second case, I followed very nearly the same plan, with -the exception of my first incisions, which were made something in a -horseshoe shape. In the third case, I removed a considerable portion of -integument, and, I conceive, with marked advantage. In the two former -cases, I think the cure was protracted by preserving all the diseased -external parts.” - -Dr. Gurdon Buck, of the United States of America, in a case of -anchylosis, with deformity, after a gunshot wound, removed the -knee-joint by a transverse incision from one condyle to the other -across the lower margin of the patella. A longitudinal incision -intersected this, extending four inches above and below it. The flaps -being dissected up, the joint was opened into by an incision across the -ligamentum patellæ at the inferior edge of the bone, and also across -the lateral ligaments. The adhesions of the articular surfaces were -broken up by forced flexion very gradually applied. A slice was then -removed with the common amputating saw from the surface of the condyles -of the femur, including the pulley-like surface, care being taken to -make this section on a plane parallel with the surfaces of support -upon which the condyles rest, when the body is erect. The articular -surface of the tibia was next removed on a level with the upper -extremity of the fibula, after the insertions of the capsular ligament -had been dissected up from the posterior half of the circumference of -the head of the bone. The broad, fresh-cut bony surfaces, which were -very vascular and healthy, admitted of accurate coaptation without -stretching the tendons and other parts in the ham. To secure them in -close contact, and prevent displacement, a flexible iron wire was -passed through both bones on either side, and the two ends twisted and -left out between the flaps of skin. The patella, being disorganized -and softened, was removed, except the superior margin, which affords -insertion to the quadriceps muscle. The flaps of integument having -been trimmed, were brought together by sutures and adhesive plaster, -and the limb placed in a fracture-box. The constitutional fever was -moderate, and disappeared in a fortnight. Suppuration never exceeded -half an ounce daily. At the end of five weeks and a half the wires -became loose, and were removed. No exfoliation followed. At the end -of nine weeks the wound had entirely healed, and the limb could be -raised bodily from the bed. There is no mobility between the bones; the -difference in the length of the limb, as compared with the other, is -one inch and a half, which permits the foot to clear the surface of the -ground, which cannot be done when the limb is of the same length as the -other. - -Mr. Jones, since the publication of his original cases, has in a -subsequent one not only preserved the patella, but even the ligamentum -patellæ, which he considers to be a great improvement when it can be -effected; he operated in the following manner: A longitudinal incision -down to the bone, four inches in extent, was made on each side of -the knee-joint, midway between the vasti and the flexors of the leg. -These two cuts were then connected by a transverse one just over the -prominence of the tubercle of the tibia, care being taken not to cut -the ligamentum patellæ. The flap was turned upward; the patella and its -ligament were freed, drawn over the internal condyle, and kept there -by means of a broad, flat, and turned-up spatula. The joint was thus -exposed, the synovial capsule was divided as far as could be seen, -when the leg was forcibly bent, the crucial ligaments, almost breaking -in the act, only required a slight touch of the knife to divide them -completely. The articular surfaces of the bones were now completely -brought into view, when the diseased portions were removed by suitable -saws, the soft parts being kept aside by assistants; the external -condyle had been hollowed out by a large abscess, so that it was -necessary to saw off (obliquely) another portion of the carious bone, -and to gouge out the remainder, until the healthy cancellous structure -was reached. The articular surface of the patella had also to be gouged -until sound bone was attained. The bones were brought into apposition, -and the patella and its ligament replaced, as nearly as possible; at -the end of seven weeks the patient, twelve years old, was able to turn -the limb from side to side, and ultimately recovered. - -This little boy I saw walking firmly on his leg, an admirable instance -of conservative surgery. It is, nevertheless, an operation which ought -not to be done on the field of battle, unless perfect quiescence and -every desired accommodation can be obtained, and no endemic disease -prevail. - -90. Amputation of the leg is performed in two ways--by the circular -incision and by two flaps, the circular incision being only applicable -to the calf. In either way the stump should, if possible, be seven -inches long, for the more convenient application of an artificial leg, -which is now made with a socket to fit the stump, instead of resting -against the bent knee, unless the stump be too short for its proper -adaptation otherwise. - -The operation by the circular incision is performed by necessity in -the thick part of the leg, and the bone is usually sawn through about -four inches from the patella, so that, when the stump has healed, there -may be sufficient length of bone left to support with steadiness the -weight of the body on the knee, and that greater facility may be given -to the motion of the leg, from the preservation of the insertion of -the flexor tendons. The most eligible place for the application of the -tourniquet, when used, is about one-third of the length of the thigh -from the knee, on the inside, where the artery perforates the tendon of -the triceps muscle, and where it can be most conveniently compressed -against the bone by a small firm pad, the instrument being on the -outside, or opposite the pad; or the compress may be placed between the -hamstring tendons, a little distance from the hollow behind the joint, -the instrument itself being on the fore part of the thigh. In this -method the pad must be thicker, and the compression is more painful, -and not more secure. The surgeon should stand on the inside of the leg -to be operated upon, that he may more readily saw the fibula at the -same time as the tibia, by which the chance of splintering the fibula -is diminished; for this bone is held much more steadily under the saw -when the tibia is undivided, whatever pains may otherwise be taken by -the assistants to secure it. The limb should be a little bent, and the -circular incision made with the smaller amputating knife through the -skin and integuments to the bone on the fore part, and to the muscles -on the outside and back part; and as the attachment of the skin to the -bone will not readily allow its retraction, it must be dissected back -all round, and separated from the fascia, the division of which in the -first incision would avail nothing, from its strong attachments to -the parts beneath. The muscles are then to be cut through, nearly on -a level with the first incision, down to the bones. The interosseous -ligament between the tibia and fibula is to be divided with the catlin; -and as several of the muscles cannot retract in consequence of their -attachment to the bones, they are to be separated with the knife; -in the same manner the inter-muscular septa, or expansions running -between them, are to be divided, as they would else prevent their -retraction. The retractor with three slips is now to be put on, the -center slip running between the bones, by which the soft parts may be -pulled back to a sufficient distance, any adhering part being divided -by the point of the knife. The bones are to be sawn through with the -usual precautions, and the retractor removed, when the three principal -arteries should be secured: the anterior tibial, on the fore part of -the interosseous ligament, between the tibia and fibula; the peroneal -artery behind the fibula; and the posterior tibial near it, more -inward and behind the tibia; this artery will frequently, however, -contract very much, and will only show itself on the compression being -taken off the artery above. It in general causes more trouble to secure -it than the others, and I have two or three times seen, even in London -hospitals, the needle dipped round it in despair, when merely pulling -out the artery with the tenaculum, and dissecting a little round it, -would have shown the small retracted bleeding vessels arising from it, -and have prevented, in all probability, a secondary hemorrhage. The -tourniquet, if used, being removed, the smaller vessels tied, and the -stump sponged with cold water and dried, the integuments and muscles -should be brought forward as much as possible, and the strips of -adhesive plaster applied from side to side--that is, the wound is to be -closed vertically or nearly so, that the strips of plaster may not in -any way press upon the fore part of the tibia, by which its protrusion -will be avoided, an occurrence which almost invariably follows when the -line of approximation is horizontal and the strips of plaster press -upon the bone. If the spine of the tibia be sharp, it should be removed -by the saw, whether the operation be done by the circular incision or -by the use of flaps. - -91. The flap operation, as performed by Mr. Luke, differs from that -of the thigh in some particulars. There is a greater variety in -the proportion which the soft parts in the posterior flap bear to -those in the anterior, and the distance from the bones at which the -limb is transfixed in the first step of the operation is subject to -such variety that, when the calf is large, the mid-point for the -introduction of the knife lies at some distance from the posterior -aspect of the bones; in a small calf, it is close to it. The course -of the knife through the limb is oblique instead of transverse, for -the purpose of accommodating the line of incision to the plane of the -two bones. The anterior flap is formed in the same way as in the thigh -amputation, but it has proportionately more integuments and is thinner; -yet its base and length are rendered equal to the base and length of -the posterior flap, and may be adjusted evenly with it when the stump -is dressed. In the circular division of the remaining soft parts, -after the formation of the flaps, there is a necessary variation in -the proceedings, from the circumstance of there being two bones united -by interosseous membrane. It may, however, be accomplished by sweeping -the knife around the more distant bone of the two, its point being -afterward carried between the bones through the interosseous membrane. -While the knife is between the bones, its edge may be so turned that -the membrane may be divided longitudinally to any convenient extent for -the easy introduction of a retractor, and the soft parts around the -bone nearest to the operator may subsequently be divided by a sweep of -the knife in a manner similar to that adopted for the division of parts -around the more distant bone. The sawing of the bones and dressing of -the stump are accomplished as in the thigh amputation; but more care is -required to avoid pressure on the acute margin of the tibia, (which, -when very sharp, should be removed,) and to prevent the pendulous state -of the flaps. - -[Illustration: - - _A._ The mid-point between _B_ and _C_, at which the knife is - introduced for carrying it across the limb. - - _A_ to _D_. The course of the incision to form the posterior flap, _E_. - - _F_ to _g_. The course of the incision to form the anterior flap.] - -When the nature of the injury renders amputation necessary at or -immediately below the tuberosity of the tibia, the operation may -be done with safety. Baron Larrey recommended the removal of the -head of the fibula in such cases; I have done it with impunity, and -thereby made a better stump than if it had not been done; but as -the articulating surface of the head of the fibula does sometimes -enter into the composition of the knee-joint, and as this cannot be -known beforehand, the removal of this portion of the fibula is not -advisable, neither must the tibia be sawn through above the tuberosity -lest the capsular ligament be implicated. As an operation by which -the knee-joint is saved, it is important; for although the stump is -very short, it forms a solid support for the body, enables the patient -to walk without the aid of a stick, and admits of the adaptation of -an artificial leg. The skin, in these cases, must be saved in every -direction by flaps, to form a covering. When in sufficient quantity, -the operation may be done by the circular incision, as much muscle -as possible being saved to aid in forming a covering on the under -and outer sides. The posterior tibial artery will be found to have -retracted behind the head of the bone, whence it, or others which may -bleed, must be drawn out. The nerves should be cut as short as possible. - - -EXCISION OF THE ANKLE-JOINT. - -[Illustration] - -92. This operation should be performed in the following manner: Begin -the incision behind the external malleolus, an inch and a half above -its lower extremity, and carry it downward and then forward across the -front of the ankle-joint, then under the internal malleolus and upward, -close behind this process, to the extent of an inch and a half; this -incision should merely divide the skin, and should not, on any account, -wound the subjacent parts. Raise the flap thus made, and, placing the -leg on its inside, detach and turn aside the peronei tendons from the -groove behind the external malleolus. Cut through the external lateral -ligaments of the ankle-joint, keeping the knife close to the end of the -fibula; then, with the large bone-scissors or nippers, cut through the -fibula from one-half to three-quarters of an inch above its junction -with the tibia, and, after dividing the ligamentous fibers connecting -the two bones, remove the malleolus externus. Turn the leg on to its -outer side, and cut through the internal lateral ligament close to the -tibia, to avoid wounding the posterior tibial artery; this will allow -the foot to be dislocated outward, and the lower end of the tibia -to be brought well out through the wound. An assistant keeping the -foot and tendons out of the way, the lower end of the tibia is to be -removed by a fine saw to the same extent as the fibula, or as high as -the injury or disease requires. The articulating surface, or injured -part of the astragalus, is then to be removed, after which the foot -is to be returned to its proper position, and the cut surfaces of the -tibia and astragalus brought into close approximation, and so kept by -suture, strapping, and bandage. The limb is to be placed on an outside -leg-splint, having a foot-piece to it; and in order to prevent any -matter oozing, an opening should be maintained on the outside of the -joint, with a corresponding hole in the dressing and splint for this -purpose, until the recovery is completed. The shot-hole will sometimes -answer the purpose, when the injury is inflicted by a musket-ball. -There are no vessels to tie, unless wounded accidentally. - - -REMOVAL OF THE OS CALCIS. - -93. If this bone should be much shattered, and the injury nearly -confined to it alone, it may be removed in the following manner: Make -a semilunar incision down to the bone from the posterior angle of the -inner malleolus, across the sole of the foot to the external malleolus, -the convexity of the flap being forward. This flap being turned back, -the tendo Achillis is brought into view, and is to be separated from -its attachment or cut across above it. The point of junction between -the calcis and astragalus having been ascertained, the ligamentous -fibers are to be cut through and the joint between them opened, when -the knife is to be carried from behind forward, in order to divide the -interosseous ligament between them. Some ligamentous fibers passing -between the calcis and cuboid bones are then to be cut through, when -the os calcis may be dissected out without difficulty. The posterior -tibial artery and nerve will be divided. - -This bone was first removed for disease of its substance by Mr. -Hancock, and the operation has been done several times since by Mr. -Greenhow and others with success. - -94. When the bones of the leg are not injured, although those of -the tarsus are so far destroyed as to render amputation necessary, -the operation introduced by Mr. Syme for removing the foot at the -ankle-joint will be well adapted for this injury, provided the soft -parts have not been so much destroyed as to prevent the formation of -the covering flap or flaps. His directions are:-- - -“Pressure should be made on the tibial arteries by the finger of an -assistant or a tourniquet applied above the ankle. The only instruments -required are a knife, the blade of which should not exceed four inches -in length, and a saw. The foot being held at a right angle to the leg, -the point of the knife is introduced immediately below the malleolar -projection of the fibula, rather nearer its posterior than anterior -edge, and then carried straight across the bone to the inner side of -the ankle, where it terminates at the point _exactly opposite_ its -commencement. The extremities of the incision thus formed are then -joined by another passing in front of the joint. - -[Illustration] - -“The operator next proceeds to detach the flap from the foot bone, -and for this purpose, having placed the fingers of his left hand over -the prominence of the os calcis, and inserted the point of his thumb -between the edges of the plantar incision, guides the knife between -the bone and nail of the thumb, taking great care to cut parallel with -the bone and to avoid scoring or laceration of the integuments. He -then opens the joint in front, carries his knife outward and downward -on each side of the astragalus so as to divide the lateral ligaments, -and thus completes the disarticulation. Lastly, the knife is carried -round the extremities of the tibia and fibula so as to afford room -for applying the saw, by means of which the articular projections are -removed, together with the thin connecting slice of bone covered by -cartilage. The vessels being then tied, and the edges of the wound -stitched together, a piece of wet lint is applied lightly over the -stump, without any bandage, so as to avoid the risk of undue pressure -in the event of the cavity becoming distended with blood, which would -be apt to occasion sloughing of the flap. When recovery is completed, -the stump has a bulbous form, from the thick cushion of dense textures -that cover the heel, and readily admits of being fitted with a boot. - -“The advantages which I originally anticipated from this operation -were--_first_, the formation of a more useful support for the body -than could be obtained from any form of amputation of the leg; and, -_secondly_, the diminution of risk to the patient’s life, from the -smaller amount of mutilation, the cutting of arterial branches -instead of trunks, the leaving entire the medullary hollow and -membrane, and the exposure of cancellated bone, which is not liable to -exfoliate like the dense osseous substance of the shaft. From my own -experience, amounting to upwards of fifty cases, and that of many other -practitioners who have adopted amputation at the ankle, I now feel -warranted to state that these favorable expectations have been fully -realized, and that, in addition to its other advantages, this operation -may be regarded as almost entirely free from danger to life.” - -This operation has not answered, in some of the hospitals in London, -the expectations entertained of it from its success in Edinburgh, the -flap formed from the under part, or heel, having frequently sloughed. -This, Mr. Syme declares, is the fault of the operators, and not of the -operation, sufficient attention not having been paid to make the flap -of a proper length, and no more, and to preserve the posterior tibial -artery intact, until it has divided into its plantar branches. He -insists, with reason, that the operation should be done exactly as he -has described it in the following explanation:-- - -“A transverse incision should be carried across the sole of the foot, -from the tip of the external malleolus, or a little posterior to it, -(rather nearer the posterior than the anterior margin of the bone,) -to the opposite point on the inner side, which will be rather below -the tip of the internal malleolus, but can be readily determined by -placing the thumb and finger at opposite sides of the heel. If the -incision be carried farther forward, a considerable inconvenience is -experienced from the greater length of the flap; and I believe a great -deal of the difficulty that has been attributed to the operation has -arisen from this source--the operator getting into the hollow of the os -calcis, cuts and haggles, in striving to clear the prominence of the -bone, with the desperate energy of an unfortunate mariner embayed on -a lee shore in a gale of wind. Another incision is then to be carried -across the instep, joining the ends of the former. The next point to be -attended to is, that in separating the flap of skin from the os calcis -you must cut parallel to the bone. This is of the greatest importance, -since when the flap is detached from the bone, its only supply of -nourishment must be the branches which run through it parallel to the -surface; and if, instead of keeping parallel to the surface, you cut -on the flap as a butcher does when he skins a sheep--you will, by -scoring it in this way, necessarily cut across these branches. I have -reason to believe--nay, to know--that the sloughing which has occurred -in some cases has been due to these defects in the performance of the -operation; the flap having been cut too long, difficulty has been -experienced in separating it from the calcaneum, and this has led to -the scoring of the flap, which has been inevitably followed by death of -a portion or the whole of it.” - -Domestic surgery, or that of civil life, has in these operations of -excision of the ankle-joint, and of amputation at that part, repaid -her Amazonian sister of military warfare for the improvements she has -introduced into the great art and science of surgery; and a degree of -generous emulation will be excited and maintained between them, which, -it may be hoped, will, during the present war in the East, add much to -its scientific and preservative character. - -95. A musket-ball will seldom pass through the foot without injuring -a joint of some kind, or wounding a tendon or nerve; and the injury -to the fascia, which is very strong on the sole of the foot, and -frequently covered by much thickened integument, is always attended -with inconvenience. The extraction of balls, of splinters of bone, of -pieces of cloth, and the discharge of matter become more difficult, and -often cause so much disease as ultimately to render amputation of the -foot necessary. Tetanus is a frequent consequence of these injuries, -and is a disease, in its _acute_ form, certainly irremediable by any -operation or medicine at present known. Amputation has always failed -in my hands, although it was strongly recommended by Baron Larrey. The -operative surgery of the foot should be done as soon after the injury -as it can be conveniently accomplished; for a large, clean, incised -wound is a safe one, compared with a torn surface of much less extent, -and a splintered bone with extraneous substances; as a ball lodged in -the foot is always very dangerous, great attention should be paid in -the examination of even slight wounds. A cannon-shot can seldom strike -the foot without destroying it altogether; it may, however, strike -the heel and destroy a considerable part of the os calcis, without -rendering amputation necessary, if the ankle-joint be untouched; for by -due attention in removing the spicula of bone at first, and by making -free openings for the discharge of matter in every direction in which -it may appear inclined to insinuate itself, the limb may be preserved -in a useful state. - -The following case, from the surgeon of the 44th Regiment, in the -Crimea, is an instance of the removal of the foot after the manner -recommended by the late M. Roux, every effort having previously been -made to save it: “Chloroform having been administered, an incision was -commenced immediately in front of and below the internal malleolus; -this was carried downward and forward until it reached the center of -the sole of the foot. From the extremity of this a second incision was -made nearly at right angles, extending backward along the sole and -upward over the attachment of the tendo Achillis to the os calcis. -A third incision was carried from this round and below the external -malleolus to meet the first at its commencement. Disarticulation of the -ankle-joint was made from the outside, the soft parts put well on the -stretch by forcibly depressing the foot, when, by successive sweeps of -the scalpel, care being taken to keep the edge close to the bone, the -os calcis was separated from its connection with the soft parts. The -plantar arteries were divided at the very extremity of the flap. The -operation was completed by sawing off the two malleoli and the thin -scale of the articulating surface of the tibia. The anterior tibial -and the two plantar arteries each required a ligature. Sutures were -inserted, and the flap supported by strips of wet lint. The operation -was performed on the 4th of July. The stump was dressed the second -day after the operation. There had been no hemorrhage; the flap was -partially adherent; on the outer side the skin was red, tense, and -shining; the sutures were very tight; they were removed from this part; -no appearance of sloughing. - -“July 26th.--The ligatures came away upon the sixth day; no sloughing -of the flap occurred; a small abscess formed both on the outside and -inside of the leg, just where the malleoli were sawn off. These were -opened; the redness of the skin rapidly disappeared after this. The -line of incision is now entirely healed at the outer part; the inner is -not so far advanced, but is doing well. The flap is becoming a firm, -round cushion; and the pressure, when he walks, will fall upon the skin -taken from the sole of the foot. The advantages which this operation -appears to possess are, that the flap is not so large and baggy as in -the early stage after Syme’s amputation; it is performed with greater -facility and rapidity, and there is less chance of wounding the -posterior tibial artery.” - -The accompanying sketch is of the astragalus and calcis of the right -foot, with a ball lodged on the inside, where it joins the smaller -apophysis of the os calcis. The round spot (No. 3) represents the ball, -and the tendons of the anterior tibial and of the common flexor muscles -of the toes must have been divided by it; the proper flexor of the -great toe is at some little distance below, and unhurt; the posterior -tibial nerve and the artery, about to divide into the two plantars, -are still farther distant. In this case the ball might and ought -to have been removed by the gouge, the small chisel, the screw, or -other instrument supplied for this purpose, as soon as possible after -the injury. Nothing was done, however; inflammation and ulceration -extended into the ankle-joint, and the amputation of the foot by the -flap operation at the joint was performed and failed. The leg became -affected; and the case ended in amputation of the thigh, from which the -man recovered, and was sent to England. I know not his name, nor the -regiment he belonged to, nor the surgeon who attended him, nor any more -of the case, as the bone only has been sent to me from Scutari as a -personal attention. - -[Illustration: - - 1. Astragalus. - 2. Os calcis. - 3. The ball. - 4. Ligament descending from the tibia, torn by the ball. - 5. Tendons of tibialis anticus and flexor communis cut across by the - ball. - 6. The other end of the same tendons. - 7. The posterior tibial artery dividing into two branches. - 8. The posterior tibial nerve. - 9. The tendon of the flexor proprius pollicis.] - -If the ball had entered to a greater depth, the proper operation would -have been to remove the bone altogether, which is a difficult and -disagreeable operation, even when done in cases in which this bone has -been dislocated, and is projecting under the skin. It is much more -so when in its proper place; less so when the ends of the tibia and -fibula are also removed for disease of these parts, in which case, -the bone being softened, it yields readily to the scissors, by which -it should be divided, and to which it opposes, when sound, a great -resistance from its solidity. The removal of the astragalus alone has -been successfully performed for disease in children, in two instances, -by Mr. Statham, of University College Hospital, and has been strongly -recommended by Dr. Buchanan, of Glasgow, and others. The operation, -according to Mr. Statham’s method, is to be done as follows: An -incision, four and a half inches long, is to be commenced within the -anterior edge of the fibula, and carried down in a straight line beyond -the anterior end of the metatarsal bone of the little toe; a second -incision, about an inch in length, should then be made from the center -of the wound downward toward the sole of the foot, for the purpose -of giving room. The integuments are then to be raised from the bone, -from the upper edge of the first incision, carrying with them the -extensor tendons toward the inside of the foot, to give more room for -ulterior proceedings, without injuring them. The under joint of a pair -of short, strong scissors, such as are supplied in the capital cases of -instruments, ought then to be pushed under the neck of the astragalus, -at the hollow, where it is attached by a strong interosseous ligament -to the os calcis. The upper blade being then closed upon the bone, it -may be divided, but not without considerable force. The articulating -end of the astragalus with the os naviculare can then be easily removed -by a strong pair of forceps, its ligamentous attachments being first -divided by the knife. In order to extract the remaining portion of -bone, the under blade of the strong scissors must be again pushed -under it from before backward, and made to cut it in two. The outer -part being now separated from the internal end of the fibula, care -being taken not to injure the perpendicular ligament going from that -bone to the os calcis, this piece should be forcibly removed by strong -forceps--an operation which could not be easily borne unless chloroform -were used. The remaining piece or pieces must follow, when an -examination should be made by the finger to ascertain that none remain. -The parts should be brought together, a little lint and cold water -applied, the limb placed on a splint, and interfered with afterward as -little as possible. The wood-cut represents the forceps for extracting -a ball imbedded in the astragalus. - -[Illustration] - -Many years have elapsed since I stated that muscles might be cut across -without, or with very little, inconvenience resulting from their -division. Mr. Stanley has lately shown that tendons even may be cut -across with little disability following, in a boy who had suffered -an injury to the wrist; inflammation followed, with disease of the -bones; and Mr. Stanley, instead of amputating the hand, made a flap -on the back of it through the tendons. He removed seven of the small -bones--all, indeed, except the trapezium supporting the thumb. The -tendons reunited, and the boy has a remarkably good motion of the hand -and fingers--proving the propriety of an operation which does so much -credit to Mr. Stanley. - -The astragalus may be also removed by a similar flap operation dividing -the extensor tendons of the toes, commencing on the outside of the -fibula, and being carried round in front, but not so far as to injure -the tibialis anticus tendon, nor the anterior tibial artery and nerve; -or, when the incision reaches the edge of the outer extensor, the whole -of them are to be separated from the parts beneath, and drawn inward, -when the operation of removing the bone is to be completed, as in -the former instance. But many surgeons believe that when tendons are -forcibly drawn aside, after being separated from their attachments, -they are apt to slough, and that their division would, in most cases, -be less injurious. In neither operation need tendon, artery, vein, or -nerve of any importance be divided. - -It may perhaps be stated that less regard is paid generally to gunshot -wounds of the foot in which balls lodge than is desirable; and that -other methods of operating may be devised for removing the astragalus -less difficult in their performance, and more advantageous for the -sufferers. The other bones of the instep and foot should be treated in -a similar manner when balls lodge in them. Their removal may be more -readily effected. - -96. Wounds from cannon-shot injuring the fore part of the foot are -better remedied by amputation at the joints of the tarsus with the -metatarsus, than by sawing these bones across; but when the injury -affects only one or two toes, they may be removed separately, -recollecting that it is of greater importance to preserve the great -toe than any other, and that this toe is worth preserving alone, -when any one of the others would be rather troublesome than useful. -Musket-balls seldom commit so much injury as to require amputation as -a primary operation, although they may frequently render it necessary -as a secondary one. The splinters of bone are to be removed, the ball -and extraneous substances are, if possible, to be taken out; and if -the bones, tendons, and blood-vessels are so much injured as to render -the attempt to preserve them useless, amputation is to be performed. If -the preservation of the limb be thought practicable--and it generally -will be so in wounds from musket-balls--the attempt must be made -under the most rigid antiphlogistic treatment, the local application -of leeches and cold water from the first, with free openings for the -subsequent discharge. Musket-balls seldom injure the metatarsal bones -so as to require their removal with their toes, and under the treatment -above mentioned these wounds will in general be healed without further -operation. Wounds from grape-shot occasionally render the removal of -the metatarsal bone of the great toe at the tarsus necessary, although -much should be done to save it. The little and adjacent toes are also -sometimes removed at the tarsus, the middle ones but seldom, as it is -not an easy operation to perform, in consequence of the naturally close -attachment of these bones, and the additional compactness they have -acquired from the pressure of the shoe. Hemorrhage from the arteries -of the foot authorizes amputation in a very slight degree, even when -superadded to other causes; for the incisions necessary to secure the -bleeding vessels will not, in general, add much to the original injury, -unless they be very extensive; while, on the contrary, they render the -wound less complicated and more manageable. - -97. Amputation at the tarsus, when it is proposed to save the flap from -the under part of the foot, is performed in the following manner: The -joints of the metatarsus with the tarsus having been well ascertained, -an incision is to be made across the foot, in the direction of the -joints, but from half to three-quarters of an inch nearer the toes, -and the integuments drawn back over the tarsus. From the extremities -of this incision, two others are to be made along the sides of the -great and little toes, for about two inches and a half, according to -the thickness of the foot; the ends of these two incisions are to be -united by a transverse one down to the bone, on the sole of the foot, -the corners being rounded off. The flap thus formed on the under part -is to be dissected back from the metatarsal bones, including as much -of the muscular parts as possible, as far as the under part of the -joints of the tarsus. The metatarsal bones are now to be removed by -cutting into and dislocating each joint from the side, commencing on -the outside, by placing the edge of the knife immediately above, but -close to the projection made by the posterior part of the metatarsal -bone supporting the little toe, which prominence is always readily -perceived. The arteries are to be secured, any long tendons and loose -capsular ligament to be removed with the knife or scissors, and the -under flap, formed from the sole of the foot, is to be raised up so as -to make a neat stump when brought in contact with the upper portion of -integuments that was first turned back; the whole to be retained in -this position by sutures, adhesive plaster, and bandage. When the skin -of the under part of the foot is much torn, which is not uncommon in a -wound made by a fragment of a shell, the flap cannot be formed from it; -in this case it must in a great measure be saved from the upper part; -but the integuments being here so much thinner, the flap is not so good -a defense against external violence, and will be more readily affected -by cold. The metatarsal bones may be sawn across in a straight line, in -preference to removing them at the joint; and although the whole may be -sawn across at once with more ease than any one of them individually, -except the outer ones, yet the stump is never so much protected from -external violence as when the operation is performed at the joints of -the tarsus. - -98. Amputation of the foot, leaving the astragalus and calcis, may, -in certain cases of injury anterior to these bones, be performed with -advantage, care being taken to make the under flap so large that the -line of cicatrization may be on the upper and anterior edge of the -stump, rather than transversely across the face of it, in order to -render it firmer, and better able to resist and sustain any pressure -which may be applied to it. - -The limb being placed on the table, and held by an assistant, the -surgeon ascertains the situation of the joint formed by the junction -of the astragalus with the scaphoides, which will be indicated by the -prominence on the inside of the tarsus, discoverable by passing the -finger forward from the malleolus internus toward the side of the great -toe. The joint of the os cuboides with the os calcis on the outside -is always to be found about half an inch behind the projection formed -by the posterior part of the metatarsal bone of the little toe. The -under part of the foot being firmly held in the palm of the surgeon’s -hand, he places the point of the thumb on the external joint, and that -of the forefinger over the internal one; these indicate a transverse -oblique line for the first incision, which should commence near the -thumb, and be continued with a semilunar sweep, the convexity toward -the toes, until it terminates at the side of the foot where the -forefinger was placed. The joint between the astragalus and scaphoides -is now to be opened, by directing the knife from within obliquely -outward toward the projection of the metatarsal bone of the little -toe. These bones are then to be dislocated by pressure, and the -ligaments retaining them divided. The joint between the os cuboides -and the os calcis is next to be opened from without inward, and the -bones dislocated. The strong inter-articular ligament being cut, and -the joint largely opened, the knife is to be passed between the under -surfaces of the scaphoides and cuboides, and the soft parts adhering to -them, and a flap cut from behind forward sufficiently large to cover -the wound, which is then to be dressed in the usual manner. - -99. Mr. Wakley, jun., has lately performed a successful operation for -the removal of the astragalus and calcis, deserving of imitation in -peculiar cases. It is done as follows:-- - -“The patient being under chloroform, the diseased foot (the left) -having been drawn forward, so as to be free from the table, an incision -was made from malleolus to malleolus, directly across the heel. A -second incision was next carried along the edge of the sole, from -the middle of the first to a point opposite the astragalo-scaphoid -articulation, and another on the opposite side of the foot, from the -vertical incision to the situation of the calcaneo-cuboid joint. These -latter incisions enabled the operator to make a flap about two inches -in length from the integument of the sole. In the next place a circular -flap of integument was formed between the two malleoli posteriorly, -the lower border of the flap reaching to the insertion of the tendo -Achillis. This flap being turned upward, the tendon was cut through, -and the os calcis, having been disarticulated from the astragalus and -cuboid bones, was removed, together with the integument of the heel -included between the two incisions. The lateral ligaments connecting -the astragalus with the tibia and fibula were next divided, and the -knife was carried into the joint on each side, extreme care being -observed to avoid wounding the anterior tibial artery, which was in -view. The astragalus was then detached from the soft parts in front -of the joint and from its articulation with the scaphoid bone, and the -malleoli were removed with the bone-nippers. The only artery requiring -ligature was the posterior tibial. During the few minutes the -operation lasted, the patient did not manifest the slightest symptoms -of pain or uneasiness. On bringing the edges of the flaps together, -they were found to fit with accuracy, and were secured by twelve -interrupted sutures. The wounds were covered by several folds of lint, -and supported by a light bandage. The patient, who had lost but very -little blood, was then removed to his bed. - -[Illustration: The incisions above described are here marked out on a -healthy foot.] - -[Illustration: The skeleton of the foot will at the same time show the -amount of bone removed.] - -[Illustration: These drawings exhibit the present condition of both -sides of the foot--the amount of deformity is less than might have been -expected.] - -“On the 21st of February he was discharged the hospital, exactly two -months after the operation, to go into the country, the foot being -well, with the exception of a small opening. He came again up to town -on the 15th of April, and has become stout. The sinus on the left side -of the foot had closed, but a slight collection of matter had formed -a little above the instep; this was discharged by means of a puncture -with the lancet, and he was directed to return to the country, and dash -cold water over the foot two or three times daily. On the 10th of June -he returned to town to his employment. There was then not the vestige -of a wound, the last opening having completely closed. He was ordered -to wear a high-heeled boot. He is now a healthy-looking man, and walks -very well.” - -As the posterior tibial must be divided, the preservation of the -anterior artery is essentially necessary; the success of the operation -depends upon it. This artery, accompanied by its vein and nerve, lies -close upon the astragalus; the artery may be said to be even attached -to it, a point requiring the greatest attention in dissecting out the -bone without injuring this vessel, which is seen under the scalpel. - -100. Amputation of a single metatarsal bone, on the outside or inside -of the foot, is to be done by an incision round the root of the toe, -terminating in a line on the outside of the foot, which is continued -down to the joint of the tarsus. The integuments are turned back above -and below from the metatarsal bone, which is to be dissected out, -with the toe attached to it, and the flaps brought together so as to -leave but one line of incision. In military surgery, there is always a -wound; and when the removal of the bone is necessary, it is in general -an extensive one, with loss of substance, so that a covering cannot -be saved in this way, especially on the upper part of the foot, when -struck by a ball or piece of shell. The surgeon, therefore, must be -prepared to look for his covering on the under part, where he will -occasionally not be able to procure it in sufficient quantity, and it -must not be forgotten that the neighboring parts will often be injured. -The object must then be to save the integuments from such parts as -are uninjured, so as to cover in the wound as nearly as possible when -the bone has been removed. In doing this, the first incision should -commence at the upper part and inside of the toe, and be carried round -so as to separate the toe from its attachment to its fellow. If the -injury be entirely on the upper part, the continuation of this incision -must be so regulated as to form the whole of the flap from below, and -its commencement above must be continued round the injured part so -as to meet the lower end near the articulation of the bone with the -tarsus, and _vice versa_. If the ball have gone directly through, -destroying the integuments above and below, the incisions must surround -the injured part in such a manner, on the upper and under side of the -foot, as to allow the flaps to be formed in every other part, except -where the injury was inflicted, from which granulations must arise. By -saving skin everywhere else, the wound will be much diminished in size, -will heal sooner, will be less liable to suffer from external violence -and less obnoxious to the subsequent pain which generally at intervals -attends wounds of this kind. - -[Illustration: _Amputation above Knee._ - - _a_, wooden bucket for stump; - _b_, pin to attach foot; - _c_, the rolling foot; - _d_, straps of attachment to body.] - -[Illustration: _Amputation below Knee, No. 1._ - - _a_, wooden shape to receive knee; - _b_, pin; - _c_, rolling foot; - _d_, _e_, straps of attachment.] - -[Illustration: _Amputation below Knee, No. 2._ - - _a_, wooden bucket to receive the whole of stump; - _b_, fixture to foot; - _c_, rolling foot; - _d_, straps for knee.] - -101. M. de Beaufoy has invented a foot for the wooden pin used by the -soldiers in the Invalides, at Paris, who had suffered amputation above -or below the knee; this, Mr. Bigg, of Leicester Square, has tried on -some old soldiers at Chelsea Hospital; one of them reports that he has -not only found his step to be steadier, but that he could walk twice -the distance in the same time that he could with his ordinary pin-leg. - -The advantage of the invention is, that whereas a common wooden pin -only gives one point of support, and consequently the body is obliged -to raise itself so as to describe an arc, of which the end of the -wooden pin is the center, the curved foot acts like a _series of -levers_, each successive point of it being a _fulcrum_. The precaution -should be taken to have the aperture at _a_, fig. 2, for the insertion -of the pin, made square, to prevent its turning when in use. - - - - -LECTURE VI. - -PRIMARY AMPUTATION, ETC. - - -102. An upper extremity should not be amputated for almost any accident -which can happen to it from musket-shot; and there is scarcely an -injury of the soft parts likely to occur which would authorize -amputation as a primary operation. - -103. If the head or articulating extremity of the bone entering into -the composition of the shoulder-joint be merely or slightly injured -by musket-shot, the arm ought to be saved with some defect of motion -in the joint. The wound should be enlarged in the first instance, to -allow of a sufficient examination with the point of the finger, and -any loose pieces of bone should be removed. Inflammation is to be -restrained within due bounds until suppuration has been established, -when, if a clear depending opening should not exist for the discharge -of the matter poured out, it should be made, and any loose portions of -bone removed. The principal points to attend to are, the prevention -of sinuses around the joint, by the formation of dependent openings, -position, perfect quietude, due support, the methodical application of -bandages, and occasional mild stimulating injections into the wound. A -simple incised wound penetrating the joint, and even injuring the bone, -does not call for any immediate operation. An attempt should be made -to effect a cure by the first intention, which can only be managed by -means of proper position and support. - -104. If the head of the bone be much splintered, or if a ball have gone -through it, that portion should be sawn off; for a part thus injured -has often been a source of great inconvenience and suffering for many -years afterward--during, in fact, the remainder of the life of the -sufferer; which misery would have been avoided by the excision of the -head of the bone in the first instance--an operation which ought in -fact to be done even at a later period, if it had not been performed -at the time when the injury was received. Secondary operations of this -kind are never so successful as primary ones, and great discrimination -should be exercised in attempting to save the head of the bone, or, in -other words, to avoid the operation for its removal. - -105. When the splinters extend far into the shaft of the humerus, -it may be proper to amputate the whole extremity, especially if the -great artery be also wounded; but the shaft is seldom broken in such -accidents to any great extent, and amputation should be confined almost -to injuries from cannon-shot or shells, or heavy machinery, destructive -of the soft parts as well as of the bone. - -106. When the injury done to the upper arm is so extensive that it -cannot be saved, although the head of the humerus be not injured, the -amputation should take place immediately below the tuberosities, and -not at the joint, which latter operation always renders the shoulder -flatter, and the appearance of the person more unseemly, than when the -head of the bone is left in its place. - -107. It will frequently happen that the arm may be irrecoverably -shattered, and the thorax partake in a less degree of the injury, there -being apparent only some slight contusion or grazing of the skin; if -low down, the elasticity of the false ribs may have prevented the -integuments being much injured in appearance, although the blow has -been violent; yet the force of the large shot may have ruptured the -liver or spleen. If higher up, it may perhaps fracture the ribs, in -addition to a more severe contusion of the integuments. When these -accidents occur, the symptoms arising from the wound or contusion -of the trunk of the body are to be first considered. If they do not -indicate a speedy dissolution of the patient, or the prospect of such -an event in two or three days, the operation ought to be performed, -and a chance of recovery given to the sufferer, which he would not -have, the arm being retained, and the injury of the chest remaining -the same. The danger to be apprehended in the more favorable cases is -from inflammation, and this will be rather diminished than increased -by the operation; the danger of deferring which is manifest and -certain, while the injury committed in the thorax or abdomen is not -ascertained, and its effects may be obviated. If the termination should -be unfavorable, it can only be a matter of regret for the sake of the -individual, and not for the non-performance of a duty. If the cavity -of the chest be laid open, or several ribs beaten in, or a stuffing -of the lungs take place from a large ruptured blood-vessel--all of -which circumstances are obvious, and cannot be mistaken--the operation -would, in all probability, be useless. A hemorrhage of short duration, -or the expectoration of blood in moderate quantities, although a -dangerous symptom, is not to be considered as depriving the patient -of a reasonable chance for life, for it frequently follows blows from -more common causes, from which many people recover. If the operation -be delayed to ascertain what injury may have been done to the chest, -from the symptoms that will follow, the danger resulting from both will -be increased; and even when it has been ascertained that there is but -little mischief existing in the thorax, the operation can no longer be -performed with the same propriety, in consequence of the inflammation -which has supervened; and the patient will probably die, when he would -have recovered under a more decided mode of treatment. - -108. A round shot or flat piece of shell may strike the arm, after -rebounding from the ground, or when nearly exhausted in force, without -breaking the skin, or only slightly doing it, yet all the parts within -may be so much injured as not to be able to recover themselves: the -bone may be considerably broken or splintered, the muscles and nerves -greatly contused. The injury may not, perhaps, be quite so extensive. -The bone may be merely fractured, and yet the soft parts will often be -so much destroyed as not to be able to carry on their usual actions. -A ruptured blood-vessel may, with an apparently slight external wound -of this nature, pour out its blood between the muscles, and inject the -arm to nearly double its size, all of which are causes rendering an -operation necessary, and requiring decision, for inflammation will, -and mortification may, ensue in a short time, when the most favorable -moment for operation will have been lost. - -109. _Amputation at the shoulder-joint_ is an operation of little -surgical importance. The fear formerly entertained of loss of blood -has passed away, and every surgeon now knows that if he should happen -to cut the axillary artery unintentionally, it can be held between the -forefinger and thumb, without difficulty or danger, until a ligature -can be placed upon it. No accomplished surgeon of the present day -should give himself the least concern about compressing the subclavian -artery. It is, on the contrary, better, when the arm is raised from -the side preparatory to entering or using the knife, that the surgeon -should then feel the pulsation of the artery in the axilla, that he -may the more easily avoid, and subsequently command it. The axillary -artery does not throw out much blood at each pulsation, and a little -pressure with the end of the forefinger will always prevent bleeding, -until the surgeon is prepared to take hold of the vessel with the -tenaculum or forceps. The operator should, in fact, divest himself of -all fear of hemorrhage. When gentlemen are afraid, however, and cannot -help it, (for Henry IV. of France, _ce roy si vaillant_, always felt an -inconvenient intestinal motion when a fight began,) compression may be -made upon the subclavian artery by the thumb of an assistant, the round -handle of a key, or the padded end of the handle of a tourniquet; the -latter forms the best pad, and is usually at hand. - -110. The great point to be attended to in performing the operation is -to save skin to cover the stump. The directions, therefore, which are -usually given for doing it after any particular method can only be -occasionally useful; for the surgeon may not always be able to select -the parts to be divided or retained. In cases of malignant disease -of the bone and periosteum of the middle of the arm, my experience -directs the removal of the whole of the bone at the joint, and not the -amputation below the head; although the appearance of the integuments, -and of the bone itself, would seem to encourage the attempt to preserve -the roundness of the shoulder. In such cases, the removal of the -extremity at the joint may be done by any one of the many ways which -have been recommended for its performance. In none should the acromion -or coracoid process be exposed, unless previously injured. Neither is -it necessary to lose time, or to give pain, by depriving the glenoid -cavity of its cartilage; but it should always be borne in mind that if -the nerves be not shortened after the removal of the arm, they may be -included in or adhere to the cicatrix, and cause, during a long life, -much distressing pain to the sufferer. - -111. Amputation at the shoulder-joint, performed immediately after -the receipt of an injury, is now a very simple operation, for which -simplicity English surgery is also indebted to the Peninsular war. As -a _secondary_ operation, or done at a later period, when the parts are -all impacted together, it is less so. In both stages it is absolutely -necessary to remember--1st. That, except in cases of disease, and not -of injury, the shaft of the bone must be broken; and that _all_ the -directions usually given for rotation of the arm inward and outward -during the operation are _unnecessary cruelties_ not to be attempted, -and rarely to be effected if attempted, with a broken bone. 2d. That -the arm should always be raised from the side and supported by the -hand of an assistant, who can feel, if he please, at any time of the -operation, the pulsation of the axillary artery; and all operative -methods are hereby condemned in which this precautionary measure is not -the first step. - -112. _Operation by two flaps, external and internal._--The -outer--beginning nearly an inch below the acromion process, the hair in -the axilla having been previously removed--is to be carried down with -a gentle curve so deeply as to divide the deltoid muscle, and to show -the long head of the triceps at its under and outer edge. The second -incision is to be carried in a similar direction on the inside, through -the deltoid muscle, but need not divide the insertion of the pectoralis -major, which should be exposed. These flaps being held back, the joint -will be seen and readily opened into at its upper part, by cutting upon -the head of the bone, in doing which the long tendon of the biceps will -be divided, allowing the head of the humerus to drop from the glenoid -cavity sufficiently to admit the forefinger of the left hand, on which -the supra-spinatus, infra-spinatus, and teres minor may be cut through -externally, as they go to be inserted into the great tuberosity, -and the thick tendon of the sub-scapularis muscle internally, where -it is attached to the smaller tuberosity. The head of the bone is -then readily drawn out from the glenoid cavity, when the inner flap, -including the axillary artery, vein, and nerves, may be taken hold -of between the two forefingers and thumb of an assistant, while the -surgeon, with one sweep of the knife, divides all the remaining parts -below. The axillary and the posterior circumflex arteries will have to -be secured; the anterior circumflex, when arising from the posterior, -is frequently cut off with it; the nerves are to be shortened; the -flaps brought together by sutures; and an especial pad placed upon the -pectoralis major, to prevent unnecessary retraction, if possible. - -113. _The operation by one_, or nearly one upper flap, is to be -performed when the under soft parts of the arm have been destroyed, -and the bone broken. It may be done by thrusting a small, two-edged -knife through the integuments and under the deltoid muscle, from side -to side, to form a flap; or it may be made by commencing an incision -an inch above the posterior fold of the armpit, and carrying it over -the arm in a curved form, the convexity being downward, to the same -height on the anterior fold; the lowest part of the incision being five -fingers’ breadth from the point of the acromion, the posterior end or -point of it being somewhat higher than the anterior one. The flap being -turned up, and the tendon of the pectoralis major divided, the head of -the bone is to be exposed and separated as before stated, as much as -possible of the integuments being preserved on the under part of the -arm. This will often be best done by dissecting out the head and broken -pieces of bone, and then preserving in succession every piece of sound -integument, before the artery, vein, and nerves are divided. - -114. Lisfranc and many French and continental surgeons recommend -the operation to be done with a pointed, double-edged knife, in the -following manner: The arm being approximated to the trunk, in a state -of half pronation, the point of the knife is to be entered at a -small triangular space, which may be perceived on the inside of the -fullness of the shoulder, bounded above by the scapular extremity of -the clavicle and a small part of the acromion; on the inside, by the -coracoid process; and on the outside, by the head of the humerus. The -knife thus entered obliquely is to be passed across to the outside, -opening in its passage into the joint, when, by sliding the knife -forward over the head of the bone, while the deltoid is raised up by -the operator or an assistant, a flap is to be formed, during which -proceeding the arm is to be raised from the side, to facilitate -its performance. If this flap be well made, the upper part of the -capsular ligament, the tendons of the long head of the biceps, and the -supra-spinatus are divided, and the tendons of the infra-spinatus, -teres minor, and sub-scapularis are also cut through in part, if not -entirely. The upper and posterior flap is thus completed. - -In the second step of the operation, the surgeon passes the knife -behind the head of the humerus, and makes the under and anterior or -inner flap, by cutting downward and inward, including in it a very -small portion of the deltoid, the pectoralis major, latissimus dorsi, -teres major, the triceps, coraco-brachialis, the short head of the -biceps, and the vessels and nerves, when the limb is separated from -the body. The flaps are nearly of the same size, and are to be brought -together by sutures. - -In the secondary operation, or that done several weeks after the -receipt of the injury, in consequence of the attempt to save the arm -having failed, it should be borne in mind that the soft parts will -often be found so altered and impacted together that they will not -yield or separate; and nothing is gained but by each cut of the knife, -causing thereby some little delay, inconvenience, and loss of time. - -115. _Amputation of the arm immediately below the tuberosities of the -humerus_ ought to be done in the following manner: The arm being raised -from the side, and an assistant having compressed, or being ready to -compress, the subclavian artery, the surgeon commences his incision -one or two fingers’ breadth beneath the acromion process, and carries -it to the inside of the arm, below the edge of the pectoral muscle, -then under the arm to the outside, where it is to be met by another -incision, begun at the same spot as the first, below the acromion -process. The integuments, thus divided, are to be retracted, and the -muscular parts cut through, until the bone is cleared as high as the -tuberosities. The artery will be seen at the under part, and should be -pulled out by a tenaculum or spring forceps, and secured as soon as -divided. The bone is best sawn, the surgeon standing on the outside; -the nerves should be cut short, and the flaps brought together by two -or three silk or leaden sutures. There are few or no other vessels to -tie, and the cure is completed in the usual time, while the rotundity -of the shoulder is preserved. This operation is similar to that already -recommended for the amputation at the joint, which in many cases it is -intended to supersede. - -116. _Excision of the head of the humerus._--The point governing the -modus operandi of this operation is, and ought to be, the fact that, -under the most favorable state of recovery which can take place, the -shoulder-joint usually becomes so stiff that its ordinary motions may -be considered to be lost. Operative processes which have for their -principal object the sparing of the deltoid muscle are unnecessary, -for, if spared, it is as useless as if it had been cut; and it seems to -have been forgotten that, when cut, it reunites, and becomes nearly as -strong as before it was injured. It is the joint that cannot be moved, -not the muscle which has lost its power. I prefer, therefore, in doing -this operation, in cases of some standing, to make a _short_ crescentic -flap by an incision across the anterior part of the shoulder, as in the -operation of amputation, which, on being turned up, leaves the joint -exposed. The edge of the knife being applied to the head of the bone -in a line below, but immediately under the acromion process, divides -the capsular ligament, and with it the long tendon of the biceps, on -which the arm drops from the socket, or glenoid cavity, and allows the -finger to be introduced, when the three muscles inserted into the great -tuberosity may be cut through, and the sub-scapularis inserted into the -small tuberosity will also be divided. The head of the bone is then -readily brought out, and may be easily detached from any surrounding -connections, and sawn off with little or almost no loss of blood. The -elbow is to be supported, so as to bring the end of the sawn bone in -apposition with the glenoid cavity. The flap may be allowed to unite -with the parts below as soon as it will, the shot-holes, if any, being -in general sufficient to allow of such discharge as may be necessary. - -In cases of _recent_ injury, considerable aid will be obtained in -keeping the sawn end of the humerus in apposition with the glenoid -cavity, by not dividing the long tendon of the biceps. This must be -done by dissecting it out of its groove in the humerus, between the -tuberosities, and by cutting through the capsular ligament vertically, -so as to follow it up to its attachment to the upper edge of the -glenoid cavity, when it may be easily drawn aside with a blunt hook, -until the operation has been completed--a proceeding difficult of -accomplishment in old cases of disease or injury, and in them not -necessary nor advisable. - -The accompanying sketch shows the head of the humerus of the right -arm or side, with a ball lodged in it, a relic from Inkerman, sent to -me as an especial mark of attention by one of the medical officers -at Scutari, but without the name of the man, the regiment he belonged -to, or the surgeon who performed the operation for its removal. The -following account was wrapped round the bone. It commences a day or two -after the operation was done at Scutari, and shows that the man died -from an affection of the lungs, not uncommon, as was first shown during -the late war, after operations following extensive suppurations:-- - -[Illustration: - - _a._ The head of the humerus sawn off below the tuberosities. - _b._ The ball. - _c c._ Fractures of the head of the bone.] - -“Pulse soft, 120. He passed a rather restless night, although he had -another opiate at one A.M., and partially removed the dressings. In -the morning he was better; he took some tea and a little wine with -arrow-root, but was very much depressed in spirits. The wound looked -well, there being less discharge, and of a more healthy character; -no increased inflammation around the wound, but no tendency to union -by the first intention on removal of the stitches. He was put upon -farinaceous diet, with four ounces of wine and beef-tea. He continued -to do well till the evening of the 16th, when he complained of -tightness of the chest and slight cough. Harshness of respiratory -murmur and increased vocal resonance, but no crepitation, could be -detected on the right side on auscultation; he complained also of -pain in the hypogastrium and slight diarrhœa. At bedtime he had a -sedative antimonial draught, after which he rested well, but perspired -profusely. On being particularly questioned, he admitted that he had -had diarrhœa several times since landing at Varna, and had had bloody -stools after the battle of Alma, for which, however, he had never been -off duty; he had also frequently been troubled with cough, and two -of his family, he understood, died of consumption. For two days he -continued to improve in spirits, to take his food better, and the wound -assumed a healthy granulating appearance, but a very small portion -of the end of the humerus appeared white, as if going to necrose. On -the evening of the 18th his breathing was more oppressed, and his -countenance flushed and anxious. On examination of the chest, the -lower two-thirds of the right lung were dull on percussion; bronchial -breathing in the lower half, with crepitation above; in the left lung -loud sub-crepitus; diarrhœa had also supervened during the day, but was -checked for the time by an opiate enema. From this date his strength -gradually sank; the diarrhœa returned again and again, in spite of -repeated opiate enemata and small doses of Dover’s powder with hyd. c. -cretâ. The surface of the wound assumed a less healthy appearance; the -respiration became more labored, and he gradually sank till Saturday, -November the 25th, when he died at half-past ten A.M. - -“On examination of the head of the bone, after its removal, there was -found an irregular, rugged cavity in the cancellated tissue, about -an inch long, by half an inch broad, extending nearly transversely -from the smaller to the greater tuberosity, and above the latter a -musket-ball was found deeply imbedded, its external convex surface -being on a level with the articular cartilage. From this several small -fissures radiated over the globular head, and from each end of the -cavity a much deeper one extended round the anatomical neck, separating -the articular portion of the bone, in two-thirds of its circumference, -from the shaft. - -“At the post-mortem examination, the surface of the wound looked -black and sloughy near the seat of injury, but more healthy in the -direction of the incisions. A small portion of the end of the humerus -was of a pearly white, in progress of necrosing; but around the shaft, -immediately below this, and in the glenoid cavity, the process of -repair had commenced. Both lungs were found engorged with frothy -serum; the lower two-thirds of the right lung hepatized; traces of -old tubercle in apices of both lungs, with miliary tubercle scattered -throughout the whole substance of the left and upper part of the right. -The whole tract of the colon, from the cæcum to the rectum, presented -traces of ulceration, the ulcers being seldom larger than a split pea, -with hardened, elevated edges; the bases in some instances were formed -by the peritoneum only; generally they were scattered irregularly, -but occasionally they were found in rows corresponding to the long -diameter of the gut. In the rectum the ulceration was more extensive, -in some parts the size of a farthing, the edges very irregular, and the -direction more transverse.” These appearances precisely resemble those -observed during the autopsy in cases of death from consumption, and are -not therefore peculiar to the dysentery under which he had suffered.” - -117. Professor B. Langenbeck, in order to save the deltoid muscle, -proposed and practiced the operation in the following manner, during -the Danish war in Sleswick-Holstein, with success in several instances: -Begin the incision through the integuments and deltoid muscle -immediately below the anterior border of the acromion, and continue -it directly downward, over the minor tuberosity of the humerus, to -the extent of four inches. Separate the parts, open the sheath of the -long tendon of the biceps muscle, and draw out and hold it on one side -with a blunt hook. Rotate the arm outward, (_if it will rotate_,) to -facilitate the division of the tendon of the sub-scapularis; then -rotate the arm inward, to aid in the division of the tendons of the -supra-spinatus, infra-spinatus, and teres minor muscles, inserted into -the great tuberosity. Complete the division of the capsular ligament, -push the bone through from below, using the arm as a lever if you can, -and saw it off. No arteries of consequence are wounded. - -This operation would not be so easy of execution as is supposed, in -cases in which the head and neck of the humerus are broken from the -shaft; it would be very difficult of execution in old cases in which -the soft parts are so hardened and impacted as to admit of little or no -motion. - -The extent to which the shaft of the humerus may be removed with the -head cannot be distinctly defined. The greater the distance, the less -will be the chance of the bone uniting to the glenoid cavity, in such -a manner as to render it a useful limb, whether by the formation of -a ginglymoid joint, or by anchylosis. In the present state of our -knowledge the bone should not be sawn lower than the insertion of the -deltoid muscle. If the arm were preserved by an operation below that -part, it is probable that the bone, however supported, would not become -attached to the glenoid cavity. It might however become useful, by some -artificial help, as has occurred in cases of false joint in the middle -arm, after ununited fractures. - -118. Excision of the head of the humerus is not to be done in every -instance of compound fracture of that bone, as the following cases will -show:-- - -Lieutenant Madden, 52d Regiment, was wounded at the assault of Badajos -in 1812, by a musket-ball, which fractured the head of the humerus, -and lodged in it. The broken pieces were from time to time removed -by incisions, together with the ball, and he ultimately preserved a -very serviceable arm. He is now a very zealous member of the Church of -England. - -Robert Masters, 40th Regiment, was wounded at the battle of Toulouse, -on the 12th of April, 1814, by a musket-ball in the right shoulder, -which lodged in the head of the bone. Shown to me a few days afterward -as a case for amputation at the shoulder-joint, I directed the excision -of the head of the bone as soon as the parts became more quiescent. -Under venesection, purgatives, leeches, the constant application of -cold, and low diet, the high inflammatory symptoms which had supervened -subsided, and, six weeks after the accident, the ball, and part of -the head of the humerus, were removed, after an incision had been -made through the external parts for the purpose. Three mouths after -the receipt of the injury, the man was sent to England, with no other -inconvenience than that resulting from the loss of motion in the -shoulder, which was stiff. The use of the forearm was preserved, and a -limited one of the upper arm, by moving the shoulder-bone on the trunk. - -Private Oxley, 23d Regiment, was wounded at the battle of Toulouse, in -April, 1814, by a musket-ball, which entered at the anterior edge of -the deltoid muscle, passed across the head of the humerus, injuring -it in its course, and went out near the posterior edge of the muscle, -through which, at its middle part, the deficiency in the rotundity of -the head of the humerus could be distinctly felt. Shown to me a few -days afterward as a slight but peculiar wound, it was marked as a case -for excision, if circumstances should render it necessary. No bad -symptoms, however, supervened; the man only complained of the restraint -put upon him, and the lowness of his diet. Some pieces of bone came -away, or were removed, and in July he was sent to England, the wound -being healed and free from pain; the shoulder stiff. The lower arm he -used as before the accident. - -General Lord Seaton suffered from a nearly similar wound, at the taking -of Ciudad Rodrigo, and recovered with a good use of his arm. - -These cases were fortunate in their results, but such do not always -follow. Major C. was wounded in one of the battles in the Pyrenees, -in 1813, by a musket-ball, which injured the head of the left humerus -from side to side. Thirty years afterward the wounds still discharged, -and gave him great uneasiness. A probe discovered much diseased bone. -I advised the excision of the head of the bone, to which he would not -assent. His courage had been broken by continued suffering. - -Ensign Moore, of the Bengal army, was wounded at Sobraon, on the 10th -February, 1846, by a musket-ball, which passed through the anterior -and inner part of the deltoid muscle, one inch and a half below the -inner part of the acromion process, struck and went through the head of -the bone, which it splintered, and made its exit behind, in front of, -but near the inferior angle of the scapula. He remained in camp three -days, and was sent to hospital at Ferozapore, where he suffered much -from inflammation, pain, etc., and after a month was sent to Subaltro -in the Hills, where some pieces of bone came away, during which time -he suffered severely, and was much weakened by it and the discharge. -On the 20th October, 1846, he was removed to Bunda, in Bundeleund; -here more bone came away, accompanied by much discharge. Thence -he proceeded in April, 1847, to Juanpore, where he suffered three -attacks of inflammation, two of them very severe; the constitutional -disturbance was great. The posterior wound was reopened, and a large -quantity of offensive matter discharged. On the 7th of August, 1847, -the suppuration is stated to have been still great, and the strength -very much reduced, on which account he was recommended to proceed to -Europe. On the 9th June, 1848, the wounds were healed, the last piece -of bone having come away about ten days before. The pieces of bone -are from the head and from the part adjoining. The head of the bone -is greatly diminished in size, so much so as to appear to have been -almost entirely removed; the joint is stiff, if not anchylosed, the -shoulder flat, the under use of the arm perfect, that of the upper -part dependent on the motion of the shoulder-blade. The removal of the -head of the bone, immediately after the receipt of the injury, would -have been the best course to have pursued, for the arm when the cure -took place was not in a better state than it would have been in if the -operation had been performed at first, and the patient would have been -spared two years of great suffering, not unattended with considerable -danger. - -M. Baudens, in a very able paper, an extract of which, made by himself, -is published in the “Comptes Rendus” of the French Academy of Sciences, -for February, 1855, on the Resection of the Head of the Humerus, seems -to have overlooked, or not to have seen, the foregoing observations, -as he assumes, as a consequence of his own observations on fourteen -primary cases of which one only died, that the resection of the head of -the humerus ought to be the rule in surgery when a ball has broken this -part, and that amputation of the limb should be the exception--a point -long since settled in my surgical works. - -He considers that surgical writers in general have supposed that the -bone remains suspended in the middle of the muscles, which does not -accord with his practice, nor with the remarks made by me on this -subject. - -He recommends the following mode of operating: The arm being slightly -turned outward and backward, the point of a small, straight amputating -knife is to be entered on the outside of the coracoid process, -immediately over the head of the humerus; lower the hand and carry the -point of the knife in a straight line for ten or twelve centimeters -downward, always applied to the bone, which serves as a guide. - -If the incision thus made should not be large enough to expose the head -of the humerus, a transverse subcutaneous one should be made through -the muscular fibers toward the superior angle. If it be sufficiently -large and open, this is not necessary. The long tendon of the biceps -will be seen at the bottom of the incision, and is to be cut across. - -Bring opposite the incision, by rotating the arm, first the great -tuberosity, then the smaller one, in order to divide the four -muscles attached to them. The division of these parts will largely -open the joint, when the elbow being carried backward and upward, -the head of the bone will protrude. Detach gently the periosteum, -slip the chain saw behind and below the head of the bone, so as to -leave the periosteum as much uninjured as possible, doing in fact a -sub-periosteal extirpation. - -Tie the vessels, cover the upper end of the humerus with the periosteum -thus saved like a hood, and keep it in contact with the glenoid cavity. - -He maintains that when a ball has broken the head of the humerus, if -the removal of the head be not effected, one of three things follows: -the operation is performed subsequently, or the patient dies of -purulent deposits, or recovers with a stiff joint, accompanied by -fistulous openings of a disagreeable nature. - -He contends that a ginglymoid joint is always formed by his method, -which enables the sufferer to make much greater use of it than if -the operation were performed in any other way; but it will be very -difficult of performance if the bone should be so much injured as to -prevent the tuberosity following the motion to be given to the elbow, -and is not therefore recommended. - -119. If, from some complication of injury, the axillary or other artery -should give way during the treatment, the extremity is not to be -amputated. The artery is to be secured by one ligature applied above -the opening in it and by another below it, the surgeon always bearing -in mind the fact that the proper way to get at the axillary artery is -by cutting _across_ the fibers of the pectoral muscle, and not in their -direction, and that it will be better to amputate the arm than to tie -the subclavian artery above the clavicle. - -120. _Amputation of the arm_ by the common circular incision should -only be practiced in the space between the lower edge of the insertion -of the pectoralis major and the elbow-joint; and rarely in cases of -injury from musket-balls. No common flesh-wound, made either by cannon -or musket-shot, even including a division of the artery, absolutely -demands this operation, the bone being uninjured. If, in addition to a -destructive flesh-wound, the bone be broken, or if it be mashed with -the muscles by an oblique stroke of a round shot, or the forearm be -carried away or destroyed, it is admissible. It is to be done in the -following manner: An assistant draws up the integuments with both -hands; another does the same downward, if the parts admit of it; the -forearm is to be moderately bent. The integuments are to be divided -by a circular incision, and retracted. The muscles and vessels are -then to be cut through by one sweep of the knife, if it can be done. -The muscles adhering to the bone are next to be separated from it to -the extent of two inches. The retractor is to be applied, and the -periosteum divided by one circle of the knife around the bone, and -in the circle thus cut the saw is to work until the bone is divided; -attention being paid to the directions already given to saw in a -perpendicular, not slanting direction. The artery or arteries are to be -tied, the surface of the stump cleansed with warm and then with cold -water, and dried. Leaden sutures are useful. - -121. Mr. Luke performs the operation by two flaps on the same principle -as in the thigh. There is a close resemblance in the manner of -amputating the arm by the double-flap operation to that adopted for -the amputation of the thigh. The first flap is made posteriorly to the -bone, by transfixing the limb, for which purpose the knife is entered -at the mid-point between the anterior and posterior surfaces, carried -transversely across the limb, and made to cut toward the posterior -surface, in an oblique direction, until all the soft structures are -divided. It is necessary, in entering the knife, to bear in mind that -the bone lies opposite to the mid-point, and that, in carrying the -knife across the limb, it would strike against the surface of the -bone, unless means were adopted for its prevention. This is easily -done by grasping the structures which are to form the posterior flap -between the fingers and thumb of the left hand, and by drawing them -backward during the time the knife is entering at the mid-point and -being carried across the limb. Having formed the posterior flap, the -anterior one is formed as in amputation of the thigh, by cutting inward -from the surface toward the bone with a sweep, which will make this -flap equal in length to the posterior. The operation is completed by -dividing the remaining soft parts by means of a cut carried circularly -around the bone, and by sawing the bone in the line of division. The -after-treatment is the same as in the thigh. - -122. _Excision of the elbow-joint._--An incised wound of moderate -extent into the elbow-joint, cutting off with it a part of the condyle -of the humerus, or the head of the radius, or a part of the ulna, -demands the removal of the injured piece of bone only. The forearm -should be bent, and the antiphlogistic treatment fully carried out. -A ball fracturing the olecranon, or other portion of a single bone, -although opening into the joint, does not immediately require any -operation. - -If a ball should lodge in the lower part of the humerus, or in either -of its condyles, it should be removed as quickly as possible by the -trephine, or other appropriate instrument. - -When the articulating ends of the humerus, radius, and ulna are wholly -or in part injured by a musket-ball, it was formerly the custom to -amputate the arm in such instances of great mischief--an operation -which should be superseded by that of excision of the joint, by which -the forearm will be saved, and considerable use of it retained. - -To perform this operation, a straight, strong-pointed knife is to -be pushed into the joint behind, immediately above but close to the -olecranon process, and exactly at its inner edge, to avoid the ulnar -nerve, which lies between it and the inner condyle, to which it may -be considered to be affixed. The incision thus begun is to be carried -outwardly to the external part of the humerus, dividing the insertion -of the triceps. At each end of this transverse cut an incision is to -be made upward and downward for about two inches each way, the three -resembling the letter =H=. The flaps thus made being turned up and -down, the olecranon should be sawn across, together with the great -sigmoid cavity and the coronoid process of the ulna, the insertion -of the brachialis internus having been previously separated from the -coronoid process. Before this is done, the ulnar nerve should be -separated with its attachments from the inner condyle, and turned -aside to avoid injury. The joint being now fully exposed, the head -of the radius may be sawn off or cut through with the strong spring -scissors if possible, above the tubercle into which the biceps tendon -is inserted. The extremity of the humerus should next be pushed through -the wound, and the broken end sawn off, a spatula or other thin -solid substance being placed underneath it, to prevent the brachial -artery or median nerve being injured. Any hemorrhage which there may -be having ceased, the forearm is to be bent, the bones are to be -placed in apposition, and the incisions approximated by sutures and -sticking-plaster, duly supported by compress and bandage, so that -union may take place if possible, particularly of the transverse wound -first made. The arm should be supported by a sling, and dressed early, -as the shot-hole or holes must remain open and discharging. Some motion -of the new joint to be formed may be expected under gentle passive -movements; but as a stiff joint cannot always be avoided, the arm -should be kept bent. - -123. _Amputation of the elbow-joint_ has been recommended, but not -frequently performed. It may be done in any way by which good covering -can be obtained, and it has been supposed that the long stump thus -made is more useful if the olecranon process be sawn across, and left -with the triceps attached to it, than if it be removed. When the parts -are sound, a flap may be made in front by introducing a straight, -double-edged knife over the outer condyle, and carrying it across and -through the soft parts over the opposite or inner condyle, when by -cutting downward and outward a flap is to be formed of from three to -four fingers’ breadth in length. A shorter flap is to be made behind, -when both are to be raised, and the bleeding vessels previously -secured, the external lateral ligament being divided. The radius is to -be separated from the humerus, when the olecranon may be sawn across, -or, if the arm be bent, separated from the humerus without difficulty. -The flaps are to be brought together and retained in the usual manner. - -124. _Amputation of the forearm_ is seldom required after wounds from -musket-balls. The bones can be readily got at, and large pieces removed -with ease. The arteries can be cut down upon and secured without -difficulty, except at the upper part, and even there with some little -sacrifice of muscular parts, which are not to be spared. The fascia -may be divided freely in every direction, and as mortification from -defect of nourishment rarely takes place in the fingers, as it does in -the toes, when the great arteries of the limb have been injured, every -effort should be made to save a forearm, however badly it may at first -appear to be injured. - -The flap operation is to be preferred to the circular, particularly -when done a little above the wrist; to which operation Baron Larrey -and the surgeons of France particularly objected during the late war. -Having done it most successfully since 1806, however, it is recommended -as preferable to any other, even when the injury admits of its being -done neat the carpus. When the nature of the injury does not admit of -two equal flaps being formed, it must be done by two unequal ones, or -even by one, it being important for the fixing of an artificial hand or -other help to have a long stump. - -The arm being placed and held firmly in the intermediate position -between pronation and supination, with the thumb uppermost, so that the -radius and ulna are in one line, a sharp-pointed straight knife is to -be entered close to the inner edge of the radius, and brought out below -at the inner edge of the ulna. It is then to be carried forward for -half an inch, and made to cut its way out with a gentle inclination, so -as to form a semicircular flap. Re-entered at the same point as before, -a similar flap is to be made on the outside, the position of the bones -being a little altered to admit of its easy execution. The two flaps -are to be turned back; the tendon of the supinator radii longus, and -all other tendinous, muscular, or interosseous fibers, not cut through, -are then to be divided, and the linen retractor run between the bones, -which are to be sawn across at the same time. All pressure being taken -off, the tendons and the vessels, if long, are to be cut short, and the -arteries to be tied, after which the flaps are to be brought together -by sutures, and retained by sticking-plaster, compress, and bandage. - -125. When the operation is to be performed above the middle of the arm, -it may be done by the _circular_ incision. - -The arm being placed with the thumb uppermost, an assistant should -retract the integuments as much as possible, while the operator makes -a circular incision through them. They are then to be drawn up for -nearly an inch. The muscles on the inside of the arm should be divided -by one slanting cut to the bones; then those on the outside. The bones -are to be cleared by cutting through any muscular fibers attached to -them, when the interosseal ligament should be divided, and the linen -retractor passed between the bones, which may be sawn through at the -same time without difficulty. The stump is to be dressed in the usual -manner. The operation may be done by cutting through the integuments -and muscles at once in an oblique manner, until the flaps thus formed -shall be sufficiently large to make a thick cushion over the ends of -the bones. - -126. _Amputation at the wrist_, or the joint of the radius and ulna -with the first row of the bones of the carpus, has been recommended -by some surgeons as preferable to amputation above the ends of the -radius and ulna. The hand being placed midway between pronation and -supination, the soft parts are to be divided by a circular incision -beginning from half an inch to an inch below the ends of the radius and -ulna. The integuments being turned up without the tendons, they are -to be divided, and the joint is to be opened into before the spinous -process of the radius; and, while the hand is pressed down, the knife -should divide all the soft parts, and separate the carpus from the -radius and ulna. The wound is to be closed by sutures in the usual -manner. When a circular incision cannot be made, in consequence of the -nature of the injury, and this operation is still preferred, a covering -for the bones must be obtained wherever it can be procured, by one or -more flaps. - -127. _In all injuries of the hand_, the value of a thumb and a finger, -or of two fingers, or even of one, should be borne in mind, and no part -should be removed that can be saved, and appears likely to be of use. -When cannon-shot, large splinters of shells, or grape-shot have struck -the hand, amputation will often be necessary; but the foregoing precept -should never be forgotten. - -A musket-ball fairly passing through the hand generally fractures two -metacarpal bones, although a small ball may pass between them without -breaking either. The wounds should be enlarged, and the broken ends of -the bone sawn off, or the splinters removed, and the points of bone -smoothed off, the tendons to be carefully preserved, and vigorous -antiphlogistic measures adopted. The tendency to tetanus or trismus -will be best obviated by such measures, the incisions, when necessary, -being made in the direction of the bones and tendons. Any hemorrhage -which can ensue will be readily commanded by ligature, by torsion of -the vessel, or by a small graduated compress and bandage, when those -are inapplicable. Injuries by musket-balls to the metacarpal bones -rarely take place without implicating one or more flexor or extensor -tendons, and the consequence is that the fingers to which they belong -are often bent inward toward the palm, constituting a defect less -inconvenient, however, than if the finger remained straight and -immovable. - -128. When one or more fingers are destroyed, and the metacarpal bones -injured, they are to be sawn or cut off, but not removed at the carpus, -although an opening into the joint of the carpus will generally do -well, if skin can be saved to cover it. In all cases of amputation of -one or more fingers, the metacarpal bones, if injured, should be left -as long as possible, and particularly that of the index finger, when -the thumb remains. In all cases it is better, if possible, to leave -the heads of the metacarpal bones in their places, rather than open -into the joint of the carpus, if it can be avoided. If the articulating -heads must come out, a strong, thin scalpel is to be pushed in between -the bones, the ligaments cut through above, below, and at the sides, -and care should be taken, in removing one or two of these bones, not -to dislocate the others, and the joint should be covered by a flap or -flaps made for the purpose, the sides of the remaining fingers being -covered in a similar manner. This succeeds admirably, when the two -outer bones and fingers only are taken away. - -129. _The phalanges_ of the fingers may be removed by making a flap -from the upper or under part, or from both, or from the sides. The -square flap from the upper part of the finger is preferable, when the -joint with the metacarpal bone is to be operated upon, the commencing -points of the flap being united by a transverse incision on the -under part of the joint. It should be recollected, that in all these -excisions the larger end of bone belongs to that which is not removed, -as may be shown by bending the finger; and that the ligamentous -attachment between the metacarpal bones, connecting a middle one to -its fellows on each side, should be cut through, when the joint will -be easily dislocated. Attention should be paid to the division of the -lateral ligaments, in the removal of any of the bones of the fingers. - -Professor B. Langenbeck has operated in some instances, and he says -successfully, without the loss of the finger, by sawing off, in his -first case, the articulating ends of the first phalanx and of the -metacarpal bone of the forefinger, in consequence of an injury from -a rotating piece of machinery; in another, the ends of the first and -second phalanges of the middle finger after a severe laceration; and in -a third case, by sawing off the end of the second phalanx, and removing -the whole of the bone of the third of the forefinger from the soft -parts, leaving the nail; the man recovering with a shortened but useful -finger. In all these cases the flexor and extensor tendons were from -the first uninjured. - -M. Langenbeck has also removed the metacarpal bone of the thumb in the -following manner: “An incision is to be made along the whole length of -the bone toward the palmar aspect, thus avoiding the tendons. Then free -both articulating extremities, separate the soft parts from the body -of the bone, which is to be drawn outward by a strong pair of forceps, -with two bent points or teeth at each extremity. To prevent the -shortening or drawing inward of the thumb, it is to be kept straight -and duly extended by a splint and other apparatus.” He recommends, with -Flourens, the preservation of as much as possible of the periosteum, -and uses for its detachment a small curved knife with a square end. -Separating the periosteum from the bone is more easily directed than -done. Professor Quekett, at my request, made some trials on the humerus -to ascertain the point, and found that the periosteum could not be -separated from the cartilaginous covering of the head of the bone, in -the manner proposed, although it could be done by scraping half an inch -below the insertion of the capsular ligament, and a sufficient portion -saved to cover the sawn end of the bone, in the manner recommended by -M. Baudens. - - - - -LECTURE VII. - -SECONDARY AMPUTATIONS, ETC. - - -130. _Secondary amputations_, or those performed after the lapse of -six or more weeks from the receipt of an injury, when suppuration has -been fully established, are not as successful in military as in civil -hospitals, in which these operations are more commonly performed for -incurable diseases than for injuries. When, however, they are done in -them for injuries, they are not equally successful. - -131. In military warfare these amputations are frequently done -from necessity, not choice, after the first forty-eight hours; and -especially after four or five days to the end of six weeks, in -parts which have been lately, or are still affected by some of the -accompaniments of inflammation, or are in a state of irritation. In -these cases the cellular or areolar tissue has become firmer and -more compact than usual; the muscles are not perfectly healthy; the -blood-vessels are larger and more numerous, and ready to assume -actions unusual to them in a state of health. Where the bones have -been diseased, much bony matter may be deposited between the muscles, -and in some cases the vessels even are surrounded by it. After a few -hours’ remission, the constitutional symptoms often return, the wound -sloughs, and secondary hemorrhage is not an infrequent consequence. -The ligatures are a source of irritation, and prevent union, which, in -fact, should not in such cases be attempted, and, if attempted, will as -rarely succeed. - -132. In these states of constitutional derangement, inflammation of the -veins and sloughing of the stump are not uncommon, augmented by, if -not dependent in some degree on, the state of the atmosphere, which in -autumn, the season for many military movements, gives rise to endemic -fevers, and even to dysenteries and cholera, which the soldier is often -so unfortunate as to acquire in crowded hospitals. If the man should -escape with life, a joint will frequently be lost which might have been -saved, if the operation had been performed in the first instance below -it. When the injury is in the thigh, this is a most important point for -consideration. - -133. If the sufferer should escape these dangers, there remain the -sudden and usually disastrous affections from depositions of matter -in the viscera, alluded to in aphorisms 58, 59, 60, 61, and 62, which -are by no means so common when the patient is in better health; the -connection of these with inflammation of the veins deserves a more -close investigation than has as yet been bestowed upon it by civil or -by military surgeons since attention was first drawn to it by me in -1815. - -134. In secondary amputations in parts which have partaken of the -extensive irritation which accompanies the original injury, more of -the soft parts must be preserved, although they cannot be said to be -unsound. In other words, the bone must be cut shorter, or the stump -will be conical and bad, particularly if sinuses containing pus are -found to run up between the muscles, or between them and the bone -itself--a state very likely to give rise subsequently to caries. - -In sawing the bone, it may be again stated, the point of the saw should -incline downward, and when two-thirds of the bone have been divided, -it should be made to cut perpendicularly, whereby the _side_ next the -operator is the last part divided; the hazard of splintering the bone -at that moment will then be avoided, particularly if the limb to be -removed be held with great steadiness. - -135. In secondary amputations, twice, nay, three times the number of -arteries will often bleed as in primary ones. In the thigh, the femoral -artery should be drawn out with a tenaculum or spring forceps, and tied -firmly with a single thread of dentists’ silk, one of the two ends -being cut off close to the knot. The smaller the vessel, the smaller -the thread required. Torsion or twisting the smaller vessels, so as to -rupture their inner coats, answers very well in cases in which many -small ones bleed. When a nerve is known to accompany an artery, it -should be carefully separated from it. - -136. If the bleeding should continue from above the ligature on the -extremity of an artery, it is generally caused by some small branch -given off from it, which has been cut so close to the trunk of the -vessel as not to have been observed. In that case, the artery itself -should be drawn out by the tenaculum or spring forceps until the -bleeding point can be seen, and a ligature placed above it, when the -piece below should be cut off with the first ligature applied. This -inconvenience will be in general avoided by taking care to divide the -principal artery at one stroke of the knife, and with it half an inch -at least of the surrounding tissues, if the operation be done by the -circular incision; if by flaps, the extent of the exposed arteries -should be carefully examined, and the ligatures applied at the highest -point of exposure, when all below should be removed. - -137. When a tourniquet is used, and applied too close to the incised -parts, it often prevents, even when loosened, the principal vessel from -being found, from its having pressed on the ends of the muscles. If one -be used, it should be removed as soon as possible after the principal -artery has been secured. The repeated tightening and loosening of the -tourniquet will cause more vessels to bleed in the end, and more blood -to be lost, than if it had not been used; it ought not, therefore, to -be resorted to when good assistance is procurable. In cases of this -kind, in which the stump may not cease to ooze, the circulation being -good, and sponging with cold water not effectual, the wound should -not be finally closed for two, four, or more hours, until the oozing -has ceased, and the parts can be freed from the coagulated blood, and -brought together. - -138. In cases in which union is not expected to take place, both -ends of the ligature should be cut off; for union of the external -parts is not to be desired in many instances of secondary amputation, -particularly after serious injuries; the inflammation consequent on -which has in some degree implicated the structures divided in the -operation, rendering them less liable to take on the healthy action of -adhesion. The soft parts should be simply approximated by two or more -sutures, the edges of the wound having a piece of lint or fine linen -between them. This precaution should be particularly attended to after -a great battle, when it is perceived that from the air, the crowded -state of the hospital, or the season of the year, the stumps, although -they may appear to unite in the first instance externally, do not in -reality do so internally. - -139. It has been proposed to use ligatures made of cat-gut or other -animal substances, which may be cut short, and left in the wound to -be absorbed. This has taken place in some instances, while in others -little abscesses have followed, allowing their discharge, and not -expediting the cure, so that the practice has not prevailed; it is said -that greater success has attended in America ligatures used in this way -made of very fine shreds of the strong tendons of the large deer of -that country. Ligatures should not be applied on large veins when they -continue to bleed, if it can be avoided, although it has frequently -been done without subsequent inconvenience. A little delay and moderate -pressure will generally suffice to arrest the bleeding. - -140. If the surgeon find, after completing the operation, that the bone -cannot be sufficiently covered to make a good stump, a piece should -be sawn off at once, and the error remedied, with little comparative -inconvenience to what would occur afterward, if the bone be too long. -No false shame should prevent its being done. If, however, the error -have occurred, and the end of bone should become uncovered during -the process of healing, it may be allowed to separate of itself, as -it cannot be sawn off at this period without difficulty and much -suffering; for an exposed surface will then remain, from which an -exfoliation will take place before the stump can heal. In cases of -great protrusion, an incision should be made down to the bone, which -should be firmly held by strong forceps, or by a tube in which it -will fit, when it is to be sawn off by the chain saw at a sound part, -above that which has been exposed. The wound, in all cases, should -be well supported by compress and bandage, to secure a good stump; -whence the necessity for the bone being shorter than in those secondary -amputations which are done at the period of election, and which will, -on the contrary, often unite without difficulty. In primary operations, -cold water is most applicable in the first instance; in secondary -amputations, warmth by fomentations, rather than by even the lightest -of poultices. - - -ON COMPOUND FRACTURES. - -141. A fracture of a bone, however _simple_ it may be in its nature, -is said to be _compound_ when accompanied by an external opening in, -or a wound of, the soft parts, communicating with the broken bone--a -complication which usually gives rise to ulcerative inflammation and -suppuration throughout the whole extent of the injury, preventing -thereby those milder processes being effected which, under the more -favorable circumstances of the skin being unbroken, lead to a speedy -union of the broken parts; whence the desire manifested by the surgeon, -in ordinary cases of compound fracture, to close the external wound, if -possible, but which, from the nature of a gunshot wound, it is useless -to attempt. A fracture is said to be _comminuted_ when the bone is -crushed, as by a heavy wheel passing over it. It may still, however, -be a _simple_ fracture, that is, without an external wound; and in -that state it is much less dangerous than a similar injury accompanied -by an external opening, however small, the edges of which cannot be -immediately and permanently reunited. - -142. An arm or a leg, as a general rule, is not to be amputated in the -first instance for a compound fracture caused by a musket-ball, unless -the ball be of large size, and the bone much shattered. An effort -should always be made to save it; and, under reasonable circumstances -with regard to the extent of injury, the comfort, climate, and ordinary -good health of the sufferer, the object will frequently be obtained -under good surgical treatment. - -143. It is not so with the thigh. After the battle of Toulouse, -forty-three of the best of the fractures of the thigh were attempted -to be saved under my direction, and even selection. Of this number -thirteen died; twelve were amputated at the secondary period, of whom -seven died; and eighteen retained their limbs. Of these eighteen, the -state three months after the battle was: five only could be considered -well, or as using their limbs; two more thought their limbs more -valuable, although not very serviceable, than a wooden leg; and the -remaining eleven wished they had suffered amputation at first. Of the -officers with fracture of the femur, one (having been taken prisoner -during the action) died under the care of the French surgeons, by whom -he was skillfully treated; the other has preserved a limb, which he -rather wishes had been exchanged for a wooden leg. - -In the five successful cases, the injury was in all at or below the -middle of the thigh. In the thirteen others who retained their limbs, -the injury was not above the middle third; and of those who died -unamputated, several were near or in the upper third, and either -died before the proper period for secondary amputation, or were -not ultimately in a state to undergo that operation. Of the seven -amputations which died, two were at the little trochanter, by the flap -operation; and the others were for the most part unfavorable cases. -In one case only was the head or neck of the bone fractured. The man -lived for two months, and, from the dreadful sufferings he endured, it -was much regretted that he had not lost his limb at the hip-joint at -first. The operation ought, however, to have been the removal of the -head and neck of the bone; but he was not seen in time by those who -could or would have done this operation, which was then, however, only -contemplated for the first time. - -Nearly all the wounded, after this battle, had every possible -assistance and comfort, from the second day after the action. The -hospitals were well supplied with bedsteads--no inconsiderable point -in the treatment of fractures--and several of the surgeons had been in -almost every battle from the commencement of the war. The medicines and -materials for their treatment were in profusion. The sick and wounded -(1359 in number, including 117 officers) were in charge of two deputy -inspectors-general, ten staff-surgeons, six apothecaries, and fifty-one -assistant-surgeons; and the whole worked from morning until evening -with the greatest assiduity. The surgery of the British army was then -at the highest point of perfection it attained during the war; and -this enumeration is given to show the number of medical men required -under the most favorable circumstances for 1500 wounded men, if they -are to have all the aid surgery can give them. Doctors are not the most -ornamental part of an army perhaps, but there are days in a campaign -when many poor fellows find them to be the most useful. - -Every broken thigh or leg was in the straight position, and the success -was greater than on any previous occasion. Nevertheless, with all -these advantages, there can be little doubt that if amputation had -been performed in the first instance, on the thirty-six out of the -forty-three who died or only partially recovered, some twenty would -have survived, able, for the most part, to support themselves with a -moderate pension, instead of there being perhaps five, or at most ten, -nearly unable to do anything for themselves. Baron Larrey, with the -_élite_ of the military surgeons of France, as well as of those of -Germany, have maintained this opinion; and the result of the practice -as yet observed in the Crimea essentially confirms it, partly from -the greater extent of mischief done to the bone by the large needle -two-ounce rifle bullets of the Russians, and partly perhaps from the -want of the accommodation and appliances which the circumstances of -the siege of Sebastopol did not admit of. In the present state of -our knowledge, it is perhaps the safest practice, particularly under -doubtful circumstances, in which it cannot be ascertained whether rest, -the best surgical care, and comfort may not be wanting; without all -which a favorable result cannot be expected. - -144. War is an agreeable occupation, trade, or professional employment -for the few only, not for the many; and particularly not for the -poor, when they have the misfortune to have their limbs broken by -musket-shot. There are very few men in England who know what are the -first principles of a medico-military movement with an army in the -field; and it will not materially signify whether there should be -even one so instructed, until the nation at large shall be impressed -with the idea that no expense, no trouble, ought to be spared to -obtain for their soldiers so unhappily injured the utmost comfort -and accommodation that can be procured for them, as well as the best -surgical assistance. The first was little attended to in England during -three-fourths of the Peninsular war; and the latter was supposed to be -obtained, when the demand was urgent, by giving a warrant to kill or -cure to persons as dressers who were unable to undergo an examination -with any prospect of success, and prove themselves worthy a commission. -Many a gallant soldier lost his life from the want of that proper -attendance and care alluded to; many a desolate and unhappy mother -mourned the loss of a son she need not have mourned for under happier -circumstances, and who might have been the support, the happiness, of -her declining years. Yet England calls herself the most humane, as -well as the greatest, nation upon earth; she claims to be the most -civilized, and she may be so; but certainly, in the case of those who -have hitherto fallen in her defense, she could not on many occasions -have been more careless or less compassionate. I have endeavored to -impress on the directors of the East India Company in particular the -injustice, the carelessness, of their treatment of the wounded soldiers -of the royal army of Great Britain. My remonstrances have hitherto been -in great part useless. It is to be hoped, however, that the present War -Minister will cause an official public inquiry to be made into this -matter, for that alone can cause this grievance to be redressed. Old -habits are not to be overcome but by public opinion. - -145. The peculiar difficulty in treating a gunshot fracture takes place -when the bone is splintered for some distance, as well as broken. In -these cases, inflammation occurs internally in the membranous covering -of the cancellated structure of the bone, ending in the death of the -parts affected; while the periosteum takes on that peculiar action -externally which ends in the deposition of ossific matter around the -splinters which have lost their life, and are enveloped by it. The -bony matter, at first small in quantity, is gradually augmented, and -deposited for some distance in the surrounding parts, so that it has -been known to include the neighboring vessels and nerves in less than -twenty days; at the end of a few weeks the quantity of ossific deposit -is often very remarkable. Each splinter of bone becomes the sequestrum -of a necrosis, in a similar manner as it is known to occur in the bones -of young persons spontaneously affected by that disease, with this -essential difference, that in the idiopathic disease there is only -_one_, as if worm eaten, sequestrum, perhaps the length of the shaft -of the bone, easily removable by one operation, while there may be in -the traumatic disease several dead centers of ossific deposit, each of -which requires to be removed by an operation to effect a cure. This new -bony deposit will often be half an inch and more in thickness, and at -a late period is as hard as the old bone. The repetition of operations -required in such cases is very distressing, particularly in the thigh, -in which the disease often continues for months, and even for years. - -The following case, related by Colonel Wilton, is instructive: -“Lieutenant Timbrell, late of my old regiment, the 31st, had both his -thighs broken at the battle of Sobraon; he would not allow amputation, -so the doctor put him in a boarded ‘dooley,’ and his legs in a kind -of trough. As I was also wounded, I used to see him almost daily, and -I never heard him complain except the days when the doctor tried to -extend his legs. Some time after our return to England (perhaps seven -or eight months) I went to visit him, and found him quite recovered, -and able to enjoy a day’s shooting as well as most people. He showed me -many pieces of bone which had come away from his wounds, and appeared -to have lost about three inches of his height; his limbs were rather -bowed. He is now paymaster of the 6th Foot; and when I saw him, a -few days before he embarked for the Cape, he was as active as ever, -although I do not think he could either run or jump.” - -146. A musket-ball will often lodge in the less dense parts of -bones, such as the great trochanter or the condyles of the femur, -without fracturing the bone; it will sometimes even pass through the -femur above and between the condyles, merely splitting, but without -separating the bone in parts or pieces. Balls sometimes lodge in the -shaft of the femur without breaking it, and frequently do so in the -tibia, the humerus, the bones of the cranium, and even in others of -less size. Balls thus lodged will sometimes remain for years--nay, -during a long life--without causing much inconvenience. It is, however, -generally the reverse, and they are often the cause of so much -irritation and distress that the sufferers are willing to have them, -and even their limbs, removed at last at any risk. Whenever, then, a -ball can be felt sticking in a bone, although it cannot be brought into -view, it should, if possible, be dislodged and removed by the trephine, -by small chisels, by small, strong-pointed curved elevators, or by any -of the screws invented for the purpose, which have sometimes been found -efficient. An apparently useful instrument of this kind is attached -to the forceps for extracting balls; it is more frequently used in -France than in England. When the ball can be seen as well as felt, the -surgeon must be guided by his own experience and judgment with respect -to the most fitting instruments. It is to be removed if possible, -whatever may be the means used for its abduction, after the wound has -been properly enlarged for the purpose. - -147. When a ball merely grazes a bone without breaking it, and -passes through the limb, and no splinters can be felt by the finger, -dilatation is unnecessary in the first instance; although some small -splinters may be cast off subsequently, or a layer of bone may -exfoliate, requiring assistance for their removal. - -The bone may be fractured in a case of this kind transversely, and will -require only the simplest treatment in an almost similar manner. - -148. If the ball should enter and be flattened against the bone without -breaking it, and lodge against it or in the soft parts, it should be -sought for and removed. When the ball is flattened and the bone broken, -it may lie between the broken extremities, and even lodge in one of -them, rendering the case more complicated, and the necessity for close -investigation more urgent. A leaden ball when striking on the sharp -edge of a long bone, such as the spine of the tibia, has been known to -be divided on it, without the bone being broken. This has happened in -the arm. - -149. When a ball strikes the shaft of a bone, such as the femur, -directly and with force, it shatters it often in large, long, and -pointed pieces, retaining their attachment to the muscles inserted into -them. A fracture of this nature in the middle of the thigh will often -extend downward into the condyles, and as high as, although rarely -into, the trochanters. These are cases for immediate amputation. - -150. Gunshot fractures of the head and neck of the femur have hitherto -been fatal injuries, unless the whole extremity has been removed. It is -hoped death may be prevented without this most formidable operation, -by the removal of the head and neck of the bone, according to aphorism -85. If the upper third of the femur below the trochanter be badly -fractured, and an attempt be made to save the limb, death generally -occurs after several weeks of intense suffering, more particularly -when the bone is broken by the large two-ounce balls now used by the -Russians in the Crimea. - -The least dangerous and the most likely to be saved are fractures of -the lower third, or at most of the lower half, of the thigh-bone. When -they do not communicate with the knee-joint, an attempt ought always -to be made to save the limb. - -151. The preservation of a femur fractured by a musket-ball, when -splintered to any extent, ought only to be attempted if the principal -splinters can be removed. When the splinters of the femur are long and -large, it has been supposed that if they retain their attachment to -the soft parts, they may be placed in apposition and preserved. This -may be doubted. It ought, however, only to be attempted under the most -favorable circumstances, and will not often succeed even then. In the -humerus it is different. An examination by the finger in the first -instance is necessary to ascertain the extent of the injury to the -bone, and to enable the surgeon to remove the broken portions, as well -as the ball or any extraneous substances which may be in the wound. -The incisions necessarily required for this purpose in the thigh are -sometimes neglected, or the surgeon refrains from making them from -the great thickness of the muscular parts, and from the wound having -taken place on the inside, near the great vessels, so as to render -incisions of sufficient size or extent in some degree dangerous. -The thickness of the muscular parts is not a sufficient reason for -avoiding an incision, neither is the vicinity of the great vessels -and nerves, although they may not be divided; if the situation of the -bone on the outside of the thigh be attended to, the broken portions -may sometimes be got at at that part, if not on the inside. If this -cannot be done, amputation had better be had recourse to. The object -of the examination of such a wound being to ascertain the state of the -fracture, and to remove the splinters and any extraneous substances, -the extent and number of the incisions must depend on them; the true -principle of what has been called dilatation of wounds. If the ball -should have merely struck and grazed the bone, and passed out, causing -a transverse fracture only, there is no necessity for making incisions -at the moment, although one or more may be subsequently required to -aid in the discharge of an exfoliated piece of bone, or of a splinter -which may have been overlooked. If the ball lodge deeply in the soft -parts, after breaking the bone, it should be removed, if practicable, -by a second or counter-opening, and a free vent should always be made -for the discharge. It may, however, be laid down as a general rule, -that whatever is likely to be required during the first few days had -better be done on the first than on the second or third; for after -inflammation has commenced, any handling or examination of the limb, -however gently made, gives great pain. - -152. After the first incisions have been made, and the larger -splinters, which can be felt, have been removed, a secondary danger -occurs from those which are smaller, and may have been overlooked, or -not been discovered. This arises from the enveloping of these splinters -in the new ossific matter described as being formed by the inflamed -periosteum. This evil must be prevented by a careful examination of the -wound when suppuration has been fully established, and the sensibility -of the parts is in some degree diminished; when, if loose splinters -of bone can be felt, they ought to be removed by incisions carefully -and gently made to the extent which may be required. If this be not -done early, the ossific deposit will take place around, and shut them -in, even if the wound should close, which it usually will not. Their -retention is accompanied by a firm thickening of the part, and in due -course of time a spot of inflammation implies the formation of an -abscess, and an ulcerated opening through the new bony deposit. When -this abscess breaks externally, the probe will pass through the hole -in the new bone, and rest on the rough, dead, and now perhaps movable -splinter, the extraction of which can alone afford permanent relief. -The earlier this is done the softer the ossific matter will be; at an -early period, it will cut like Parmesan cheese intermixed with lime. If -deferred until the bony matter is quite hard, it must be cut through -with the chisel, or bone scissors or forceps, the application of which -sometimes requires great force. - -153. The successful treatment of a gunshot fracture of the thigh -cannot be effected while the patient is lying on a little straw or -a mat on the ground, and proper bedsteads should always form a part -of the hospital stores of an army in the field. There is one in use -at the Westminster Hospital, and another at the Royal Westminster -Ophthalmic Hospital, which may be taken as models. Each, when complete, -with mattress, etc., costs ten pounds, and, with a second inclined -plane and mattress, might answer for two fractures; six may be easily -carried in any common or spring cart wherever they are wanted. They -would alleviate the sufferings, the horrible torments, many suffer -unnecessarily. There is a very good and even cheaper one in use in -the London Hospital, well worthy attention. An instrument or iron -machine, movable from bed to bed, has been invented by Dr. Thomson, -of Stratford-on-Avon, which lifts a man readily from his bed, and, -after he has been dressed, lays him down again with ease in a similar -manner to the bedstead alluded to. It has, however, the advantage of -being movable, while the apparatus in the bedstead is fixed. Lord -Strafford has sent one to his regiment, the Coldstream Guards, and Dr. -Thomson has sent another. Young backs and young knees only can bend -for consecutive hours over men lying on the ground. Doctors of fifty -years of age cannot do it; they are physically unequal to the labor. -A staff-surgeon half a century old on a field of battle is almost an -absurdity in the art, if not in the science of surgery: he ought to be -promoted to the rank of inspector. The custom of the present day is -to promote men more on account of the length of their services than -because of their value: whereas, to make good physicians and surgeons, -it should be from their value, combined with a due regard to a moderate -yet sufficient length of service, which certainly should never exceed, -even if it amounted to, twenty years; ten or twelve, in time of war, -would be better,--a matter of expense against life and human misery. - -154. The position of the patient in a gunshot fracture of the thigh -or leg is of the utmost importance. He should lie on his back, and -the limb should be straight. It is almost impossible to keep a man’s -thigh in the bent position, or on its side, without his turning on -his back, and the union of the bone, if it take place at all, must -then be at an angle. The bent position forward, or on an inclined -plane, is defective, inasmuch as the matter, which must necessarily -be secreted in great quantity, will gravitate backward in spite of -every care to prevent it. When a proper bedstead is used, a slightly -inclined plane will sometimes be advantageous at a later period, when -the body may also be raised, even to the erect position, the principal -object being to take off the action of the two muscles inserted into -the smaller trochanter, which, with the rotators behind, raise and -evert the upper end of the broken bone. This direction outward should -be met by a similar direction of the lower part of the bone, and by -the application, from time to time, of a proper splint, compress, and -bandage on the elevated bone, if they can be borne with perfect ease. - -155. Splints are of various kinds, and made of different substances. -The discovery of gutta-percha has enabled some to be made of that -substance, which, when moulded into sheets, of from one to two or three -eighths of an inch in thickness, can be rendered soft and pliable -by the application of hot water, regaining its firmness as it dries. -Splints can thus be made of any size or length, and of any form, with -apertures, if necessary, for the passage of the discharge from the -wounds. Leather tanned without oil, and called splint-leather, is -equally useful; if, when dried, the splints thus made become too hard, -and press unequally, they can be softened by hot water, and removed and -replaced with little comparative inconvenience. - -One wooden splint of more than the length of the limb, somewhat similar -to that called Desault’s, is absolutely necessary for the thigh, if it -can be borne, which it rarely can, as a means of extension, or rather -of preserving length. A shorter one on the inside, and one behind, will -sometimes be required to complete the set A short one may be wanting -for occasional use in front. - -156. The bones of the leg being more exposed, admit of greater -liberties being taken with them, and of larger portions, or even parts, -being taken away successfully, than ought to be attempted in the thigh. -A leg should, therefore, be seldom amputated for a fracture from a -musket-ball. The splinters should be removed to almost any extent and -number, and irregular portions sawn off from both ends, if they should -be thus implicated. If one bone of the leg remain uninjured, the case -becomes comparatively simple. The position should be straight on the -heel, as a general rule, admitting of few exceptions. - -157. The best apparatus for a compound fracture of the leg in either -civil or military surgery, particularly in the latter, is that -contrived by Mr. Luke, which may be seen in use at the London Hospital, -and is supplied by Mr. M’Lellan, 3 Turner Street, Whitechapel Road. -It is a simple iron cradle of small size, such as is used to guard a -limb from the weight of the bedclothes, composed of three bars or large -segments of a circle, united at their middles and ends or sides, as -all cradles are, by a bar of iron of equal thickness. This is placed -on a board a little wider than itself, with a ledge or bar at each -side to prevent the cradle from moving, aided by two buttons or little -pieces of wood on each side, which, being movable, turn over the iron -bars, and thus render the board and cradle one firm piece. In this -the leg is to be slung, to the center bar above, by ordinary tapes. A -splint made of copper, to prevent rust or injury, hollowed to receive -the leg, extending beyond the foot with a footboard, and beyond the -condyles of the femur above, enables the tapes to be passed under the -limb for slinging it; while from the extension of the splint beyond the -condyles, it causes the leg and thigh to move together, in a manner -which will often prevent the pain which follows a sudden motion of -the patient. Solid wooden side splints are still wanting, and these -should have holes cut in them to allow a vent for the discharge and -for the application of dressings; or if a portion of the splint, say -the middle, should require removal altogether for this purpose, the -upper and lower parts may be united by a semicircular bar of iron, at -the pleasure of the surgeon; within this the dressings may be applied, -and by it the splint will be rendered firm.[3] When the leg is thus -slung, the knee will be somewhat bent, the thigh raised, the muscles of -the leg behind relaxed, and the patient can be moved with much greater -facility than with any other apparatus; one great advantage of this -apparatus is, that it can be used with effect even if the patient be -obliged to lie on the ground. It admits of being slung as a whole in -a spring-cart, by additional but strong, elastic straps fastened to -or applied on the under part of the board, and thus a double slinging -motion may be obtained when the sufferer is obliged to be moved. - -[Footnote 3: This apparatus has, I think, been improved upon at the -Bristol Hospital by the addition of a bar on each side of the center -one.] - -[Illustration] -These splints are so portable that they may be carried into the field -or upon the deck of a ship, to bring the patient to the surgeon. - -In using the apparatus, the back of the leg and lower end of the thigh -are to be evenly supported on a pad placed on the leg-rest; a splint is -to be placed on each side of the leg, and the whole secured by straps -carried around near the knee and ankle. The leg is then to be suspended -by two straps from the bar of the cradle placed over the leg as -represented, so as to swing without touching the folding board on which -the cradle is placed. The foot should be secured to the foot-piece by a -bandage. - -Solid splints, and a firmly-fixed cradle, under which the leg may hang, -may be said to be the _sine qua non_ of the treatment of a gunshot -fracture of the leg. The French in the Crimea have an apparatus called -a GOUTTIÈRE, to be hereafter noticed. - -158. Half-a-dozen pairs of long poles made light and of tough wood, -which might always be replaced without difficulty, and a good thick -ticking for each pair, having a case or pipe on each side in which the -poles might run, ought to be a part of the surgical stores of every -regiment on service in time of war. Two short irons, having at each -end a ring through which the poles may run, will keep the ticking or -sacking extended, and the patient flat and immovable unless shaken by -accident. The sacking will roll up into little compass, if the poles -should not be forthcoming or are not wanted, and, when the ground is -damp, will make an excellent bedstead as well as a covering for the -doctor. If four legs be added to each bearer, a great facility will -be obtained on halting when the carriers are tired, the sufferer -being raised from the ground, which in muddy or boggy places is very -desirable. - -159. The _arm_, when fractured by musket-shot, admits even of more -strenuous efforts being made to save it; from its smaller size, and -the more ready exposure of the bone or bones when badly broken, the -danger is less. If an artery should yield by ulceration, it should be -laid bare by operation, and a ligature placed on each bleeding end. -An additional or second wound in the forearm only complicates the -case, and the loss of a finger or two does not augment the danger. In -fact, amputation should rarely take place in the first instance, and -only in the second when mortification has commenced, or the strength -and health of the patient will no longer bear the drain upon them. -The head of the bone should be removed, with as much of the shaft as -may be injured; the elbow-joint should be excised, if the condyles -are destroyed and the joint injured; if the middle of the bone should -be destroyed, the upper and lower ends of it should be approximated. -A great advantage is derived from the facility with which the upper -extremity can be supported as compared with the lower, and the aid to -the general health which may be obtained from the locomotion sufferers -with broken arms are capable of undergoing. - -160. In making incisions for the removal of splinters of bone, both -at an early and at a late period, particularly in the latter, when -the soft parts are all impacted together, and _nothing is gained -beyond what is cut_, the course of the trunks of nerves, as well as -of the great arteries, should be carefully attended to, and those -parts avoided; for a successful cure of the fracture will be much -deteriorated in value, if accompanied by a loss of motion or of -sensation in the hand or fingers. - -161. Splints for the arm should be made of solid materials, although -light; some a little hollowed, and at a right angle, to correspond with -the bend of the arm, and to admit of a little motion of the radius -and of the forearm and hand, which relieves the position, is more -comfortable for the sufferer, and tends to prevent stiffness of the -elbow. The pads of lining for the splints should be made of cleaned or -carded wool, rather than of tow or old linen, protected by some one or -other of the modern modifications of caoutchouc or gutta-percha. - -162. The medical treatment of compound fractures should be directed -to allay pain and to prevent as far as possible any excess of general -irritation and fever; to sustain, at a subsequent period, the strength -of the sufferer by appropriate medicines, good and sufficient diet, and -a free circulation of air, without all which little can be expected, to -say nothing of absolute rest and those ordinary attentions and comforts -so necessary for the restoration of health. - -163. The following returns are illustrative of the principles -recommended with reference to primary and secondary amputations. The -first two show the seats of injury in 1359 persons wounded and admitted -into hospital after the battle of Toulouse. The fifth return should be -considered rather as an approximation to the truth than as the exact -truth, as it does not include those who died on the field of Waterloo, -but those only who reached Brussels, and does not include those who -were sent to Antwerp. - - No. 1.--RETURN OF SURGICAL CASES _treated and_ CAPITAL OPERATIONS - _performed in the General Hospital at Toulouse, from April 10th to - June 28th, 1814._ - - +-----------------+--------+-----+--------+-----------+----------------+ - |DISEASES AND | Total |Died.| Dis- |Transferred|Proportion of | - |STATE OF WOUNDS. |treated.| |charged | to |death to the | - | | | |to duty.|Bourdeaux. |number treated. | - +-----------------+--------+-----+--------+-----------+----------------+ - |Head | 95 | 17 | 25 | 53 |1 in 5-10/17 | - |Chest | 96 | 35 | 14 | 47 |1 in 2-35/96 | - |Abdomen | 104 | 24 | 21 | 59 |1 in 4-1/3 | - |Super’r extrem’s | 304 | 3 | 96 | 205 |1 in 101 | - |Inferior ditto | 498 | 21 | 150 | 327 |1 in 23-5/7 | - |Comp’d fractures | 78 | 29 | ... | 49 |1 in 2-20/29 | - |Wounds of spine | 3 | 3 | ... | ... |1 in 1 | - |Wounds of joints | 16 | 4 | ... | 12 |1 in 4 | - | | | | | | | - |Amputations-- | | | | | | - | | | | | | | - |Arm 7}| | | | | | - |Leg and thigh 41}| 48 | 10 | ... | 38 |1 in 5-1/3 | - | +--------+-----+--------+-----------+----------------+ - | Total | 1242 | 146 | 306 | 790 |1 in 8-128/145| - +-----------------+--------+-----+--------+-----------+----------------+ - -Wounded officers 117, not included, making a total of 1359, among whom -thirteen cases of tetanus occurred, all of which proved fatal. - - No. 2.--OFFICERS. - - +-----------------+---------+------------+---------+-----+----------+ - |NATURE Of |Admitted.|Discharged. |Sent to |Died.|Remaining.| - |WOUNDS. | | |Bordeaux.| | | - +-----------------+---------+------------+---------+-----+----------+ - |Head | 6 | 4 | 1 | ...| 1 | - |Chest | 10 | 2 | 2 | ...| 6 | - |Abdomen | 1 | ... | ... | ...| 1 | - |Sup’r extremities| 33 | 9 | 15 | ...| 9 | - |Inferior ditto | 49 | 12 | 21 | 1| 15 | - |Comp’d fractures | 7 | ... | 1 | 2| 4 | - |Slight wounds | 11 | 7 | 2 | ...| 2 | - | +---------+------------+---------+-----+----------+ - | Total | 117 | 34 | 42 | 3| 38 | - +-----------------+---------+------------+---------+-----+----------+ - -One secondary amputation of the arm occurred, and recovered; four -of the inferior extremities, of which one died from tetanus. The -thirty-eight remaining eventually went to Bordeaux, and thence to -England. - - No. 3.--RETURN _of_ CAPITAL OPERATIONS _performed at the Hospital - Stations of the Army in Spain, between the 21st of June and 24th of - December, 1813, including the battles of Vittoria, the Pyrenees, and - San Sebastian, to the entrance into France._ - - +---------+-----------+--------+-----+-------+-------+------------+ - |STATIONS.|OPERATIONS.|No. |Died.|Dis- |Under | REMARKS. | - | | |operated| |charged|treat- | | - | | |upon. | |cured. |ment. | | - +---------+-----------+--------+-----+-------+-------+------------+ - |Vittoria |Shoulder- | | | | | | - | |joint | 13| 10 | 2 | 1 | | - | |Upper | | | | | | - | |extremities| 108| 58 | 40 | 10 | | - | |Lower ditto| 148| 95 | 38 | 15 | | - | |Trepan | 3| 3 | | | | - | | | | | | | | - |Santander|Upper | | | | | | - | |extremities| 22| 5 | 8 | 9 | | - | |Lower ditto| 23| 9 | 6 | 8 | | - | | | | | | | | - |Bilbao |Shoulder- | | | | |{The great | - | |joint | 5| 5 | | |{number of | - | |Upper | | | | |{amputations| - | |extremities| 146| 48 | 46 | 52 |{at this | - | |Lower ditto| 68| 36 | 16 | 16 |{station was| - | |Aneurism | 1| 1 | | |{in part | - | | | | | | |{occasioned | - | | | | | | |{by hospital| - | | | | | | |{gangrene. | - | | | | | | | | - |Passages |Shoulder- | | | | | | - | |joint | 1| ... | ... | 1 | | - | |Upper | | | | | | - | |extremities| 11| 1 | 3 | 7 | | - | |Lower ditto| 14| 6 | 3 | 5 | | - | |Trepan | 3| 2 | 1 | | | - | |Aneurism | 1| 1 | | | | - | | | | | | | | - |Vera |Upper | | | | | | - | |extremities| 12| 4 | 8 | | | - | |Lower ditto| 5| 3 | 2 | | | - | | +--------+-----+-------+-------+ | - | |Total | 584| 287 | 173 | 124 | | - | +-----------+--------+-----+-------+-------+ | - |Recapitulation:-- | | | | | | - | Shoulder- | | | | | | - | joint | 19| 15 | 2 | 2 | | - | Upper | | | | | | - | extremities | 299| 116 | 105 | 78 | | - | Lower ditto | 258| 149 | 65 | 44 | | - | Trepan | 6| 5 | 1 | | | - | Aneurism | 2| 2 | | | | - +---------------------+--------+-----+-------+-------+------------+ - -If one-sixth of the number remaining under treatment be considered -to have died, which is a low calculation, the deaths will stand to -the recoveries as 300 dead to 276 recovered, or a loss of more than -one-half of the secondary operations. - - No. 4.--CAPITAL OPERATIONS _performed in the Field with Divisions of - the Army during the same period_. - - |DIVISIONS. - | |OPERATIONS. - | | |Number operated upon. - | | | |Died. - | | | | |Discharged cured. - | | | | | |Under treatment. - | | | | | | |Tetanus occurred. - | | | | | | | | REMARKS. - +--------+--------------+-----+-----+-----+-----+-----+--------------+ - |Cavalry |Upper | | | | | | | - | |extremities | 3 | 1 | 2 | | | | - | |Lower ditto | 3 | 2 | 1 | | | | - |First |Shoulder-joint| 3 | ... | 2 | ... | ... | 1}Sent | - |division|Upper | | | | | | }to | - | |extremities | 14 | 1 | 3 | 5 | ... | 5}General | - | |Lower ditto | 10 | 2 | ... | 1 | 1 | 6}Hospital. | - | |Trepan | 2 | 2 | | | | | - |Second |Shoulder-joint| 1 | ... | 1 | | | | - | |Upper | | | | | | 5}Sent to | - | |extremities | 16 | ... | 5 | 6 | ... | }General | - | |Lower ditto | 21 | 3 | 6 | 7 | ... | 5}Hospital. | - | |Aneurism | 1 | ... | ... | 1 | | | - |Third |Shoulder-joint| 1 | ... | ... | 1 | | | - | |Upper | | | | | | | - | |extremities | 17 | 2 | ... | 15 | | | - | |Lower ditto | 10 | ... | 2 | 8 | | | - |Fourth |Upper | | | | | | | - | |extremities | 10 | ... | 10 | | | | - | |Lower ditto | 20 | ... | 20 | | | | - |Fifth |Shoulder-joint| 12 | ... | 8 | 2 | ... | 2}Sent | - | |Upper | | | | | | }to | - | |extremities | 57 | 1 | 36 | 2 | ... |18}General | - | |Lower ditto | 41 | 10 | 13 | 2 | ... |16} Hospital. | - |Sixth |Shoulder-joint| 1 | 1 | | | | | - | |Upper | | | | | | 2}Sent to | - | |extremities | 7 | ... | 5 | ... | ... | }General | - | |Lower ditto | 6 | 1 | 1 | 3 | ... | 1}Hospital. | - |Seventh |Upper | | | | | |14}Sent to | - | |extremities | 18 | ... | 3 | 1 | ... | }General | - | |Lower ditto | 9 | 1 | ... | 1 | ... | 7}Hospital. | - | | | | | | | |}The whole | - |Light |Shoulder-joint| 1 | ... | ... | ... | ... |}of these | - |division|Upper | 21 | ... | ... | ... | ... |}cases sent to| - | |extremities | | | | | |}the General | - | |Lower ditto | 8 | ... | ... | ... | ... |}Hospital; | - | |Trepan | 4 | ... | ... | ... | ... |}results not | - | | | | | | | |}known at | - | | | | | | | |}the division.| - | | +-----+-----+-----+-----+-----+ | - | | Total | 317 | 27 | 118 | 55 | 1 | | - | +--------------+-----+-----+-----+-----+-----+ | - |Recapitulation:-- | | | | | | | - | Shoulder-joint| 19 | 1 | 11 | 3 | ... | 4}Sent | - | Upper | | | | | | }to | - | extremities | 163 | 5 | 64 | 29 | ... |65}General | - | Lower ditto | 128 | 19 | 43 | 22 | ... |44}Hospital. | - | Trepan | 6 | 2 | ... | ... | ... | 4} | - | Aneurism | 1 | ... | ... | 1 | ... | | - +-----------------------+-----+-----+-----+-----+-----+--------------+ - -Of 310 amputations 25 died, 172 recovered in the field, and 113 were -sent to the rear, of whom one-sixth may be considered to have died, -making a total of 45 deaths in 310 cases--the proportion of upper -extremities to lower in the 310 being as 182 to 128, thus greatly -influencing the result, which is consequently much more favorable -than if the numbers had been reversed. The proportion of upper to -lower extremities in the secondary amputations, as by return No. 3, -is equally in favor of the upper, and can only be accounted for, when -compared with Return No. 4, by the army being constantly in motion and -the hospitals at a distance. The difference of results at the several -stations is also remarkable; it is so with the divisions in the field. -The 3d and 4th divisions, under Staff-Surgeons Lindsey and Boutflower, -kept their amputations with them in bivouac, and their success is -remarkable; that of the 4th division has no parallel. The light -division, on outpost duty, could not keep their amputations. These two -returns include 886 amputations. - -The labors of the surgeons of the army may be judged of by the fact -that, during the last three months of the year to which these returns -refer--viz., from September 25th to December 24th, 1813--the number of -sick and wounded amounted to 37,144, a number nearly equal to that of -the whole army. - - No. 5.--RETURN _of_ CAPITAL OPERATIONS, _Primary and Secondary, - performed in the British General Hospitals, Brussels, or brought in - from the Field between 16th June and 31st July, 1815_. - - |OPERATIONS. - | |General total. - | | |Primary operations. - | | | |Died. - | | | | |Remaining. - | | | | | |Proportion of deaths - | | | | | |to operations. - | | | | | | |Secondary operations. - | | | | | | | |Died. - | | | | | | | | |Remaining. - | | | | | | | | | |Proportion of deaths - | | | | | | | | | |to operations. - | | | | | | | | | | |Total remaining. - | | | | | | | | | | | |Of these - | | | | | | | | | | | |doubtful. - | | | | | | | | | | | | |Transferred - | | | | | | | | | | | | |to Antwerp. - | | | | | | | | | | | | | |REMARKS. - +---------+---+---+---+---+-------+---+---+---+------+---+--+--+--------+ - |Shoulder-| | | | | | | | | | | | | | - | joint | 8| 6| 1| 5|1 to 6| 12| 6| 6|1 to 2| 11| | | | - |Hip-joint| 1|...|...|...|... ...| 1|...| 1|......| 1|..|..|A French| - | | | | | | | | | | | | | |soldier,| - | | | | | | | | | | | | | |who | - | | | | | | | | | | | | | |recover-| - | | | | | | | | | | | | | | ed. | - |Thigh |148| 54| 19| 35|1 to 3| 94| 43| 51|1 to 2| 86| 9| 4| | - |Leg | 93| 43| 7| 26|1 to 6| 50| 16| 34|1 to 3| 60|..| 4| | - |Arm | 72| 21| 4| 17|1 to 5| 51| 13| 38|1 to 4| 55|..| 6| | - |Forearm | 39| 22| 1| 21|1 to 22| 17| 5| 12|1 to 3| 33|..| 3| | - |Carotid | | | | | | | | | | | | | | - | artery | | | | | | | | | | | | | | - | tied | 1|...|...|...|... ...| 1|...| 1|......| 1|..|..| | - |Trephine | 2|...|...|...|... ...| 2| 1| 1|1 to 2| 1|..| 1| | - | +---+---+---+---+-------+---+---+---+------+---+--+--+ | - |Total |374|146| 32|104|... ...|228| 84|144|......|248| 9|18| | - +---------+---+---+---+---+-------+---+---+---+------+---+--+--+--------+ - - - -LECTURE VIII. - -CHARACTERS OF HOSPITAL GANGRENE. - - -164. This most destructive disease owes its names of hospital gangrene, -phagedena, gangrenosa, _pourriture d’hôpital_, sloughing ulcer, -etc. etc. to the different appearances the affected parts assume -on different occasions, according to the intensity of the morbid -poison applied, and possibly also to the state of constitution of the -individual attacked. The peculiar nature of this poison has not yet -been ascertained. Professor Brugmans says that in 1797, in Holland, -charpie composed of linen threads cut of different lengths, which, on -inquiry, it was found had been already used in the great hospitals in -France, and had been subsequently washed and bleached, caused every -ulcer to which it was applied to be affected by hospital gangrene; and -the fact that this disease was readily communicated by the application -of instruments, lint, or bandages which had been in contact with -infected parts, was too firmly established by the experience of every -one in Portugal and Spain to be a matter of doubt. Its character as a -thoroughly contagious disease is indisputable. Its capability of being -conveyed through the medium of the atmosphere to an ulcerated surface -is also admitted, although some have thought that the infection was -not always applied to the sore, but affected it secondarily, through -the medium of the constitution. Brugmans says that hospital gangrene -prevailed in one of the low wards at Leyden in 1798, while the ward or -garret above it was free. The surgeon made an opening in the ceiling -between the two, in order to ventilate the lower or affected ward, -and in thirty hours three patients who lay next the opening were -attacked by the disease, which soon spread through the whole ward. Our -experience in Portugal and Spain confirmed this fact, and left no doubt -on the mind of any one who had frequent opportunities of seeing the -disease, that one case of hospital gangrene was capable of infecting -not only every ulcer in the ward, but in every ward near it, and -ultimately throughout the hospital, however large. The disease, as long -as it remains unaltered by destructive applications, may be considered -to be infectious as well as contagious. - -This infection can penetrate the dressings so as to affect the ulcer -through them, although requiring a difference of time in different -parts of the body. Ulcers on the lower extremity experienced the -influence of the morbid poison in general at an earlier period than -those on the upper extremity; and a wound might be seen in a healthy -state on the arm, while one on the leg had been evidently suffering -from this disease for some days, if the complaint had become mild, or -somewhat chronic. If the morbid poison were in its active state, then -the deterioration of the ulcers on the arm was almost if not quite -contemporaneous with that on the leg. - -165. Mr. Blackadder has given the following account of the disease from -inoculation in his own person, which is, therefore, more to be relied -upon than any other:-- - -“While engaged in examining the stump of a patient who had died from -this disease, I accidentally wounded one of my fingers with the -point of a double-edged scalpel, but so slightly that not a drop of -blood made its appearance, and on this account I did not consider -any particular precautionary means necessary. In the course of about -sixty hours, however, the wound had become inflamed, and I was -attracted to it by an occasional smart, stinging sensation, which -ultimately extended a considerable way up the arm. On the fourth day -the inflammation had increased, and the stinging sensation was almost -constant. Headache, nausea, and general indisposition followed, with -frequent chills, which increased very much toward evening; but which, -with the other symptoms, were considerably relieved by the use of -neutral salts, the pediluvium, and warm diluents. A vesicle, having -a depression in its center, and containing a watery fluid of a livid -color, was now forming upon a hard and elevated base; the surrounding -integuments became tumefied, of an anserine appearance, and extremely -sensitive to the touch; at about the distance of the fourth of an inch -from the base of the tumor, a very distinct areola, of a bluish-red -color, made its appearance, and remained visible for several days. At -this period, circumstances rendered it necessary for me to be exposed -to wet, to undergo considerable fatigue, and immediately afterward to -travel to a considerable distance. The inflammation, however, gradually -subsided, but the stinging, accompanied by a burning sensation, still -continued, and the sore had no disposition to heal; yet it did not -enlarge externally, but was disposed to burrow under the integuments. -This phagedenic disposition was ultimately got the better of by laying -open the sore, and by repeated applications of caustic; but it was -two months before a complete cicatrix had formed. The new cuticle -remained for a length of time extremely sensitive to the touch; and -it was upwards of six months before it had acquired the color of the -surrounding integuments.” - -166. M. Delpech was disposed to consider that the misfortunes and -sufferings of the French army had a great depressing influence on the -soldiers, from which at other times they would have been exempted, and -that this aided the propagation of the malady; but many soldiers of the -British army, free from these particular depressing causes, suffered in -a similar manner. Dr. Tice, at Coimbra, says:-- - -“An uncommon depressing affection of the mind often exists among -persons suffering from this disease, painful to witness--a morbid -dejection, or apathy, which could scarcely be removed, and on which, -in very bad cases, no impression could be made. In others, the humane -solicitations of the medical officers have failed against the influence -of oppressive gloom, amounting to despair. Expectation and hope seemed -to be exiled from their minds by the dominion of painful despondency, -which, prevailing in melancholy disorder, seemed uncontrolled or -checked by the intrusive importunities of the present, or the -consciousness of a future existence.” - -A wound attacked by hospital gangrene in its most concentrated and -active form presents a horrible aspect after the first forty-eight -hours. The whole surface has become of a dark-red color, of a ragged -appearance, with blood, partly coagulated, and apparently half putrid, -adhering at every point. The edges are everted, the cuticle separating -from half to three-quarters of an inch around, with a concentric -circle of inflammation extending an inch or two beyond it; the limb is -usually swollen for some distance, of a shining white color, and not -peculiarly sensible, except in spots, the whole of it being perhaps -edematous or pasty. The pain is burning, and unbearable in the part -itself, while the extension of the disease, generally in a circular -direction, may be marked from hour to hour; so that in from another -twenty-four to forty-eight hours, nearly the whole of the calf of a -leg, or the muscles of a buttock, or even of the wall of the abdomen, -may disappear, leaving a deep, great hollow, or hiatus, of the most -destructive character, exhaling a peculiar stench, which can never be -mistaken, and spreading with a rapidity quite awful to contemplate. -The great nerves and arteries appear to resist its influence longer -than the muscular structures, but these at last yield; the largest -nerves are destroyed, and the arteries give way, frequently closing the -scene, after repeated hemorrhages, by one which proves the last solace -of the unfortunate sufferer. I have seen all the largest arteries of -the extremities give way in succession, and until the progress of the -disease was arrested by proper means, the application of a ligature was -useless. The joints offer little resistance; the capsular and synovial -membranes are soon invaded, and the ends of the bones laid bare. The -extension of this disease is, in the first instance, through the medium -of the cellular structure of the body. The skin is undermined, and -falls in; or a painful red, and soon black patch, or spot, is perceived -at some distance from the original mischief, preparatory to the whole -becoming one mass of putridity, while the sufferings of the patient -are extreme. A complaint of this kind cannot be local, even if a local -origin be admitted; the accompanying fever is usually dependent on the -previous state and general constitution of the patient, modified by the -season of the year, or the prevailing type of febrile disease. - -This gangrenous disease does not always prevail in this, its most -concentrated form; the destroying process assumes more of a sloughing -than of a gangrenous character, whence Delpech has denominated it -pulpous, rather than gangrenous. It is in its nature almost equally -destructive, although not quite so formidable in appearance. It -may attack the whole surface of an ulcer at once, or in distinct -points, all, however, rapidly extending toward each other, until -they constitute one whole. The red of the granulations becomes of a -more violet color, and the change is accompanied by burning, a pain -not usually felt in the part, while a layer of ash-colored matter is -soon seen covering them, which adheres so firmly as not to be readily -removed; or, if separated, shows that it is a substance formed upon the -surface, and constituting a part of the granulations themselves, which -are ultimately confounded with it. - -About the end of the first week, and sometimes much later, this kind -of ulcer becomes more painful, the edges or the circumference of the -wound assume a browner hue, and the parts become somewhat pasty, the -whitish color of the part particularly affected being opaque, gray, and -soft. It may be said that the false membrane, having become very thick, -has lost the little vitality it possessed, and become putrid; the -discharge, which had been partly suppressed, now reappears, not as pus, -but as a fetid ichor, exhaling the peculiarly offensive stench of this -disease. This pulpy, yellowish, putrid substance becomes thicker, and -extends deeply; it invades the whole substance of a muscle, under which -a probe may be passed, and the instrument brought out through it, with -the loss, perhaps, of some striæ of blood, from parts which are not yet -actually destroyed; the mass is, however, adherent, although its extent -diminishes by the putrefaction and wasting away of its surface. - -There are two characters always peculiar to this disease, in which it -differs from all other gangrenous ulcers from ordinary causes; these -are, the circular form it assumes after a very few days, even in its -slighter varieties, and its peculiar odor or stench. - -167. If this disease were entirely a local complaint, caused by the -application of a morbid poison, giving rise to the destructive changes -described on the surface of an ulcer, it should be followed by febrile -or constitutional symptoms at the end of several days only; and -Delpech is disposed to think that in such cases these constitutional -symptoms take place from and after the sixth day. If it were entirely -a constitutional disease, giving rise to the destructive changes -described as taking place on the surface of an ulcer, the febrile -symptoms should precede the changes in the ulcerated surface. That -the febrile symptoms do seem to follow the appearance of the local -alteration, is in many cases indisputable; that they precede or -accompany the local symptoms in many other cases, is indubitable; -and that the disease in a mild state, although yet capable of -committing much mischief, is neither preceded nor followed by febrile -or constitutional symptoms, cannot be doubted. The febrile symptoms -themselves differ essentially from each other when they do occur, -generally partaking the character of the endemic fever prevailing in -the country at the season at which they appear. The fever is sometimes -inflammatory, sometimes typhoid, and occasionally resembles the -bilious remittent of the summer and autumn in hot climates, and ends in -typhus. It is probable that a want of attention to these circumstances -decided the opinions entertained by different individuals as to the -general character of the febrile symptoms, and of the treatment to be -pursued for their removal. That this disease was generally considered -a constitutional complaint, until nearly the end of 1813, must be -admitted; and it was the very indifferent success which attended its -treatment by constitutional means and simple detergent applications, -which caused the surgeons of the British army to view it more as -a local disease, capable of giving rise to severe constitutional -symptoms--a change of opinion which was materially influenced by the -knowledge that the French surgeons more generally considered, with -Pouteau, that it was local in the first instance, and treated it by -the actual cautery. In my hands, constitutional treatment, and every -kind of simple mild detergent applications, always failed, unless -accompanied by absolute separation, the utmost possible extent of -ventilation, and the greatest possible attention to cleanliness; and -not even then without great loss of parts in many instances. This -induced me, at Santander, in November and December, 1813, to try the -mineral acids, not as then generally used as stimulants or detersives, -but as caustics. This proceeding was always, however, accompanied by -a constitutional treatment, regulated by the nature of the symptoms, -which at that station were never benefited by bleeding, although it had -proved so effectual, without the local remedies, at the neighboring -sea-port of Bilbao. - -168. Dr. Boggie, the great advocate for constitutional treatment, says -that under him, at Bilbao, in 1813, where caustic applications were not -used, or only as detersives, the disease was arrested by blood-letting -to the amount of one or two pounds, and, in some cases, to the extent -of three or four. He admits, however, that bleeding must be resorted -to with the greatest caution in persons of less robust constitutions, -who may have lingered long in hospital, or suffered much from ill -health; and that in some cases it is altogether inadmissible--an -acknowledgment which is decisive, in my mind, that constitutional -treatment is only auxiliary. He says he never saw the puncture made by -the lancet affected by this disease; a convincing proof to me, who have -seen it, that the virulence of the complaint, as an infectious disease, -was subsiding at Bilbao when the treatment he introduced proved so -effectual. - -In one case at Santander, in which hospital gangrene in the hand and -arm and tetanus existed together, they were both cured by venesection, -which failed as signally in doing the least good in a case in the next -bed, under nearly similar circumstances. - -Dr. Boggie admits that “in that form of gangrene named phagedena, a -very great destruction of parts may sometimes take place without the -constitution being much affected by it. Now, if blood-letting be used -in such a case, or even in the advanced stage of the true inflammatory -gangrene, when disorganization has taken place, and the system is -sinking under the consequent debility, the vital powers being nearly -exhausted, the result must be obvious; but when it is used with -caution, and in cases where it is really applicable, it will be found -to be a most valuable remedy.” In all cases, Dr. Boggie, like every -one else, had recourse to emetics, purgatives, and such other general -treatment as the febrile symptoms appeared to indicate. As local -applications, he recommends cold water, alone or mixed with a small -portion of acetic acid, constantly applied and frequently renewed. -Poultices and warm applications he objects to; and after the sloughs -separate, he approves of dry lint and weak solutions of sulphate of -zinc. Should the sloughs adhere after the inflammation has abated, -warm, stimulating ointments, and sometimes weak solutions of the -nitrate of silver or of the mineral and vegetable acids, may be had -recourse to. - -169. To Mr. Blackadder must be attributed the introduction of the use -of Fowler’s solution of arsenic as an escharotic, in November, 1813, -while he was at Passages; it answered remarkably well in arresting -the progress of the disease, and was afterward found to be equally -efficient in the hospitals at Antwerp. The only objection to its -use that I am aware of is, that it caused in some few cases slight -symptoms of its poisonous effect having taken place on the bowels, -apparently from absorption,--an inconvenience which might become a -serious evil, and which caused a preference to be given to the mineral -acids, which act equally well without incurring a similar risk of -evil. Mr. Blackadder, stationed on the same coast, within about forty -miles of Dr. Boggie at Bilbao, took a diametrically opposite view -of this complaint to the doctor; and believing the disease to be -purely local in the first instance, considered venesection as almost -always unnecessary, although he admitted that cases may occur in -which the abstraction “of a small quantity of blood would be likely -to be attended with more good than harm; but certainly,” he adds, -“blood-letting is an operation which ought to be avoided as much as -possible in gangrenous phagedena, particularly when the previous injury -has been extensive, such as that of a penetrating gunshot wound.” - -Dr. Walker, who served at Bilbao at the same time, concludes an able -report in the following terms:-- - -“Lately, however, the disease put on a milder form, and the sloughing -did not proceed with that rapidity that it did at first, nor was the -fever so violent. And more lately still, since the setting in of the -cold weather, the type of the fever seems to have changed entirely, -and to have put on the inflammatory type, so as to require strong -evacuants, and even bleeding, which has been used with the greatest -success by Staff-Surgeon Boggie, who has for a considerable time had -the more immediate care of the patients of this description at the -Cordeleria Hospital.” - -170. “When this disease does not proceed rapidly, and is confined to -the ulcerative form,” Delpech says, “it may be removed by stimulant -applications, such as vinegar, the vegetable and mineral acids, the -Egyptian ointment, etc.” Of these he prefers vinegar applied on lint, -after having rubbed or scraped off any false or pulpy membrane which -appears to conceal the surface of the ulcer. “Some good effect,” he -adds, “has been observed from the careful application of powdered -charcoal to the whole surface of the sore, which,” he says, “ought -not to be in the gangrenous, or pulpy, or putrid state, but merely -ulcerative or phagedenic; and not even then, when this peculiar -ulceration assumes a deeply hollowed-out form, rapidly filled with -an abundant and tenacious discharge.” Of constitutional treatment -he evidently thinks little; and, while he admits the propriety and -necessity of treating every accompanying state of fever, whether it be -inflammatory, catarrhal, bilious, remittent, etc., by its appropriate -means, he does not seem to think they have much influence on the local -disease, although he firmly believes that the suppression of the local -disease materially assists in arresting, in a great measure, such -constitutional symptoms as may be dependent on it, unless influenced -by some peculiarity of constitution. His principal local remedy was the -hot iron or actual cautery applied to every part. - -He says (page 86) some surgeons of the Anglo-Portuguese army of Lord -Wellington had assured him that the mineral acids, the hydrochloric, -nitric, and sulphuric, had been frequently employed in the British -hospitals in Spain with success; and he particularly mentions M. -Guthrie, _Inspecteur au Service de Santé_, as the person from whom he -especially received his information; thus establishing the fact that -the use of the mineral acids in a dilute and concentrated state was -known to, and had been essentially introduced into practice by, the -surgeons of the British army during the war in Spain--a fact which -admits of no dispute as to the origin of its use. - -171. In India, Mr. Taylor, late surgeon 29th Regiment, now a deputy -inspector-general in the medical department in the Crimea, reports:-- - -“Hospital gangrene appeared among the wounded of the 29th Regiment a -little later than in the hospitals of other corps. The disease declared -itself, on the 18th of January, in a stump case; and between that date -and the 26th of the same month fifteen cases had come under treatment. -At first I could tell, by the peculiar dark, florid countenance of the -patient, that his wound had taken on the gangrenous affection; yet I -cannot say that there was, in these cases, any marked inflammatory -fever. Subsequently, in the prevalence of the disease, this dark-red -color of the face was neither well marked nor by any means so constant. -In many cases the disease seemed purely local; but in the great -majority there was certainly much feverish constitutional disturbance -accompanying the local affection, and often preceding it. My experience -of the disease, as it occurred among the wounded at Ferozepore, does -not enable me to determine, satisfactorily to myself, whether it be -essentially a local or a constitutional affection. I am inclined to -place it in the former category; and there is no doubt whatever in my -mind that the essential means of treatment are local. - -“In the treatment of this disease, I proceeded regularly on one plan, -and found that so efficacious that I was not inclined to try any other. -The plan adopted was, the application of the strong nitric acid, so as -completely to cut off the diseased from the sound part, or part so far -sound as only to be affected with inflammation. The acid, however, -required to be rubbed in with the blunt end of the probe, so that it -not only destroyed the cuticle, but killed the cutis vera, and probably -the cellular membrane underneath. The narrow yellow ring of dead skin -thus formed separated like a piece of leather, generally carrying with -it the whole slough, and leaving a clean, healthy surface, as well as -edges to the wound. I never attempted to apply the acid to the surface -underneath the slough, neither is such an application necessary; the -vital seat of the disease is in its circumference, however large -the area. I must admit that the disease sometimes crossed the acid -boundary, and a second, and even a third application of the remedy -was required; but this was rare. Neither was constitutional treatment -neglected, but this varied according to the state of the patient; -emetics, purgatives, saline medicines, and low diet being sometimes -required; while in other instances ether, ammonia, laudanum, and -generous diet were administered. - -“When speaking of the symptoms of this disease, I should have mentioned -that a burning, gnawing sensation was sometimes loudly complained of. -The application of the acid soon removed that pain, and the acid itself -did not often seem to produce much suffering. In one instance, deemed -a favorable one, I tried venesection, and I fear did mischief. Calomel -and antimonials were useful. I did not try the arsenical solution. -The change of air, which the march of the wounded, on their return to -Kussowlee, occasioned, certainly had a very beneficial effect on all -the gangrenous and sloughing sores. - -“At the same time that hospital gangrene was prevalent at Ferozepore, -some wounds took on a malignant fungous affection, which spread -over the healthy surface like the hospital gangrene. The dirty, -fibrous-looking, fungous growth rose considerably above the edges of -the wound, partially overlapping them; these edges were inflamed, but -not livid and vesicated as in the cases of gangrene; but here also the -disease took the circular or oval form. The affection here noticed I -observed only in wounds of the forearm and hand; Colonel Barr’s wound, -which was of the forearm near the wrist, took on this disease. The -application of nitric acid in the same way as for hospital gangrene -eventually checked its progress. - -“In no case that came under my observation did the gangrene directly -prove fatal, though in many cases it contributed largely in bringing -about an unfavorable termination.” - -172. _Conclusions._ First.--Hospital gangrene never occurs in isolated -cases of wounds. - -Second.--It originates only in badly-ventilated hospitals, crowded with -wounded men, among and around whom cleanliness has not been too well -observed. - -Third.--It is a morbid poison, remarkably contagious, and is infectious -through the medium of the atmosphere applied to the wound or ulcer. - -Fourth.--It is possibly infectious, acting constitutionally, and -producing great derangement of the system at large, although it has not -been satisfactorily proved that the constitutional affection is capable -of giving rise to local disease, such as an ulcer; but if an ulcer -should occur from accidental or constitutional causes, it is always -influenced by it when in its concentrated form. - -Fifth.--The application of the contagious matter gives rise to a -similar local disease, resembling and capable of propagating itself, -and is generally followed by constitutional symptoms. - -Sixth.--In crowded hospitals the constitutional symptoms have been -sometimes observed to precede, and frequently to accompany, the -appearance of the local disease. - -Seventh.--The local disease attacks the cellular membrane principally, -and is readily propagated along it, laying bare the muscular, arterial, -nervous, and other structures, which soon yield to its destructive -properties. - -Eighth.--The sloughing of the arteries is rarely attended by healthy -inflammation, filling up their canals by fibrin, or by that gangrenous -inflammation which attends on mortification from ordinary causes, and -alike obliterates their cavities. The separation of the dead parts is, -therefore, accompanied by hemorrhage, which, when from large arteries, -is usually fatal. - -Ninth.--The operation of placing a ligature on the artery at a -distance, or near the seat of mischief, does not succeed, because the -incision is soon attacked with the disease, unless it has been arrested -in the individual part first affected, and the patient has been -separated from all others suffering from it. - -Tenth.--The local disease is to be arrested by the application of the -actual or potential cautery: an iron heated red hot, or the mineral -acids pure, or a solution of arsenic, or of the chloride of zinc, or -of some other caustic which shall penetrate the sloughing parts, and -destroy a thin layer of the unaffected part beneath them. If a sinus -or sinuses have formed under the skin or between the muscles, from the -extension of disease in the cellular or areolar structure, they must be -laid open, and the cautery applied; for if any part affected be left -untouched or undestroyed by the acid, the disease will recommence and -spread from that point. The parts touched by the acids or cautery may -be defended by cloths or other material, wetted with hot or cold water -according to the feelings of the sufferers, and poultices of various -kinds may be had recourse to, if unavoidable. - -Eleventh.--After the diseased parts have been destroyed by the actual -or potential cautery, they cease in a great measure to be contagious, -and there is less chance of the disease being propagated to persons -having open wounds or ulcerated surfaces. A number of wounded thus -treated are less likely to disseminate the disease than one person on -whom constitutional treatment alone has been tried. - -Twelfth.--The pain and constitutional symptoms occasioned by the -disease, considered as distinct from the symptoms which may be -dependent on disease endemic in the country, are all relieved, and -sometimes entirely removed, by the destruction of the diseased surface, -which must, however, be carefully and accurately followed, to whatever -distance and into whatever parts it may extend, if the salutary effect -of the remedies is to be obtained. - -Thirteenth.--On the separation of the sloughs, the ulcerated surfaces -are to be treated according to the ordinary principles of surgery. -They cease to eliminate the contagious principle, and do not require a -specific treatment. - -Fourteenth.--The constitutional or febrile symptoms, whenever or at -whatever time they occur, are to be treated according to the nature of -the fever they are supposed to represent, and especially by emetics, -purgatives, and the early abstraction of blood if the fever be purely -inflammatory, and by less vigorous means if the fever prevailing in -the country be of a different character. Pain should be alleviated by -opium, which should be freely administered. - -Fifteenth.--The essential preventive measures are separation, -cleanliness, and exposure to the open air,--the first steps toward -that cure which cauterization will afterward in general accomplish. - -Sixteenth.--If the sufferer be very young, or of a weakly habit, his -strength will frequently require to be supported in the most efficient -manner by a due administration of cinchona bark, wine, and a generous -diet,--means often found essentially necessary after all severe attacks -of debilitating diseases. - -The formidable nature of this terrible disease, before the local -application of caustic remedies was fully adopted, will be best -understood by the following document. - - RETURN _of the_ NUMBER OF CASES _of_ HOSPITAL GANGRENE _which have - appeared at the Hospital Stations in the Peninsula between 21st June - and 24th December, 1813_. - - +---------+---------+-------+-----+----------+--------+------------+ - | |No. |Dis- |Died.|Under |No. | | - |STATIONS.|of cases |charged| |treatment.|operated|REMARKS. | - | |occurred.|cured. | | |upon. | | - +---------+---------+-------+-----+----------+--------+------------+ - |Santander| 160 | 72 | 85 | 53 | 25 |Most of | - |Bilbao | 972 | 557 | 387 | 28 | 183 |these cases | - | | | | | | |were sent | - | | | | | | |from | - | | | | | | |Vittoria. | - | | | | | | | | - | | | | | | | | - |Vittoria | 441 | 349 | 88 | 4 | 74 | | - |Passages | 41 | 2 | 2 | | |Thirty-seven| - | | | | | | |transferred | - | | | | | | |to | - | | | | | | |Santander. | - | | | | | | | | - | | | | | | | | - |Vera | | | | | |Vera, being | - | | | | | | |almost on | - | | | | | | |the field of| - | | | | | | |battle, had | - | | | | | | |no case. | - | | | | | | | | - | | | | | | | | - | | | | | | | | - | +---------+-------+-----+----------+--------+ | - | | 1614 | 980 | 512 | 85 | 282 | | - +---------+---------+-------+-----+----------+--------+------------+ - - - - -LECTURE IX. - -ON WOUNDS OF ARTERIES, ETC. - - -[Illustration] - -173. The efforts resorted to by nature for the suppression of serious -hemorrhages depend on the capabilities of the arteries as resulting -from their structure, into which it becomes an object of importance -minutely to inquire. With this view, the old division of an artery -into three coats may be continued, the difference between ancient and -modern anatomy being in their subdivision into different textures or -layers. The annexed diagram shows the edge of a large artery, which -has been divided circularly, and magnified so as to exhibit six layers -in a distinct manner; each of the three ancient coats is divided into -two. The _inner_ or old serous coat is shown to be separable into -_two_: the epithelial, marked 1, and the fenestrated, marked 2. The -_middle_ coat is also separated into _two_: the inner, or _muscular_, -marked 3, and the outer, or _elastic_, marked 4. The _outer_ coat is -divisible also into two layers, the _inner_, marked 5, and the _outer_, -marked 6; number 5 being composed more of elastic fibers: number 6 more -of areolar fibers, by which tissue, in a less condensed state, the -arteries of the extremities are attached to their sheaths. Such may -be considered to be the general composition of a large artery, each -particular structure remaining to be examined. - -[Illustration: No. 1. - - OLD. MIDDLE. YOUNG.] - -174. If a small portion of the inner coat of an artery be gently -scraped with a knife, or if the inside of the cheek be treated in a -similar manner, a little white soft substance is brought away on it, -called _epithelium_, a name given to it by Ruysch, from the delicate -layer of epidermis investing the female nipple, έπι, upon, θηλή, -_a nipple_. The epithelium of the human body is divided into three -kinds by microscopists--the _tesselated_, _pavement_, or _scaly_; the -_cylindrical_, or _conical_; and the _spheroidal_, or _glandular_. The -tesselated, as it exists in arteries, is represented in diagram No. -1, in three different stages--in the young person, in middle age, and -in the very old person; one stage gradually degenerating or changing -into the other, at each different period of life. It is composed of a -single layer of nucleated cells, of a flat, oval, round, hexagonal, or -polygonal form, and about 1/1400 of an inch in diameter, the nucleus -in each cell containing within itself one or more nucleoli, and even -several paler granules. The epithelium has a thickness proportioned -to the friction or pressure to which it is exposed, particularly when -covering the skin. In the arteries of the young, and in the mammalia -generally, the epithelium is strongly marked; in older persons, all -traces both of cells and nuclei have disappeared. It lines not only -the internal surface of the arteries and veins, but the mouth with its -mucous glands; the _conjunctiva_ of the eye; the pharynx and œsophagus; -the vagina and cervix uteri; the entrance of the female urethra, and -the serous membranes. - -The _conical_ or cylindrical is composed of cells closely set together, -of a conical, cylindrical, or pyramidal form, about 1/1200 of an inch -long, each cell inclosing a flat nucleus, with nucleoli. It lines the -urethra in the female, from the entrance where the tesselated ends, -and extends inward to the urinary tubules of the kidneys; the greater -part of the male organs in a similar manner; the digestive canal and -gland-ducts, from the cardia to the anus. - -The _spheroidal_ or _glandular_ epithelium consists of cells, more or -less circular or spherical in figure, each having a large nucleus in -its center. The epithelium is met with in all glandular organs, such as -the liver, kidney, lachrymal, and salivary glands, and in these cells -the proper secretion of the gland is developed. The tesselated and -cylindrical kinds are, on the contrary, more or less protective. - -The two first kinds are sometimes ciliated, by the addition, at -their free extremities, of several fine, pellucid, blunt, and pliant -hairlike processes or cilia, about 1/5000 of an inch long, which are, -during life, in constant motion. This kind of epithelium, known as the -ciliary, lines the whole respiratory track of mucous membrane; the -_palpebral_ conjunctiva, as opposed to the tesselated on the eyeball; -the ventricles of the brain; the posterior half of the uterus, and the -Fallopian tubes. - -The epithelium is placed upon the second layer of the internal coat, -which, from certain appearances of apertures or windows, has been -called the _perforated_ or _fenestrated_ layer. (See diagram No. 2.) -It can be peeled off in small pieces only, and shows under a power -of 250 diameters a series of well-marked fibers running in almost -parallel lines upon a comparatively structureless membrane, resembling -the inner layer of the cornea, as in the left-hand figure of the -diagram, the fibers being arranged in the length of the vessel. They -frequently bifurcate, and almost immediately join again, so that an -oval space, resembling a hole, is perceived. This is not always a hole -or perforation, as it is generally described to be, as may be seen -and proved by the fact that the supposed opening is sometimes filled -up by small bodies, like nuclei, as if the oval space were occupied -by a cell. This fenestrated layer varies in thickness in different -vessels, and is more strongly developed in the lower animals than in -man; by some authorities it is not regarded as a distinct layer, but -as the innermost layer of longitudinal fibers belonging to the middle -coat. When this layer is very thick, the fibers which are yellow do -not all run in the direction of the length of the vessel, for others -crossing at right angles may sometimes be observed, as delineated in -the right-hand figure of diagram No. 2. These two layers compose the -ancient inner coat of an artery, and are frequently the seat of disease. - -[Illustration: No. 2.] - -The middle coat, as it was termed, forms by much the greatest part -of the thickness of an artery, and, generally speaking, is of a more -or less yellow color. It appears fibrous to the naked eye, and can -be peeled off not unfrequently in a series of circular layers; when -examined microscopically, it is seen to be composed of _two_ sets of -fibers arranged in a circular direction. The inner layer is composed -principally of muscular fibers, of the organic or involuntary kind. -(See line marked 3 on the circular diagram.) The outer layer, marked -line 4 on the same diagram, is made up chiefly of elastic fibers, with -a much smaller amount of the muscular or contractile element. These -conjoined layers form the muscular coat of Mr. Hunter, the fibrous or -contractile coat of later anatomists, who denied its muscularity from -the supposed absence of fibrin--an error fallen into from chemical -science being unequal at that time to its discovery, or rather of its -more elementary part, called _protein_, the principal constituent -both of albumen and fibrin, which two are now found to differ from -each other in the addition only of three per cent, of sulphur. Mülder -says, in his “Animal and Vegetable Chemistry,” (Part II. p. 307:) “The -combinations of sulpho-phospho protein (_fibrin_ and _albumen_) and of -sulpho-protein _casein_ with acids, alkalies, and salts are especially -remarkable. Protein is soluble in weak alkalies. Since, therefore, the -serum of the blood is always slightly alkaline, being a proteate of -soda, with sulphur and phosphorus, it keeps the sulpho-phospho protein -in solution. This property is the cause of the blood remaining in a -liquid state--a chief requisite for animal life. - -“If a weak alkaline solution of protein be neutralized by an acid, -the solubility of sulpho-phospho protein is greatly diminished. The -sulphuric and phosphoric acids, by not dissolving protein, stanch -bleeding. Acetic acid, by which protein is dissolved, does not, neither -does the hydrochloric. - -“Protein, according to Mülder--although it is doubted by Liebig--is -a complex substance, consisting of several heterogeneous organic -compounds united into one whole, easily acted upon by strong reagents. - -“If a protein compound be brought into contact with an alkali, ammonia -is immediately disengaged, and the alkaline solution can hardly be -made weak enough to prevent the disengagement of ammonia. If either -fibrin or coagulated albumen be dissolved in a weak potash lye, ammonia -is always perceptible. Protein, therefore, is always in a state of -decomposition, as serum is alkaline.” - -In diagram No. 3, fig. 3, the organic or _involuntary_ muscular fibers -of the intestine are shown, consisting of more or less flattened -bands, the fibers of which are soft, and marked with minute granules, -sometimes exhibiting traces of nuclei. These purely muscular fibers are -most abundant next to the inner coat of the artery, and diminish in -number as they approach the outer layer, their place being occupied by -firmer and more elastic fibers of a yellow color, seen collectively in -the circular diagram, as line 4, and separately in diagram 3, fig. 4, -and in diagram 4. - -[Illustration: No. 3.] - -[Illustration: No. 4.] - -The _involuntary_ muscular fibers of an artery do not always form -a continuous layer; they are often smaller than those found in the -intestines, bladder, and uterus, and occur as fusiform cells, detached -from each other, and having a large, club-shaped nucleus, as shown at -fig. 6 in diagram 3. - -The _voluntary_ muscular fibers differ from the _involuntary_, in -having cylindrical fibers of much larger size, with transverse and -longitudinal markings, unlike the flattened fibers of less size of the -involuntary muscles, which have also a faintly granular appearance, -instead of the more determined transverse and longitudinal lines of the -voluntary muscles. - -The _outer_ or _elastic_ layer of the ancient _middle_ coat, -represented by line 4 in the circular diagram, contains muscular -fibers, but it is formed principally of strong, elastic fibers -difficult of separation, and, when torn across, have curled -extremities, as shown in the diagram marked 4, differing only in size -from those found in the ligaments of the spine, and in the ligamentum -nuchæ of quadrupeds, as shown in the separate diagram marked 4. - -The _external_ coat of an artery, divided also into _two_ layers, is -shown on the circular diagram by lines 5 and 6. These two layers are -composed of the yellow elastic fibers last noticed, and another set -of fibers, _white_ in color and _in_elastic in structure, arranged -in various directions; the _inner_ layer predominating in yellow -elastic, the outer layer in white inelastic fibers, constituting -a firm investment to all the other layers of which the artery is -composed. The white inelastic fibers are shown in diagram No. 3, -fig. 5, with a yellow elastic fiber curling round them. The constant -crossing and recrossing of these two sets of fibers form certain -spaces, which, when not in a compact form, become real spaces, meshes, -or areolæ, constituting what is now called areolar tissue, rather -than the cellular of the older anatomists, from the circumstance that -the areolæ communicate, and that perfect cells in any tissue do not. -These elements of areolar tissue can be readily distinguished by the -action of acetic acid, under which reagent the white fibers will -almost disappear, leaving only a slight trace of fibers containing -oval nuclei, as seen and marked in diagram 3, fig. 5. It is seen when -unraveled in _b_, diagram 5. - -[Illustration: No. 5. - _a._ Yellow elastic fibers. - _b._ White inelastic fibers. - _c._ Nuclei. - _d._ Fiber, with nucleus.] - -The inner layer of the middle coat, or muscular coat, as it may be -justly termed, forms, it will be seen, the greatest part of the -thickness of the wall of certain arteries, and in some instances, as in -the anterior tibial artery, constitutes nearly the entire thickness of -the vessel. The _internal_ coat in all is frequently seen puckered in a -longitudinal direction. - -175. The arteries are supplied with blood by vessels of small size, -which do not come off immediately from the part of the artery they are -destined to supply, but principally from neighboring vessels. They are -called vasa vasorum. They are arranged precisely in the same manner as -those of the areolar tissue. A few of these vessels penetrate as far as -the middle or muscular coat, but do not reach the inner, which has no -vessels, proximity to the circulating fluid being apparently sufficient -for its nutrition. - -Arteries are supplied with nervous influence by branches from the -sympathetic system running in their walls, and through their connection -by ganglions with the organs they supply with blood. - -176. The cells, nuclei, and nucleoli alluded to are supposed to be -thus produced. In a shapeless, consistent, sometimes almost gelatinous -mass, to which the name of _cyto_-blastema or _formative substance_ -has been given, containing the materials requisite for the production -of cells, small, round grains or nucleoli are perceived in the act of -formation. Around these grains a layer of granular matter is deposited, -which continually increases in thickness, and constitutes the kernel -or nucleus. This is oval shaped or round, almost always opaque, has -a granular surface, and is considered to be a vesicle, a little cell -itself. From the surface of this kernel a small, very thin transparent -vesicle is raised, appearing as a segment of a sphere, which soon -expands, and becomes so large, when full grown, that the kernel lies -as a minute corpuscle upon its interior wall; the material for its -formation being supplied by the cyto-blastema, it is converted into a -vesicle by the kernel which is first formed, its embryo existing in the -formative substance. - -The first trace of organization is the production of a small, -perceptible body, or nucleolus, which deposits on the surface a -granular substance from the cyto-blastema, to give rise to a little -producing organ, the kernel or nucleus. This further transforms the -surrounding cyto-blastema into a granular surface, from which the -vesicle is formed, raised, expanded, and filled with a liquid, in which -vesicle thus enlarged the kernel remains inclosed and adhering to a -certain spot of its wall. - -If two nucleoli lie close to one another, they coalesce and become one -solid mass, capable of producing one cell only, containing one kernel -and two nucleoli. This view is that of Schleiden and Schwann, supported -by Mülder, but not entirely approved by Henle; inasmuch as no kernel -can be perceived in the cells of many cellular systems while in the -act of formation. In the elementary parts of animals which have long -since lost their cellular form, the remnants of kernels are frequently -found, as has been demonstrated in the preceding diagrams. The manner, -however, in which the elementary first-seen granules are formed in the -cyto-blastema, science has not yet been able to discover. The chemists -have proved that all elementary organic substances consist of carbon, -hydrogen, oxygen, and nitrogen, susceptible of endless modifications -of their respective forces, under which an organic molecule or ovum is -produced, and after that, under certain circumstances, an animal such -as man. - -177. When the current of blood through the main trunk of the arteries -of an extremity is cut off, the circulation is carried on by the -collateral branches. This collateral circulation is more perfect, more -active in young persons during the increase or growth of the body, -than it is either at maturity or in the decline of life. The important -point is not, however, alone referable to the time of life at which the -continuity and permeability of the main trunk cease to exist, but to -the nature of the disease or injury which has given rise to it. - -When an aneurismal limb has been injected, on which an operation has -not been performed, the collateral vessels have all been found larger -and more fully shown than on the opposite side, although not to the -same extent as in cases of a similar nature in which the operation has -been done. - -It is necessary that this enlargement of the collateral branches should -lake place at an early period, because in many cases of aneurism -the artery beyond or below the tumor is obliterated long before any -operation is performed. The main supply of blood has been already cut -off from the extremity, and the operation adds very little to the -derangement of the circulation which has for some time taken place -below the tumor. - -When an operation has been successfully performed for aneurism, and -the patient has died some time afterward, dissection has shown various -arteries enlarged, both above and below the part where the trunk was -obliterated by the ligature; and not only an enlargement of arteries, -which, from their regularity have received names, but others have -been developed not usually known to exist, or not of a size to be -conveniently traced. These through their frequent anastomoses bring the -blood at last into several large trunks, by which it is again conveyed -to the original vessel below all and every obstruction which may have -taken place; thus compensating by a circuitous route for the loss of -the direct supply. The principal object of inquiry is, do these vessels -always exist, or at what period of time do they begin to enlarge, so as -to enable them to carry on the circulation, in the manner in which it -is presumed to be done?--for few will assert that the enlargement of -these particular collateral vessels was an accidental play of nature, -and existed previously to the commencement of the disease or injury -for which the operation was performed. On this point, the theory of -the operation for aneurism and its applicability to wounded arteries -appears to hinge; and, what is of more importance, on which the -practice resulting from it depends. - -Two distinct kinds of collateral circulation are at present -acknowledged: one by direct large communicating arteries; the other -through the direct medium of the capillary vessels inosculating -with each other. Where direct communicating arteries exist, little -subsequent change beyond enlargement takes place in them. It is -otherwise with the indirect capillary vessels. When the radial or -ulnar artery has been divided in the hand, the blood will not only -flow readily from each end of the divided vessel, but equally red and -arterial from both, the communication being through direct arterial -branches from one vessel to the other. It will also be red and arterial -if the division take place at the wrist, and may be so in the brachial; -but if the femoral in the lower part of the thigh be wounded, the color -of the blood issuing from the lower end of the artery, if any issue at -all, will be _dark or venous_. It is so, because it has been obtained -from the capillary arteries, which in this case being empty received -blood by regurgitation from the veins, the valves of which when present -do not prevent its reflux course. If a limb be injected and carefully -dissected four or five days after a ligature has been placed during -life high up on the principal trunk, the capillary vessels will be -seen to be well injected; but few or none will be found large enough -to admit of their inosculation being traced throughout. If another -limb be injected and dissected, some sixty days after the ligature -has been applied, a difference will be distinctly observed between -the two preparations. In the latter, the capillaries will not appear -to be so fully injected, but several larger and more tortuous vessels -will be found in situations where they were not expected to exist; -and the anastomoses of these one with another, generally by arches, -may be traced to their communication with the principal trunk, both -above and below the obliterated part. If an incision were made in the -nearest pervious portion of the lower part of an artery in the thigh of -a person who had undergone this operation, arterial blood would issue -from it. The communication would have become direct by communicating -branches, and the capillaries would have returned to their accustomed -duties. - -178. During the first twenty-four hours after the division of an artery -such as the femoral, or the application of a ligature, the temperature -of the limb is commonly diminished; after that period, and as the -action of increase takes place, the temperature is usually from three -to five degrees higher than in the opposite healthy limb. At the end of -from eighteen to twenty-eight days, in a successful case, it is found -to be equal in both. - -It is asserted by some sanguine supporters of the all-powerful -influence of the collateral circulation, that it is sufficient at all -times, and under all natural circumstances, to maintain the life of -the extremity. The practice of the Peninsular war proved the fallacy -of this opinion in too many instances to admit of any doubt of its -inadequacy to do so in the lower extremity after the division of the -femoral artery, under ordinary circumstances. The fact of enlargement -or of a new development of vessels having taken place after the -commencement of disease or the reception of an injury, has been -demonstrated by dissection, and it is through them the life of the limb -is to be preserved; but time is required for their development. When a -limb is lost through mortification, as the consequence of a division -or obstruction of the principal artery, it usually takes place after -the infliction of a sudden injury, in consequence of these collateral -branches not having had time to enlarge. - -179. The collateral circulation is therefore not the same, and is not -in the same stage of preparation, in a limb suffering from a divided -or wounded artery, as in one in which an aneurism has for some time -existed; this is the reason why mortification is more common after -wounded arteries than after operations for aneurism. - - - - -LECTURE X. - -PROPER TREATMENT OF WOUNDED ARTERIES, ETC. - - -180. The due appreciation of the means adopted by nature and by art -for the suppression of hemorrhage, as well as the proper treatment of -wounded arteries, is owing to the surgery of the war in the Peninsula. -They were suspected after the battles of Roliça, Vimiera, Oporto, and -Talavera, but did not receive their complete development until after -the battle of Albuhera. It was not until after that of Toulouse they -were partially admitted; and it is only of late that they have been -almost everywhere acknowledged, taught, and practiced. - -Previously to the time of Mr. Hunter, the diseased or dilated state -of the coats of an artery which constitutes an aneurism was, when it -occurred in the ham, very often fatal. The operation of Anel, first -performed in 1710, of cutting down to the artery, and placing a -ligature upon it immediately above the dilated part, was not approved, -and Mr. Pott, the great contemporary of Mr. Hunter, recommended in bad -cases that amputation should be resorted to in the first instance; -although Desault had succeeded, in 1783, in a case of popliteal -aneurism, in which, after the manner of Anel, he had placed the -ligature on the artery a little above the aneurismal swelling in the -ham. Mr. Hunter’s contemplative mind, aided by his knowledge of anatomy -and of disease, led him to believe that the ligature thus applied on -the artery in the ham failed, because the vessel was unsound at that -part, and was therefore incapable of taking on those healthy actions -necessary for the obliteration of its canal above the ligature, -which are known to take place when the artery is in a normal state. -He concluded that this was sufficient to account for the failures, -without especially taking into consideration the difficulty of applying -the ligature in the ham immediately above the aneurismal sac, and -of the probability of the sac suppurating when thus molested; an -occurrence aiding materially in the necessity for the loss of the limb -by amputation, performed then under circumstances of constitutional -irritation, which would render it less likely to be attended with -success. - -From the consideration of these and other circumstances, Mr. Hunter was -induced to propose, in 1785, that the ligature should not be placed on -the artery near the tumor in the ham, but at a greater distance on the -fore part or middle of the thigh, and Scarpa subsequently recommended -it to be placed even higher--a recommendation which has been generally -followed, and the spot now selected for this operation is at the lower -part of the upper third of the thigh. This operation was therefore -performed not only for aneurism, but improperly for a wound of the -artery, not only in the ham, but even in the leg; it consequently -failed in almost every instance of traumatic injury, thus rendering -amputation necessary, which was generally followed by death. - -181. The Hunterian theory implies:-- - -1. That the artery is in general sound at the part in the front of -the thigh selected for operation, while it is usually unsound in the -popliteal space behind, or in the ham, where Desault operated, and -Anel recommended it to be done; that operation is now abandoned on the -continents of Europe and America, as well as in England. - -2. That a ligature can readily be placed upon it at a distance from the -disease in the fore part of the thigh, and will usually be followed by -success as far as concerns the obliteration of the artery immediately -below the part on which it is applied. - -3. That the artery being aneurismal, the collateral branches had begun -to enlarge, so as to be better able to carry on the circulation, after -the supply of blood to the lower part of the limb by the main trunk had -been cut off. - -4. That no branches of importance are usually given off between the -ligature on the artery on the fore part of the thigh and the sac of the -aneurism in the ham. - -5. That if such branches were ever given off, and brought the blood -from their collateral communications back into the main artery below -the ligature, and thence into the sac, so as to renew its pulsatory -movements, they would ultimately disappear, from the impelling force -not being sufficient to prevent a gradual coagulation taking place, -which would soon fill up the cavity of the sac, and thus prevent its -further enlargement; at which stationary point a process of removal -by absorption would begin and continue, until the diseased sac with -its contents had diminished, if not entirely disappeared, leaving only -a trace behind of its former existence, the process thus described -being frequently assisted by a commencing obliteration of the artery -immediately below the aneurism. The essential point in this theory, -which has immortalized the name of Hunter in surgery, depends on the -integrity of the aneurismal sac, which ultimately retains, as a general -rule, subject to rare exceptions, any blood which may be brought into -it, either by the collateral branches from above, or from below by what -may be called regurgitation, until it has become coagulated, when the -sac is so filled up that no more blood can pass into it to cause its -further distention, or any ulterior evil. - -This theory of Mr. Hunter, then so new, so beautiful in itself, was -eagerly embraced by nearly all the civilized world; and surgeons -were not content with applying it to cases of diseased or aneurismal -arteries, to which it is especially applicable, but they extended it -indiscriminately to cases of wounded arteries, to which the practice of -the war in Spain proved it was inapplicable, and in which I have, since -1811, maintained it could only succeed as a matter of _accident_, not -of principle. - -182. The essential features of the theory opposed to Mr. Hunter, with -respect to wounded arteries, and called mine, are:-- - -1st. That the artery at the wounded part is free from previous disease, -and may be expected to take on those healthy actions which, after the -application of a ligature, lead to the obliteration of its canal, and -the consequent suppression of hemorrhage. - -2d. That the circulation of the blood by the collateral branches is -less free in a sound limb than in one which has suffered during several -weeks from the formation of an aneurism. - -3d. That this freedom of circulation is less in the _lower_ than in the -_upper_ extremity, under all circumstances. - -4th. That mortification of the foot and leg, and often of the whole -limb, followed by the death of the person, is a common occurrence -after a ligature has been placed high up on the artery in the thigh, -in consequence of a wound; while it is not so common an occurrence -when such operation is performed in the same place for an aneurism of -several weeks’ duration. If the vein be also wounded, mortification is -almost inevitable. - -5th. That mortification of the hand and arm rarely follows the -application of a ligature to the artery of the _upper_ extremity in any -part of its course, however near the heart. - -6th. That when the collateral vessels are capable of carrying on the -circulation through the lower extremity, the _lower_ end of the divided -artery bleeds _dark_ or _venous_-colored blood, while its _upper_ end -bleeds _scarlet_ or _arterial_-colored blood. In the upper extremity, -the color of the blood from the lower end of the divided artery is -little altered--a consequence of the greater freedom of anastomosis, or -of the freer collateral circulation in the upper extremity. Facts of -the greatest importance in surgery. - -7th. That whenever the collateral vessels are not capable of carrying -on the circulation of a limb, mortification or death of the part -ensues; and _that whenever this collateral circulation is sufficient to -maintain the life of the limb, blood must pass into the artery below -the wound, and must, as a general rule, pass up and out through the -lower end of the divided artery, unless prevented by the application of -a ligature, or by some accidental circumstance, forming an exception to -the rule, but not the rule itself_. - -8th. That the collateral branches are capable of bringing blood into -the artery above the aneurismal sac and between it and the ligature, -is admitted in the Hunterian theory, which blood the aneurismal sac -receives, and usually retains. When the artery is a wounded artery, -and the ligature is applied at a distance above the wound, blood is -often brought into it below the ligature in a similar manner; but as -there is _no aneurismal sac_ to receive and retain it, the patient -bleeds perhaps to death, unless surgery come to his assistance. - -9th. The presence of an aneurismal sac in one case, and its absence in -the other, is the essential difference destructive of the Hunterian -theory for the treatment of aneurism being applicable to that of -wounded arteries. - -10th. The processes for the natural suppression of hemorrhage are -somewhat different in the upper and lower ends of an artery, and are -less capable of resistance in the lower. This end frequently yields -to the pressure of the blood regurgitating from below, and renews a -bleeding which may have been suppressed for weeks, unless its closure -has been rendered more permanent by the application of a ligature. - -11th. The absence of the aneurismal sac renders the application of two -ligatures absolutely necessary, one on each end of a divided artery, or -one above and one below the wound, if the artery should not be divided; -constituting the most essential feature of my theory, and the principal -point to be attended to in the treatment of wounded arteries. - -12th. This bleeding from the lower end of the vessel, which is more -or less of a venous color, and issues in a continuous stream, may be -restrained by compression properly made on the course of the lower part -of the wounded artery; but in no instance should recourse be had to -a ligature on a distant part of the artery above the seat of injury, -until every other possible effort to arrest the hemorrhage from the -lower end of the vessel has failed. - -13th. The great principles of surgery to be observed in cases of -wounded arteries, and which ought never to be absent from the mind of -the surgeon, are two in number:-- - -1. That no operation ought to be performed on a wounded artery unless -it bleed. - -2. That no operation is to be done for a wounded artery in the first -instance but at the spot injured, unless such operation not only -appears to be, but is impracticable. - -183. The means adopted by nature for the suppression of hemorrhage -have been investigated by Celsus, Rufus, Galen, Œtius, etc., down to -Dr. Jones, the most important English writer on this subject; but the -methods of inquiry they all adopted appear to have been insufficient -and unequal to the object in view. They bled an animal until he died, -and then reasoned on the manner or means by which the bleeding was -suppressed, when it was in fact arrested by death. It is obvious, then, -that it is only when nature has not been interfered with, and the -patient has not died from bleeding continued to the last moment, but -has, on the contrary, lived some time after the hemorrhage has ceased, -that the processes by which its suppression has been accomplished can -be fairly investigated. These processes essentially depend on the size -and variations of structure in an artery, which have been shown to be -dissimilar in large and small arteries, and not even quite alike in the -upper and lower ends of the same artery--facts which were elicited from -observations made on men on the field of battle during the Peninsular -war, and consequently not liable to error. It was then proved that -arteries of moderate dimensions, such as the middle part of the femoral -or the axillary, tibial or brachial, and particularly all below these -in size, are capable, by their own intrinsic powers, when completely -divided, of arresting the passage of the blood through them without any -assistance from art, or from the surrounding parts in which they are -situated. The establishment of this fact overthrew at once the theory -which relates to the importance of, and necessity for, the sheath of -the vessel, and the offices it performs in suppressing hemorrhage -in vessels of this size, and in a great measure that supposed to be -derived from the formation of an external coagulum, the _bouchon_ of -the French. - -184. When the femoral artery has been fairly divided in the lower part -of the thigh, the patient has, in almost all the cases which have come -under observation, either died without assistance, or the hemorrhage -has ceased spontaneously. Having been thus arrested for twelve hours, -the efforts of nature are usually sufficient to prevent its return -from the _upper_, although not from the _lower_ end of the vessel; but -then it is of _venous_ and not of _arterial_ color--a fact I first -demonstrated, and which is now acknowledged to be of the greatest -importance. The great evil to be dreaded in such cases is not from -hemorrhage from the _upper_ end of the divided artery, but from the -_lower_, and from _mortification of the foot_. - -The _upper_ end of an artery retracts on being divided, and this -retraction is accompanied by a contraction of the cut extremity of the -vessel, which assumes the shape of the neck of a French wine-bottle -or Florence oil-flask. The contraction is confined in the first -instance to its very extremity, so that the barrier opposing the flow -of blood is formed by this part alone. The contraction, however, goes -on increasing for the space of an inch; it is usually filled up with -an internal coagulum of a round, pyramidal shape, adhering firmly to -the contracted end of the artery, loose at its apex, and extending -frequently as far as the first collateral branch, but rarely under -any circumstances beyond two inches; the very orifice of the artery -on the outside being in a few days covered by a layer of a yellowish -green-colored substance or fibrin, which indicates its situation in a -remarkable manner. Some of these processes are continued even after the -external wound has healed; the artery generally goes on diminishing and -contracting as far as it is useless, so that of three or four inches, -from one to two may be impervious, the remainder being contracted, -although still permeable by a probe. An accompanying nerve, where there -is one, would do the reverse, the cut extremity would become enlarged -or bulbous, gradually diminishing as it is traced upward, until it -regains its proper size. - -The processes adopted by nature for closing the lower end of a divided -artery of the size of the femoral at the inferior part of the thigh -are somewhat different from those employed at the upper or opposite -extremity. The retraction or contraction of the _lower_ end of a -divided artery is neither so perfect nor so permanent as at its _upper_ -end, and the small internal coagulum is in many instances altogether -wanting, or very defective in its formation. The closure of the lower -orifice being less perfectly accomplished than of the upper, it is -the more likely to suffer from secondary hemorrhage, which may be -distinguished from that from the upper end of the artery at an early -period after the accident, by the _venous color of the blood, and from -its flowing or welling out in a continuous stream, as water rises from -a spring, and not with an arterial impulse_. - -The retracting and contracting powers in the lower end of a divided -artery are nevertheless considerable, and are sufficient in some cases -to nearly close the lower end of the femoral artery when divided by -amputation above the knee. When the femoral artery is cut across, the -lower portion of the vessel is emptied by its last efforts, combined -with the action of the capillaries. When the collateral circulation -is powerful, blood soon regurgitates into the artery, but the force of -the regurgitation can be in no proportion to that of the propulsion at -the other or _upper_ divided end of the vessel, which will generally -be able to resist this impulse, while the _lower_ one often opens and -bleeds after the lapse of a few days. In all the cases I have had an -opportunity of examining, in which hemorrhage had taken place from the -lower end of the artery, the following appearances were observable -after the interval of from four to five days. - -The same kind of yellowish-green matter marks and conceals the -situation of the lower extremity of the artery in the wound as it -does the upper. It is, however, thinner where it immediately covers -the end of the artery, which in none of these cases was contracted in -the conical manner described as taking place in the upper extremity. -On the introduction of a probe with the greatest gentleness into the -artery from below, it usually makes its appearance at a point on the -yellow space, raising a thin portion as it protrudes. On laying open -the artery, the orifice would seem to have been once closed by this -layer of fibrin, but with a less degree of contraction than the upper -end of the same artery; the layer still, however, forming an obstacle -sufficient to cover and close three-fourths of the orifice, the blood -having flowed through the remaining fourth, which had probably given -way by accident; which accident is usually some sudden or continued -motion being given to the extremity or part injured, and which motion -it is imperatively necessary to avoid, when the lower end of a wounded -artery has not been secured by ligature. - -A soldier, who had his arm carried away by the bursting of a shell at -the siege of Ciudad Rodrigo, was brought to me shortly afterward. The -axillary artery, becoming brachial, was torn across, and hung down -lower than the other divided parts, pulsating to its very extremity. -Pressed and squeezed in every way between my fingers in order to make -it bleed, it still resisted every attempt, although apparently by the -narrowest possible barrier, which appeared to be at the end of the -artery, and formed by its contraction. The orifice of the canal was -marked by a small red point, to which a very slight and thin layer -of coagulum adhered, the removal of which had no influence on the -resistance offered by the very extremity of the artery to the passage -of blood through it. In this, and in another instance of a similar -nature, the end of the artery being cut off at less than an eighth of -an inch from the extremity, it bled with its usual vigor. In both, the -vessel for near that distance was contracted so as to leave little or -no canal at its orifice, which in these cases was filled by a coagulum -of the size and shape of a very small pin. - -[Illustration: - - 1. Axillary artery. - 2. Axillary vein. - 3, 3. Branches of axillary plexus of nerves. - 4. Curved, pointed and plugged ends of the artery and vein. - - The vessels are here represented as they lay exposed in the lacerated - parts. The pointed and plugged ends of the vessels were of a dark - coagulum color, while above both artery and vein had a reddish, - vascular appearance, and were held in close relation by their sheath. - The artery bent distinctly to the very base of the coagulum.] - -Mr. Deputy Inspector-General Taylor informs me that a soldier of the -44th Regiment was struck by a cannon-shot on the 21st of June, 1855, in -front of Sebastopol; it carried his left arm away from the shoulder, -leaving the artery, vein, and nerves exposed as in the accompanying -sketch. The thought, he says, crossed my mind, as I held the artery -between my finger and thumb, that it might be for the benefit of -the patient to place a ligature on the artery at the highest point, -exposed, cutting off the part below, having had a precisely similar -case at Ferozeshah, in India, in which the soldier recovered without -the artery being tied, or any hemorrhage recurring. The shot, in -carrying away his arm, struck him very severely on the chest, and -I fear has injured the lungs, but there is so much ecchymosis that -the presence or absence of sounds cannot be distinguished by the -stethoscope. Of this injury of the chest the man died some days after -its receipt. The body was buried without examination, but no hemorrhage -had taken place from the wound. - -Private J. Barnes, 29th Regiment, on the 16th of May, 1811, at the -battle of Albuhera, received a musket-ball in the right thigh, behind -and above the knee, inclining downward and inward, close to the -condyles of the femur, and in the direction of the femoral artery -becoming popliteal; it bled violently at the moment, and so continued -for a few minutes, during which time he conceives he lost two quarts of -blood. It then ceased, and he was dressed in the usual slight manner, -and remained two days upon the field of battle, until removed to -Valverde, nine miles, on a bad road, on men’s shoulders, in a blanket -converted into a bearer. He was considered as one of the slighter -cases, until the gentleman in immediate charge of him requested me to -see him, on account of his toes being in a state of mortification. - -On the evening of the 3d of June, eighteen days after the accident, -the man was placed on a bullock car, to be removed with the rest of -the wounded to Elvas, the mortification of the foot having ceased to -increase, and a line of separation having been formed. Shortly after -the cars moved, I was informed that he was bleeding from the wound: it -evidently appeared to flow from the popliteal artery; and as it issued -slowly, I supposed from the lower divided end. The foot being partly -lost, I determined on amputation above the knee, which was performed -at Olivença. The amputated limb was sent after me to Elvas, that it -might be examined at leisure. I carefully traced the course of the -wound, and found in it a little coagulated blood, but could not see the -mouth of the vessel. A probe passed into the upper end of the artery -was obstructed before it reached the ulcerated surface by nearly an -inch; and on passing it up the lower one, it was stopped exactly in the -middle of the track of the ball, by a veil or substance drawn across -the mouth of the vessel, which, on careful examination, showed the -point of the probe at one part of the circle, although too small to let -it through; from this part I conceive the hemorrhage came. The divided -ends were one inch apart. The _upper_, or femoral portion, for nearly -an inch, contained a firm coagulum, filling up that part of the artery, -which had contracted like the neck of a claret bottle. The _lower_ or -popliteal portion of the artery had a very peculiar appearance; the -substance drawn across appeared to have closed it completely at one -time, and to have given way from the rough motion of the car at the -point now open, which was very small even when the sides of the artery -were approximated. A very little soft coagulum was behind it; and if -the man had not been removed, the vessel might have remained secure. -This case shows very distinctly the means adopted by nature for the -suppression of hemorrhage from both ends of a divided artery. - -Corporal Carter, of the pioneers of the 29th Regiment, was wounded -at the battle of Roliça, in August, 1809, by a musket-ball, which -passed through the anterior and upper part of the forearm, fracturing -the ulna. Shortly afterward a profuse hemorrhage took place, and the -staff-surgeon in charge tied the brachial artery. In the night the -hemorrhage recurred, and the man nearly bled to death. The arm was then -amputated, when the ulnar artery was found in an open and sloughing -state. - -_Remarks._--A simple incision to expose the wounded artery, and placing -two ligatures upon it, would have saved this man his arm and his life. - -At the battle of Vimiera, which followed a few days afterward, a -soldier received a somewhat similar wound, save that the brachial -artery bled forthwith, the hemorrhage being stopped by the tourniquet. -Warned by the preceding case, I cut down on the artery, carefully -avoiding the nerve, which had been tied in the former instance, and -found the artery more than half divided. It was secured by a ligature -above and below the wound: the bleeding did not afterward return, and -the man recovered. - -185. Thomas Carryan, of the 3d Regiment, was wounded at Albuhera, on -the 16th of May, 1811, on the inside of the calf of the right leg, -the ball passing out on the fore and outside of the tibia: it bled -considerably for some minutes, when it ceased, and the hemorrhage -did not return until the 15th of June, on which day a little blood -followed the dressings, and increased on the patient making any -exertion; so that on the 4th, the gentleman under whose care he was -tied the femoral artery on the outside of the sartorius muscle, which -suppressed the hemorrhage for that day, the limb continuing with little -or no interruption of the same temperature to the hand as the other. On -the 5th, the original wound had a bad appearance, and some coagulated -blood was readily pressed out of it; on the 6th, a greater quantity -came away; and on the 7th, the exertion of using the bed-pan was -followed by a stream of arterial blood, which ceased on tightening the -precautionary tourniquet. - -The limb was amputated above the ligature on the artery. Its dissection -showed the anterior tibial artery to have been destroyed for some -distance, and the muscles on the back part of the leg nearly in a -gangrenous state. The patient died a few days afterward. - -_Remarks._--If an incision had been made in the leg so as to expose the -artery, and ligatures had been placed on it above and below the wound, -the man, in all probability, would not have died. - -Sergeant William Lillie, of the 62d Regiment, aged thirty-two, was -wounded in the right thigh, on the 10th of April, at the battle of -Toulouse, by a musket-ball, which passed through, in an oblique -direction downward and inward, close to the bone, describing a track of -seven inches. The ball was extracted behind on the field. He said he -had bled a good deal on the receipt of the injury, which he had stopped -by binding his sash round the limb. The discharge from the wound was -considerable; it appeared, however, to be going on well until the -20th of the month, when, on making a sudden turn in bed, dark-colored -blood flowed from both orifices of the wound in considerable quantity. -I had given an order, as the Deputy Inspector-General in charge of -all the wounded, that no operation should be performed on a wounded -artery without a report being sent to me, and an hour at least granted -for a reply, unless the case were of too urgent a nature to admit of -it. It appeared to be so in this instance, and before I arrived Mr. -Dease had performed the operation for aneurism at the lower part of -the upper third of the thigh. I could only express my regret that it -had been done, and point out the probability of the recurrence of the -hemorrhage from the lower end of the artery, which took place on the -7th of May, when the limb was amputated, and the man subsequently died. -On examination the artery was found to have been divided exactly where -it passes between the tendon of the triceps and the bone. The upper -portion of the artery thus cut across was closed. A probe introduced -into it from above would not come out at the face of the wound, -although the impulse given to this part on moving it was observable in -the middle of a large, yellowish-green spot, which I had previously -declared to be the situation of the extremity of the artery which had -contracted behind this, in the shape of a claret bottle, for about an -inch, having within it a small coagulum. The lower end of the artery -from which the hemorrhage had taken place was marked by a spot of a -similar character; but on passing a probe upward from the popliteal -space, it came out at a very small hole in the extremity of the artery, -in the center of the yellow spot, the canal of the artery not being -contracted and diminished, but only apparently closed by a layer of the -yellowish-green matter laid over it, and adhering to its circumference. - -Sergeant Baptiste Pontheit, of the French 64th Regiment, was wounded -by a musket-ball at the battle of Albuhera, on the upper and fore part -of the thigh; it passed out behind, in the direction of the femoral -artery. He lost a great quantity of blood before the hemorrhage ceased, -but the wound went on well until the 26th, ten days after the battle, -when he felt something give way in his thigh, and found himself -bleeding from the wound, which, however, soon ceased on pressing his -hand upon it. In the afternoon, on again moving, he lost about half -a pint of florid blood, which induced the surgeon on duty to place a -tourniquet on the limb. When at leisure (in the course of two hours) I -removed the tourniquet, and as no hemorrhage occurred, and there was -no swelling in the vicinity of the wound, I replaced the dressing with -a precautionary screw tourniquet, explaining to him its use, and the -probable nature of his wound, together with the operation requisite to -be performed in case of further bleeding. - -On turning in bed at night he lost a little more blood, which ceased -on his tightening the tourniquet, which was shortly after loosened. In -the morning, everything being removed, there appeared some swelling -about the wound, the opening of which was filled up by a coagulum: -gentle pressure being made, it readily turned out, and was followed -by a stream of arterial blood, leaving little doubt of the femoral -artery being wounded. Compression being effected in the groin, I -made an incision three inches and a half in length, taking the wound -as a central point, and exposed the femoral artery and vein: both -were wounded, the former being half destroyed in its circumference, -surrounded with coagulated blood, and appearing as if it had sloughed -from being touched by the ball, the course of which was directly -past it, and would have carried it away if it had not been for the -elasticity of the artery. A ligature placed above, and another below -the wound, secured both artery and vein; the incised wound was brought -together by adhesive plaster, and the limb placed in a relaxed -position. The operation was of short duration; he lost little or no -blood, but, the circulation was very languid, and the man exceedingly -low. The warmth of the leg and foot was soon below the standard of the -other; warm flannels were applied, and some brandy was given to him. -In the evening the heat was more natural, and the man returned thanks -for the humanity and kindness shown to him, congratulating himself and -me upon the success of an operation which he had supposed would be -infinitely more severe. The next morning he ate a tolerable breakfast, -but felt a pricking sensation in the calf of the leg, which was as -warm to the hand as the other, but the foot was cold. The second day -the swelling of the limb, its appearance, and discoloration on the -under part, indicated approaching mortification, which on the third was -evident, and on the fourth, at mid-day, he died, the limb up to the -wound being nearly all in a gangrenous state. No adhesion had taken -place in the wound, or in the artery, which showed the inner coat cut, -the ligatures being firm, and no coagulum behind them. - -Captain St. Pol, of the 7th or Royal Fusiliers, was wounded in the -ham from behind, while in the ditch at the foot of the great breach -at Badajos. He fell instantly, and lost, as he thinks, a considerable -quantity of blood. On recovering he was raised from the ground, and -walked a few paces prior to his being carried to his tent, where I -saw him in the afternoon of the next day, the 7th. The leg had ceased -to bleed before his arrival in camp. A substance could be felt on the -inner side of the patella, which, by the sensation communicated to the -finger on moving, appeared to be the ball, which was extracted. Some -dark-colored blood issued from the cavity; the ball was lying loose -and unconnected; the finger, on being passed into the joint, which was -swollen, discovered no splinters of bone, and the entrance of the ball -behind would not admit the finger. His having walked some distance on -the leg, and the absence of any splinters between the articulating -extremities of the bones, induced Dr. Armstrong, the surgeon of his -regiment, and myself to think that the ball had entered with little -injury to the bone; and after stating to the patient the little hope we -had of ultimately saving the limb, independently of the great danger -to which he was exposed, compared to the certainty of the operation of -amputation at the moment, we recommended its being done, but he would -not consent. The next day he was removed to Badajos on a litter, the -heat of the tent being unsupportable. - -On the morning of the 9th I saw him early, when the want of circulation -in the foot was evident from its having lost its natural color and -warmth; the knee was swollen, but not painful, and I had no doubt that -the artery had been divided by the ball. The marbled appearance and -tallow-white color soon indicated the loss of the leg above the calf; -and vesications had formed on the foot, already of a green color. - -On the 12th, the extent of the gangrene was defined on the back of the -knee up to the original wound at its lower edge, gradually receding -as it advanced to the fore part of the leg, which for three inches -below the knee was apparently sound; the uneasiness of the knee being -moderate, and the incised wound looking perfectly healthy, although the -latter had not united. - -On the 16th, the separation of the dead from the living parts having -taken place behind, and being well marked and commencing on the fore -part, the limb was amputated as low down as possible. Sixteen vessels -were tied; the parts were gently brought together, without any hope of -union. According to subsequent experience, this operation should not -have been performed. The dead parts only should have been removed, and -the stump left to nature until the health was perfectly restored. - -On the 24th he died. - -On examining the amputated limb, the popliteal nerve was found -untouched, the ball having passed on the inside; the popliteal vein -was also entire, having a small tumor adhering to its under part -between it and the artery, the divided end of which was closed by a -yellowish-green firm substance readily distinguishing it from the -surrounding parts. On clearing the whole from the bone, and making a -small circular opening into the tumor, which was elastic and covered -with brown fibrous layers, it proved to be an aneurismal sac, smooth on -the inside, containing florid arterial blood and some little coagula. -The artery, on being carefully opened to the closed end, appeared to -have been injured above the part divided by the ball, and communicated -with the sac by a small fissure or rupture. The end of the artery was -then slit up, so as to show the very little thickness of the closing -substance and the great original contraction of the diameter of the -vessel. There was no internal coagulum, neither was there any laid over -the external part of the artery; between it and the bone there was a -coagulum about the size of a small phial cork. The other end of the -artery could not be found, from the gangrenous state of the parts. - -Private P. Turnbull, of the grenadiers of the 74th Regiment, of good -stature, was wounded on the 10th of April, 1814, at Toulouse, by a -musket-ball passing from the inside to the outside of the middle of the -thigh; he says it bled considerably at first, but the bleeding soon -ceased; the wound was not painful, and he thinks he observed the leg -and foot to be colder than the rest of his body for the first two or -three days, but did not much attend to it, further than conceiving the -numbness, coldness, and impeded power of motion as natural to the wound. - -On the 18th of April, the gentleman in charge of this patient pointed -him out to me as an extraordinary case of gangrene coming on without, -as he supposed, any sufficient cause. The wound on the outside of the -thigh, or the exit of the ball, was nearly healed, and that on the -inside was without inflammation or tumefaction, and with merely a -little hardness to be felt on pressure. The pulsation of the artery -could be distinctly felt to the edge of the wound, but not below it; -the leg was warm, the gangrene confined to the toes. The artery of -the other thigh could be distinctly traced down to the tendon of the -triceps. As he was at a small hospital, about two miles from town, -on the field of battle, I did not see him again until the 20th, and -afterward on the 23d, when, although the gangrenous portion included -all the toes, it had the appearance of having ceased. Satisfied that it -would again extend, I left directions with the assistant-surgeon that -the limb should be amputated _below the knee_. - -The surgeon, whom I had not seen, and who did not understand the -subject, disobeyed the order, conceiving that there must be some -mistake. On visiting the hospital, a little after daylight on the -25th, I was greatly annoyed at finding that the operation had not -been done, and that the mortification had begun to spread the evening -before. It was then too late. On the 26th it was above the ankle, -with considerable swelling up to the knee. At night the man died; and -the next morning, at six o’clock, I removed the femoral artery from -Poupart’s ligament to its passage through the triceps, which part was -affected by the mortification. - -The ball had passed between the artery and vein in the spot where -the vein is nearly situated behind it and adherent only by cellular -membrane, through which the ball made its passage, the coats of the -vein being little injured, and those of the artery not destroyed in -substance, although bruised; it was at this spot much contracted in -size, and filled above and below by coagula, which prevented the -transmission of blood, and the vein above and below the wound was -filled by a coagulum and was also impassable. This preparation is -unique; it is perhaps the only one in existence proving the elasticity -which vessels possess, and their capability of avoiding to a certain -extent an injury about to be inflicted upon them. It is in the museum -at Chatham. - -186. When a round and small ligature is properly applied to an artery -of a large size, such as the femoral, the sides of the vessel are -brought together in a folded, plaited, or wrinkled manner; the ancient -inner and middle coats of the artery, including the modern four, are -divided, while the outer one remains entire and apparently unhurt. If -the ligature be removed, an impression or indentation made by it on the -outer coat will remain as a mark; and if the artery be slit open in a -careful manner, the division of the inner coats will be obvious. These -changes were known to Desault, and are mentioned by Deschamps in his -work on the Ligature of Arteries. They were more satisfactorily proved -to occur by Dr. Jones, and have been clearly stated by Mr. Hodgson and -others. The remaining part of the process differs from the account they -have given, and, according to observations I have had opportunities -of making on the living and on the dead, is as follows: the inner and -middle coats, formed by four distinct layers or structures, are not -only divided, but the inner ones particularly appear to be curled -inward on themselves, so that the cut edge of one half or side is not -applied to its fellow in the usual way of two surfaces, but by curling -inward meets its opponent on every point of a circle, and in this -way forms a barrier inside that of the external coat, which is tied -around it by the ligature; so that, in fact, when a small ligature is -firmly tied, its direct pressure is not applied to the inner coats, -which have been divided and have curled away from it, but to the two -layers of the outer coat, which are in consequence of that pressure -made to ulcerate or slough--processes which could scarcely fail to -take place also in the other coats if they were subjected to pressure -in a similar manner. The cut edges of the four inner layers being from -this provision of nature perfectly free, are capable of taking on the -process of inflammation, which stops at the adhesive stage. This they -do by the effusion of lymph or fibrin both within and without, to a -greater or less extent as the case may require. The outer coat of the -artery must either yield by ulceration or sloughing, or the ligature -must remain until it is decomposed and destroyed. It usually yields by -sloughing, in consequence of its being deprived of life by the pressure -of the ligature, which is left at liberty by the ulceration which takes -place in the sound part of the artery immediately above and below the -part strangulated, which part is frequently brought away in the noose. -The artery does not always yield by sloughing, particularly if it be a -large one and the ligature thick and soft. In this case, a part of the -outer coat, and particularly the white, inelastic substance, from its -folding or plaiting under the ligature, seems to escape that degree of -pressure necessary to destroy it; and when the remaining part yields, -it continues entire, and is only removed by a subsequent process of -ulceration occasioned by its irritation as an extraneous body. - -In such cases, the layers of the external coat could not close around -the inner ones, which are thus shown to be capable of forming an -effectual barrier without it, although it materially assists in giving -greater strength to the cicatrix, by the effusion of fibrin which takes -place within, without, and around. - -While this process is going on without, and at the very extremity of -the artery, the vessel is gradually contracted above it, and its coats -become more or less inflamed, soft, and vascular. The inner layers -are seen to be wrinkled transversely, and a small coagulum of blood -is formed within them. This sometimes completely fills the artery, -but it is more common for a small, tapering coagulum to be formed, -adhering by its base to the extremity of the vessel; the white color -of which renders it distinctly observable, when contrasted either -with the coagulum or the inner coat of the artery, which latter is -usually of a red or scarlet color while the inflammatory action is -going on. A coagulum, contrary to the usually received opinion, is not -absolutely necessary to the permanent closure of the artery, although -it certainly assists in maintaining it. An artery is also supposed to -contract gradually up to its first collateral branch; but this is not -always the case, and depends entirely on the use for which the branch -is required. After amputation at the middle of the arm, the artery will -go on diminishing in size up to the subscapular branch, the circumflex -arteries diminishing in proportion, in consequence of their being so -much less necessary than before the operation. In several instances the -principal artery has remained pervious below the collateral branch, the -next immediately above the part where the ligature has been applied. -Neither will the presence of a collateral branch immediately above -where the ligature has been placed upon the artery always, although -it sometimes may, interfere with the consolidation of the wound, and -the closure of the canal of the vessel. It may impede the process, -and render it for a time less safe, and in some instances it may -prevent it altogether, but I have so often seen large arteries, heal -after division close to the giving off of a considerable branch, -that I consider them to be always capable of doing so, provided they -are naturally sound. If they are not sound, it is very doubtful what -process may take place; but it will be less likely to be a healthy one, -if interfered with by the immediate proximity of a collateral branch. -The power which suppresses hemorrhage in a bleeding artery resides, it -must be borne in mind, in the very extremity of the vessel itself. It -is, however, advisable to take care that a ligature shall be applied -above rather than immediately below a branch given off from a trunk, -more particularly when it may be doubted whether the trunk is free from -disease. - -In 1834 I placed a ligature of strong dentists’ silk on the right -common iliac artery of a lady of middle age for a swelling in the -hip, supposed to be a gluteal aneurism, which, after commencing the -operation, was found to occupy a considerable part of the iliac region. -The lady died a year afterward, and it was then found that the ligature -had been applied at the distance of five-eighths of an inch from the -bifurcation of the aorta, and three-eighths of an inch above the origin -of the internal iliac, independently of the line of separation between -the parts of the iliac divided by the ligature, which did not seem to -be wider than the ligature itself. The separated ends were united at -the point of separation by new matter, the orifice or end of each being -closed by a very narrow barrier, the inner coat of the artery being -redder than natural, somewhat irregular and contracted, and containing -hardly any coagulum. _The fact was thus proved in the largest artery -in the body save one, that a coagulum is not necessary for the safety -of the union, while the immediate vicinity of so large a vessel as the -internal iliac, to say nothing of the aorta itself, also proves that -the danger hitherto expected from the neighborhood of a collateral -branch is more imaginary than real_--two great facts the practice of -the Peninsular war led me to declare, and which ought no longer to be -doubted. - -The preparation exemplifying these points is in the museum of the Royal -College of Surgeons, together with the ligature still carrying in its -noose the portion of the artery it strangulated and brought away with -it. - -187. A ligature should always be round and small, provided it be -sufficiently strong. The strength of a ligature is variously estimated; -some surgeons trying it by the strength of their own fingers, others -by what they conceive to be the resisting power of the coats of the -artery, in which perhaps they may err. The only way in which a surgeon -can hope to acquire correct information on this point is by trying on -the dead body what force of fingers is required to cut the inner coats -of arteries of various sizes; and then taking the least force required -for this purpose, to ascertain whether he can easily pull the ligature -over or off the divided end of the artery. If a surgeon will take the -trouble to do this, he will find that he has estimated the necessary -force much too highly, and that he is in more danger of breaking his -ligature than of failing to secure the artery. Hemorrhage has, however, -been known to occur from the ligature having slipped off the end of an -artery, which had been divided in the operation for aneurism, although -I have never seen it happen after amputation, where the vessels were -tied with a small, firm ligature. It constitutes a valid objection to -the division of the artery between the ligatures, when two are applied. - -A ligature composed of one strong thread of dentists’ silk, well waxed, -is sufficiently firm for the largest artery. It does not, however, much -signify what may be the shape, size, form, or substance of ligatures, -when they are applied to arteries in a sound state, provided they are -not too large, are fairly and separately tied, and with a sufficient -degree of force to retain the ligature in its situation until separated -by the usual processes of nature, which generally take from fourteen to -thirty days for their completion. - -188. When arteries are unhealthy, the selection and proper application -of a ligature are points of great importance. A larger although yet a -small, round ligature should be fairly, evenly, and firmly, although -not so forcibly applied as on a sound artery; without the intervention -of any substance whatever between it and the cellular covering of the -vessel. The secondary hemorrhages which are recorded by different -writers as prone to occur, and which did take place, happened, I am -disposed to believe, more from the application of improper ligatures -than from any other cause; for the inner coat of an artery is so prone -to take on the adhesive state of inflammation that if a strong, small -ligature be applied in the manner directed, it is more than probable -that the closure of the artery will be effected. Ulceration will, -however, sometimes take place on the inner coat of the vessel, and -slowly extend outward, undoing in its progress any steps which may have -been begun for the consolidation of the extremity of the artery. When -a secondary hemorrhage does occur from this or from any other cause, -it is usually from the beginning of the second to the fourth week; but -there is no security for the patient until after the ligature has come -away, unless it is retained an inordinate length of time, from having -included some substances which do not readily yield under irritation, -such as the extremity of a nerve, or a slip of ligament which is not -sufficiently compressed in the noose of the ligature. - -Secondary hemorrhage may also take place from the extension of -ulceration or sloughing to the artery from the surrounding parts, and -perhaps as frequently as from any other cause; but when mortification -occurs, there is no secondary hemorrhage, unless in that species -which is called hospital gangrene. The advantages to be derived from -the application of a strong, small ligature, from the least possible -disturbance of the surrounding parts, and from absolute quietude, while -the healing processes are going on, must be so obvious as to require -no further observation. An undue interference with the ligature, by -pulling at it, cannot be too earnestly deprecated at an early period; -although, at a subsequent time, some force is occasionally required for -its removal after amputation. - - - - -LECTURE XI. - -THE FEMORAL ARTERY, ETC. - - -189. When the femoral artery is _cut across_ in the upper part of -the thigh, whether it be done by a cannon-shot, a musket-ball, or a -knife, the patient does not always bleed to death at once, although he -frequently dies after a time in consequence of the shock and the loss -of blood. - -At the battle of Toulouse a large shot struck an officer and two men -immediately behind him, and nearly tore off the right thigh of each. -The artery was divided about, or less than three inches below Poupart’s -ligament. I saw the officer shortly afterward, in consequence of his -surgeon saying it was a case for amputation at the hip-joint. The -bleeding had ceased, the pulse was feeble; the countenance ghastly, -bedewed with a cold sweat, and with every indication of approaching -dissolution. The house being at an advanced point, and close to one -of the French redoubts, the fire of round shot and musketry was so -severe upon and around it as to induce me to remain, until the battery -should be taken by the troops then advancing upon our flank. In order -to occupy my time usefully, I returned to the officer, and found he -had just expired. Desirous of seeing by what means the hemorrhage had -been arrested, I cut down upon the artery, took it carefully out, and -found that its divided end was irregularly torn; a slight contraction -had taken place just above, but not sufficient to have been of the -slightest utility in suppressing the bleeding, which was in fact -prevented by an external coagulum, which filled up the ragged extremity -of the vessel, and which in a few days, if he had lived, would have -been removed with the purulent discharge, an internal one forming -in the mean time, the extremity of the artery also contracting and -retracting, so that a secondary hemorrhage might not have taken place, -indeed would not in the generality of instances. - -At Salamanca I had the opportunity of examining the thigh of a French -soldier, whose femoral artery had been divided perhaps even higher up -by a cannon-shot. He lived until the next morning, when I saw him, no -operation whatever having been attempted, nor a tourniquet applied. -He died exhausted, but not from any immediate bleeding, which, when -once stopped, had not returned. The artery was in a similar state to -the preceding one, with this slight difference, that the orifice was a -little more contracted; the external coagulum filled up the ragged end -of the artery, and was slightly compressed within by the contraction, -which kept it in its place. The rest of the coagulum filled the hollow -in the surrounding parts, which the retraction of the artery had -occasioned. In this case, so unlike those I have hitherto noticed, the -first natural cause giving rise to the suppression of the bleeding was -the diminution of the power of the heart; the second, the formation of -a coagulum in the hollow of the sheath left by the retraction of the -artery. Contraction had begun, but had done nothing essential. (See -_Aph._ 413.) - -In other instances in which I have examined the extremities of such -large arteries when divided, the appearances have been more or less of -a similar nature; unless where the persons had died immediately, when -the torn extremities were found quite open, with little surrounding -coagulum. I have, however, seen persons wounded in this manner live -for several days, when I have found, after death, the extremity of the -artery open, and no appearance of blood having passed into it below -Poupart’s ligament. The consent necessary between the inner coat of the -artery and the blood for the free passage of blood had been destroyed -by the injury. - -190. A _small puncture_ in an artery, made with a needle, will -sometimes heal, as it generally does in dogs. I have, however, seen -several instances in which the femoral artery was wounded by a -tenaculum, during amputation, and a secondary hemorrhage followed, -requiring the application of a ligature. A _larger puncture_, or a -longitudinal slit of from one to two lines in extent, does not commonly -unite, except under pressure, although the edges of the wound may -not always separate so as to allow blood to issue in any quantity. -It sometimes only oozes out, and occasionally does not do even that, -unless some obstacle to the circulation takes place below, when blood -is propelled with a jet; and the edges of the cut having thus been -separated, blood continues to be thrown forth in considerable quantity. -In an artery of the size of the temporal, a small longitudinal slit -may sometimes heal without the canal of the artery being obliterated, -although this very rarely takes place in one of a large calibre. - -In all cases of punctured wounds, when pressure can be effectually -made, and especially against a bone, it should be tried in a graduated -manner over the part injured, in the course of the artery above and -below the wound, and if in an extremity, over the whole limb generally, -the motions of which should be effectually prevented, and absolute rest -enjoined, if the artery is of any importance. This should be continued -for two, three, or more weeks, according to the nature of the injury. - -A medical student, being desirous of bleeding his friend, also a -student, in the arm, opened the ulnar artery, which in this case was -very superficial. On discovering the error he had committed, he closed -the wound, and applied a firm compress and bandage, under which it -healed. On applying the ear to the part, it sounded like an aneurism, -although there was scarcely any tumor, the thrilling sound being -apparently occasioned by friction against the cut edges of the artery. -This thrilling noise diminished, and the vessel immediately below the -wound gradually recovered its pulsation, except at the exact situation -of the injury, where none could be distinguished. It was obliterated at -that part for the length of the eighth of an inch. - -The master tailor of the 40th Regiment, tempted by the approaching -prospect of plunder, was induced, on the night of the assault on -Badajos, to give up the shears, and arm himself with the halbert, and -was properly rewarded for his temerity by a wound from a pike in the -right arm, from which, he says, he bled like a pig, and became very -faint. On his arrival at the spot indicated for surgical assistance, he -fainted; but this was attributed to the unwarlike propensities of the -man, rather than to any sufficient cause. The wound was not more than -one-third of an inch long, a little below the edge of the pectoralis -major, and immediately over the artery. The arm and hand were numb and -cold; the pulse was not distinguishable at the wrist, and it appeared -to cease at the place of injury, which was harder and a little more -swollen than natural. He said that his pulse had always been felt by -the doctors in the usual place. The wound healed without any trouble. -On the 1st of May the pulsation of the artery could be felt a little -below the wound. On any exertion he had a good deal of unpleasant -numbness in the thumb and forefinger. A small cicatrix formed at the -place of the wound, which was otherwise quite natural to the touch. -This case proves that when a large artery is wounded in man by a sharp -cutting instrument, to a certain but moderate extent the process of -cure takes place through inflammation and by the obliteration of that -part of the canal of the vessel. Continental surgeons have since -sacrificed whole hecatombs of animals to prove this fact, which had -been so many years before recorded in England as having occurred in man. - -It has not been satisfactorily proved in man that a large artery, such -as the femoral or even the brachial, has been opened to the extent of -one-third or a fourth of its circumference, and that the wound has -healed without the canal becoming impervious. A _smaller wound_ of a -large artery may close without obstructing the canal of the vessel, but -the part is not so firm or so solid as before, and may yield, and give -rise to an aneurism, having apparently the characters of a small true, -as opposed to the spurious diffused, or even circumscribed swelling, -which more usually follows a similar accident. - -Colonel Fane was wounded by an arrow in the right side of the neck, -opposite the bifurcation of the carotid, which caused a considerable -loss of blood at the moment. The wound healed, leaving only a mark -where the point of the arrow had entered. Some time afterward he -observed a small swelling at the part, which, from its pulsation, was -declared to be an aneurism. Uneasy about it, he asked my opinion at -Badajos, after the siege. It had not increased, but it caused him some -anxiety, and I promised to place a ligature on the common carotid if -the aneurism should increase in size. He was unfortunately killed in -action a year afterward, by a shot through the head. - -191. When a large artery, such as the brachial, is cut _transversely_ -to a fourth of its circumference in man, it forms a circular opening as -in animals; and if the artery be large, the bleeding usually continues -until the person faints, or it is arrested by pressure. In dogs the -bleeding commonly ceases without any assistance from art, and without -the animal being exhausted; in horses and sheep the bleeding usually -continues till the animals die; while in man, even with the best aid -from compression, hemorrhage will in all probability recur, unless the -circulation be altogether arrested. If the external opening only should -be closed, a spurious, circumscribed aneurism will be the consequence -in so small an artery as the temporal, and a ligature will sometimes be -required above and below a little aneurism of this description. In a -larger artery the spurious aneurism may or may not be diffused. - -When an artery of this size is _completely divided_, it is less likely -to continue to bleed than if it had been only wounded. When it is -merely cut or torn half through, but not completely divided in the -first instance, it is in the same state with regard to hemorrhage as if -it had partially given way by ulceration. It can neither retract nor -contract, and will continue to bleed until it destroys the patient, -unless pressure be accurately applied and maintained until further -assistance can be procured. The practice to be pursued is to divide the -vessel, if it be a small one, such as the temporal artery, when it will -be enabled to retract and contract; and the bleeding will in general -permanently cease under pressure, especially when it can be applied -against the bone. If the artery is of a larger class, and continues -to bleed, it should be sufficiently exposed by enlarging the wound; a -ligature should be applied above and below the opening in the vessel, -which may or may not be divided between them at the pleasure of the -surgeon. - -In June, 1829, I happened to be at Windsor, on a visit to my old -friend, the late Dr. Ferguson, and was called to a young gentleman, -the upper part of whose right femoral artery had been accidentally cut -by the point of a scythe. On dilating the wound, a tourniquet being -on the limb, black blood flowed freely from it; on unscrewing the -tourniquet by degrees, arterial blood showed itself, and the upper end -of the artery was secured by ligature when the tourniquet was removed. -Venous-looking or black blood then again flowed in greater abundance -than before, evidently from a large vessel. This I restrained by -pressure made below the wound with the thumb of the left hand, while -I laid bare the lower part of the artery, from a slit in which, near -an inch in length, the black blood was seen to flow. A ligature passed -around the vessel below the wound suppressed the bleeding. The artery -was not divided, and the young gentleman perfectly recovered, and has -continued well until this day. The absolute necessity for two ligatures -was here well shown, as well as the flow of dark-colored blood from the -lower end of the artery. This gentleman is now an officer in the army, -and suffers no inconvenience from his accident. - -192. When a large artery is wounded at some depth from the surface, -and the external opening is small, blood not only issues through the -opening, but is often forced into the cellular structure of the limb to -a considerable distance; the pulsation of the tumor is observable, and -the thrill or sound which accompanies a ruptured artery is distinct. If -a large quantity of blood, partly in a fluid, partly in a coagulated -state, be collected immediately over and around the wound in the -artery, the tumor may not pulsate or give forth any sound, if the -coagulated blood be in considerable quantity, although some elevation -of the tumor may be observed corresponding to the pulse. - -This rising or pulsation of the swelling often depends on the impulse -given to the whole, as a mass, by the artery against which it is -lying, and not upon blood circulating through it. An impulse of this -kind is distinguishable in a bronchocele which lies immediately over -and in contact with the carotid artery. It is the same when blood is -extravasated by the rupture of several small vessels, in consequence of -the passage of a wheel over the limb, especially in the thigh, where a -swelling containing fluid blood will sometimes pulsate in a well-marked -manner, until it gradually diminishes as the blood coagulates, when -the motion becomes a mere elevation at each stroke of the heart. The -whizzing sound or thrill attendant on a ruptured artery is in these -cases wanting, being a very diagnostic mark of this accident; although -where there is true aneurism, and it has burst, forming a diffused -and spurious one, the thrill may be wanting; but the history of these -cases enables a surgeon to distinguish between them. If several ounces -of blood are thrown out, and remain fluid, they ought to be evacuated, -or suppuration will ensue. If they become coagulated, the mass will -be gradually absorbed. Fluid blood should be evacuated by a small -opening, and the part afterward treated by compress and bandage. If the -fluid or partly coagulated blood should increase in quantity, and the -swelling continue to enlarge and pulsate, the extension of the mischief -should be arrested by opening the swelling and securing the artery by -ligature. When the external opening is enlarged, and the clots which -filled it up are at all disturbed, arterial blood begins to flow, and -the finger will readily follow the track through which it passes down -to the artery, if it should not be too far distant. If the incision -be made sufficiently large to enable the operator to remove these -clots of blood with rapidity, the finger will more readily pass down -to the wound in the artery, which, if a large one, may be thus easily -discovered, if within reach and sight, provided the tourniquet be -thoroughly unscrewed, and the surgeon is not afraid. A ligature should -then be placed above and below the opening in the artery. - -When an artery is wounded, and the external opening in the integument -heals so as to prevent the blood from issuing through it, a traumatic, -spurious, circumscribed, or diffused aneurism is said to form, -according to the facility which is offered by the structure of the -parts for the confinement or diffusion of the extravasated blood. A -traumatic aneurismal tumor of this nature differs essentially from -aneurism which has taken place as a consequence of disease, and not of -direct injury. If a spurious aneurism form from disease, the artery is -in general unsound for some distance above and below the tumor. In the -aneurismal tumor from a wound, the artery is perfectly sound, except as -far as concerns the seat of injury. There is, then, not only a great -and essential difference between these two kinds of aneurism as regards -their nature, but also with respect to the collateral circulation, and -the operation to be performed for their cure; and the surgeon may not -overlook these facts. - -A school-boy, about fourteen years of age, let a pen-knife drop from -his hand while sitting down, and drew his knees suddenly toward each -other to catch the falling knife; the point was thus forced into the -inner and middle part of the thigh, and wounded the femoral artery. -The medical man on the spot put a plaster on the little incision in -the integuments, and the wound quickly healed. The boy complained of -uneasiness, but was supposed to be making more of it than necessary, -and was made to go into school as usual. The limb, however, began to -swell, and the boy was brought to London, supposed to be suffering from -abscess, and placed under the care of Mr. Keate, who, suspecting the -evil, carefully introduced the point of a lancet, and, after a clot -of blood had been forced out, a jet of arterial blood flew across the -room. The hemorrhage was arrested by pressure below Poupart’s ligament, -while Mr. Keate enlarged the opening in the integuments, and removed -two washhand-basinsful of coagulated blood. He then put his finger on -a large opening in the artery, under which two ligatures were passed -by means of an eye-probe, and the artery was divided between them. The -muscles had been cleanly _dissected_, and the cavity extended from the -fork internally, and trochanter externally, to the knee. There was much -less suppuration than could have been expected. The ligatures were -detached about the usual time, and the patient entirely recovered. - -This admirable case should be imprinted on the mind of every surgeon. -With the hope that it will be so, I refrain from commenting on three -or four cases which have occurred within the last two years, in which, -from neglect of the precept inculcated by it, very distressing if not -fatal consequences ensued. - -193. There is no precept more important than that which directs that no -operation should be done on a wounded artery unless it bleed, inasmuch -as hemorrhage once arrested may not be renewed, in which case any -operation must be unnecessary. The following case shows how firmly the -principles on which wounded arteries ought to be treated were fixed in -my mind in the year 1812; and there is no case during that eventful -period to which I look back with more satisfaction than the following:-- - -John Wilson, of the 23d Regiment, was wounded at the battle of -Salamanca by a musket-ball, which entered immediately behind the -trochanter major, passed downward, forward, and inward, and came out on -the inside of the anterior part of the thigh. The ball could not have -injured the femoral artery, although it might readily have divided some -branch of the profunda. Several days after the receipt of the injury, I -saw this man sitting at night on his bed, which was on the floor, with -his leg bent and out of it, another man holding a candle, and a third -catching the blood which flowed from the wound, and which had half -filled a large pewter basin. A tourniquet with a thick pad was placed -as high as possible on the upper part of the thigh, and the officer -on duty was requested to loosen it in the course of an hour; that was -done, and the bleeding did not recommence. The next day, the patient -being laid on the operating table, I removed the coagula from both -openings, and tried to bring on the bleeding by pressure and by moving -the limb; it would not, however, bleed. As there could be no other -guide to the wounded artery, which was evidently a deep-seated one, I -did not like to cut down into the thigh without it, and the man was -replaced in bed, and a loose precautionary tourniquet applied. At night -the wound bled smartly again, and the blood was evidently arterial. -It was soon arrested by pressure. The next day I placed him on the -operating table again, but the artery would not bleed. This occurred -a third time with the same result. The bleedings were, however, now -almost immediately suppressed, whenever they took place, by the orderly -who attended upon him; care having been taken to have a long, thick -pad always lying over the femoral artery, from and below Poupart’s -ligament, upon which he made pressure with his hand for a short time. -_Absolute rest_ was enjoined. The hemorrhage at last ceased without -further interference, and the man recovered. - -This case was one of considerable interest at the time, and is the -model one on which the treatment of all such injuries should be -founded. If the wound had bled, I should have introduced my finger, and -enlarged it transversely, continuing the incision until the opening was -sufficiently large to see to the bottom of the wound or the bleeding -part. It is necessary in such cases to be attentive to the course of -the great vessels and nerves, but not to the safety of muscular fibers, -the division of which leads to no permanent injury. As pressure on -the main trunk led to the ultimate suppression of the hemorrhage, -it may be said that a ligature placed high up on the femoral artery -would not only have done the same, but would have relieved the man -from the anxiety necessarily dependent on the momentary fear of a -recurrence of the hemorrhage. There are two objections to this method -of proceeding: the likelihood of mortification taking place, which -in similar cases has been known to occur; and the possibility of -the hemorrhage being renewed through the anastomosing branches. The -temporary suspension of the circulation by pressure does little or no -harm, more particularly where the pad used is so thick and narrow as to -cause it to fall principally on the artery, and only in a slight degree -on the surrounding parts, which by a little attention may be readily -accomplished. It is not then good practice to cut down upon an artery -on the first occurrence of hemorrhage, unless it be so severe or so -well marked as to leave no doubt of its being from the main trunk of -the vessel itself; nor is it then advisable to do so, except the artery -continue to bleed; for many a hemorrhage, supposed to have taken place -from the main trunk of an artery, has been permanently stopped by a -moderately continued pressure exercised in the course of the vessel, -and sometimes on the bleeding part itself; particularly if the blood -be of a dark color, indicating that it comes from the lower end of the -vessel. - -A painter could not have had a better subject for a picture -illustrative of the miseries which follow a great battle, than some of -the hospitals at Salamanca at one time presented. Conceive this poor -man, late at night, in the midst of others, some more seriously injured -than himself, calmly watching his blood--his life flowing away without -hope of relief, one man holding a lighted candle in his hand, to look -at it, and another a pewter washhand-basin to prevent its running over -the floor, until life should be extinct. The unfortunate wretch next -him with a broken thigh, the ends lying nearly at right angles for want -of a proper splint to keep them straight, is praying for amputation or -for death. The miserable being on the other side has lost his thigh; it -has been amputated. The stump is shaking with spasms; it has shifted -itself off the wisp of straw which supported it. He is holding it with -both hands, in an agony of despair. These Commentaries are written to -prevent as far as possible such horrors; and they may be prevented by -efficient and well-appointed medical officers; but there must also be -greater attention to these points than has hitherto been given by the -government of the country. - -Don Bernardino Garcia Alvarez, captain of the regiment of Laredo, -thirty years of age, was wounded at the battle of Toulouse by a -musket-ball, which passed through the thigh, a little above its middle. -The wound was not considered a dangerous one until the 30th, twenty -days after the injury, when a considerable bleeding took place; and -as the vessel from which it came seemed to be very deeply seated, the -Spanish surgeon in charge tied the common femoral artery. I saw the -gentleman in consequence of this having been done. The hemorrhage was -suppressed by the operation, and the limb soon recovered its natural -temperature, but gangrene made its appearance on the great toe on the -third day afterward. It did not seem to increase, but the limb swelled -as if nature were endeavoring to set up sufficient action to maintain -its life; and this continued until the tenth day after the operation, -when he died, completely exhausted. On the dissection of the limb, the -femoral artery was found to be perfectly sound in every part below -where the ligature had been applied. The vessel which bled could not be -discovered; but it was certainly a branch from the profunda, and not -the femoral itself. In this case the ligature of the femoral artery -destroyed the patient, and the practice pursued must be condemned. -The gunshot wound should have been largely dilated, at both orifices -if necessary, until the wounded vessel was discovered, which possibly -had not been completely divided by the ulcerative or sloughing process -which had taken place, and its division would in all probability have -suppressed the bleeding. - -A young gentleman, aged twelve, accompanying his brothers shooting, in -December, 1844, was struck in the upper part of the left thigh by a -duck-shot, which entered about three inches below Poupart’s ligament, -a little to the inner side of the femoral artery. He bled until he -fainted, and was taken home. There was no return of the bleeding for -three days, during which time the limb was exceedingly painful, and -soon began to enlarge. After this occasional and considerable bleedings -took place, the limb still continuing to increase in size. Fomentations -and poultices were applied; irritative fever set in, and the pain was -intense. At the end of a fortnight the small hole made by the shot -appeared to be healed over by a thin skin of a blue color, which tint -extended for some distance. The limb was enormously swollen, with -a feeling of distention, which induced the surgeon to puncture the -most prominent part with a lancet. After some clots of blood had been -removed, an alarming arterial hemorrhage took place. The femoral artery -was now tied high up, below Poupart’s ligament. The bleeding was in -some measure restrained, but not suppressed, and after a short time -it returned at intervals with augmented violence, until death ensued, -three weeks after the accident. - -_Remarks._--If an incision had been made into the thigh in the course -of the wound when the bleeding returned on the third day, and both ends -of the wounded artery had been tied, the boy would in all probability -have recovered. The ligature placed on the femoral artery above the -wound in it did restrain for a short time the flow of blood, but could -not prevent its flowing from perhaps both ends of the vessel, until -it destroyed the patient. A ligature on the external iliac would only -have caused it to be deferred for a day or two, until the collateral -branches had enlarged, or else he would have died of mortification. - -This really formidable case shows most distinctly the necessity for -always observing the rule of tying the wounded artery at the part -injured, in order that the mistake may not be made of placing a -ligature on the wrong artery--the constriction of which may cost the -patient his life, while it may not prevent a return of the bleeding. -It also shows that no loss of blood from a diffused aneurism can equal -the danger which must be encountered, and the mistakes which may be -made, by not laying it open, and seeing the hole in the artery, or its -divided extremities. - -Captain Seton, a short man, fat of his age, was wounded in a duel, in -1845, in the upper part of the right thigh, a little above and in front -of the great trochanter, the wound being continued across the thigh, -its internal opening being about the middle of the fold of the left or -opposite groin. He lost a great deal of blood at the time, the issue of -which ceased on his fainting. Ten days after the duel his countenance -was blanched, his pulse rather quick and feeble. On examining the -wounds, that on the right hip (the opening of entrance) was circular, -filled with a dry, depressed slough, and there was a narrow, faint -blush of redness round its margin. In the left groin the opening of -exit was marked by a jagged slit, already partly closed by a thin -cicatrix. There was extensive mottled purple discoloration (ecchymosis) -of the skin in both groins, and over the pubes, scrotum, and upper part -of the right thigh. In the right groin was found a large, oval, visibly -pulsating tumor, its long diameter extending transversely from about -an inch and a half on the inner side of the anterior superior spinous -process of the ilium to about opposite the linea alba, and its lower -margin projecting slightly over Poupart’s ligament into the upper and -inner part of the thigh. On handling this tumor, it appeared elastic -but firm, very slightly tender, and not capable of any perceptible -diminution in bulk by gradual and continued pressure. The pulsation was -distinct in all parts of the swelling, and was equally evident whether -the fingers were pressed directly backward, or whether they were placed -at its upper and lower margins, and pressed toward the base of the -tumor, in a direction transversely to its long axis, the parts being -for the time relaxed. The femoral artery was slightly covered by the -swelling, and the pulsations of that vessel were with some difficulty -distinguished in the upper third of the thigh, below the margin of the -tumor. This appeared to depend partly on the natural obesity of the -patient, and partly on a considerable degree of general swelling of -the thigh. Pressure on the femoral artery or over the abdominal aorta -did not arrest the pulsation in the tumor, and in the former situation -was attended with severe pain. Under these circumstances it was deemed -advisable to apply a ligature on the external iliac artery, and give -the patient a chance of the occurrence of coagulation in the tumor, -and closure of the wounded vessel, before the free re-establishment -of the circulation through the femoral artery. In the present case it -was supposed that mortification of the limb was all the less likely -to occur from the circumstance that the greater part of the effusion -appeared in front of the abdominal parietes, and therefore exercised -less pressure on the femoral vein than if further extension into the -thigh had taken place. The danger of peritonitis was by this proposal -made a new element in the calculation; but it was estimated that the -chances of this and of mortification of the limb, taken together, -were less unfavorable than the chances of immediate and secondary -hemorrhage attaching to the operation of tying the artery at the spot -injured. The operation being completed, the right foot, leg, and thigh -were enveloped in lamb’s-wool and flannel, and the limb elevated on -an inclined plane of pillows, so as to favor the return of blood as -much as possible, and prevent venous congestion. The day on which the -operation was performed was passed in considerable pain, the patient -being restless, and complaining of a sense of burning in the limb. -An anodyne, however, secured him a tolerably good night’s rest. The -day after the limb was found altogether diminished in bulk, and its -temperature equal to that of the healthy limb; no return of pulsation -had taken place in the tumor. The same evening some tenderness and -tension of the abdomen came on, though the bowels had been kept in a -regular state by occasional small doses of castor-oil. In the morning -of the second day, pain in the belly, with increased tension, hurried -breathing, short, dry cough, and tenderness over the lower part of the -abdomen, were observed. Pulse quicker and small. Leeches were applied, -and three-grain doses of calomel, with a little Dover’s powder, ordered -every three hours. The symptoms, however, became rapidly worse; the -patient complained of severe pain in the right leg, and a sensation of -great heat over the whole body, although the actual temperature was -rapidly falling below the natural standard. The right leg also became -cold sooner than the left. At seven P.M. he became more easy, and -expressed an opinion that he should “do well;” but in little more than -half an hour he expired. - -_Examination after death._--Swelling and ecchymosis of the right -thigh, particularly at the upper part, and in the right iliac region; -also swelling and ecchymosis of the scrotum, chiefly in the right -side, with general tumefaction of the abdominal parietes below the -umbilicus. A wound into which the little finger could be passed was -on the upper and outer aspect of the right thigh, about three inches -below the crest of the ilium and about an inch nearer the mesial -line than the great trochanter, and on the left side another smaller -wound, situated about the external aperture of the left spermatic -canal. The first-mentioned wound was open; the lips of the latter -were partially adherent. The course of the wound was traced from the -outside through a dense layer of fat about two inches in thickness, -(on an average.) It had divided one of the superficial branches of the -femoral artery, about half an inch below Poupart’s ligament, and about -an inch from the main body of the femoral artery; this had caused a -false aneurism. The sac contained about three ounces of blood. Blood -was also effused into the cellular structure of the scrotum, and -downward beneath the sartorius muscle. The wound passed through the -cellular tissue, across the pubes, and emerged about the situation of -the left external spermatic ring, without having divided the cord on -either side, and was quite superficial to the bladder. No other artery -appeared to have been wounded. When the parietes of the abdomen were -reflected, a considerable quantity of sero-purulent fluid was found in -the abdominal cavity; and on different parts of the large and small -intestines patches of acute inflammation were observed, particularly -on the ascending arch of the colon. The peritoneum adjoining the wound -of the operation was inflamed, and approaching to gangrene: it had not -been injured by the knife during the operation. The intestines were -unusually large, and distended with flatus. The other abdominal viscera -were healthy, but loaded to an extraordinary degree with fat. The -ligature had been properly applied to the iliac artery; the vein was -not injured; the surface of the wound and the cellular tissue in the -neighborhood of the artery were sloughy. There was some enlargement of -the right limb, but apparently no mortification. The femoral artery was -pervious; the course of the wound was through a bed of fat, fourteen -inches in length, and three inches in depth, over the pubes, and no -muscular substance was injured; the blood found in the aneurismal sac -was firmly coagulated, and there was no mark of recent oozing from the -injured artery. - -_Remarks._--If this gentleman had been wounded at the foot of the -breach in the wall of Ciudad Rodrigo, in January, he might, to his -great dissatisfaction, have been one of eleven officers whom I saw -lying dead, and as naked as they were born, on the face of the breach -of Badajos, in April. He would have been saved by _one_ doctor, or an -old woman, and a little cold water, in 1812, and did die of _seven_ in -1845, after an operation most brilliantly performed, but done in the -wrong place, even if any operation had been necessary, which it was -not. The case is an _experimentum crucis_ of principles. - -The _first error_ committed in this case was in calling and believing -a wounded artery to be a circumscribed, false, or diffused traumatic -aneurism. Nothing can be called an aneurism, by which word a dilated -vessel or a diseased shut or closed sac is understood, which has one -or more holes in it, made by a ball, or by anything else, the wound or -track of which remains open. It is simply a case of wound in which an -artery has been divided or injured, and while this track of the ball -remains open, no ingenuity of argument can make it otherwise. When the -external openings made by the ball have closed, the case may then be -called, if there be a collection of blood, whether fluid or coagulated, -one of circumscribed, false, diffused traumatic aneurism, or anything -else that philologists may please to designate it. The dissection -report proved this case to be simply a small collection of blood, three -ounces and a half, or seven small tablespoonfuls--communicating with -two open wounds. Calling this an aneurism, or a shut sac of any kind, -was then the _first_ and fundamental error, as fatal as erroneous. - -The _second_ error consisted in the belief, _contrary to all -experience_, that any sac or bag, or collection of blood by whatever -name it may be called, having two openings leading to, or into it, and -communicating with the atmosphere, could be augmented to any dangerous -extent by the further pouring out of blood from an artery of any size, -or from any artery at all, without some of such extravasated blood -being discharged or forced out through one or both of the open external -wounds in sufficient quantity to show that the opening in the vessel -was not closed. - -The _first two errors_, or defects of principles, gave rise to the -_third_, viz.: the belief that an operation was necessary where -none was required, the dissection having proved that the whole -idea of the nature of the injury was a mistake: there was no large -artery wounded; the small one, which had been wounded, had ceased to -bleed; the quantity of blood extravasated did not exceed seven small -tablespoonfuls. The third mistake could not have taken place if the -first two errors had not been committed. - -The _fourth_ error occurred from its being taken for granted that the -femoral artery was wounded; and that ascertaining the fact by opening -the small swelling which contained only three and a half ounces of -blood, would be followed by a fatal hemorrhage; which supposition arose -from this swelling receiving a pulsatory motion from its vicinity to -the femoral artery--a mistake which should not have occurred; for it -had long before been said, (page 16 of my published lectures:) “The -motion or pulsation of the swelling often depends on the impulse given -to the whole as a mass, by the great artery against which it is lying, -and not upon blood circulating through it. When blood is extravasated -by the rupture of small vessels in consequence of the passage of a -wheel over the limb--especially in the thigh, where I have seen a -swelling containing fluid blood pulsate in an almost alarming manner, -until it gradually diminished as the blood coagulated, when the motion -became a mere elevation at each stroke of the heart--the _whizzing -sound or thrill_ attendant on a ruptured artery (of a size to require -a ligature being understood) is in these cases wanting, constituting a -very distinguishing mark of this accident.” - -Surgeons fifty years ago were afraid of hemorrhage from the femoral -artery, but the practice of the Peninsular war dissipated such fears. -The reason given for not laying open the wound, and looking at the -bleeding artery, in this case, is ingenious, but not tenable. The -patient is said to have lost a large quantity of blood; and if this -were even a fact, which may, however, be doubted, is there a case on -record of a serious wound of the femoral artery, such as this was -supposed to have been, in which that vessel has been successfully -secured by ligature, without the patient having equally lost so large a -quantity of blood as to be supposed to be about to die? _It has always -been so_; the reason, however specious, is not valid, and cannot be -admitted. - -The _fifth_ error arose from imagining that the considerable loss of -blood supposed to have taken place would have rendered the patient -incapable of bearing more; for it is a recorded fact that those -operations high up on the femoral artery, from which patients have -recovered, have never been done without great losses of blood having -been previously sustained; and if the patient was so weakened that his -heart and arteries could not bear the abstraction from their contents -of a few ounces more blood--supposing such loss to be inevitable--how -could they have power to drive or force the blood through the limb by -the collateral channels, in a manner sufficient to support its life, -when the main trunk was cut off within the pelvis? _They could not do -it_--_they have rarely done it_ under such circumstance; they could not -have done it in this case; and if the patient had not died within the -first forty hours of inflammation of the peritoneum, to which accident -he ought not to have been exposed, he would have died of mortification -within forty hours more, which had already commenced, as shown by the -swelling of the limb and pain in the calf of the leg, which almost -invariably attend such mortification. - -The _sixth_ error consisted in the belief that if the femoral artery -had been wounded, a ligature on the external iliac would have -permanently arrested the bleeding. It would, in all probability, -have done no such thing, beyond a day or two--perhaps even only for -the moment. It is a delusion, persisted in notwithstanding the most -clear and positive proofs to the contrary. The patient will die of -mortification from the want of blood in the limb, if the circulation be -not re-established; and if this should take place, blood must find its -way into the lower end of the wounded artery, and perhaps even into the -upper, and renew the hemorrhage. - -If the femoral artery had been _wounded_, as was supposed in this case, -but not completely _divided_, it _must_ and _would_ have continued to -bleed through the external wound, until the patient died, or a ligature -had been placed upon it. It has been said that, in the case as it -actually occurred, the little artery, which was divided and which had -not bled for some days, could not have been safely tied, if it had bled -again, because it was only an inch long; but this is said in defiance -of every sort of proof which has been given to the contrary. - -As far back as 1815 I said: “There was no foundation for the theory -which declared that a ligature when placed on an artery such as the -femoral would fail, if in the immediate vicinity of a collateral -branch, in consequence of the flow of blood through this vessel -preventing the obstruction and consolidation of the main branch for a -distance sufficient to enable it to resist the impulse of the blood -behind.” This was said from pure practical facts, free from all kinds -of theory; and the preparation before alluded to, in the museum of the -College of Surgeons, in which I tied the common iliac artery, will show -the mark of a simple thread around it, and a single line of adhesion -resisting the whole power of the heart, the canal above the spot not -being obliterated. - -The _seventh_ error committed in this case was in contravening the -great surgical precept, formed on no inconsiderable experience during -the early part of the war in the Peninsula, “_not to perform an -operation on an artery until it bleed_.” - -194. When a wound occurs in the thigh, implicating the femoral artery -or its branches, and the bleeding cannot be _restrained_ by a moderate -but regulated compression on the trunk of the vessel, and perhaps on -the injured part, recourse should be had to an operation, by which -both ends of the wounded artery may be secured by ligature; and the -_impracticability_ of doing this should be ascertained only by the -failure of the attempt. If the lower end of the artery cannot be -found at the time, the upper only having bled, a gentle compression -maintained upon the track of the lower may prevent mischief; but if -dark-colored blood should flow from the wound, which may be expected to -come from the lower end of the artery, and compression does not suffice -to suppress the hemorrhage, the bleeding end of the vessel must be -exposed, and secured near to its extremity. - -The instruments which have been invented for the cure of aneurism, -by compressing the main trunk of the artery, will be found eminently -useful, if applied with care, in many cases of hemorrhage in which it -may be doubtful what vessel is actually injured, as in the case of -Wilson, page 215, and in cases also of wounds of the hand or foot in -which bleeding occurs through the medium of collateral branches. These -instruments, although they cannot conveniently be placed in the capital -cases of instruments, should be in store, whether with divisional or -general hospitals. - - - - -LECTURE XII. - -MORTIFICATION, ETC. - - -195. The gangrene, mortification, or sphacelus, consequent on a wound -of the main artery of the lower extremity, is, in the first instance, -_local_ and _dry_, unless putrefaction be induced by heat. (See -_Aphorism_ 28.) The following case is a good example of this and of all -the other points laid down as principles or facts:-- - -A gentleman received an injury in the upper part of the left thigh, -parallel to but a little below Poupart’s ligament, from the shaft of -a van. The late Messrs. Heaviside, Howship, and Chevalier were sent -for immediately, and my attendance was desired next day. I called the -attention of these gentlemen to the _tallowy-white_ and _mottled_ -appearance of the foot and lower part of the leg, and assured them that -the femoral artery was injured, and the femoral vein in all probability -also, from the rapid appearance of the first signs of dry gangrene. In -this they would not believe, until the shrinking and drying of the foot -and leg became obvious, the course of the tendons on the instep and -toes being marked by so many dark-red lines under the drying skin above -them. The amputation I recommended below the knee they would not hear -of, although they reluctantly admitted the fact of the mortification. -On the eighteenth day after the accident, blood flowed from the wound -in quantity, of a dark-venous color. This bleeding I pronounced to be -from the lower end of the artery. My three friends, in whose hands -the case was, could not understand this, and placed a ligature on -the external iliac artery, which did not arrest the bleeding. They -now, although too late, saw their error, and desired me to do what I -pleased, and a ligature secured the lower end of the artery from which -the blood flowed. The man died exhausted a few days afterward. - -This is a remarkable case, deserving the most serious attention. -According to the principle laid down at first as a general rule, the -thigh should have been amputated at the seat of injury the morning -after the accident, when the signs of mortification of the foot -were obvious. But it must be borne in mind that amputations at the -trochanter major or hip-joint are most formidable and not generally -successful operations; in consequence of which I have recommended -another course, deserving, in such cases, of the most deliberate -consideration and trial. (See _Aphorism_ 29.) The leg should have been -amputated immediately below the knee, as I had ordered it to be done -in the case of Turnbull, (page 202,) because that is the part in all -such cases at which nature seems capable of arresting the progress of -the mortification, if the constitution and powers of the sufferer are -good, and equal to the calls upon them. The impairing, the destructive -influence a mortified leg exerts on the whole system is removed, and -an amputation substituted for it of comparatively little moment. When -the hemorrhage took place, the lower end of the artery should have -been tied. The upper end never bled, and the ligature on the iliac -artery was useless. In this case, it is probable, as the vein was also -injured, that the life of the part at and above the knee might not have -been preserved, and the patient would have died. - -In a case of the kind in which the artery was wounded at the _lower_ -part of the thigh instead of the _upper_, amputation at or just -below the wound may be the proper course; this amputation, although -dangerous, being much less so than one at the upper part of the thigh -or hip-joint. Nevertheless, amputation should not be had recourse to -unless the extension of the mortification is beyond a doubt. - -196. In Aphorism 29, it is strongly recommended not to amputate a thigh -when mortification has stopped just below the knee, and a line of -separation has been formed between the dead and the living parts--an -opinion formed on a principle laid down in opposition to those usually -received by the profession at large, and which have been entertained -from the fact that amputations done under these circumstances are -commonly fatal. - -Richard Cook, aged fifty, a mason, while sitting on a square block -of stone, on the 23d of February, was struck by another, which drove -the popliteal space or ham against the edge of the block on which he -sat, causing him great pain, and otherwise greatly bruising the leg, -although no bones were fractured, nor was the skin torn. The limb, on -his admission into the Westminster Hospital half an hour afterward, -was much larger than the other, and of a dark reddish-blue color, -evidently from the bruise or extravasation of blood, which appeared -to be still issuing from the vessel or vessels, as the limb continued -to increase in size, until it became at last greatly swollen. The -pulsation of neither the anterior nor the posterior tibial artery could -be distinguished through the swelling the next morning. The bowels -were opened, and a cold spirit lotion was applied to the calf and -around the leg, and the swelling somewhat subsided, the limb becoming -quite a blue-black, which, with the tenseness of the parts, distinctly -indicated the effusion of a large quantity of blood. It was soon -obvious that greater mischief had occurred than had been expected; -and on the 2d of March, as vesications, filled with a bloody fluid, -were formed on the outside of the leg, over the fibula, and the whole -limb was manifestly about to pass into a state of gangrene, if it had -not already done so, I prepared everything for tying the popliteal or -other arteries, if found necessary, and made a long and deep incision -on the outer and back part of the leg, through the integuments and -muscles posterior to the fibula, and removed a considerable quantity of -coagulated blood from between the muscles and from a large cavity which -extended upward into the ham, without causing further hemorrhage; in no -part of that cavity could an artery be felt. The patient’s countenance -and body had assumed a jaundiced hue; the pulse was very quick; the -tongue foul; the countenance sunken; the skin hot; the head wandering. -Poultices of linseed-meal and stale beer were applied, with gentle, -stimulating applications. Brandy and wine were ordered in proper -quantities every hour or two, with sufficient doses of the muriate of -morphia at night to allay irritation and induce sleep. The incision, -together with these remedies, gave great relief, and on the 7th the man -seemed to have been saved from a state of the most imminent danger. -On the 8th the pulse was 112, the tongue clean, the skin of a whiter -color, the bowels opened by injections; eight ounces of brandy were -given in the twenty-four hours; wine, with sago, arrow-root, jelly, -oranges, and anything he chose to ask for. The greatest cleanliness was -observed, and the chloride of lime was used in profusion all around -him. The mortification of the limb was complete; a line of separation -formed about four inches below the knee in front, and extended behind -toward the ham. On the 26th, the dead parts having almost entirely -separated from the bones all round, those which remained were cut -through where dead, the bones were sawn about five inches below the -knee, and the lower part of the limb removed, leaving an irregular, -and, in part, a granulating stump, with an inch of bone projecting from -it. On the 24th of May this portion was found to be loose; diluted -nitric acid had been applied to its surface, and on the 20th of June -it separated. On the 16th of August Cook left the hospital in good -health, with a very good stump, having cost the hospital £57 in extra -diet. In this case, there can be little doubt of the popliteal artery -having been torn; and if the incision made on the 2d had been had -recourse to during the first two or three days, and the artery sought -for, and secured if found bleeding, it is possible the mortification -might have been prevented; although it is probable, from the pressure -arising from the great extravasation and coagulation of blood, that -the collateral circulation was so much impeded as not to have been -able to maintain the life of the limb below even during that time. The -incision made on the 2d saved the life of the patient, by taking off -the tension of the part, and relieving thereby in a remarkable manner -the constitutional irritation which hourly appeared likely to destroy -him; indeed, no one expected anything but his dissolution. When the -line of separation had formed, he was evidently unequal to undergo the -operation of amputation, in order to make a good stump, without great -risk, and the dead parts were therefore merely separated for the sake -of cleanliness and comfort. Experience has demonstrated in too many -cases of the kind that the formal operation of amputation at this time, -as recommended by most modern surgeons, would in all probability have -cost him his life. - -The application of powdered charcoal, particularly that made from bog -earth, or of areca wood, or Macdougall’s disinfecting powder, or of the -disinfecting liquids now in use, such as the chlorides of lime, sodium, -and zinc, removes in a great degree the intolerable odor which renders -the room of the sufferer unbearable, and essentially interferes with -his amendment. Incisions should be made into the dead parts to allow -the evacuation of the fluids contained within them, while the parts -themselves may be removed from time to time; so that when the period -arrives at which an amputation is considered advisable, the bones, if -of the leg, may be sawn through at or below the line of separation, -and nearly the whole of the mortified soft parts removed, so as to -leave little of those which are dead and offensive. This operation is -done without the patient feeling it; it gives rise to no irritation, -inconvenience, or danger; Nature is not interfered with in her -operations; and in due time the parts which remain are separated and -fall off, leaving a stump more or less good, but which will always bear -the application of a wooden leg; and thus the knee-joint is saved--a -saving of no small importance to the patient, and a new precept in -surgery. - -197. The following cases may be considered conclusive:-- - -A private of the 5th division of infantry received a wound at the -battle of Salamanca from a musket-ball, which passed across the back -part of the right leg, from above downward and inward. It entered -about two inches below and behind the head of the fibula, and passed -out near the inner edge of the tibia. There was little blood lost at -the time, and it was considered to be a simple wound; eight days after -the injury, some blood flowed with the discharge; this increased during -the night, and, on examining the limb on the morning of the ninth day, -it was evidently injected with blood, which flowed of a scarlet color -from both orifices. It being doubtful which vessel was wounded--whether -it was the trunk of the popliteal artery, or the posterior tibial -or peroneal after its division into these branches--it was thought -advisable to place a ligature on the femoral artery about the middle -of the thigh, which suppressed the hemorrhage. The case was now shown -to me, as one in proof of the incorrectness of the opinion I had a few -days before stated, of the impropriety of such an operation being done. -The seeming success did not long continue; hemorrhage again took place -from the original wound, and the limb was then amputated. The posterior -tibial artery had been injured, and had sloughed. The man died. - -_Remarks._--A straight incision, directly through the back of the calf -of the leg, of six inches in length, and two ligatures on the wounded -artery, would have saved this man’s leg and life. - -Henry Vigarelie, a private in the German legion, was wounded on the -18th of June, at the battle of Waterloo, by a musket-ball, which -entered the right leg immediately behind and below the inner head -of the tibia, inclining downward, and under or before a part of the -soleus and gastrocnemius muscles, and coming out through them, four -inches and three-quarters below the head of the fibula, nearly in the -middle, but toward the side of the calf of the leg. In this course -it was evident that the ball must have passed close to the posterior -tibial and peroneal arteries; but, as little inflammation followed, and -no immediate hemorrhage, it was considered to be one of the slighter -cases. On the latter days of June he occasionally lost a little blood -from the wound, and on the 1st of July a considerable hemorrhage took -place, which was suppressed by the tourniquet, and did not immediately -recur on its removal. It bled, however, at intervals, during the -night; and on the morning of the 2d it became necessary to reapply the -tourniquet, and to adopt some means for his permanent relief. - -The man had lost a large quantity of blood from the whole of the -bleedings; his pulse was 110, the skin hot, tongue furred, with great -anxiety of countenance: the limb was swollen from the application of -the tourniquet from time to time, a quantity of coagulated blood had -forced itself under the soleus in the course of the muscles, increasing -the size of the leg, and florid blood issued from both openings on -taking the compression off the femoral artery. On passing the finger -into the outer opening, and pressing it against the fibula, a sort of -aneurismal tumor could be felt under it, and the hemorrhage ceased, -indicating that the peroneal artery was in all probability the vessel -wounded. - -In this case there was, in addition to the wound of the artery, a -quantity of blood between the muscles, which in gunshot wounds, -accompanied by inflammation, is always a dangerous occurrence, as -it terminates in profuse suppuration of the containing parts, and -frequently in gangrene. Its evacuation therefore became an important -consideration, even if the hemorrhage had ceased spontaneously. - -The leg having been condemned for amputation above the knee, the -officers in charge were pleased to place the man at my disposal: and -being laid on his face, with the calf of the leg uppermost, I made an -incision about seven inches in length in the axis of the limb, taking -the shot-hole nearly as a central point, and carried it by successive -strokes through the gastrocnemius and soleus muscles down to the deep -fascia, when I endeavored to discover the bleeding artery; but this was -more difficult than might be supposed, after such an opening had been -made. The parts were not easily separated, from the inflammation that -had taken place; and those in the immediate track of the ball were in -the different stages from sphacelus to a state of health, as the ball -in its course had produced its effect upon them, or their powers of -life were equal or unequal to the injury sustained. - -The sloughing matter mixed with coagulated blood readily yielded to the -back of the knife, but was not easily dissected out. The spot which -the arterial blood came from was distinguished through it, but the -artery could not be perceived, the swelling and the depth of the wound -rendering any operation on it difficult. To obviate this inconvenience, -I made a transverse incision outward, from the shot-hole to the edge -of the fibula, which enabled me to turn back two little flaps, and -gave greater facility in the use of the instruments employed. I could -now pass a tenaculum under the spot whence the blood came, which I -raised a little with it, but could not distinctly see the wounded -artery in the altered state of parts, so as to secure it separately. -I therefore passed a small needle, bearing two threads, a sufficient -distance above the tenaculum to induce me to believe it was in sound -parts, but including very little in the ligature, when the hemorrhage -ceased; another was passed in the same manner below, and the tenaculum -withdrawn. The coagula under the muscles were removed, the cavity -washed out by a stream of warm water injected through the external -opening, the wound gently drawn together by two or three straps of -adhesive plaster, and the limb enveloped in cloths constantly wetted -with cold water. The patient was placed on milk diet. - -On the 4th, two days after the operation, the wound was dressed, and -looked very well; the weather being very hot, two straps of plaster -only were applied to prevent the parts separating. On the 5th a -poultice was laid over the dressings, in lieu of the cold water, the -stiffness becoming disagreeable. On the 6th, as the wound, although -open in all its extent, did not appear likely to separate more, the -plasters were omitted, and a poultice alone applied. On the 8th and -9th it suppurated kindly; and on the 10th, or eight days from the -operation, the ligatures came away, the limb being free from tension, -and the patient in an amended state of health, his medical treatment -having been steadily attended to. - -The man was brought to England, to the York Hospital at Chelsea, and -walked about without appearing lame, although he could not do so for -any great distance. He suffered no pain, except an occasional cramp -in the ball of the foot, and some contraction of the toes, which took -place generally when he rose in a morning, and continued for a minute -or two, until he put them straight with his hand; this I did not -attribute to the operation, but to some additional injury done to the -nerves by the ball in its course through the leg. - -This case, which has been followed by many others equally successful, -even after the femoral artery had been ineffectually tied, established -the practice now followed in England by all educated surgeons; and -is another of those great additions to surgery for which science is -indebted to the Peninsular war. - -198. It may be permitted to repeat, that if an artery such as the -axillary be laid bare previously to an operation for amputation at the -shoulder, and the surgeon take it between his finger and thumb, he will -find that the slightest possible pressure will be sufficient to stop -the current of blood through it. Retaining the same degree of pressure -on the vessel, he may cut it across below his finger and thumb, and -not one drop of blood will flow. If the artery be fairly divided by -the last incision which separates the arm from the body, without any -pressure being made upon it, it will propel its blood with a force -which is more apparent than real. All that is required to suppress this -usually alarming gush of blood is to place the end of the forefinger -directly against the orifice of the artery, and with the least possible -degree of pressure consistent with keeping it steadily in one position -the hemorrhage will be suppressed. It is more important to know that if -the orifice of the artery, from a natural curve in the vessel, or from -other accidental causes, happen at the same time to retract and to turn -a little to one side, so as to be in close contact with the side or end -of a muscle, the very support of contact will sometimes be sufficiently -auxiliary to prevent its bleeding. - -In amputation at the hip-joint, the femoral and profunda arteries -are frequently divided at or just below the origin of the latter, -and bleed furiously if disregarded; but the slightest compression -between the finger and thumb stops both at once. They never have given -me the smallest concern in these operations, or others of a similar -nature; and surgeons should learn to hold all arteries that can be -taken between the finger and thumb in great contempt. It is quite -impossible for a man to be a good surgeon--to do his patient justice -in great and difficult operations attended by hemorrhage, unless he -has this feeling--unless his mind is fully satisfied of the truth -of these observations. While his attention ought to be directed to -other important circumstances, it is perhaps absorbed by the dread -of bleeding, by the idle fear that he will not be able to compress -the artery and restrain the bleeding from it--that he may have half -a dozen vessels bleeding at once--that his patient will die on the -table before him. Once fairly in dismay, and the patient is really -in danger; but, endowed with that confidence which is only to be -acquired through precept supported by experience, he surveys the scene -with perfect calmness: taking the great artery between the finger and -thumb of one hand, he places the points of all the other fingers, of -both hands if necessary, on the next largest vessels; or he presses -the flaps or sides of the wound together until his other hand can be -set at liberty by an assistant, or in consequence of a ligature having -been passed around the principal artery. This is a scene sufficient -to try the presence of mind of any man; but he is not a good surgeon -who is not equal to it--who does not delight in the recollection of -it when his patient is in safety, and his recovery assured. It was in -consequence of what was then considered the too great boldness of the -practice that my old friend, Sir Charles Bell, whose loss to science -cannot be too much regretted, represented me seated on a pack saddle -on the back of a bourro, (_Anglice_, a jack-ass,) on the top of the -Pyrenees, expatiating on their merits (which he did not believe) to the -descendants of the Bearnois of Henri Quatre on one side, and to the -children of the lieges of Ferdinand and Isabella on the other; but no -one now disputes their accuracy. The surgery of the Peninsular war was -many years in advance of the surgery of civil life. - -199. The principles laid down for the treatment of wounded arteries in -the _lower_ extremity are equally to be observed with respect to those -of the _upper_. There is, however, little or no fear of mortification -taking place in the upper extremity, the collateral circulation being -more direct and free; while there is greater danger from this cause of -hemorrhage from the lower end of the artery, if a ligature should not -have been placed upon it, or if it should not be retained a sufficient -length of time. - -200. The error of placing a ligature on the subclavian artery above -the clavicle, for a wound of the axillary below it, should never be -committed. One person dies for one who lives after this operation, when -performed under favorable circumstances, independently of the loss -which may be sustained by a recurrence of bleeding from the original -wound, which is always to be expected and ought to take place; when -it does not happen, it is the effect of accident, which accident in -all probability occurs from the state of _absolute rest_ having been -carefully observed. - -201. The necessity for an aneurismal sac below the clavicle, and -for its remaining and continuing to remain intact, until the cure is -completed, when the subclavian artery has been tied above, is rendered -unmistakable by the following case:-- - -Ambrose C. was admitted into the Charing Cross Hospital, in August, -1848, in consequence of a bruise from a sack of beans; there was -axillary aneurism, extending under the pectoral muscle up to the -clavicle. A ligature was applied in the usual situation on the -outside of the scalenus muscle, and came away on the twenty-second -day. The aneurismal sac suppurated, and burst three days afterward, -when a quantity of pus and blood, partly fluid, partly coagulated, -but very offensive, was discharged. The opening was enlarged, and -everything appeared to be going on well, at which time I saw him. On -the nineteenth day after the ligature came away, I visited him again -with Mr. Hancock, and merely observed that he must keep himself very -quiet, and I thought he would do well. In the evening he died from -hemorrhage, while eating some gruel. On examination after death, the -artery was found to be sound, except where it communicated with the -sac by an opening three-quarters of an inch in length. The ligature -had been applied midway between the thyroid axis and the first of the -thoracic branches. There was a small coagulum, of half an inch in -length, both internal and external to the ligature, _but not extending -to the branch above or below it_. The artery was of its natural size as -far as the remains of the sac, but beyond it the axillary artery was -diminished; the remains of the sac were void of coagulum, except where -it communicated with the artery, to which opening a small coagulum -had adhered, but had given way at its lower part, and thus caused his -death. _Between the opening and the ligature_, five large branches -entered into or were given off by the artery, and through some of these -blood was brought round by the collateral branches in an almost direct -manner, so that the man’s life depended on the resistance offered by -the small coagulum after the sac had given way; proving in an exemplary -manner the value of the sac remaining entire. - -If this case will not convince the incredulous, it would be useless to -bring even the sufferers in such cases from their graves, to affirm the -fact of the inapplicability of the theory of aneurism to the treatment -of a wounded artery--of the impropriety of placing a ligature on the -subclavian artery above the clavicle, for a wound of the artery below -it. - -Corporal W. Robinson, 48th Regiment, was wounded at the battle of -Toulouse, by a piece of shell, which rendered amputation of the right -leg immediately necessary, and so injured the right arm as to cause -its loss close to the shoulder-joint eighteen days afterward. At the -end of a month the ligatures had separated, and the wound was nearly -healed, although a small abscess had formed on the inside, near where -the upper part of the tendon of the pectoralis major had been separated -from the bone. Sent to Plymouth, this little abscess formed again, and -was opened on the 2d of August, three months after the amputation. -The next day blood flowed so impetuously from it as to induce the -surgeon to make an incision, and seek for the bleeding vessel, which -could not be found. The late Staff-Surgeon Dease, warned by the case -of Sergeant Lillie, (page 198,) strongly objected to the subclavian -artery being tied above the clavicle, and, true to the principle -inculcated at Toulouse, advised the application of a ligature below -the clavicle on a sound part of the artery, but as near as possible to -that which was diseased. The operation was done by the senior officer, -Mr. Dowling, who carried an incision from the clavicle downward through -the integuments and great pectoral muscle, until the pectoralis minor -was exposed. This was then divided, and a ligature placed beneath it -on the artery where it was sound, at a short distance from the face of -the stump, where it was diseased. The man recovered without further -inconvenience. - -202. In all those cases in which it has been supposed necessary to -place a ligature on the artery above the clavicle, after a _failure_ -in the attempt to find the artery below it, the failure has occurred -from _the error committed_ in not dividing the integuments and great -pectoral muscle _directly across_ from the lower edge of the clavicle -downward. It is quite useless dividing these parts in the course of -the fibers of the muscle, and the case of Robinson is the model on -which all such operations should be done. If this operation had not -succeeded, the ligature of the artery above the clavicle was a further -resource; but as the artery was sound below, with the exception of the -end engaged in the face of the stump, the operation was successful; -no doubt should be entertained in such cases of the propriety of an -operation which is attended with little risk, compared with that which -destroys one man for every one it saves. - -203. Punctured wounds of the arteries of the arm and forearm ought to -be treated by pressure applied especially to the part injured, and -to the limb generally; but when the bleeding cannot be restrained in -this manner, in consequence of the extent of the external wound, the -bleeding artery is to be exposed, and a ligature applied above, and -another below the part injured, whether the artery be radial, ulnar, or -interosseal. - -204. When the external wound closes under pressure, and blood is -extravasated in such quantity under the fascia and between the muscular -structures as is not likely to be removed by absorption under general -pressure, the wounded artery should be laid bare by incision and -secured in a similar manner, even at the expense of any muscular fiber -which may intervene. - -205. When an aneurismal tumor forms _some time_ after such an accident, -in the upper part of the forearm in particular, the application of -a ligature on the brachial artery is admissible, on the Hunterian -principle. - -206. When the ulnar artery is wounded in the hand, which is -comparatively a superficial vessel, two ligatures should be placed upon -it in the manner hereafter to be directed. When the opening is small, -pressure may be tried. - -207. When the radial artery is wounded in the hand, in which situation -it is deep seated, the case requires greater consideration. When there -is a large open wound, and the bleeding end or ends of the artery can -be seen, a ligature should be placed on each; but this cannot always be -done without more extensive incisions than the tendinous and nervous -parts will justify. - -208. When search has been made by incisions through the fascia, (as -extensively as the situation of the tendons and nerves in the hand -will permit,) which are best effected by introducing a bent director -under it, the current of blood, through either the ulnar or the -radial artery at the wrist, or even through both, should be arrested -in turn by pressure, which in most cases of this kind will succeed, -if properly applied, and thus show the vessel injured. The bleeding -point should be fully exposed, and all coagula removed, when a piece -of lint, rolled tight and hard, but of a size only sufficient to cover -the bleeding point, should be laid upon it. A second and larger hard -piece should then be placed over it, and so on, until the compresses -rise so much above the level of the wound as to allow the pressure to -be continued and retained on the proper spot, without including the -neighboring parts. A piece of linen, kept constantly wet and cold, -should be applied over the sides of the wound, which should not be -closed so as to allow of any blood being freely evacuated; and if the -back of the hand be then laid on a padded splint, broader than the -hand, a narrow roller may be so applied as to retain the compresses -in their proper situation, without making compression on or impeding -the swelling of the adjacent parts, the fingers being bent, in order -to relax the palmar aponeurosis--a proceeding which should never be -neglected in any operation in the palm of the hand. It has been lately -proposed by M. Thierry, a French surgeon, to raise and bend the arm, -as a means of impeding the circulation where the artery passes over -the elbow-joint, and the proposal deserves adoption, but not to the -extent he recommends, which cannot be long submitted to. Pressure made -at the same time on the radial or ulnar artery, or on both, by a piece -of hard wood two inches long, shaped like a flattened pencil, is much -more effectual, and more to be depended upon. When from the bones -being broken, or the hand so swollen, or from other circumstances, -pressure, however lightly and carefully applied, cannot be borne in -the manner directed, and the attempts to secure the artery at the -bleeding spot have failed, and pressure on the radial or ulnar artery -has been equally unsuccessful, in consequence of the swelling or other -circumstances, both may be tied at the wrist in preference to placing -a ligature on the brachial artery, although that even must be done as -a last resource, if the bleeding should still continue. If it be asked -why not do this in the first, rather than in the last instance, the -answer is, that it has so often failed to prevent a renewal of the -bleeding from both ends of a wounded artery in the hand, that complete -dependence cannot be placed upon it, particularly if there should be -a division high in the arm of the brachial into the radial and ulnar -arteries. When, however, the arteries leading to the wound have been -secured, either by pressure or ligature, NEAR to the part, and the -bleeding returns by the collateral circulation, which in the hand is so -free, the arresting the supply of blood through the main trunk may and -often has suppressed the hemorrhage, at all events for a sufficient -time to enable the injured parts to recover themselves, provided the -forearm is bent and raised, and the person kept at _rest_ in the most -restricted manner, without which this operation will in all probability -fail. It is in these cases that the instrument alluded to, page 226, -will be useful, rendering the ligature on the trunk of the vessel -unnecessary, more particularly if the bleeding should appear to depend -on some peculiarity in the structure of the coats of the artery. - -209. When the obstacle to the application of pressure arises from the -injured state of the metacarpal bone or bones, one or more should be -removed, with the fingers if necessary, so as to expose a clear and -new surface, on which the bleeding vessels may be seen and secured. -In some cases, particularly if there should be a hemorrhagic tendency -in the arterial system generally, as known from previous accidents, -the first compress may be wetted with the perchloride of iron, the -ol. terebinth., the dilute sulphuric acid, or the tincture of matico; -these remedies may be also administered internally. Some new styptics -have lately been much lauded in Malta and other places, but sufficient -proofs have not been given of their efficiency. - -210. When the radial artery is wounded as it turns from the back to -the inside of the hand, to form the deep-seated palmar arch, it meets -a branch of the ulnar nerve about to terminate in the muscles of the -thumb. If the treatment by pressure above recommended should not -succeed, the muscles forming what is called the web, between the thumb -and metacarpal bone of the forefinger, should be cut through, and the -bleeding vessel exposed. They are the adductor pollicis on the inside, -and the abductor indicis on back of the hand. - - - - -LECTURE XIII. - -WOUNDS OF THE ARTERIES, ETC. - - -211. The precept so strongly insisted upon, that no operation should -be done on a wounded artery unless it bleed, and at the place from -which it bleeds, has been particularly opposed with reference to the -neck, the opponents believing that placing a ligature on the primitive -carotid is an operation not attended with much risk, and that it may -therefore be done as a precautionary measure when the wounded part -does not bleed; this statement is an error. Of thirty-eight cases -collected by Dr. Norris in 1847, in which this vessel was tied for -aneurism, twenty-six died, and twelve suffered from affection of the -brain, the frequency of which occurrence has been singularly overlooked -by practical surgeons; although proving, in a very marked manner, -that the operation of tying the primitive carotid is not a trifling -affair, and that the success, when compared with the failures, is only -as one and one. A much more important objection is the difficulty of -deciding, in many cases of wounds of the neck, what artery is wounded, -and what trunk should be tied; whether it be the external carotid or -its branches, or the internal, or the vertebral artery. Errors have -been committed on all these points by men of the greatest anatomical -and surgical knowledge; the trunk of a sound artery having been tied -instead of that of a wounded one, inflicting thereby on the patient a -second and useless wound, more dangerous, perhaps, than the original -one it was intended to relieve. - -When Professor of Anatomy and Surgery to the College of Surgeons in -1830, I stated that in wounds of the neck which rendered it advisable -to place a ligature on some part of the carotid, on account of the -supposed impracticability of laying bare the bleeding orifice, it was -generally the _external_ carotid which should be secured, rather than -the primitive trunk; there not being sufficient reason for cutting off -the supply of blood to the head by the internal carotid, unless the -operation on the external carotid should fail. This direction should be -implicitly followed. - -212. A man was wounded by a ball in the side of the neck, and suffered -severely from secondary hemorrhage. Some days after being brought into -the hospital, M. Breschet, unable to arrest the bleeding, was about to -apply a ligature to the common carotid, when the man died in time to -prevent it. On examination after death, the vertebral was found to be -the artery wounded, between the second and third vertebræ. The ligature -of the carotid, had he lived a little longer, would have been a useless -addition to his misery. - -Professor Chiari, of Naples, tied the trunk of the left common carotid -on the 18th of July, 1829, on account of a false aneurism below the -mastoid process, consecutive to a wound made by a sharp-pointed -instrument under the angle of the jaw. The man died on the ninth day, -and the wounded artery was found to be the vertebral, between the -transverse processes of the first and second vertebræ. M. Ramaglia -says, a man, thirty-nine years of age, was wounded by a sharp-cutting, -penetrating instrument, below the left ear, from which an aneurismal -swelling resulted. The common carotid was tied, but as this did not -arrest the pulsations of the aneurism, the ligature was removed, and -the patient, after suffering from various accidents, died, when the -vertebral was found to be the artery wounded. - -M. Maisonneuve, of Paris, lately laid the following most instructive -case before the Academy of Medicine: A lady was shot by her husband, -who stood close to her, with a pistol loaded with ball. The wound was -inflicted on the anterior part of the neck, on a level with the left -side of the cricoid cartilage. The hemorrhage had been considerable -when the surgeons, Messrs. Maisonneuve and Favrot, arrived, though -the wound looked at first as if the ball had not penetrated deeply. -There were pain and numbness of the left arm; respiration, voice, and -deglutition were, however, normal. On examining with the probe, it was -found that the cricoid cartilage had been bared, and that the ball -had then run from above downward, leaving the trachea and œsophagus -internally, and the common carotid artery, the internal jugular vein, -and the pneumogastric nerve externally, and was impacted in the body -of the sixth cervical vertebra, where it could easily be felt. Some -attempts at extraction were made, but they caused so much pain that -they were given up. The patient was bled six times in four days, -and had large doses of opium; she improved considerably under this -treatment, and the inflammation was very moderate. - -On the eighth day hemorrhage occurred at the wound, and again on the -ninth, but it ceased of itself on each occasion. When, however, it -broke out a third time, the surgeons proceeded at once to search for -the bleeding vessel. An incision about three inches long was made on -the anterior edge of the sterno-mastoid muscle, a little external to -the wound inflicted by the ball; the carotid sheath was then brought -into view, and the vessels were found intact. The cricoid cartilage -and the first rings of the trachea were afterward seen to have been -grazed by the ball, which was found implanted in the body of the sixth -cervical vertebra, whence it was easily extracted. Severe hemorrhage -ensued immediately upon the removal of the ball, the blood seeming to -proceed from the vertebral artery, which appeared to have been wounded -within the canal formed by the foramina of the transverse processes. -By placing the finger on the hole left by the ball, the orifice whence -the blood issued was distinctly seen; forceps were applied to it, and -held firmly for a little while to arrest the hemorrhage. An aneurismal -needle, with a very small curve, was then made to carry a double thread -behind the vessel. One of these was used to tie the artery above, and -the other below the aperture whence the blood issued. - -The operators at first thought they were mistaken in supposing that -they had tied the vertebral artery, as the vessel seemed quite free, -while it is known to be protected by the transverse processes in -that locality, and believed they had secured the inferior thyroid. -The hemorrhage ceased at once, and some smaller vessels were then -tied, among which was the inferior thyroid artery. Everything went -on favorably at first; the threads fell on the ninth day after the -deligation of the vessel, and the patient remained in a satisfactory -state for the next five days, when severe febrile symptoms, unpreceded -by shivering, set in; and on the eighteenth day after the operation, -the twenty-seventh after the infliction of the wound, the patient was -suddenly seized with a violent pain in the cervical region, cried out -loudly, and fell into deep coma, which lasted for about seven hours, -when she expired, notwithstanding the most strenuous means were used to -rouse her. - -On the post-mortem examination, the course of the ball was found as -stated above, viz., it had run from the integuments to the body of the -sixth cervical vertebra, leaving the trachea and œsophagus internally, -and the carotid sheath and its contents externally, untouched. The -inferior thyroid artery was wounded just before it reaches the thyroid -gland, and had a firm clot, about half an inch in length, filling its -cylinder. The transverse process of the sixth cervical vertebra was -fractured, and had left the wounded vertebral artery unprotected. -The vessel above and below the wound in its coats was filled with a -firm clot for about an inch in each direction. The body of the sixth -cervical vertebra had been perforated by the ball, which had dug for -itself a canal communicating with the cavity of the spine by a small -aperture, evidently of very recent formation. This aperture resulted -clearly from the necrosis of the thin shell of bone which formed the -bottom of the canal. The cancelous texture of the body of the vertebra -was infiltrated with pus, and a sero-purulent fluid was found in the -spinal canal, both in the cellular tissue external to the dura mater -and in the sub-serous texture of the meninges. No other lesion existed -in any other part of the frame. - -213. M. S., a female, aged fifty-three, was admitted into the -Westminster Hospital, with a large, movable tumor in the neck, under -the sterno-mastoid muscle of the right side. An operation having been -commenced for its removal, the tumor was found to be of a more than -doubtful character, and to dip down between and behind the great -vessels of the neck. In the course of the operation, the external -carotid was opened a little above its bifurcation, and a ligature -was applied on the common carotid. The bleeding was not in the least -arrested; a ligature was then placed on the external carotid above -the hole in the artery, which still continued to pour out blood; a -third ligature was now put upon the internal carotid, with no better -success. A fourth ligature was then applied on the external carotid, -below the hole in it, including the superior thyroid, which was given -off at that part; after which the bleeding ceased, and never returned. -Three ligatures came away in three weeks; the fourth remained during -five weeks. The patient recovered from the operation, but the tumor -grew again, and the woman died exhausted at the end of six months. On -examination after death, the arteries referred to were found to be -obliterated for some distance above and below the parts injured. - -The utter inefficiency of everything but the two ligatures, the one -immediately above, the other immediately below the part opened, could -not be more distinctly proved, if a case were even invented for the -purpose; and the fact could not be more satisfactorily shown that in -every case of wounded--not aneurismal--artery in the neck, one ligature -should be applied above, and another below the opening in the injured -vessel, and not one alone on the common trunk, even if that should be -the part injured. - -It is argued that when a man has his internal carotid cut on the inside -of his throat, by a foreign body of any kind thrust through his mouth, -the artery cannot be tied by two ligatures at the wounded part through -the mouth, not even if it were enlarged from ear to ear. What, then, -is to be done? The artery should be secured by ligature by an incision -made on the outside of the neck. This being admitted, the question then -is, shall the wounded artery be laid bare at the part injured, or two -inches or so lower down, where the main trunk can be most easily got at -by men of even very moderate anatomical knowledge?--an operation which -has frequently failed, although it has frequently succeeded, and is -therefore most approved. _I am willing, for the present_, to consider -it nearly impracticable to tie the internal carotid safely from the -outside of the neck, at the part wounded, without great anatomical -knowledge, and to accept, for the moment, as the proper operation, the -ligature of the common trunk of the carotid, at the distance of two -or more inches, being the operation of Anel; but I venture to ask, -with what fairness can this operation, thus done on one side of the -neck, at the distance of two inches, the other side remaining sound, -be considered similar to that of Mr. Hunter, done on the thigh for a -wound in the calf of the leg, at the distance of perhaps twenty inches, -with all the intervening collateral branches perfectly sound? It cannot -be considered an analogous operation, with propriety or fairness, nor -ought the one to be compared with the other, although it is done; and -thus the subject is mystified to all those who do not understand it -thoroughly. It is because English surgeons miscall this the operation -of Hunter, that French surgeons claim the operation of Hunter as that -of Anel, and deny the priority of Hunter, although the two operations -are essentially distinct. The operation of Anel for _aneurism_ of the -popliteal artery would be destructive; the operation of Hunter for _a -wound_ of the popliteal artery would be equally so. - -This point must, however, be pressed further. Let us suppose that the -internal carotid has been opened by a wound inflicted through the -mouth, and death is about to follow, unless the hole in the artery -can be tied up. How is it to be done? The Hunterian theorists say it -is _impracticable_ to tie the artery at the wounded part, and the -primitive trunk must therefore be secured. - -Let us now suppose that a ligature has been placed on the common -carotid, and the bleeding continues; what is to be done? By the -Hunterian and Anellian theorists there is nothing more to be done--the -patient _must_ die. By my theory there is another operation to be done, -and the patient need not necessarily die. As there is already a wound -in the neck made by the surgeon, there would be little difficulty, by -extending it, in ascertaining that the blood came from the brain, and -that nothing but a ligature on the internal carotid artery above the -part wounded through the mouth could save the patient; and why not do -this operation at first, and place a ligature above and another below -the wound in the artery? - -214. It is with great satisfaction I quote the opinion of M. Velpean -on this subject, as showing the greater advance Parisian surgeons have -made than even many of high attainments in London: “In hemorrhage from -the neck, the mouth, the throat, the ear, or the skull, everything -should be done to reach the branch of the carotid which has been -wounded, rather than tie the carotid itself.” Alluding to a wound of -the inferior pharyngeal artery, he says: “The search for this artery -will cause but little or no inconvenience, for the same incision will -suffice for the ligature of the external or internal carotid, the -lingual, the facial, or the superior thyroid artery, if it become -necessary, each artery being capable of being taken hold of and -compressed, until the one which is really wounded is ascertained.” He -further adds: “Surgeons found it formerly more convenient and sure -to tie the primitive trunk of the carotid, for all arterial diseases -of the head, than to tie the external or internal carotid or their -branches; _but this is not admissible in the present day_.” Operating -for a tumor on the left temple, which he considered aneurismal, he -first tied the common trunk of the carotid, and then the internal. The -tumor diminished in size, but hemorrhage took place from the wound, -and was frequently repeated until the sixteenth day, when the patient -died hemiplegic. The hemorrhage came from the external carotid, and the -blood escaped through the upper opening of the common carotid. He says -himself he ought to have tied the external carotid also; or, after the -first bleeding, have applied a ligature on the upper end of the common -trunk. - -215. Dr. Twitchell, of Keene, N. H., United States, says a soldier, -in a sham fight, in 1807, received a wound, from the wadding of a -pistol, on the right side of the head, face, and neck, which was much -burned. A large wound was made in the mouth and pharynx; nearly the -whole of the parotid gland, with the temporal, masseter, and pharyngeal -muscles, was destroyed. The neighboring bones were shattered, and the -tongue injured. The hemorrhage was not copious, although the external -carotid and its branches were divided. Ten days after the accident, -the sloughs had all separated, and left a large circular aperture, of -from two to three inches in diameter, at the bottom of which might be -seen distinctly the internal carotid artery, denuded from near the -bifurcation of the common trunk to where it forms a turn to enter the -canal in the temporal bone. Directly on this part there was a dark -speck, of a line or two in diameter, which suddenly gave way while -Dr. Twitchell was in the house. With the thumb of his left hand he -compressed the artery against the base of the skull, and effectually -controlled the hemorrhage. The patient fainted. As soon as he -recovered, the doctor says: “I proceeded to clear the wound from blood, -and having done this I made an incision with a scalpel downward, along -the course of the artery, to more than an inch below the point where -the external branch was given off, which, as stated above, had been -destroyed at the time of the injury. Having but one hand at liberty, I -depended upon the mother of the patient to separate the sides of the -wound, which she did, partly with a hook, and occasionally with her -fingers. At length, partly by careful dissection, and partly by using -my fingers and the handle of the scalpel, I succeeded in separating the -artery from its attachments; and, passing my finger under it, I raised -it up sufficiently for my assistant to pass a ligature round it. She -tied it with a surgeon’s knot, as I directed, about half an inch below -the bifurcation.” Dr. Twitchell removed his thumb, and sponged away the -blood, not doubting that the hemorrhage was effectually controlled; -but, to his surprise and disappointment, the blood immediately began to -ooze from the rupture in the artery, and in less than ten minutes it -flowed with a pulsating jet. He compressed it again with his thumb, and -began to despair of saving his patient, but resolved to make another -attempt. Raising his thumb, he placed a small piece of dry sponge -directly over the orifice in the artery, and renewed the compression -till a rather larger piece of sponge could be prepared. He placed -that upon the first, and so went on, pressing the gradually enlarged -pieces obliquely upward and backward against the base of the skull, -till he had filled the wound with a firm cone of sponge, the base of -which projected two or three inches externally. He then applied a linen -roller in such a manner as to press firmly upon the sponge, passing -it in repeated turns over the head, face, and neck. On the 30th of -December the patient was discharged cured, several fragments of bone -and two teeth from the upper jaw having been cast off. Some deformity -remained, in consequence of the depression on the side of the face. - -The inutility of tying the primitive trunk for a wound of the internal -carotid is distinctly shown in this case, which is no less valuable -from the fact demonstrated, that if the internal carotid can be exposed -and injured within the angle of the jaw by an accident, it can be -exposed and secured by ligature at the same part by an operation. - -216. When, then, the internal carotid is wounded through the mouth, -what operation is to be performed? That of placing a ligature -above, and another below the opening made into it; and after much -consideration, and many trials, the following operative process is -recommended to the attention of those who are best acquainted with the -subject:-- - -An incision is to be begun opposite to and on the outside of the -extremity of the lobe of the ear, and carried downward in a straight -line, until it reaches a little below the angle of the jaw, at the -distance of nearly half an inch, more or less, as may be found most -convenient from the form of the neck. This incision exposes the parotid -gland without injuring it. A second is then to be made from the -extremity of the first, extending at a right angle forward, under or -along the base of the lower jaw, until the end of it is opposite the -first molar tooth. This incision should divide the skin, superficial -fascia, platysma myoides muscle, and the facial artery and vein. The -second molar tooth should then be removed, and the jaw sawn through -at that part. Then cut through the deep fascia, the mylo-hyoideus -muscle, and the mucous membrane of the floor of the mouth, exposing the -insertion of the internal pterygoid muscle, which is to be divided. The -surgeon will next be able to raise and partially evert the angle of the -jaw, and thus obtain room for the performance of the remaining part of -the operation, which should be effected by the pointed but blunt end of -a scalpel, or other instrument chosen for the purpose of separating, -but not of cutting. The styloid process of the temporal bone may -then be readily felt, and exposed by the separation of a little -cellular membrane, and with it the stylo-hyoid muscle, which is to be -carefully raised and divided. The external carotid artery will thus be -brought into view, together with the stylo-pharyngeus muscle and the -glosso-pharyngeal nerve attached to it. These are to be drawn inward by -a blunt hook, when, if care be taken to avoid the pneumogastric nerve, -the internal carotid may be felt, seen, and secured by ligature with -comparative facility outside the tonsil, there being between them the -superior constrictor of the pharynx, which, in a case of wound through -the mouth, must have been divided. The pneumogastric nerve should be -drawn outward, and the external carotid artery also, if in the way. -The division of the jaw will not lead to further inconvenience, as the -bone always reunites, when divided, with little difficulty. That this -operation requires a thorough knowledge of the anatomy of the parts, is -true; and this can only be acquired by repeated dissections. - -217. The nearest successful case to the operation thus recommended was -performed by Dr. Keith, of Aberdeen. - -E. Kennedy, aged twenty-five, accidentally swallowed a pin, the head -of which could be felt below and behind the left tonsil, covered by -the lining membrane of the pharynx; it could not be extracted by any -attempt made for its removal. The membrane was snipped by a pair -of probe-pointed scissors, to expose the head of the pin. This was -followed by the discharge of mouthfuls of arterial blood, and it was -evident that the internal carotid artery had been injured. Pressure on -the common carotid stopped the bleeding, and the operation of placing -a ligature on the internal carotid was effected in the following -manner: The patient’s head being supported by a pillow, her face was -turned toward the right shoulder, when an incision was made from -below the ear along the ramus of the lower jaw to below its angle. No -hemorrhage occurred, and the vessel was speedily exposed and secured by -a double ligature passed under it, with less difficulty than the depth -of the vessel would lead one to expect. One ligature arrested the flow -of blood, and the other was therefore withdrawn. The woman recovered, -without any return of the bleeding. Dr. Keith, aware of the necessity -for tying the other end of the artery, if it should bleed, watched the -case day and night until the period of danger had passed away. The -pin gave no trouble, until felt by the patient as about to go down -the œsophagus, which it did to her great satisfaction and relief from -further anxiety. - - - - -LECTURE XIV. - -LIGATURE OF THE COMMON ILIAC ARTERY, ETC. - - -218. The operation for placing a ligature on the aorta should not be -done by making an opening through the front of the abdomen, as has -hitherto been proposed. It should in future be attempted and executed -nearly in the same manner as the operation for placing a ligature on -the common iliac, which has succeeded. The aorta bifurcates usually on -the body of the fourth, or on the inter-vertebral substance between -it and the fifth vertebra, although it may be higher or lower--a fact -which cannot be ascertained previously to the operation; the most usual -place is nearly opposite to the margin of the umbilicus on the left -side. It is about half an inch above this that the ligature should -be placed on the aorta, if this operation is ever done again, rather -lower than higher, on account of the origin of the inferior mesenteric -artery. As the aorta is to be reached by carrying the finger along the -common iliac, the comparative situation of that vessel is next to be -estimated. - -The length of the two common iliac arteries varies according to the -stature of the patient, and the place at which the aorta bifurcates. -The common iliacs again divide into the external and internal iliacs, -which division is usually opposite to the sacro-iliac symphysis. The -length of the common iliac artery is therefore tolerably well defined, -as scarcely ever exceeding two inches and three-quarters, and seldom -being less than two inches. The external iliac is a little longer -than the common iliac, and the place of subdivision of the common -iliac into external and internal can always be ascertained, during an -operation, by tracing the external iliac upward to its junction with -the internal to form the common trunk, which proceeds upward and inward -to the aorta. The left margin of the umbilicus being taken as a point -opposite to that which may be presumed to be the part at which the -aorta divides, and the situation of the external iliac becoming femoral -being clearly ascertained, a line drawn between the two will nearly -indicate the course of these two vessels; sufficiently so, at all -events, to enable the operator to mark with his eye, or with ink, the -place where he expects to tie the artery; and to regulate the length of -the incision, so that this ideal spot may correspond to its center. It -is necessary to recollect, also, that the whole of one hand and part -of the other must be introduced into the wound, to enable the operator -to pass a ligature round the artery, and to tie the knots: so that an -external excision of less extent than five inches will not suffice, and -six will afford a facility in operating, which will save pain to the -patient and inconvenience to the operator. In calculating the length -of the incision, allowance must be made for the size, obesity, and -muscularity of the patient. If a rule be placed on the crest of each -ilium, about one inch and a half behind the anterior superior spinous -process, it will pass in a well-formed man across the junction of the -fifth lumbar vertebra with the upper part of the sacrum, and a little -way behind where the common iliac divides into external and internal. -The center of an incision, six inches in length, beginning about half -an inch above Poupart’s ligament, and about the same distance to the -outside of the inner ring, and carried upward, will fall nearly on a -line with this point. The incision should be nearly parallel to the -course of the epigastric artery, but a little more to the outside, -in order to avoid it and the spermatic cord, and having a gradual -inclination inward toward the external edge of the rectus muscle; the -patient being on his back, with the head and shoulders raised, and -the legs bent on the trunk. The aponeurosis of the external oblique -muscle having been opened inferiorly, is to be slit up for the whole -length of the external incision; and the director having been first -passed under the internal oblique muscle, through a small opening -carefully made into it, it is to be divided in a similar manner. The -transversalis is then to be cut through at the under part, and its -tendinous expansion divided at the upper part, the greatest precaution -being taken by the finger to prevent the peritoneum being injured. -The fascia transversalis is then to be torn through at the lower and -outer part, so that the fingers may be passed inward from the ilium, -and the peritoneum detached from the iliac fossa, and turned with its -contents inward, by a gradual and sidelong movement of the fore and -second fingers inward and upward, until, passing over the psoas muscle, -the external iliac artery is discovered by its pulsation. It is then to -be traced upward and inward toward the spine, when its origin and that -of the internal iliac from the common trunk will be felt. The point of -the forefinger will then be nearly in the center of a line drawn from -the umbilicus to the anterior superior spine of the ilium; hence the -necessity for an incision six inches in length, if the artery is to be -tied high up, which is to be accomplished by tracing it in a similar -manner to its origin from the aorta. - -The _common trunk_ of the iliac arteries and the _aorta itself_ may -be tied by the same method of proceeding; the only difference which -can be practiced with advantage will be to make the incision a little -longer at its upper part, no inconvenience arising from the addition -to the length of the external wound, while the subsequent steps of -the operation will be much facilitated by it. The following method of -proceeding, adopted in two cases in which I placed a ligature on the -common iliac artery with a successful result, will bring the operation -so graphically before the reader that it cannot be misunderstood, -and may be readily followed in operating: I began the operation, -the patient lying on the back, by an incision on the fore part of -the abdomen, commencing an inch and a half below the inside of the -anterior spine of the ilium, and the same distance within it, carrying -it upward, and diagonally inward toward the edge of the rectus muscle -above the umbilicus, so that the incision was between six and seven -inches long. If the incision be made more outwardly, toward the side -in a straight or vertical line from the ilium toward the ribs, great -difficulty will be experienced in turning over the peritoneum with its -contents, so as to place the finger on the last lumbar vertebra--an -inconvenience which will be avoided by making the incision diagonally, -and of the length directed. - -After dividing the common integuments, the three layers of muscles -were cut through in the most careful manner; the division of the -transversalis muscle was attended with some difficulty, inasmuch as -there was but little fascia transversalis, and the peritoneum was -remarkably thin--as thin as white silver paper. On attempting to -reach the under part on the inside of the ilium, so as to turn the -peritoneum over, which in sound parts is always done without the least -difficulty, I found that it could not be done on account of the tumor -which projected inward adhering to it; some bleeding took place from -the large veins which surrounded it, giving rise to the caution not -to proceed further in that direction. At this moment, in spite of the -greatest possible care that could be taken by Mr. Keate, who raised and -protected the peritoneum, a very small nick was made in it, sufficient -to show the intestine through it. Perceiving that I could not tie the -internal iliac as I had at first intended, and that I must place the -ligature on the common iliac, I tried to gain a greater extent of -space upward; but where the tendon of the transversalis muscle passes -directly across from the lower ribs to aid in forming the sheath of -the rectus, the peritoneum is usually so thin and so closely attached -to it that it can only be separated with great difficulty. I knew this -from the operation I had before performed, when, in spite of all the -precaution I could then take, the peritoneum was at this spot slightly -opened. It occurred in the present instance, and the right lobe of the -liver was thus exposed. - -The opening thus made on the fore part of the abdomen was not large -enough to admit two hands. The peritoneum being, however, separated a -little from the posterior wall of the abdomen from the outside, by the -fingers, for a cutting instrument was inadmissible, four of the fingers -of one hand were introduced beneath it, and it was turned a little over -toward the opposite side. In doing this it must be remembered that the -peritoneum must be raised, the hand being pushed toward the back as -little as possible, in order to avoid getting behind the fat commonly -found in that part of the body, which would lead to the under edge -of the psoas muscle instead of the upper surface, and thus render the -operation embarrassing. - -The peritoneum being carefully drawn over with its contents, I found -I could only get one hand, or a little more, underneath it in search -of the artery, the tumor below preventing any further detachment of -the peritoneum in that direction. I therefore passed my finger across -the psoas muscle, and it rested on the fifth lumbar vertebra. The -common iliac artery was not to be felt, however, even as high up as the -fourth lumbar vertebra, nor was the aorta; they had both risen with the -peritoneum, and my finger resting on the spine was beneath them. Mr. -Keate endeavored to raise or draw over the peritoneum, to give me an -opportunity of seeing the vessels, but it could not be done. However, -he felt the pulsation of the iliac artery, which had been raised with -the peritoneum, to which I found it adhering. Carefully separating it -with the end of the forefinger of the right hand, I passed a single -thread of strong dentists’ silk, as it is termed, in a common solid -aneurismal needle, by the aid of the thumb and forefinger of the left -hand, round the artery without seeing it. I could then bring the artery -a little forward by means of the aneurismal needle, when it appeared -to be perfectly clear, and from the distance of the bifurcation of the -aorta above, which could be distinctly felt, I calculated that the -common iliac was tied exactly at its middle part. All pulsation below -immediately ceased. - -The two ends of the ligature were twisted, and the peritoneum replaced -in its proper situation, care being taken that the two small openings -into it should be well covered under the skin, so that they might not -be in the line of the incision, and that they should be covered by -newly divided healthy parts, so that they might thus adhere to each -other. Three strong sutures and three or four smaller ones were put in -through the skin, in order to prevent the parts bursting asunder from -the movements of the patient. This operation was only formidable, as a -whole, from the circumstance that space could not be obtained for the -introduction of both hands; for, strange as it may appear, the safety -of and ease in doing the operation depend on the first incision in the -fore part of the abdomen being so large that the peritoneum containing -the bowels may be freely drawn over by the expanded hands of the -assistant, so that the operator can see what he is doing beneath. In -my first case the whole of the parts under the peritoneum could be -distinctly seen, and several gentlemen (not in the profession) who were -present saw the common iliac artery in its natural situation. - -The patient suffered little or nothing from the operation, which was -performed on the Saturday; there was no augmentation of the pulse until -Sunday evening, when it rose to 120; she then experienced some pain, -which was materially diminished, although not altogether removed, by -the abstraction of fourteen ounces of blood. At four in the morning, -Mr. Hancock, now senior surgeon to the Charing Cross Hospital, took -away fourteen ounces more, after which she had not a bad symptom. The -bowels were not moved for the first four days. The temperature of the -limb diminished, but not much, which may be attributed to its having -been constantly rubbed night and day by two persons; and a hot brick, -or bottles of hot water, covered with flannel, having been applied to -the feet, of the temperature of from 120° to 140°. One nurse rubbed the -lower part of the limb, and another the upper, for three days and three -nights; if an interval of a few minutes occurred, a hot flannel was -put on the limb. The friction was very slight, so as not to injure the -cuticle. The patient occasionally dozed a little; still the same gentle -friction was kept up. The ligature came away on the twenty-sixth day -after the operation. The external incision healed very readily, but was -followed, as is usual in all extensive wounds of the muscular wall of -the abdomen, by a slight herniary projection, requiring the support of -an abdominal bandage. - -The situation of the ureter and rectum on the left side in this -operation, and of the ureter and cæcum with its appendix on the right -side, should be well understood, and it should be known that the ureter -rises with the peritoneum. The relative situation of the common iliac -artery and vein should be particularly attended to, when passing the -ligature around the vessel. On the left side, the artery lies external -and anterior to its commencement; on the right, the artery passes over -the commencement of the vena cava and the left iliac vein, which do not -follow the peritoneum when drawn toward the opposite side. The bowels -should be thoroughly well evacuated before the operation is performed, -but purgatives should not be given for some days after it has been -done. The food should be liquid, and inflammation should be subdued by -leeches, general bleeding, fomentations, and opium. - -219. The _aorta_ may be as readily tied by this mode of proceeding -as the common iliac; and I am satisfied it is in this way such an -operation ought to be performed, provided it become necessary to -attempt it, which I suspect it will not be; for when an aneurism has -formed so high up that it prevents the application of a ligature on -the side on which the disease is situated, the common iliac will be -more readily tied above it, instead of the aorta, by performing the -operation on the opposite or sound side of the body; for as a ligature -can be applied with great ease on the sound side on the middle of -the common iliac artery, it requires very little more knowledge and -dexterity to pass over to the opposite or diseased side, and tie -the artery above the aneurismal tumor, the size of which would have -prevented the operation being done on its own or the affected side. -The placing a ligature on the aorta for an aneurism in the pelvis will -thus be rendered unnecessary--a most important result, deduced from the -operation described. - -220. If the _internal iliac_ is to be tied, the operator traces it -downward from its origin, in preference to passing his finger from -the external iliac artery inward in search of it. Having placed the -point of his forefinger on the vessel at the part where he intends to -pass his ligature, he scratches with the nail upon and on each side -of it, so as to separate it from its cellular attachments, and from -the vein which accompanies, but lies behind it. Thus far the operator -proceeds by feeling; but it is now necessary that the sides of the -wound should be separated, and kept apart by blunt spatulæ curved at -the ends, so as to take up as little space as possible, and not to -injure the peritoneum. The surgeon should, if possible, see the artery, -and the ligature carried on the eye of a bent probe, or a convenient -aneurismal needle, should be passed under it from within outward, -when it should be taken hold of with the forceps; the probe or needle -should then be withdrawn, and the ligature firmly tied twice, or with -a double knot. Great care must be taken to avoid everything but the -artery. The peritoneum which covers it and the ureter which crosses it -must be particularly kept in mind. The situation of the external iliac -artery and vein, which have been crossed to reach it, must always be -recollected, and, if there be sufficient space, they should be kept -out of the way, and guarded by the finger of an assistant. - -221. The _external iliac_ artery has been so often and so successfully -tied that a description of the two methods of proceeding commonly -adopted will suffice, with a few additional remarks. The first, -recommended by Mr. Abernethy, is in accordance with the operations -on the common, and on the internal iliac. The patient being laid on -his back, with the shoulders slightly raised, and the legs bent on -the trunk, an incision is to be made about three inches and a half in -length in the direction of the artery, terminating over or a little -above Poupart’s ligament. The aponeurosis of the external oblique -muscle will be exposed, and an opening being made into it, a director -is to be introduced, and it is to be slit up to the extent of the -external incision. The internal oblique and transversalis muscles -are then to be “nicked,” so as to allow a director or the point of -the finger to be introduced below them, when they also are to be -divided, the finger separating them from the fascia transversalis -and the peritoneum. The fascia transversalis running from Poupart’s -ligament to the peritoneum is now to be torn through with the nail, -immediately over the pulsating artery, and the peritoneum is to be -separated by the finger, and pushed upward until sufficient room has -been obtained; which in this, as well as in all other operations on the -iliac arteries, is sometimes difficult on account of the protrusion -of the intestines covered by the peritoneum, when the patient is not -sufficiently tranquil. The artery is yet at some depth; it is covered -by a dense cellular membrane, connecting it to the vein on its inside, -which must be torn through with the nail. The anterior crural nerve -is separated from the artery by the psoas muscle, at the outer edge -of which it lies. The aneurismal needle should be passed between the -vein and the artery, and the point made to appear on the outside of the -latter. - -In this operation the ligature is placed on the external iliac, above -where it gives off the epigastric and the circumflexa ilii arteries; -as the operation is very much the same as that already described, with -the exception of the incision being shorter and nearer to Poupart’s -ligament, it is obvious, if it were found necessary from disease to tie -the artery higher up, or even to tie the common iliac, that it might be -done by merely enlarging the wound. It is therefore the best mode of -proceeding when the aneurismal swelling in the groin has encroached on -Poupart’s ligament. - -Another method has been recommended by Sir Astley Cooper, which is -perhaps more followed where there is little doubt of the artery being -sound. - -“The patient being placed in the recumbent posture, on a table of -convenient height, the incision is to be begun within an inch of the -anterior superior spinous process of the ilium, and is to be extended -downward in a semicircular direction to the upper edge of Poupart’s -ligament. This incision exposes the tendon of the external oblique -muscle; in the same direction the above tendon is to be cut through, -and the lower edges of the internal oblique and transversalis abdominis -muscles exposed; the center of these muscles is then to be raised -from Poupart’s ligament; the opening by which the spermatic cord -quits the abdomen is thus exposed, and the finger passed through this -space is directly applied upon the iliac artery, above the origin of -the epigastric and circumflexa ilii arteries. The iliac artery is -placed upon the outer side of the vein; the next step in the operation -consists in gently separating the vein from the artery by the extremity -of a director, or by the end of the finger. The solid curved aneurismal -needle is then passed under the artery, and between it and the vein -from without inward, carrying a ligature, which, being brought out -at the wound, the needle is withdrawn, and the ligature is then tied -around the artery, as in the operation for popliteal aneurism. One end -of the ligature being cut away, the other is suspended from the wound, -the edges of which are brought together by adhesive plaster, and the -wound is treated as any other containing a ligature.” - -This method of operating will suffice when the artery is to be tied for -an aneurism which does not extend as high as Poupart’s ligament. When -it does, the operator will be so much inconvenienced by it, while the -sound part of the artery above the tumor will be so much in a hollow -behind it in the pelvis, that a ligature cannot readily be passed -around it; the disturbance to the peritoneum will be much greater, and -much more likely to give rise to peritonitis, than if the incision were -made an inch longer on the face of the abdomen. The surgeon, instead of -searching for the artery, as Sir Astley Cooper has directed, through -the passage by which the spermatic cord quits the abdomen, and thus -passing the fingers directly under the peritoneum, will find it very -much for his own ease, and for the advantage of his patient, to pass -his fingers under the peritoneum from the inside of the wall of the -ilium, from which it readily separates, and thus approach the artery -from the outside instead of from below. He will obtain more room, reach -the artery easily above the origin of the circumflexa ilii, and avoid -that disturbance of the peritoneum, in applying the ligature, which -often leads to inflammation. The ligature should be passed under the -artery from within outward, so as to avoid the vein, which I have seen -injured by passing the needle from without inward. - -If the surgeon have unluckily divided the epigastric artery, either in -this or in any other operation, all that he has to do is to enlarge the -incision, and tie both ends of the divided vessel; I have no hesitation -in saying it will not be of any consequence, either in this operation -or in one for hernia. - -222. In all cases of aneurism of the gluteal and sciatic arteries, -the internal iliac artery should be tied, instead of an operation on -the part itself. In all cases of wounds of those arteries, which are -the only ones rendering an operation for placing a ligature on these -vessels necessary, the wound should in a great measure regulate the -course of the incision. The operation is an act of simple division, -first through the common integuments for the space of five inches, -then through and between the fibers of the gluteus muscle to the same -extent; a dense aponeurosis covering the vessels is to be next divided, -when the bleeding will lead to the injured vessel. Place the body on -the face, turn the toes inward; commence the incision one inch below -the posterior spinous process, and one inch from the sacrum; carry it -on toward the great trochanter in an oblique direction to the extent of -five inches. Divide the gluteus muscle and the aponeurosis beneath it, -and seek for the artery as it escapes through the upper and anterior -part of the sciatic notch, lying close to the bone. If the vessels -of the gluteus muscle bleed, so as to be troublesome, and cannot be -stopped by compression, they must be secured. - -If the sciatic artery be the vessel injured, the incision should be -made in the same direction, but about an inch and a half lower down. -If the course of the wound render it doubtful which artery has been -injured, the incision should be as nearly as possible between the two -lines directed, the wound being always the best guide; care should -be taken in every instance to include nothing in the ligature but the -artery. - -Dr. Tripler, of the United States Army, was called to a person who had -fallen backward with great force on a glass bottle, which had thus been -driven into the right buttock, within an inch of the ischiatic notch. -The fingers passed into the wound could be felt on the inside of the -thigh. The man was deluged with blood, and in a state of syncope. The -wound was plugged and bandages applied. Several hemorrhages took place, -and on the thirteenth, five days after the receipt of the injury, the -wound was enlarged, and the gluteal artery tied as it emerged from the -pelvis. The bleeding ceased for three hours, when it returned with as -much force as ever. After various ineffectual attempts to suppress -the bleeding by pressing on the external iliac and femoral arteries, -it was determined to tie the internal iliac, which was done in a very -satisfactory manner, and the bleeding did not return. The man died -three days after the operation, and an examination after death took -place; but, strange to say, no notice is taken, no mention whatever -is made of the wounded vessel. It is simply remarked that the last -ligature was found embracing the internal iliac artery an inch below -the bifurcation, and a firm coagulum already deposited above the point -of ligation. - -According to the principles laid down in this work, two errors were -committed in this case. The first, in tying the gluteal artery _as it -emerged from the pelvis_. The second, in tying the internal iliac, -which was unnecessary. The bleeding which caused this operation to -be resorted to is described _as a welling up of the vital fluid_, as -returning _slowly and sluggishly_; the color is not alluded to. It is -probable that the gluteal artery was not divided, but only wounded; -and if the injured part had been sought for, and one ligature applied -above, and another below the wound in it, the hemorrhage would not have -returned, and life perhaps might not have been lost. - -The operations were highly honorable to the gentlemen concerned, as -proving their anatomical knowledge. The principle on which they acted I -presume to condemn. - -223. Compression should never be made on the femoral artery when a -ligature is about to be placed upon it for aneurism, because the -pulsation is thereby suppressed, and the most important guide to the -vessel is at the same time taken away. When the artery has been wounded -near the groin, and is bleeding, compression must be had recourse to -in the first instance to arrest the hemorrhage; the first incisions -must therefore be made without the information which the pulsation -gives as to the precise situation of the artery, although a finger may -be allowed to rest, or a mark be made on the part, beneath which the -artery could be felt before the pressure was applied. The external -incision should always be made longer or shorter in proportion to the -depth at which the artery is situated. It should be at least one-third -longer in the middle than at the upper part of the thigh; for, while a -long incision always facilitates the subsequent steps of the operation, -it never does harm, unless it is out of all reasonable proportion. -The center of the incision should be, if possible, directly over that -part of the artery on which it is intended to apply the ligature; but -no inconvenience will arise from its being applied nearer its upper -extremity. The patient being laid on his back, and properly supported, -the knee is to be bent and turned outward, by which the head of the -femur will be rolled in the acetabulum, and the femoral artery will be -more distinctly felt at the upper part of the thigh, below Poupart’s -ligament. It lies on the psoas muscle, having the vein on its inside, -and the anterior crural nerve about half an inch on its outside, -having passed between the psoas and iliacus muscles, although some -branches soon approach the artery, and run down on the external part -of the sheath. The relative position of the parts having been duly -considered, an incision is to be made _directly_ in a line over the -pulsating artery, and carried through the skin, cellular tissue, and -superficial fascia, down to the deep-seated or fascia lata of the -thigh. If an absorbent gland should be in the way, it must be turned -aside or removed. The arteria profunda femoris is given off about -two inches below Poupart’s ligament, on the back part of and outside -the femoral, while three or four small vessels spring from half an -inch to an inch below it on the fore part, and one or other of these -may be divided. They are the superficial epigastric, the superficial -pudic, the superficial circumflex of the ilium, and probably an artery -supplying the absorbent glands. If they bleed so as to be troublesome, -they must be secured, more particularly if the femoral artery is to -be tied below them. The fascia lata is now to be divided, with that -part of the fascia transversalis which, descending beneath Poupart’s -ligament, forms the sheath of the artery, when the vessel will be -exposed. In dividing this fascia and sheath, the point of the knife -is always to be directed to the center of the artery, so that if it -be cut by accident it may be seen, when the only result will be the -necessity for the application of a ligature above and one below it. The -artery being fully exposed, as ascertained by the pulsation being felt -by the finger, it is to be separated from its cellular attachment to -the sheath on each side by a blunt or silver knife; and the aneurismal -needle or probe, armed with a strong single thread of dentists’ silk, -is to be passed under it from the inner or pubic side outward, by which -all injury to the vein from the round point of the needle or probe will -be avoided. Two common knots are to be made in the usual manner, when -one thread may be cut off, or the two twisted together and brought -carefully out of the wound; the edges of which are then to be duly -approximated and retained in that situation by sticking-plaster and -a moderate compress, secured in a similar manner. The knee is to be -bent forward to relax the parts, and laid on the outside with a pillow -beneath it. - -The needle will pass more easily under the artery if the thigh be bent -on the trunk; before the knots are tied, the surgeon should ascertain -that pressure on the part or artery, which he has nearly surrounded by -the ligature, suppresses the pulsation in the tumor below. - -224. The point of a sword entering the anterior part of the thigh two -inches below Poupart’s ligament, and wounding the superficial femoral -artery, will necessitate the application of two ligatures, one above -and the other below the wound in the vessel; but as the profunda under -ordinary circumstances is given off posteriorly at this spot, it is -possible the upper ligature may be placed on the main artery a little -above the bifurcation. The result might, and would probably be, on -some sudden movement of the patient, a recurrence of the hemorrhage by -regurgitation from the profunda into the main trunk below the ligature; -and thus through the wound in the artery, the lower ligature assisting -by the obstacle it offers to the passage of blood through it. In such -a case, the wound should be reopened, and the profunda sought for and -tied. It has been argued that the ligatures, being applied close to -the origin of collateral branches, must fail. This error has been -demonstrated, (Aph. 186,) and need not be further insisted upon. That -it should still be maintained by some surgeons and teachers, who prefer -old jog-trot theories to demonstrated facts, and cannot perceive that -an exception is not a fundamental rule, is much to be regretted. - -225. The operation for popliteal aneurism lower down in the thigh is to -be done in the following manner:-- - -The surgeon, having turned the knee outward and bent the leg inward -into the tailor’s sitting position, to show the course of the sartorius -muscle, should trace the artery from the groin downward, until it -appears to pass under that muscle. The external incision, four inches -in length, made in the course of the artery, should pass over this -point one inch, so that when the fascia lata is divided, the sartorius -muscle may be seen crossing over to the inside at the lower extremity -of the wound. The fascia lata is to be divided upward for the space of -two inches of the incision. The forefinger is then to be introduced -into the wound, and pressure made with it rather outwardly, when it -will readily distinguish the pulsation of the artery, still included in -its sheath. This is to be opened by slight and repeated touches of the -knife directly over the center of the line of the vessel, or it may be -divided on the director, when the artery will be exposed. The point of -the forefinger will easily recognize it from the roundness and firmness -of the feeling communicated by it, as well as by its pulsation; and -the end of the nail, or handle of the scalpel or blunt knife, will -separate it with facility from its attachments, to such an extent as -to admit the blunt point of the solid, unyielding aneurism needle to -be passed beneath it from the pubic side. If the point of the needle -do not readily come through the cellular attachments of the artery on -the outside, this part must be touched lightly with the scalpel, or -rubbed with the nail until the ligature is exposed, which should then -be taken hold of with the forceps and one end drawn out, while the -instrument with the other end is withdrawn. The operator, taking both -ends of the ligature, which has been in this manner passed under the -artery, between the fingers of one hand, presses upon the artery with -the forefinger of the other, so as to arrest the course of the blood in -it, when, if there be an aneurism blow, the pulsation in it will cease. -The ligature is then to be pressed upward as far as the artery has -been detached, and is to be tied with a double knot. The wound is to -be dressed as in the previous case with adhesive plaster and compress, -but without a bandage; and the patient is to be placed in bed, with his -knee bent forward, or resting on the outside, if more agreeable to him. - -The operation is done in this manner on that part of the femoral -artery which is not covered by muscle, and all interference with the -sartorious is avoided. It is the improvement on the Hunterian operation -recommended by Scarpa, and ought always to be adopted. This method -obviates all discussion as to placing the ligature on the outside of -the sartorious muscle, or as to the fear of injuring the absorbents; -as to the saphena vein, it can always be seen, and its course traced -up the thigh and avoided. After the first incision has been made and -completed down to the fascia lata, that part is to be divided to the -extent of two inches, but this must be dependent on circumstances; the -object being to obtain a view of the sheath containing the artery, -the opening into which, after the first touch of the knife, may be -completed with the assistance of the director under it. The artery will -be less disturbed in its lateral attachments by an opening into the -sheath, of three-quarters of an inch in length, than by one of half -the extent, as it will admit of the aneurism needle being passed under -it with more facility, and consequently with less disturbance to the -surrounding parts. There is no reason to believe that a free opening -into the fascia of the thigh has ever done mischief, or even one made -in the sheath, provided the artery has not been unnecessarily disturbed. - -The warmth of the limb operated upon should be maintained by gentle -friction from the toes upward to the knee; when left at rest it should -be enveloped in flannel. The wound should not be dressed until the -fourth day, the limb being kept quite quiet; the patient should move as -little as possible in bed, and the part of the heel on which the limb -rests should be examined from time to time, as it may under pressure -become gangrenous. - -Suppression of the secretion of urine is not uncommon during the first -twenty-four hours after all these operations; it may be gradually -removed by the patient’s taking mild diluent drinks. The constitutional -irritation is frequently great, the pulse rising in forty-eight hours -from 85 to 120; if this continue until the third day, when the fear -of mortification will have passed away, it should be moderated by the -abstraction of a small quantity of blood. In some cases of this kind -I have had occasion to bleed twice, and with the happiest effect, -the pulse having fallen in consequence to its natural standard. The -medicines given at the same time were saline draughts every six hours, -with from four to six or more drops of Battley’s solution of opium. The -ligatures come away on and about the fifteenth day. In many cases they -remain a much longer time without inconvenience. - -226. The popliteal artery is never to be secured by ligature, unless -wounded and bleeding. Under ordinary circumstances, an incision should -be made at least three inches long in the course of the wound, the -patient being laid on his face and the limb extended. If the injury -to the artery has been committed where it lies in the ham between the -heads of the gastrocnemius muscle, the bleeding and the pulsation -will point out its situation. The integuments and fascia having been -divided, the posterior saphena vein and nerve, if seen, are to be -avoided and drawn aside, when, by carefully separating some dense -cellular or areolar membrane and drawing the heads of the gastrocnemius -from each other, the bleeding artery will be seen as well as the vein -and nerve. The nerve should be drawn inward with a blunt hook and the -vein carefully drawn outward. - -“On the 2d of February, 1855, a young gentleman, aged nineteen, had -a heavy mortising chisel thrown at him, which entered the upper part -of the calf of the leg. There was arterial bleeding, which a man near -him stopped by keeping his finger on the wound. I saw him two hours -after the accident; there was bleeding ‘per saltum;’ presumed that -the posterior tibial was cut. Consulting with two other surgeons, he -was turned over on the table; the limb was distended, and a firm clot -filled up the cavity; I pressed moderately upon either side of the -wound, but there was no return of hemorrhage. The patient was therefore -put to bed, a bandage applied, and an assistant left in charge. The -day following there was less tension in the calf; no hemorrhage. -Having recently read a case by Butcher, in the ‘Dublin Quarterly,’ -upon the treatment of wounded arteries by compression, I followed out -his rules. The case did well up to February 13th, when he had a sudden -and severe pain in the calf of the leg, which was much distended, and -the clot pulsating strongly. In a few minutes a large stream burst -out, so large that I was satisfied it could not be from the posterior -tibial. I put my finger in the sinus and found that its direction was -first backward, then backward and upward. I again proposed to dilate -the wound and search for the vessel, when an objection was started by -one of my friends, that if the artery were wounded immediately on its -division, there would not be sufficient space for the clot to form. -As this objection was made, and I failed to combat it, I summoned -the consulting surgeon of the district. After carefully considering -the case, he strongly advised a fair trial should still be given to -compression. Hemorrhage returned upon the 16th. A consultation advised -ligature of the femoral artery, which operation I did. Bleeding -returned on the 25th, and on the 26th I cut down and found a small slit -in the popliteal, and put a ligature above and below it, which saved -the life of the patient.” - -227. The posterior tibial, or the peroneal artery, or both, if wounded -at the same time, are to be tied according to the principles laid down -in Aphorism 197, page 231. An incision, from six to seven inches long, -should be made nearer to the inner edge of the leg than to the center, -and should be carried through the gastrocnemius muscle, the plantaris -tendon, and soleus muscle, down to the deep fascia, under which the -arteries lie with their accompanying veins, having the posterior tibial -nerve on the fibular side of the artery. If the incision has been -made in the upper part of the calf of the leg, the peroneal artery -will be exposed by it; but if it be certain that the peroneal artery -is the vessel injured, the incision should be made toward the fibular -side of the leg. When the surgeon has divided the fascia, he will -find this artery covered by the fleshy fibers of the flexor longus -pollicis muscle, at any distance below three inches and a half from -the head of the fibula; these fibers being divided, the artery will be -found close to the inside of the bone. Above that part the artery is -under the fascia, and upon the tibialis posticus muscle. It has not an -accompanying nerve. Both arteries will be readily found by either of -the incisions, if the surgeon be acquainted with their situation. - -The posterior tibial artery may require to be tied between the ankle -and the heel. In this situation its pulsation may be felt, and that -will be the best guide to the artery. It has the tendons of the -tibialis anticus, and of the flexor digitorum communis, nearer to the -malleolus than itself, and distant about a quarter of an inch; there is -a vein on each side of the artery. Posterior to this is the posterior -tibial nerve, and nearer the heel the tendon of the flexor longus -pollicis. To tie the artery near the heel, its pulsation should be -felt, and an incision more than two inches long made upon it, through -the common integuments and superficial fascia; a strong aponeurosis -will be found beneath, covering the sheath of the vessels and adhering -to the tendons. This aponeurosis must be carefully opened on a director -passed beneath it, and then the sheath of the vessels: the artery -should be tied with a single ligature, unless wounded. The nerve is -nearer the heel. - -The posterior tibial artery may be tied a couple of inches higher up in -the small part of the leg, by making the incision on the tibial edge of -the soleus muscle, under which it lies. - -228. The posterior tibial artery, an inch and a quarter or from that -to an inch and a half below the inner ankle, gives off the internal -plantar artery, and assumes the name of external plantar. The internal -and smaller artery passes forward on the inside of the foot, under the -origin of the abductor pollicis, to the outer or metatarsal side of the -great toe. - -The external plantar artery, from the point of division, takes a course -curved toward the heel to the metatarsal bone of the little toe, which -is prominent, being a distance of about three inches; during this -course it is covered by the integuments, lateral ligament of the joint, -a quantity of granular fat, the thick plantaris fascia, the origin of -the abductor of the great toe, and the flexor brevis of the other toes. -The artery may then be felt and seen near the os calcis, having the -nerve and vein to the inner side; and lying on the accessorius muscle -and its fascia, at the depth, in ordinary cases, of about an inch and a -half. The plantar fascia extends in considerable strength from the os -calcis forward to the toes, and divides into two portions opposite the -first phalanx of each, which are inserted laterally into the sheaths -of the flexor tendons, and the sides of the ligaments connecting the -phalanges to the metatarsal bones. This fascia should, when necessary, -be slit up at the part injured, or a bent probe forcibly passed under -it to the required extent, when any intervening muscular fibers should -be divided until the bleeding point is perceived, when a ligature -above and another below the wound should be placed upon the artery. - -The external plantar artery, on reaching the metatarsal bone of the -little toe, runs forward, in nearly a straight line, between the middle -and outer divisions of the plantar fascia, the section of which will -expose it as far forward as the end of the metatarsal bone. - -229. The anterior tibial artery is to be tied at that part of its -course at which it may be wounded. When the operation is done for -aneurism, it should be performed a short distance above the tumor, -and sometimes a second operation below it will become necessary. If -the aneurism should be situated so high up and so close to the origin -of the vessel as not to admit of a ligature being applied anterior to -the interosseous ligament, it may be placed on the femoral artery of -the thigh, and the result awaited. If it appeared likely to succeed at -first, and yet the pulsation returned, the artery should be tied below -the tumor, because the return of pulsation would probably depend on the -blood regurgitating into the vessel. - -In order to tie the anterior tibial artery after it has passed from the -back to the fore part of the leg through the interosseous space, and -over the interosseous ligament, and for one-third of its descent toward -the instep, draw a line from the head of the fibula to the base of the -great toe, which will nearly describe its course. An incision four -inches in length is to be made in this line down to the fascia covering -the muscles; if the foot be bent upward, and again extended, the -bellies of the tibialis anticus and extensor digitorum communis muscles -will be more distinctly seen. The fascia is to be divided for the whole -length of the incision between them; they are then to be separated for -the same distance by the scalpel and the finger; the artery will be -found close on the interosseous ligament, between its two venæ comites. - -A case has been supposed, in which a knife, a sword, or other narrow -instrument, having penetrated the upper part of the leg, has wounded -the anterior tibial artery just after it has been given off from the -posterior tibial, behind the interosseous space or ligament. The -bleeding is free, and from the wound in the front of the leg, although -the artery cannot be secured, from the narrowness of the space between -the tibia and fibula, behind which space it is situated. This very -peculiar injury, which may, however, occur at any time, cannot be -known until an incision has been made on the fore part of the leg, and -the bleeding point seen so deep between the bones as not to admit of -two ligatures being placed on the artery above and below it. In such -a case, an incision is to be made through the calf of the leg, when -the artery can be secured without difficulty. No great inconvenience, -it is apprehended, would result from the two operations. If the sword -wound should have been a small one, although deep, compression on its -surface would in all probability have been had recourse to in the first -instance; which, while it prevented the flow of blood externally, would -scarcely impede its effusion above the fascia and under the soleus -muscle, the distention of which and of the calf of the leg would, to a -careful observer, point out the evil, and lead to the operation being -done in the first instance through the calf of the leg. - -In the middle third of the leg the origin of the extensor proprius -pollicis intervenes between the tibialis anticus and the extensor -communis digitorum muscles. The anterior tibial nerve, a branch of -the peroneal, attaches itself to the artery a little above this -middle part, and is usually found in front of it, although it is not -constantly in that situation: care should always be taken to avoid it. - -In the lower part of the leg the artery lies on the tibia, having -the tendons of the extensor digitorum communis on the outside, and -that of the extensor proprius pollicis on the inside, by which it is -overlapped, being also covered by the fascia and the integuments. - -On the instep this artery runs over the astragalus, the naviculare, -and the os cuneiforme internum, to the base of the metacarpal bone -supporting the great toe. It here divides into two branches: one -dips down between the first and second metatarsal bones, to join the -terminating branch of the external plantar artery, rendering the -collateral circulation free; the other passes on to the inside of the -great, and the opposite sides of the first and second toes. The artery -is always to be found on the fibular side of the tendon of the extensor -proprius pollicis. - - - - -LECTURE XV. - -THE COMMON CAROTID ARTERY, ETC. - - -230. The carotid artery may be tied, in almost any part of its -course, in the following manner: The patient being seated, with the -shoulders supported, so that the light may fall on the neck, the head -is to be bent a little forward, to relax the muscles on the fore -part. An incision is then to be made on the line of the inner edge -of the sterno-cleido-mastoideus muscle, by which the integuments, -the platysma myoides, and the superficial cervical fascia are to be -divided. The extent of this incision, in persons with long necks, -may be from a line beginning parallel with the cricoid cartilage to -within about half an inch of the sternal end of the clavicle: when -the neck is very short, it must be begun as high up as the lower edge -of the thyroid cartilage, so as to be as nearly as possible three -inches in length. The sterno-cleido-mastoideus muscle is then to be -drawn outward, with any vein which may be seen attached to its under -edge. The pulsation of the artery under the finger will point out its -situation, and the sterno-hyoideus and sterno-thyroideus muscles being -drawn and kept inward, the omo-hyoideus will be seen crossing in the -upper part of the hollow thus formed by the separation of these parts. -The central tendinous portion of this muscle is attached and fixed -by the deep cervical fascia, and lies immediately over the sheath of -the vessels, particularly over the jugular vein. This fascia, which -is strong although thin, is to be carefully divided below the muscle, -immediately over the center of the artery, the position of which is to -be accurately ascertained by the finger. At or beneath the same spot, -the sheath of the artery is to be opened; and the long, thin nerve, the -descendens noni, which runs upon the sheath, will at this part be seen -inclining to the tracheal side of the artery. It is to be separated and -drawn inward with the muscles. If the sheath of the artery be carefully -opened immediately over its center, the jugular vein will scarcely -interfere with it. But as it has been known to enlarge suddenly under -the exertions or excitement of the patient so as to overlap the -artery, it has been recommended to make gentle pressure on the vessel -at the upper part of the incision, and below if necessary, in order to -prevent that occurrence. The aneurismal needle is then to be introduced -and passed under the artery from without inward, by which the jugular -vein and the par vagum nerve will be avoided, more particularly if the -sheath of the vessels has been undisturbed, save where it has been -opened immediately over the artery. The point of the aneurismal needle -is to be brought out close to the inside of the artery within its -sheath, by which means all danger will be avoided of injuring either -the recurrent or the sympathetic nerves which lie behind or to the -inside of it. As to the œsophagus, thoracic duct, or thyroid artery, -they are not likely to be injured by any common operator; but he should -be aware that on the left side, if he be obliged to operate low down, -he may meet with greater inconvenience from the jugular vein, which is -more anterior to the artery, and rather overlaps it, while on the right -side it inclines outward from it. - -The carotid artery may be tied higher up in the following manner: The -incision in this instance should be begun a little below where the -former one was commenced, and should be continued upward for the same -length of three inches, in a line extending toward the angle of the -jaw. The head should be laid back to enable this to be done, and ought -to be kept in that position by an assistant. The artery at this part of -the neck is covered by the integuments, the platysma myoides muscle, -and the fascia. After the muscle has been divided, the strong fascia -must be carefully raised with the forceps and opened, and the operator -will do wisely if he divide it upward and downward on a director. -With the end of the scalpel or a blunt knife he should separate the -cellular tissue from the veins, which appear in this situation, and are -often the source of much embarrassment. The sheath of the artery is -to be opened over the center of the vessel, and the ligature is to be -passed around it as before. The descendens noni nerve runs in general -on the outside of the artery in this part of the neck, and afterward -crosses over to the tracheal side. The par vagum, which lies in the -angle formed posteriorly by the apposition of the carotid artery and -jugular vein, to which latter it is more particularly attached, is to -be avoided on introducing the aneurismal needle; and on bringing it -out on the inside, the same attention must be paid to prevent injury -to the great sympathetic or any of its branches. The surgeon in both -these operations should draw the ligature first a little outward and -then inward, so as to enable him to ascertain that he has included in -it nothing but the artery, which is to be tied with two knots; one -end may be cut off, or both may be twisted together, and brought out -of the wound opposite where the vessel has been tied. The integuments -should be accurately closed by adhesive plaster, and the patient put to -bed with the head bent forward, and properly supported. He should eat -as little solid food as possible until after the ligatures have come -away, and observe even greater precautions as to quietude than in other -instances. - -231. The external carotid artery may be tied by an operation conducted -in a similar manner. After the first incisions have been made, and -the strong cervical fascia divided, the operator must feel for the -pulsating vessel, which will be found on a line parallel with the cornu -of the os hyoides, below which part the common trunk usually divides -into the external and internal carotids, the external being the more -superficial and internal of the two at their origin. The external -carotid turns with its convexity inward; nearly opposite to but rather -above the os hyoides it is crossed by the ninth or lingual nerve, the -digastric and stylo-hyoid muscles; it should be tied below this part. - -When any of the branches of the external carotid has been wounded, -it ought to be tied by a similar operation at both ends, at the part -wounded. If the surgeon cannot do this, and the hemorrhage demand it, -the trunk of the external carotid is the vessel on which the ligature -should be placed, not that of the common carotid. - -232. The internal carotid artery, when wounded near the bifurcation -of the common carotid, is to be secured by two ligatures, and the -steps in the operation are the same as those for exposing the external -carotid, the surgeon recollecting that the internal carotid is more -deeply seated and to the outside of the external. A ligature may be -placed on the internal or external carotid, close to the bifurcation, -with safety; but if the wound of either vessel should encroach on the -bifurcation, one ligature should be applied on the common trunk and -another above the part wounded; but as neither of these would control -the collateral circulation through the _uninjured_ vessel, whichever of -the two it might be, a third ligature should be placed on it above the -bifurcation. - -When the internal carotid is wounded through the mouth, at the upper -part of the neck, it should be secured by the operation described on -page 248, Aph. 216. - -233. The arteria innominata arises from the upper part of the arch of -the aorta, generally on a line nearly parallel with the upper edge of -the cartilage of the second rib, ascends obliquely toward the right -side, and usually divides opposite the sterno-clavicular articulation -into the right subclavian and the right carotid arteries; the last of -which appears to be its continuation, although the smaller in size. -The arteria innominata is about two inches in length, rarely exceeding -two inches and a half, although it is very variable both in length -and situation, so much so as sometimes to render the operation of -placing a ligature upon it during life impracticable. It is covered -by the right vena innominata, which receives the left at a right -angle, near the origin of the artery. Exterior to the vena innominata -are the sterno-thyroideus and sterno-hyoideus muscles, some strong -fascia covering the vein at its upper part, and the first bone of the -sternum. The arteria innominata may ascend higher in the neck before -it divides, in which case its pulsation will be perceptible in front -of the trachea, and the subclavian artery will cross higher in the -neck, which is one reason for not continuing the external incision down -to the sterno-clavicular articulation in the operation on the right -carotid. The subclavian artery, given off behind or a little above the -articulation, proceeds outwardly for the space of one inch before it -reaches the inner edge of the scalenus anticus muscle, which is about -half an inch in width; so that the subclavian artery, when it clears -the outer edge of the scalenus anticus muscle in a tall man, is not -more than one inch and a half or three-quarters from its origin, even -to the spot at which a ligature is usually placed upon it. The first -branch given off is the vertebral on the upper and back part of the -artery, distant half an inch from the carotid at the bifurcation. The -thyroid axis is given off at the anterior and upper part of the artery, -a quarter of an inch more outwardly, and the internal mammary often -arises directly opposite from the anterior and inferior part of the -artery, descending into the chest behind the junction of the first and -second ribs with their cartilages. The inner edge of the scalenus -anticus muscle is close to these two last vessels. The phrenic nerve, -crossing this muscle obliquely, lies on the outside of the thyroid -axis, and on the inside of the internal mammary artery; having crossed -the subclavian artery at this part, it descends between it and the -junction of the internal jugular and subclavian veins to the chest. -Internal to this, some small branches of the great sympathetic nerve, -which lies behind, pass over the artery; and still more internal, but -distant about a quarter of an inch from the carotid artery, the par -vagum crosses likewise. The only point at which the subclavian artery -can be tied internal to the edge of the scalenus anticus muscle is at -this point, on the inside of the par vagum, in a space scarcely more -than one-quarter of an inch in width, to which the carotid will be the -best guide. It would appear that a ligature may be as readily applied -around the innominata, immediately below the bifurcation, as around the -subclavian, although little or no reliance can be placed on success -attending either operation. - -From this view of the parts it will be evident that the operation may -be done in the following manner: Raise the shoulders of the patient, -and allow the head to fall backward, by which the artery will be drawn -a little from within the chest. Let an incision be made over and down -to the sterno-cleido-mastoideus muscle, the sternal origin of which, -and nearly the whole of the clavicular origin, should be divided on -a director, carefully introduced below it, avoiding some small veins -which run below and parallel with its origin. An incision is now or -previously to be made, two inches in length, through the integuments, -along the inner edge of the muscle, which will admit of its being -raised and turned upward and outward. Some cellular texture being torn -through, the sterno-hyoideus muscle is brought into view, and should be -divided on a director. The sterno-thyroideus is then to be cut through -in a similar manner. A strong fascia and some cellular texture here -cover the artery, having the nerves above mentioned running beneath -it, the carotid being to the inside, the internal jugular vein to the -outside. By following the carotid downward, the finger will rest on -the innominata and on the origin of the subclavian, and a ligature -may be placed on either. If on the innominata, the aneurismal needle -(and several kinds should be at hand) should be passed from without -inward, immediately below the bifurcation, close to the vessel. If on -the subclavian, the surgeon must recollect that there is only about a -quarter of an inch of this artery on which the ligature can be applied; -this small space being bounded internally by the carotid artery, and -externally by the par vagum above, and the vertebral artery below. The -ligature should be applied close to the vertebral artery, the needle -being passed from below upward, the greatest care being taken to avoid -the recurrent nerve, which separates from the par vagum at this part, -and winds under the subclavian and carotid arteries, to be continued -upward to the larynx. If the ligature be placed on the arteria -innominata, the same care must be taken to draw the par vagum outward, -and to avoid the recurrent nerve. The edges of the wound should be -brought together and dressed in the usual manner, the head being bent -forward on the trunk, and maintained in that position, in order to -relax the parts, and admit of their being kept in apposition. - -This operation ought only to be performed in cases of aneurism of the -subclavian artery, in which it is presumed that the disease extends as -far as the external edge of the scalenus anticus muscle, but not more -inwardly. The arteria innominata has certainly been tied five, if not -six times in vain, and in two or three other instances the attempt -failed, the operator not succeeding in his object. In Dr. Mott’s case -the ligature came away on the fourteenth day, but the patient died -from hemorrhage, in consequence of ulceration of the artery, on the -twenty-sixth day after the operation. Dr. Graëfe’s patient also died -from hemorrhage on the sixty-seventh day. It is evident, from these -cases, that a man may live so long after the operation as to show that -he does not die from its immediate effects, or from any that must -necessarily take place. It is therefore possible that if the operation -be often repeated it may eventually be successful. - -234. The left subclavian artery rises perpendicularly out of the chest -like the innominata, but on a plane much posterior to it, so that at -the part where the vertebral artery is given off, which is about an -inch and a half from the origin of the artery, it lies nearly an inch -deeper from the surface than the vessel on the opposite side. It is -covered by, or is more directly connected with, the important parts -which are also in the vicinity of the right subclavian. The pleura -adheres to it, and can scarcely avoid being torn in putting a ligature -around it. The par vagum is parallel with and anterior to it. The -internal jugular vein and the left vena innominata lie over it. The -thoracic duct and œsophagus are connected with it; and the carotid -artery is in front. So that with the most careful dissection it is -not a very easy matter to place a ligature upon the ascending portion -of the left subclavian artery, without doing more mischief than is -compatible with the life of the patient. - -Aneurisms of the arch of the aorta have been sometimes known to appear -so far beyond the outer edge of the scalenus anticus muscle as to -impress the surgeon with the idea that they arose from the subclavian -artery, and that an operation on that vessel might be attended with -success. This error is not likely, however, to occur in the present -day, for the stethoscope will always point out the existence of such -an aneurism within the chest, and will therefore demonstrate the -impropriety of the operation. Aneurisms of this nature are usually -attended by some circumstances indicating their more internal origin, -independently of the information derived from the stethoscope. An -operation should only be attempted when the case is free from doubt. - -Whenever an aneurismal tumor in the neck is accompanied by any -alteration of the sterno-clavicular articulation, the case is clearly -one totally unfitted for any operation. The same may be said of any -case of aneurismal swelling, either internal or external to it, in -which the stethoscope applied on the sternum in the course of the -arteria innominata, or of the arch of the aorta, indicates disease. A -swelling at the root of the carotid is more likely to be an aneurism -of the arch of the aorta, or of the arteria innominata, than of the -carotid itself. The stethoscope will remove all doubt. - -235. The subclavian artery has been frequently tied above the clavicle, -_external_ to the scalenus anticus muscle. It should be done in the -following manner: The patient being placed horizontally on the table, -in such a situation that the light may be directed into the hollow -in the bottom of which the artery is to be tied, the shoulder is to -be depressed, and an incision made along the edge of the clavicle, -commencing one inch nearer the sternum than the clavicular edge of the -sterno-cleido-mastoideus muscle, and carried outward to the extent -of three inches and a half or four inches. The platysma myoides -and the superficial fascia are to be divided, taking care not to -injure the external jugular vein, which should be drawn to the outer -side of the wound. By this incision the edges of the trapezius and -sterno-cleido-mastoideus muscles will be exposed. - -The object of the operation is in the first instance to reach the outer -edge of the anterior scalenus muscle: this lies immediately below the -outer edge of the clavicular portion of the sterno-cleido-mastoideus, -and the division of a portion of this part of the muscle will greatly -facilitate the subsequent steps of the operation, although it may be -done without it. The artery will be found crossing over the first rib -at the very edge of the attachment of the scalenus anticus to it; -but a quantity of cellular substance and fascia intervenes, which -must be torn through before it can be exposed. This should be done -with a blunt, round-pointed knife, in a line parallel with the first -incision, but more immediately over the outer edge of the scalenus -muscle. The omo-hyoideus muscle passing obliquely across the root of -the neck will be in this manner exposed, which should be clearly done, -because it narrows the space in which the operation is to be performed -to a small triangle; the outside and apex of which is formed by this -muscle, the inside by the scalenus anticus, the base by the rib, above -it the subclavian vein, and above it again, but under the clavicle, -the supra-scapular artery and vein. The blunt knife, working in the -triangular space, will first expose one or more of the nerves of the -axillary plexus, which again diminishes the space; more inwardly the -scalenus anticus will be felt, and should be seen by tearing through -the thin fascia which lies behind the omo-hyoideus, and is connected -with it. The point of the finger, assisted if necessary by the blunt -knife, should be passed along the edge of the muscle until it rests -on the first rib, and at the angle formed between the muscle and the -rib the artery will be found and known by its pulsation. The operator -should detach the artery in a slight degree from its connections, with -the nail of the forefinger, and the aneurismal needle should be passed -in preference from below upward, by which the pleura will be avoided. -After the ligature has been passed under the artery, the vessel should -be pressed upon with the finger, while the ligature is firmly held in -the other hand, by which the circulation through the artery will be -stopped. The pulsation in the tumor and at the wrist should cease, when -the ligature may be tied with a double knot; for doing this, one or -two steel probes, having a ring at the end, placed at a right angle -with the shaft, will afford great assistance. - -In some instances, particularly in short-necked persons, the -omo-hyoideus lies close to the clavicle, and requires to be drawn -upward and outward from it. In others, the lowest nerve of the axillary -plexus lies over the artery, and may be mistaken for it. When the veins -coming from the neck are large and numerous, great care should be -taken to avoid injuring them, as they frequently cause not only much -hemorrhage, but great delay. Great care must also be taken in all these -operations to prevent the ingress of air into any of the veins which -may by accident be opened, as its admission in quantity has occasioned -sudden death, although the entrance of a few bubbles may not be so -dangerous as has been supposed. - -236. When the axillary artery is to be tied for a _wound_ caused by a -sharp-pointed or other instrument which has been forced through the -pectoral muscle or under it from the axilla, the patient is to be -firmly supported or placed in the horizontal position, the arm to be -slightly separated from the body, and an incision made in the course -of the axillary artery, through the integuments, superficial fascia, -and the great pectoral muscle--in fact, through the anterior fold of -the armpit. The length of the incision will depend on the part at -which the artery is to be secured. The parts divided being separated, -the pectoralis minor will be seen crossing to the coracoid process -at the upper part of the wound, and the artery may be felt below it, -inclosed in its cellular sheath, with the nerves of the arm and its -venæ comites. All other modes of attempting this operation are unworthy -consideration, and ought to be discarded as dangerous and insufficient. - -At the lower edge of the pectoralis minor, the artery is crossed by the -outer of the venæ comites, which passes between the external cutaneous -and the external origin of the median nerve, at the spot where they -separate from the plexus. The artery may be tied below this separation, -or the nerves and vein may be drawn to the outside, and the artery tied -above the union of the external with the internal root of the median -nerve as high as the origin of the arteria thoracica acromialis, the -pectoralis minor being either raised and pushed upward, or divided if -necessary. The internal root of the median nerve is in connection with -the internal cutaneous and ulnar nerves; the larger of the venæ comites -is to the inside and behind, but as it ascends it receives its fellow, -and with the cephalic vein forms in front of the artery the subclavian -vein. - -237. The brachial artery can be traced by its pulsation from the lower -edge of the teres major muscle to below the bend of the arm, where -it is covered by the pronator radii teres muscle. At first it is on -the ulnar side of the humerus, resting on the triceps, and slightly -overlapped by the coraco-brachialis and biceps muscles. In the middle -of the arm it rests on the tendon of the coraco-brachialis, is close -to the bone, and lies under the lower edge of the biceps; in which -situation it may always be compressed by bending the forearm, so -as to cause the belly of the biceps to enlarge, when pressure made -immediately below it will arrest the circulation in the brachial -artery. It then crosses toward the anterior part of the arm, and rests -on the brachialis anticus muscle until it passes the bend of the elbow. -It is accompanied by two veins, which are connected with it by a loose -cellular membrane forming a sheath. The external cutaneous and median -nerves lie a little to the outside of the artery in the upper third of -the arm. In the middle third the median nerve lies generally in front -of, but sometimes between the artery and the bone, and is on the inside -at the inferior part. The internal cutaneous nerve runs parallel with -but superficial to the artery, the ulnar nerve nearer but posterior -to it. When a ligature is to be placed on the brachial artery in the -upper part of its course, the incision should be made about three -inches in length, directly on the line of the pulsating vessel, by -which all mistakes will be avoided. The integuments should be divided -carefully, that the internal cutaneous nerve may not be injured; the -fascia is then to be cut through and the forearm bent, when the vessels -and nerves will be relaxed. The artery is to be separated from its -veins, one on each side; and it must be recollected that the external -cutaneous and median nerves are to the radial side of the artery, -the internal cutaneous and the ulnar nerves to the ulnar side of it. -In the middle of the arm the median nerve lies immediately over the -artery, except in those cases where it passes behind it; when it lies -in front it may be mistaken for the artery, from the pulsation being -communicated to it. The incision should be to the same extent of three -inches, directly in the course of the artery, and the ligature should -be passed from the ulnar to the radial side of the vessel, in order to -avoid the possibility of including either the internal cutaneous or the -ulnar nerve, and for the purpose of excluding both the veins. - -238. The brachial artery, a little below the bend of the arm, divides -into the radial and ulnar arteries--the radial being the continuation -of the brachial in direction, the ulnar in size. The brachial artery, -at the bend of the arm, is cushioned on the brachialis internus muscle, -having the tendon of the biceps on the outside, the median nerve on its -inside, which is at first continued on the same side of the artery, -which now takes the name of ulnar. This vessel inclines toward the -ulna for about an inch, and then passes between the two origins of -the pronator radii teres muscle; the median nerve crosses it at this -part to get into the middle of the arm, and is then separated from it -by the ulnar origin of the muscle. The artery continues its course, -inclining outwardly, under the pronator radii teres, the flexor carpi -radialis, the palmaris longus, and the flexor sublimis muscles, lying -on the flexor profundus. On clearing the ulnar edge of the flexor -sublimis, it is covered by the flexor carpi ulnaris, the course of -the artery having been obliquely under these muscles to the extent of -two inches. To tie it in any part of this course, they must be more -or less divided, and the only difficulty or danger arises from the -median nerve, which lies deeper under the radial origin of the pronator -teres. But the whole of the muscular fibers may be divided, without -injuring the nerve, by successive and careful incisions through them -until the artery and nerve are exposed, and a ligature may then be -applied above and below the wound in the vessel. It may be supposed, -by way of elucidation, that a man has received a wound from a sword -through the flexor muscles, which injures also the ulnar artery, as may -be presumed from its situation and the continued and impetuous flow -of blood. It may be further supposed that this wound is in a slanting -direction from the ulna toward the radius. The surgeon, if he thinks he -can calculate the point at which the artery is injured, should cut down -upon it in the direction of the fibers of the intervening muscles, and -even through them until he reaches the artery; but if he has erred in -his calculation, he should introduce a probe into the wound, and, after -having ascertained the line it has taken, he should cut, if necessary, -across the muscular fibers in that direction until he exposes the -bleeding artery; if he be careful not to divide the median nerve, no -inconvenience will arise from the operation. (_Aph._ 184, page 192.) - -239. If the ulnar artery be wounded near its origin, through the radial -side of the pronator teres muscle, an incision should be made through -the integuments and the aponeurosis of the biceps muscle; the pronator -muscle being then exposed, it is to be drawn inward and downward, or -toward the ulna, and the dissection continued until the median nerve -is brought into view. The probe introduced through the original wound -will lead to the artery, the pulsation of which will be felt and the -bleeding seen. Where the nerve crosses the artery, the vessel will be -found above or to the radial side of it, and to the ulnar side below. -It may be tied above without dividing a muscular fiber; but at the part -where the nerve crosses, and below it, some fibers of the pronator -teres must be divided, and in some cases the whole of them, before the -artery can be properly secured by two ligatures; but this division is -of little or no consequence, as the muscular fibers reunite without -difficulty. - -240. To tie the ulnar artery in the _middle third_ of the arm, the -surgeon should bend the wrist, and trace upward the tendon of the -flexor carpi ulnaris as far as it can be felt. At the point where it -becomes indistinct, an incision should be commenced and carried upward -for the space of four inches; the fascia is then to be divided to the -same extent, when the flexor carpi ulnaris may readily be traced upward -by its tendon, which is on the radial side of it; this muscle may then -be easily separated from the flexor sublimis, beneath the edge of which -the artery will be found covered by the deep-seated fascia, having a -vein on each side, and the ulnar nerve to the ulnar side of it. By this -method of proceeding the artery will be readily exposed, which is not -always the case by any other manner of operating, and it may be tied as -high up as where it passes from under the flexors of the arm. - -The ulnar artery may be easily tied near the wrist, where it is most -superficial. Bend the wrist, and make the flexor carpi ulnaris act, -when the tendon will be felt internal to the styloid process of the -ulna; make an incision two inches and a half in extent along the radial -edge of this tendon, dividing the fascia of the arm which covers it. -The artery will be felt below the deep-seated fascia, and, on dividing -it, will be seen with its venæ comites, the ulnar nerve being behind -it; that nerve must be avoided, in the application of a ligature. - -241. The radial artery may be secured by ligature with great ease in -any part of its course to the wrist. At the upper third of the arm, the -radial artery is covered by the approximation of the supinator radii -longus and pronator radii teres muscles. To expose it at this part, a -line may be drawn from the middle of the bend of the arm to the thumb, -which will indicate its course; or the supinator radii longus being -put into action, an incision is to be made from the bend of the arm -obliquely outward along its ulnar edge to the extent of three inches, -avoiding the median vein, but dividing the integuments and the fascia. -The supinator muscle is then to be gently separated from the pronator -radii teres by the handle of the knife, and the artery will be felt -covered by the deep-seated fascia; on the division of which, it will be -seen with its venæ comites lying on some adipose membrane, and on some -branches of the musculo-spiral nerve, which separate it from the tendon -of the biceps, and are to be carefully avoided. The musculo-spiral -nerve itself lies nearer the radius, rendering it advisable to pass the -aneurismal needle from that side. - -In the middle third of the forearm, the inner edge of the supinator -radii longus marks the line of the incision, which should be to the -extent of three inches. The fascia being divided, the supinator longus -is to be separated from the flexor carpi radialis, and, on the division -of the deep fascia, the artery will be found passing with its venæ -comites over the insertion of the pronator radii teres and the radial -origin of the flexor digitorum sublimis. The musculo-spiral nerve lies -close to the radial side of the artery. - -Near the wrist, the radial artery may be tied with great facility. -Make an incision two inches and a half long on the radial side of the -tendon of the flexor carpi radialis, which becomes prominent on bending -the wrist; the superficial and deep fasciæ are to be divided, when the -artery and its veins will be exposed; the nerve has not accompanied the -artery to this point, where it lies on the pronator quadratus, whence -it turns below the styloid process of the radius to the back of the -hand. - -The radial artery, on giving off the superficialis volæ to the palm -of the hand, near the end of the radius, inclines outward, and, when -between its styloid process and the trapezium, lies beneath the two -first extensors of the thumb. Passing onward to reach the angle formed -by the metacarpal bones of the thumb and forefinger, it lies first -in a triangular space between these two extensor muscles and the -third, in which situation a ligature may readily be placed upon it by -a simple incision. Proceeding onward, the artery passes _under_ the -third extensor and lies to the outside of it, where it may also be -secured by ligature without difficulty, just before it dips into the -palm and gives off the principal artery to the thumb. After the radial -artery has reached the inside of the hand, to form the deep-seated -palmar arch, it crosses the metacarpal bones nearly at a right angle, -covered by all the muscles, tendons, and nerves of the palm. A branch -of the ulnar nerve is here seen going to the muscles of the thumb. -If the graduated compression recommended in Aphorism 208, page 238, -together with due pressure on the radial and ulnar arteries at the -wrist, should fail to arrest the bleeding from a wound at this part, -the two muscles, forming what may be and is called the web, between the -thumb and forefinger should be divided until the wounded artery can be -seen. These muscles are the adductor pollicis on the inside, and the -adductor indicis on the back of the hand; and their division would lead -to little or no inconvenience. If a man, in opening an oyster, were to -divide these muscles by an accidental thrust of his knife, it would -not be considered a serious accident, although some surgeons might be -dismayed if desired to divide them surgically, to expose the artery at -the spot where it has been wounded. - - - - -LECTURE XVI. - -INJURIES OF THE BRAIN. - - -242. Injuries of the head affecting the brain are difficult of -distinction, doubtful in their character, treacherous in their course, -and for the most part fatal in their results. The symptoms which -appear especially to indicate one kind of accident are frequently met -with in another. It may even be said that there is no one symptom -which is presumed to demonstrate a particular lesion of the brain, -which has not been shown to have taken place in another of a different -kind. Examination after death has often proved the presence of a most -serious injury the existence of which had not even been suspected; -and death has often ensued immediately, or shortly after the most -marked and alarming symptoms, without any adequate cause for the event -being discovered on dissection. One man shall lose a considerable -portion of his brain without its being productive at the moment of -the slightest apparent functional inconvenience; while another shall -fall, and shortly die without an effort at recovery, in spite of any -treatment which may be bestowed upon him, after a very much slighter -injury inflicted apparently on the same part. During the war with the -United States, in 1814, a soldier in Canada was struck by a ball which -lodged in the posterior part of the side of the head; the wound healed, -and the man returned to his duty. Twelve months afterward, having got -drunk, he fell in the streets of Montreal, and died. The ball was found -lying on the corpus callosum, where it had made a small hole or sac for -itself. After the battle of Waterloo, I recommended, in the case of a -soldier similarly wounded, that nothing should be done unless symptoms -arose demanding the use of the trephine; as none occurred, and the -wound healed, the man was sent home to Colchester, where he got drunk, -and fell dead in the marketplace. The ball was lodged deeply in a cyst -in the posterior lobe of the brain. Persons rarely live with a foreign -body lodged in the anterior lobe of the brain, although many recover -with the loss of a portion of the brain at that part. An injury of -apparently equal extent is more dangerous on the forehead than on the -side or middle of the head, and much less so on the back part than on -the side. A fracture of the vertex is of infinitely less importance -than one at the base of the cranium, which, although not necessarily -fatal, is always attended with the utmost danger. The treatment of -these several injuries (although they may be at first sight apparently -similar) cannot, and must not be alike in all--a fact which should -always be borne in mind in their management. In civil life, both in -hospitals and among private persons, injuries of the base of the -cranium are most frequently met with, because they are generally the -consequence of falls; while in military life injuries of the base of -the skull are rare, and those of other parts are common. The practice -of the military surgeon, with respect to injuries of the cranium and -its contents, is therefore more successful, all things considered, -than that of the surgeon in civil life, and particularly in a great -metropolis; this may perhaps account for some of the discrepancies in -opinion which have existed between them. - -243. Many physiologists have thought they could indicate the part of -the brain injured from the symptoms which followed, and there are -some which do not admit of dispute as to their cause; but there are -very many which at present do not admit of being distinctly traced -to their source. Birds, small quadrupeds, fishes, and reptiles will -live for some weeks after nearly all the contents of the skull have -been removed. Sensation, volition, memory, judgment, sight, hearing, -and all other sensations are lost by the removal of the cerebral -hemispheres. The mobility of the iris is destroyed, not by the removal -of the hemispheres, but of the corpora quadrigemina. If the cerebellum -be cut away, a bird can no longer jump, walk, or retain its natural -position, but it can move and live. When the medulla oblongata, or -medulla spinalis, or the nerves of these parts, have been divided, -muscular contraction ceases, and all power of movement is lost. Life -is destroyed because respiration ceases when the medulla oblongata -is divided at or immediately below the origin of the eighth pair of -nerves. The removal of any one of these nervous parts in the lower -animals only weakens the powers of those which remain. In man it -destroys them, and life is extinguished. - -244. Respiration consists of four movements--1, the opening of the -mouth and dilatation of the nostrils; 2, the opening of the glottis; -3, the elevation of the ribs; 4, the contraction of the diaphragm. The -division of the dorsal spinal marrow, below the origin of the phrenic -nerve, paralyzes the movement of the ribs; above the phrenic nerves it -paralyzes the diaphragm, and respiration ceases; the yawning or opening -of the mouth and glottis alone remain. On dividing the point of origin -of the par vagum, the movements of the glottis cease. On slicing the -upper part of the medulla oblongata instead of the lower, from before -backward, the opening or yawning of the mouth ceases; another slice, -and the dilatations of the nose are arrested, and the inspiratory -movements of the trunk alone remain. - -While the power of motion in each part seems thus to be dependent on -isolated points of the medulla oblongata and the medulla spinalis, an -indirect or connecting influence is admitted to take place between them -and the remaining parts of the brain; and whatever may be its nature -or extent in animals, there can be no doubt of its being so infinitely -greater in man as to be essentially different; for none of these -experiments can be made either artificially or accidentally on any one -of these parts in him, without being productive of the ultimate if not -almost immediate death of the whole. - -Dr. Marshall Hall, in the comprehensive and luminous view he has taken -of the nervous system, supposes that each sentient and motor nerve -of the spinal marrow is further endowed with an excito-motor power -for reflex action. He calls these generally excito-motor nerves, and -considers them to be connected with a part of the medulla spinalis, -distinct from that portion which is strictly an appendage to the brain. -_Incident_ nerves arise from the skin and certain mucous membranes, -and convey impressions from them to the spinal marrow. _Reflex_ nerves -convey back the nervous influence excited through the medium of the -incident nerves, to the voluntary muscles in which they terminate; -and Dr. Marshall Hall further considers that these nerves, and the -part he calls the true spinal cord, constitute the true spinal system -which presides over ingestion and exclusion, retention and egestion; -and consequently that its influence is exerted upon the muscles which -belong to the entrances and outlets of the animal frame; or, in other -words, upon the sphincters, and the muscles of deglutition and of -respiration; and that the true spinal system maintains the tone of the -whole muscular system. Stimulating an incident or excitor nerve of the -extremities, by tickling or pricking the sole of the foot or the palm -of the hand after sensation is apparently destroyed, causes a special -muscular contraction or motion in the limb, if the excito-motor system -be uninjured. Irritating the eyelashes induces contraction of the -eyelids; and the irritation of one will sometimes cause contraction -of both. Tickling the verge of the anus induces contraction of the -sphincter muscle. Irritating the fauces and the root of the tongue, -by pressing it down with the handle of a spoon, induces an action of -deglutition. Respiration is excited by irritating or exciting the -trifacial or fifth pair of nerves, by throwing cold water on the face, -and stimulating the nostrils; by influencing the spinal nerves by a -similar use of cold water to the body and chest, and by tickling or -stimulating the sides, soles of the feet, and verge of the anus. - -The great object or value of these and other facts and physiological -experiments is to enable us to conclude, as far as possible, what part, -what great division of the brain or spinal marrow is most seriously -injured, more particularly with respect to the prognosis than to the -treatment. Great severity and persistence of the symptoms lead to the -belief that the part of the brain or spinal marrow on which they depend -is directly injured rather than indirectly affected, and that the -result is more likely to be fatal. Permanent insensibility and loss of -motion may depend on cerebral mischief only. The loss of the mobility -of the iris implies an affection of the tubercula quadrigemina. -Convulsions, vomiting, a drawing up of the limb not affected by -paralysis, stertor, a difficulty in swallowing, strabismus, and relaxed -sphincters, show derangement of the spinal functions; which is well -marked when tickling the eyelashes does not cause closing of the lid, -of the verge of the anus no contraction of the sphincter, of the sole -of the foot no motion of the toes. - -245. In order to simplify the investigation of Injuries of the Head, -they have been divided into two great classes: one denominated Injuries -from Concussion; the other, Injuries from Compression or Irritation of -the Brain. By the term Concussion of the Brain, a certain indefinable -something, or cause of evil which cannot be demonstrated, is understood -to have taken place; the effect of which is often clearly proved by -the almost instantaneous death of the individual, or by a succession -of symptoms which quickly lead to his destruction. The term concussion -is very aptly and forcibly illustrated by the homely but striking -expression in use in the sister country, when a man has been suddenly -killed by a fall on the head, “that the life has been shook out of -him.” On a dissection of the brain in a pure case of this kind, no -trace of injury or even of derangement of any part of it can be -perceived. Life is extinct, but the brain is intact. The immaterial -has been separated from the material part, by an injury apparently -inflicted on the very seat of life, with as little apparent derangement -of its structure as if death had occurred in a secondary manner from -the abstraction of blood by a rupture of the heart. - -Modern surgery has in fact added nothing to our information on the -subject, perhaps from the peculiar difficulties of the case, which may -not admit of removal in the present state of our knowledge; although -all writers seem to coincide in opinion that a sudden stoppage of the -circulation of the blood is the more immediate cause of death. That the -positive shock communicated to the brain from one side to the other, -and the repercussion which follows from its resiliency, are capable of -giving rise to a direct and visible injury, is indisputable. It usually -forms on what may be termed the edges of the hemispheres, which appear -to be discolored, bruised, and sometimes torn, so as to have caused -the term laceration to be given to this kind of injury. This mischief, -however, is most commonly found in the examination of those persons -who have survived the accident for some days, and is therefore only a -predisposing cause of death. - -246. When an injury is not immediately fatal, and life, although for -a time in imminent danger, is not destroyed, yet fluctuates on the -verge of destruction, gradually to be restored, again to fail, and at -the end of several days to be eventually extinguished, the changes -which take place in the functions of the brain during this period are -accompanied by alterations which are observable in its appearance. The -assemblage of phenomena which have taken place constitute inflammation; -and it is only by that vigorous treatment which subdues inflammatory -action that a person in whom they have occurred can be preserved. The -immaterial part of man is so intimately connected with his material -part that they cannot be suddenly separated without the material part -receiving an irrecoverable though often an imperceptible detriment; -the bonds which unite them cannot be temporarily loosened without a -derangement taking place, which appears to require for its recovery -the aid of some of those processes of nature which are known to occur -in the restoration to health of other parts of the body. A moderate -shock is often immediately followed by sickness, faintness, weakness, -and in a few hours by a slight headache, from which the person quickly -recovers without further inconvenience; or the headache may remain -for several days the sole symptom or sign of an injury having been -sustained; the slightest possible approach to that action which we -call inflammation having sufficed to effect a cure. One step further, -the headache continues, the stomach sympathizes, there is little or -no desire for food, the whole person feels more or less deranged, and -the pulse quickens. A smart purgative will perhaps relieve all these -manifestations of approaching evil, but the loss of a little blood will -be more certainly efficacious. - -A child ten years of age fell over the banisters into the passage, and -struck its forehead. It was taken up apparently lifeless, but it soon -appeared that it was only stunned; it breathed deeply, looked about -vacantly, and could not speak; it then vomited, and gradually recovered -its speech and senses. A brisk purgative was all that was required to -remove the slight headache which followed on the subsequent day. - -In more dangerous cases which ultimately prove fatal, the laceration -of the brain alluded to complicates the mischief as well as the -symptoms, and is perhaps the actual cause of death. It has, however, -been demonstrated that a slighter injury of the kind, giving rise -to long-continued symptoms, need not necessarily be fatal; in which -case it is supposed that the cure is effected by adhesion, and not by -granulation accompanied by the secretion of purulent matter. - -247. When a concussion of the brain has rendered the sufferer -insensible and motionless, the countenance is deadly pale, (the -reverse of what takes place in sanguineous apoplexy;) the pulse is -not discoverable: the man does not appear to breathe. It is useless -to open his veins, for they cannot bleed until he begins to recover; -and then the loss of blood would probably kill him. It is as improper -to put strong drinks into his mouth, for he cannot swallow; and if he -should be so far recovered as to make the attempt, they might possibly -enter the larynx and destroy him. If he should appear to breathe, and -be made to inhale very strong stimulating salts, it will probably -give rise to inflammation of the inside of his nose and throat, to -his subsequent great distress. Mild stimulants and disagreeably -smelling substances held to the nose, together with partial as well -as general friction with the warm hands, are the best means to be -adopted, and should be continued until it be ascertained that life is -extinct. If the patient should recover, some signs of breathing will -be discoverable, followed by a distinct inspiration, repeated at so -distant an interval as to render its recurrence uncertain. At last -respiration is satisfactorily established, and the pulse, which was -doubtful at the commencement of the restoration to existence, becomes -perceptible, although often irregular, and sometimes continues so until -reaction has taken place. With this partial recovery of the natural -functions of the body, vomiting is apt to supervene, and is one of -the earliest and most satisfactory symptoms of returning sensibility. -It was formerly supposed to be peculiar to cases of concussion, but -it is often present in cases evidently of compression or irritation -from external violence. The breathing becomes in general quite free; -and although it is occasionally labored, it is rarely stertorous, a -symptom which may be considered, when permanent, as a more distinct -sign of continued irritation, or of compression and of extravasation, -than of concussion. The sensibility of the surface, however, is not -fully re-established, the patient is not cognizant of any injury -committed upon him, and if he should recover, has no recollection of -what has passed. This first stage does not last long, and with the -partial re-establishment of the functions of the lungs and of the -heart, and of the circulation of the blood through the brain, although -irregularly or insufficiently performed, the second stage may be -supposed to begin. The patient is still in a state of stupefaction, -although now perhaps sensible to personal maltreatment; and in this -condition he may remain for many days; he draws away or moves the part -aggrieved; he may be able to answer in a monosyllable correctly or -otherwise to questions loudly put, as if to rouse him from slumber; -but if the answer should be longer, it will generally be incoherent. -The pupils are for the most part in a medium or in a contracted state, -but rarely dilated. Stimulants were formerly given at and up to this -point, with a view of reviving and restoring the patient to greater -activity, and to prevent a relapse into his former state. Dissection -has, however, proved that it is a state in which congestion is about -to be followed by inflammation of the brain or of its membranes; that -the stage succeeding to this is one of active inflammation, even if the -patient should eventually recover; and if he relapse into that state of -stupefactive insensibility which precedes death, sufficient evidence to -account for his decease may be found in the laceration of the substance -of the brain, in small extravasations in various parts, or in other -mischief which may not perhaps be expected. Previously to this stage -of fatal termination, the muscles are not relaxed, and do not lose -their tone, as in a similarly fatal case of compression of the brain; -the urine does not flow involuntarily until after the spinal marrow -has been some time seriously implicated, and death is at hand. This -renders it necessary, in all cases of injury of the head, to attend to -the state of the bladder, which may become distended, and render the -use of the catheter necessary. The urine will be acid as long as the -catheter is required, and will become alkaline as soon as it dribbles -away involuntarily. The bowels will at an early period be confined, -and more powerful doses of aperient medicines will be required than -are needed under more ordinary circumstances, although the sphincter -ani may be relaxed, and the power of retention be lost from the -first, provided the injury has been very severe. When the feces pass -involuntarily, it is presumed that the cerebro-spinal axis is seriously -affected, and that the excito-motory system is greatly impaired, if -not wholly destroyed. When a person is insensible, it is not always -easy or convenient to ascertain whether the feces pass involuntarily -from loss of power of the sphincter ani, or are discharged from the -ordinary action of the bowels, of which the patient cannot give -notice. It may be inferred when the urine flows in a stream, although -apparently in an involuntary manner, that the power of the detrusor -muscle of the bladder is only impaired. In general, certain efforts are -made to evacuate the bowels, although the person may be upon the whole -unconscious of the act, showing that the defect is not essentially in -the sphincter ani, but in the want of consciousness in the brain. - -Vomiting should not be solicited, as it may do harm when in excess, -but when slight, it has appeared to be beneficial. The more simple -the treatment during this the period of commencing reaction, the -more likely is it to be ultimately successful. The period at which -insensibility ceases, and the re-establishment of the natural functions -of respiration and of the circulation begins, must always be uncertain. - -248. The termination of the first and the commencement of the second -or really inflammatory stage, or that tending to recovery, is marked -on dissection by the vessels of the brain and of its membranes being -full of blood, and showing those appearances which are indicative -of inflammation. If the patient is to recover, the stupefaction, or -_assoupissement_, continues, although a greater degree of sensibility -prevails; the pulse becomes regular, if it were not so before; the -skin is hotter than natural; the patient can often be induced to show -his tongue, which is white, and to answer shortly, and tell where he -feels pain, although he often answers incorrectly; he can sometimes -put out his hand and help himself, and occasionally even get out of -bed. He usually turns to avoid the light, and the pupils are for the -most part contracted; but no reliance can be placed on the state of the -pupils at this period of the complaint; both are sometimes dilated, -or one is dilated and the other contracted--sometimes dilating on -the admission of light, sometimes contracting; or they may not be in -the least changed until shortly before death. An alteration from the -ordinary state of the pupils does not prove the absence or presence -of any serious general injury, but only that a particular part of the -brain has been more or less affected. The breathing at this period is -free, and not in the least noisy or stertorous, unless the concussion -be complicated with irritation occurring from lesion of the brain or -its membranes, or of the medulla oblongata. The patient may remain in -this state without any sensible alteration for several days, or he may, -as is more commonly the case when restoration to health is to follow, -recover his speech as well as his general sensibility; nevertheless he -frequently speaks more or less incoherently, mutters to himself as if -thinking of something, and wanders at night, becoming even delirious, -and requiring restraint to keep him in bed. Inflammation of the brain -is now fully established and must be subdued. It is at or about this -period that other symptoms occur, which are frequently enumerated as -those indicative of concussion--it should be added, of concussion in -its latter stage. The pulse becomes quicker, perhaps full or hard, -varying from 84 to 90, and even to 100. In such cases, an augmented -pulsation of the carotids may often be observed, and is considered by -some to be confirmative of the fact of concussion, although it is by -no means a sign to be entirely depended upon. Such a person will not -be comatose, but watchful, sleeps little or none, talks incoherently, -or is often really delirious, refuses food if offered, drinks with -avidity, has a hot skin, and a white tongue. If other symptoms occur, -such as spasms or convulsions, the absolute loss of any sense, or -paralysis of any or the whole of a part, the case is complicated by -laceration of the brain, compression, or other causes of mischief, -from the effects of which, if he cannot be relieved by blood-letting, -he gradually sinks into a state of coma, and dies. - -The deviations which take place from the usual and ordinary modes -of breathing are supposed to offer distinctive signs of the nature -of the injury which has taken place, but they are uncertain; they -mark the degree of injury, and perhaps the part injured, rather than -anything else. Stertorous breathing has always been considered a -sign of extravasation causing compression of the brain. Many cases, -however, have occurred of slight extravasation with partial loss of -power of one-half the body, accompanied by great numbness, without any -stertor in breathing; but a well-marked case of large extravasation has -rarely or never been observed without it, or another peculiarity of -breathing which is less thought of, although an equally characteristic -and dangerous sign of such mischief having taken place when it is -permanent; this is a peculiar whiff or puff from the corner of the -mouth, as if the patient were smoking. This, when observed among other -urgent symptoms, is usually followed by death. Stertorous breathing and -the whiff or puff at the corner of the mouth are presumed to indicate -an injury to the cerebro-spinal axis as well as to the cerebrum; but -whether the injury be direct or indirect is uncertain, although it -is frequently accompanied by extravasation or laceration. When the -breathing is only oppressed or labored or heavy, neither extravasation -nor lesion to any extent can in general be discovered after death. -The surgeon will then practically be right in considering the stertor -or whiff in breathing to be accompanied by, if not directly dependent -on, extravasation or lesion; and the heavy or labored breathing to -be dependent generally on a derangement of function, which is not -perceptible on examination. If there be truth in experimental anatomy, -stertorous breathing ought to be dependent on a direct affection of the -medulla oblongata; nevertheless there can be no doubt that a temporary -stertor or a puff at the corner of the mouth may exist without it, as a -consequence of too great an abstraction of blood. - -An officer, exercising his regiment under a hot sun in Portugal, -suddenly fell back on his horse, and was carried home insensible and -breathing stertorously; from this state he soon recovered, feeling weak -in his lower limbs and incapable of influencing the sphincter ani, -which was soon followed by incontinence of urine. His intellectual -faculties were never affected after the first insensibility; and on -the third day he rode on a mule, with care, twenty miles to Lisbon. -Many months elapsed before he recovered the necessary command over the -sphincter ani. Years have elapsed, and he cannot now always retain -his urine. In this case the spinal marrow would seem to have been -principally affected. - -It is important to recollect that the stupefaction or insensibility -of concussion is coeval with the injury, and that as few cases of -compression of the brain occur without some degree of concussion, the -insensibility may in many instances depend on it. The stupefaction -peculiar to compression, demanding relief by blood-letting or by -operation, is that which comes on some two or more hours after the -accident, and is caused by congestion or by extravasation; it must -also be distinguished from that which appears after several days, and -is the consequence of inflammatory action and effusion. The pulse has -been supposed to offer a diagnostic sign of the nature of the mischief -which has taken place in the brain; pressure or extravasation, it is -said, being attended by a slow and labored action of the heart. This -may be admitted as a general, but by no means as a certain rule, for -many of the largest extravasations, and many of the most diffused, -have been accompanied throughout by a very quick pulse. When the -physiological doctrines of the circulation are duly considered, as -well as the experiments on which they are founded, it will be evident -that the action of the heart may be influenced by other causes than -those occurring from the part of the brain apparently injured. Pressure -made purposely on the brain or dura mater in man during life is always -followed, when carried to too great an extent, by a diminution in the -frequency of the pulse, and even by syncope. - -When the stage of depression is slowly passing into that of excitement, -and inflammation is about to be set up, bleeding may be had recourse -to; but what quantity of blood, if any, should be taken away, is often -doubtful. The loss of six, eight, or even of ten ounces can do no -harm, if it do no good, and it may enable the surgeon to form a more -accurate judgment of the state or degree of the complaint than he could -otherwise have done. - -A laboring man, thirty years of age, fell from a height of fifteen -feet, on the back of his head, a small puffy tumor being perceivable -near the junction of the right parietal with the occipital bone. He was -insensible and motionless; countenance deadly pale; circulation weak -in the arms, but more marked in the carotids; respiration heavy and -slow; pupils much dilated and fixed; no relaxation of the sphincters. -Hot-water bottles were applied to the feet, and friction to the body -generally. In the afternoon he became warmer; some reaction seemed -to be taking place, accompanied by slight twitchings of the face, -and shiverings. At four o’clock he was bled to sixteen ounces, in -consequence of the pulse having become fuller, although soft and 96 in -the minute. The surface was warm and moist, and he was so far sensible -as to complain, on being pressed for an answer, of pain at the part -of the head injured. The bleeding was discontinued, in consequence of -its bringing on _convulsive_ movements ending in syncope; the pupils -contracted, the countenance became deadly white, and he breathed on -the right side of his mouth for a few minutes, with the whiff or puff -so peculiar in cases of compression of the brain. On recovering from -his swoon, the pulse became regular and 85 in number, the skin warm -and moist, and the pupils more sensible to their proper stimulus. The -bladder, which had been a little distended, acted voluntarily. The next -day he was perfectly collected, and complained only of a little pain -in the head. Pulse 84; was quiet and slept during a part of the night. -The bowels acted under the influence of the calomel and colocynth given -the evening before, and of a senna draught in the morning. He quickly -recovered, without any further bad symptoms. - -The effects of a large abstraction of blood at too early a period are -well shown in this case, especially by the convulsions and by the -peculiar kind of breathing. - -249. When the period of excitement or of inflammation has begun, -and the patient, although disposed to coma, is still irrational and -impatient when roused, he is not to be left to await the effects of a -blistering plaster or of a dose of physic, as has been recommended in -such cases, but ought to be bled sitting up in bed to whatever extent -may be necessary to relieve the symptoms, or at least to cause a near -approach to fainting, for nothing less can relieve such a person -effectually, and give him a fair chance for life. The bleeding must -be steadily repeated as the symptoms recur until relief has been -obtained, or until it becomes evident that the powers of the patient -cannot resist the inroads of the disease and of the efforts made for -its cure. The quantity of blood that may be lost in two or three days -by powerful, healthy men is sometimes enormous, amounting to 100, 150, -and even 200 ounces, with the happiest effect. The following case, -which was one of inflammation tending to effusion, will show the extent -to which it ought to be carried in an elderly person of a different -habit of body:-- - -A gentleman, sixty-seven years of age, had suffered for three weeks -from occasional attacks of gout in his right foot, which he had himself -treated by simple means, taking the pulvis ipecacuanhæ compositus at -night to relieve pain. Once or twice his family had observed that his -head was, for a short time, not so clear as usual; but no suspicion -of further evil was entertained until he awoke one morning, evidently -talking incoherently. As the gout had nearly disappeared from his feet, -sinapisms were applied to both; purgatives and diaphoretics were freely -administered, and he appeared to be relieved. On the third morning he -became more loquacious and forgetful, was occasionally incoherent, and -complained of a certain loss of power, and of numbness in the right -side. Pulse 84, full and regular; tongue white; some confusion of ideas -was evident, with slight headache. He was cupped at ten in the morning -to ten ounces, without advantage; as all the symptoms appeared to be -increasing, at four in the afternoon sixteen ounces of blood were taken -from the arm, which produced a marked effect for some time. At ten at -night, the symptoms having returned, and the blood drawn being very -much cupped and buffed, twelve ounces more were taken from the arm, -when the pulse quickened and began to intermit; he appeared to be about -to faint, and the object seemed to be attained. Calomel and opium were -then given every four hours, until the mouth became affected; but the -essential symptoms were already subdued, and the patient recovered, -with a slight sensation of numbness and loss of power of the right side -of the body and head. - -The necessary effect was in this case produced by the loss of forty -ounces of blood. In a younger and more vigorous man it might have -required three or four times as much to have been taken away by -repeated bleedings, before the object could have been attained; of -this the following case is a good instance:-- - -Mr. B., having jumped out of a carriage, the horses of which were -running away at full gallop, fell on his face, and was found insensible -and motionless. Some cold water having been poured upon him, he -gradually recovered, and afterward ate a hearty dinner, drank a -bottle of port wine, and walked home, a distance of three miles. He -thought himself quite well the next morning, and went to bathe; but on -returning about noon he felt uneasy, lay down on a sofa, began to talk -incoherently, and was soon quite delirious. At one o’clock he was bled, -but the symptoms of inflammation were not completely subdued until he -had lost eighty-four ounces of blood, the last quantity being taken -away at eleven at night. The vigorous treatment adopted in this case -during the first ten hours in all probability saved the life of the -patient. - -250. It sometimes happens that congestion precedes inflammation to such -an extent as to give rise to stupefaction and symptoms of compression. - -A Portuguese soldier of General Harvey’s brigade of the fourth division -of infantry was struck by a musket-ball at the first siege of Badajos, -on the top and toward the back part of the head; it divided the soft -parts, and grazed the bone without fracturing it. He walked from the -trenches to the rear, and said he was not much hurt. About five or -six hours afterward, he was found apparently asleep, and could not be -awakened, on which I was asked to see him. Finding the pulse at 60, -regular and full, although compressible, I directed him to be raised -and blooded until he fainted. When he had lost some twenty ounces of -blood, he opened his eyes, recovered his senses, and knew those about -him. The next day he went to the rear, free from all symptoms, and -rejoined some time afterward, in apparent good health, although he -complained more than was usual to him of the heat of the sun. - -In some less important cases of injury, one bleeding will answer the -purpose; cupping and leeches may also be resorted to with advantage; -but in all very severe ones general blood-letting is the only -trustworthy source of relief. It should always be done with effect, -the finger examining the opposite pulse, and regulating the amount to -be taken away. At an early period of concussion, the quantity drawn -should not be large; it should increase with the urgency for its -abstraction, and diminish with the frequency of the repetition, being -always, however, carefully regulated by the effect. The inability of -blood-letting to overcome the disease will be shown by the increase -in frequency of the pulse, its diminution in power under slight -compression, its greater softness, together with the persistence of the -other symptoms. - -It is in these cases that repeated small bleedings, to the amount of -six or eight ounces, ought to be resorted to, when it is doubtful -whether the loss of blood can or cannot be borne; they may then be -considered not as curative, but as explorative measures, although they -sometimes prove very effective; and when not properly regulated, the -reverse. - -In all these, and in other more desperate cases, the effect of mercury, -provided it has been early and rapidly administered, may yet be -decisive. Calomel, combined with another and not less important remedy, -opium, ought to be given every two or three hours until the effects of -both are fairly induced. - -Blisters should never be applied to the head until after the leading -symptoms of inflammation have been overcome; they will do more good -at a later period, applied between the shoulders or on the nape of -the neck. They should be dressed with mercurial and savine, or other -stimulating ointment. - -The hair should be cut close in ordinary cases, or shaved off in the -more serious ones. The head should be raised in bed, and kept wet with -a cold evaporating lotion, or one composed of two ounces of the nitrate -of potash, one of the muriate of ammonia, one pint of vinegar, and -five of water, made in small quantities at a time, as may be required; -or with a small quantity of pounded ice and water in a large bladder. -Perfect quietude, cold drinks, at pleasure, and nearly absolute -starvation should be enforced. - -The different points of practice which have been noticed are well -illustrated by the following case, in which the symptoms of concussion -were complicated by those which are commonly observed in compression of -the brain:-- - -An old man, when cleaning windows, fell from some steps on his -forehead, which he slightly cut and bruised, the left temporal -artery being divided by another small cut: it bled profusely until -the hemorrhage was arrested by a surgeon. He remained in a state of -insensibility for nearly two hours, when he rallied, and answered -questions, although imperfectly. Pulse quicker than natural, -and intermittent. He shortly afterward relapsed into a state of -insensibility, with convulsions, stertorous breathing, puffing at the -corner of the mouth, and complete loss of voluntary motion: the pulse -could scarcely be felt. This convulsive fit lasted about ten minutes, -when his respiration became natural, and his pulse was restored. The -insensibility continued for an hour, when it was attempted to bleed -him, but the pulse fell immediately, and it was not persisted in. -He soon, however, became quite sensible, sat up in bed, and vomited -some blood. In the afternoon he had another and slighter fit, from -which he quickly recovered. On the third day he was free from all -bad symptoms, and said, when asked, that he had only a very slight -headache. The pulse occasionally intermitted. On the fourth he declared -he was starved, became snappish and irritable, complained of pain in -the head, and had a quick and irregular pulse. On the fifth he got up -and dressed himself, had another slight convulsive fit, and fell into -a state of stupefaction, for which bleeding gave little relief; and -in the evening he died. From the first period of his improving until -his death, sensation and motion remained. On examination, a starred -fracture without depression was found corresponding to the wound on -the forehead, continuing to the base of the frontal bone, across -the ethmoid, over the body of the sphenoid bone, breaking off the -posterior clinoid processes, and extending to the basilar process of -the occipital bone, but not quite to the foramen magnum. The anterior -lobe of the right hemisphere of the cerebrum was lacerated to the -extent of an inch; that part was surrounded by the usual appearances -of inflammation. Some blood was extravasated on the tentorium, beneath -the posterior lobe of the brain, and lymph was effused over the whole -of its surface, between the arachnoid membrane and the pia mater. The -trephine, if resorted to, would have only added to the mischief. - -Inebriation from spirituous liquors may complicate a case at its -earliest period, from the stupefaction it occasions; but the odor of -the spirits is usually demonstrative of the fact, and the stomach-pump -in such cases is an admirable remedy. - -251. Mania sometimes supervenes on concussion, as the inflammatory -symptoms subside. It is best treated by the different preparations of -opium. - -George Grey, aged forty-five, a stout man, fell from an omnibus, -Nov. 1, 1839, and received a blow on the right parietal bone, a -little behind the coronal suture. He lies on his back in a state of -stupefaction, although sensible when pinched, but is restless, and -suffers from convulsive motions of the mouth and limbs; pupils fixed, -the right being more dilated than the left; pulse 120; heat of skin -natural; respiration deep and rapid, without stertor; the sphincters -not relaxed. A turpentine enema was given, and a calomel pill was -swallowed with great difficulty. The head was shaved, and a cold lotion -applied; he soon afterward became violent, and required the restraint -of a tight jacket. The pulse fell in the afternoon to 84. - -Nov. 2d.--Passed a restless night without sleep, and has a wild -appearance: pulse 96, and regular. At twelve o’clock became sensible, -and gave a confused account of the accident. Was freely purged, and -a quarter of a grain of the acetate of morphia was given every four -hours: the first at seven, the second at eleven, and the third at three -in the morning. - -3d.--Has passed a quiet night, but with little sleep; the morphia has -had a soothing effect; talks rationally, although a little confusedly, -and recognized his mother, who says he received a violent blow on the -head three years ago, which has rendered him mad ever since whenever he -drinks too much. Pulse 72; bowels open, and is free from restraint. At -seven in the evening, he suddenly started up in bed, saying some one -was going to murder him. Half a grain of the acetate of morphia quieted -him; it was repeated at half-past twelve and at half-past four, and -kept him quiet, although he did not sleep. - -4th.--He was collected, quiet, and free from restraint; pulse 96, -rather full; secretions natural. The morphia was continued in adequate -doses for a few days, and he gradually recovered. - -252. Concussion induces affections of the brain and of its membranes -of an equally serious nature, at a more distant period of time, when -the stage of stupefaction and insensibility is wanting; it is to guard -against such an occurrence that persons who suffer from falls or severe -blows on the head usually lose blood. A gentleman was thrown from -his gig near Hounslow, and received a very severe shock and several -bruises, without feeling much hurt, or being aware that his head had -actually touched the ground. He came up to town, went to bed, and got -up next morning suffering only from a slight headache, and stiff from -his bruises, of which, however, he thought nothing. On the second -day I saw him in consequence of headache, throbbing in the temples, -sickness, and general malaise or discomfort. Being a stout young man, -thirty ounces of blood were taken from the arm in a sitting posture, -until he nearly fainted, after which he was relieved. In the evening, -the symptoms having all returned, pulse 88, and full, he was bled in -the erect position until he fainted, forty ounces being taken away. The -blood of the morning was buffed and cupped, and the bowels had acted -freely. On the morning of the third day the pulse, which had become -fuller, yielded to the loss of twenty-four ounces of blood, and in -the afternoon, on its rising again, to sixteen more; after which the -symptoms gradually subsided, and he appeared to be restored to health, -with one interruption from irregularity in diet, requiring the further -loss of blood by cupping behind the ears, and some sharp purgation. -His cure was not, however, permanent; for having dined out a month -afterward, he became delirious during the night, and required to lose -sixteen ounces of blood in the morning, which relieved, but did not -cure him. Some pain remained in his head, the pulse continued at 90, -the tongue was white, with thirst, loss of appetite, and watchfulness. -Calomel and opium were now administered until the mouth became -affected, when he quickly got well; although a slight relapse or two -afterward convinced him that he could not drink nor lead an irregular -life with impunity. - -There are no cases of convalescence after disease or injury which -require more care than those which follow injuries of the head. -Relapses, from apparently trifling causes, are extremely frequent, -and gradually but certainly undermine the health; they are, in fact, -connected with chronic derangement of the brain, or of its membranes; -and unless successfully met, generally end, after the lapse of a few -weeks or months, in irritative fever and death. In many instances, -particularly among poor people subject to privations and of irregular -habits, in whom an injury of the head has not originally been of any -apparent importance, such a state of irritation, if it occur, combined -with debility, is very difficult to manage; it requires a combination -of local as well as of general means for its cure. A few leeches and -blisters may be applied alternately over the part affected, with great -advantage; and a mild, nourishing diet, with gentle alteratives and -tonics, will expedite the cure, especially when aided by perfect repose -and a fresher atmosphere. An issue in the arm, which establishes a -gentle but permanent drain, will often be found an efficacious remedy. - - - - -LECTURE XVII. - -WOUNDS OF THE HEAD. - - -253. Compression of the brain means a diminution of the size of certain -parts of it, resulting from the pressure of an extraneous body, whether -it be fluid or solid, in consequence of which particular symptoms -are generally known to ensue. When they occur, it is said that the -sufferer is laboring under symptoms of compression of the brain, and -apoplexy from the rupture of a blood-vessel may be considered as the -best form or illustration of the complaint. These symptoms sometimes -take place from the presence of a foreign substance, such as a point -or piece of bone, which from the smallness of its size can hardly -compress, although it may displace; and it is then said that the -symptoms arise from irritation of the brain. Many of them have also -been found to occur from loss of blood, or the absence of pressure, or -from insufficient pressure arising from changes in the circulation; -and several different opinions have been entertained on all the points -connected with these subjects. It has been argued that as the brain -is incompressible, no compression can take place. There is no proof, -however, of the fact of its being incompressible as a whole, although -it has been stoutly maintained by Monro secundus, Sir C. Bell, and -others. - -The brain is surrounded by membranes capable of secreting a halitus -or a fluid whenever it may be necessary to fill up space; it is -intersected by partitions apparently for the prevention of jar and -pressure, and is permeated in every part by vessels of various sizes, -both venous and arterial. It has been presumed that it contains at -all times the same quantity, or nearly the same quantity, of blood, -in consequence of its freedom from atmospheric pressure, through the -intervention of the bones of the skull. If this conjecture be correct, -the quantity cannot be materially increased, unless something be -displaced to make room for the addition; nor can it be essentially -diminished without something being added to supply its place. The -question turns, however, very much on the words “materially increased -or diminished;” for a very small additional quantity may be the cause -of serious mischief, and the subtraction of even less may give rise -to great cerebral disturbance; but there can be little doubt that the -actual quantity contained in the head is less at one time than at -another, the deficiency being usually on the side of the arteries; -when congestion takes place, it is for the most part venous. When a -person is about to faint on the first passage of a catheter through the -urethra, the blood deserts his face, he feels sick, his pulse nearly -ceases, and he would faint if he were allowed to remain in the erect -position. Let his head now be bent down between his knees for a minute; -his face fills with blood, his brain does the same, and he recovers -almost immediately. Young ladies, when about to faint, are prevented -from doing so by these means being adopted, which they declare, -nevertheless, to be very unladylike, although they may be doctorial and -effective. - -254. The motions of the brain covered by the dura mater are but little -observable under ordinary circumstances when a circular portion of bone -has been removed by the trephine; the surface of the dura mater remains -in general perfectly LEVEL; it is of a reddish-silvery color, and is -firmly attached to the cut edge of the bone. The surface is raised, -however, on a full expiration, and it falls on a deep inspiration. -Fluid secreted or placed upon it is seen to move synchronously with -the pulse; but the dura mater never rises up into the hole made by -the removal of the bone, unless some fluid be retained beneath it. If -the quantity of fluid extravasated or collected under it be large, it -rises immediately on the removal of the bone; but the protrusion of -this membrane does not always take place for some hours afterward if -the fluid be more diffused. The motions of the brain, when the dura -mater is thus protruded into the opening, become very indistinct, even -if they can be perceived. These two points, viz., the protrusion into -the opening and the absence of pulsation, are important facts, little -noticed by surgical writers, to be borne in mind in connection with the -practice to be pursued. - -If we sometimes see the natural and ordinary size of the brain -diminished under pressure, and that certain symptoms, such as -insensibility, syncope, convulsions, and paralysis, are consequent -on this state, and are relieved by the removal of the pressure and -the restoration of the compressed brain to its ordinary state, we may -safely conclude that some derangement takes place in its integral -parts, which may be best understood by the word compression. If we -further consider that compression can rarely exist without irritation, -and that sometimes of a formidable nature, there does not appear to -be so much difficulty in the subject as is frequently represented, -although the physiological explanation may not be so simple. In the -present state of our knowledge, we apprehend that in many cases -approaching to apoplexy, in which the symptoms are similar to those -arising from compression, all, or nearly all, the vessels, as far as we -can ascertain, are actually full of blood, instead of being partially -empty and containing less than the natural quantity. When we see a -patient, lying in a state of insensibility with a fracture of the -cranium, immediately recover his senses after the application of the -trephine and the removal of a large coagulum of blood, we are apt to -suppose that the coagulum of blood and the insensibility stand in the -relation to each other of cause and effect. It is not unreasonable to -conclude that the pressure of the extravasated blood confined by the -bone had occasioned the insensibility, and that this did not depend -alone upon some few vessels containing less blood than usual; for -the brain must be considered as a whole in all these investigations, -and reference should not be made to its vascular structures only in -explanation of the cause of its derangements. - -255. When compression of the brain is caused by an extravasation of -blood, the patient is insensible, breathes slowly, loudly, and in -a heavy, labored manner, or with stertor, and cannot be awakened, -although the noisy breathing may be for a time suspended. The breath is -sometimes emitted from the corner of the mouth, like a whiff or puff of -smoke, and with something of a similar noise: this, when permanent, -is a more dangerous symptom than the common snoring or stertorous -breathing. He sometimes froths at the mouth, and occasionally appears -convulsed, but neither hears nor sees, nor takes the least notice of -those about him. The countenance is generally flushed if the shock -or blow has been slight, pale or livid if it should have been great. -The pulse is usually slower than natural, sometimes irregular or -intermitting, occasionally quick, even from the receipt of the injury. -The pupils of the eyes may be contracted or dilated, being dependent -for their condition more perhaps on the part of the brain affected -than on the degree of injury. They are generally more contracted -in the first instance than dilated; they may afterward pass into a -medium or doubtful state; one may be even dilated, and the other not. -In general, as the mischief is continued and augmented, they become -dilated and immovable. The eyes may be turned upward, or may be fixed -in the center, or be drawn irregularly outward or inward, causing -strabismus, which is, however, a more rare occurrence. If the eyelids -should be partially open, tickling the cilia or the conjunctiva of -the ball with a straw or a feather will cause them to close, if the -spinal cord be sound. The mouth and lips are more or less compressed, -and fluids run out at the corners, unless placed on the very back -of the tongue by a long, narrow spoon, when they are swallowed with -difficulty. Paralysis of one side of the face and hemiplegia are -common; paraplegia is more rare. In both kinds of palsy one part in one -limb may be more completely affected than another, in which convulsive -twitchings are sometimes present, as well as a frequent drawing up of -the limb of the unaffected side. Tickling the soles of the feet or -the palms of the hands will sometimes cause retraction of the toes or -fingers when the limbs are apparently motionless; pricking them gently -with a pin will often give rise to convulsive startings and tremblings -of all the muscles of the extremity when tickling fails, showing that -the capability to move the part remains, although the will to do so -is wanting. The leg or arm is sometimes drawn toward the body when -separated from it; it more often falls from the hand as if it belonged -to the body of a dead person; the muscles are occasionally more stiff -and rigid, and some power of motion remains, although but little of -sensation; sometimes sensation is perfect when motion is lost, and -sensation may be lost on one side and motion on the other. The urine -at first retained may ultimately pass involuntarily, as well as the -feces; nevertheless, irritating the verge of the anus will excite -motion and contraction in the sphincter ani, if the functions of the -spinal cord be not destroyed. The action of the involuntary muscles -is little impaired in general, and the secretions are but slightly -affected; when it is otherwise, the injury must have extended to -the ganglionic system, and the whole of the nervous centers must be -materially implicated. - -The loss of motion, or of the power of moving parts of the body, is -either perfect or imperfect according to the degree of injury which -has been inflicted, varying from a sense of feebleness to an almost -utter incapability of moving the part. It is accompanied in general by -defective sensation, or numbness, or by the complete loss of sensation -and of the power of resisting heat and cold; the whole side, or one -extremity, or a part only of an extremity may be affected, and not the -whole. The mischief which gives rise to the loss of motion usually -occurs on the side of the brain opposite to that part of the body -which is paralytic. This was known and stated by Hippocrates, and the -subject has been pursued to the most complete demonstration by modern -anatomists. - -The pathological proofs are not less complete. Desault and Bichat -were by no means satisfied that the paralysis which followed an -injury always took place on the opposite side; and some pathologists -since their time, while admitting the fact, have shown that there may -be exceptions. It is acknowledged, although it is not clearly and -satisfactorily accounted for as to the face, that an extravasation of -blood into one hemisphere of the cerebrum, or even of the cerebellum, -can cause paralysis of the complete half of the body on the opposite -side. It has been demonstrated that the right side of the body and -the left side of the face may be paralytic at the same time and from -the same injury apparently of the left side of the head, the mischief -which caused the paralysis of the right side being found, in by far -the greater number of instances, on the left side of the brain, and -that which gave rise to the paralysis of the left side of the face to -have been caused by an injury in the course of the portio dura of the -seventh pair of nerves when about to leave, or after it had left, the -brain. - -Burdach found, in 268 cases of lesion of one side of the brain, that -10 presented paralysis on both sides of the body, and 250 of one -side; in 15 of these the paralysis was on the same side as the injury. -Convulsions took place in 25 cases on the same side as the disease; in -3, on the opposite side. In cases of lesion of one corpus striatum, -there were, in 36 instances, paralysis of the opposite side, and 6 with -convulsions of the same side, and in no instance convulsions of the -opposite side. In 28 cases of cerebral lesion of one side, the muscles -of the opposite side of the face were paralyzed; in 10, those of the -same side. Paralysis of the eyelid was in 6 cases on the same side, -in 5 on the opposite side. Paralysis of the muscles of the eyeball -occurred in 8 cases on the same side, in 4 on the opposite; paralysis -of the iris, in 5 cases on the same side and in 5 on the opposite, the -tongue being generally drawn toward the paralyzed side of the face. - -A man fell down stairs and received an injury on the head from the fall -which rendered him nearly insensible at the moment. There were no signs -or appearances on the outside of the head indicative of any serious -mischief, nor were any found on examination after death. The pulse was -quick, and rose to 140; the left side was paralytic; the breathing not -stertorous, but accompanied by a little puff on the right side of the -mouth; the pupils somewhat dilated; he could not speak, convulsions -supervened, and he died the day afterward. On dissection, the peculiar -flatness of the convolutions of the brain on the right side was so -remarkable, when compared with that of the left, as to leave little -doubt of its having been occasioned by something which had pressed them -forcibly upward against the inside of the cranium; and, on slicing off -a portion of the brain, a larger coagulum of blood was found below -than is usually observed to exist without the almost immediate death -of the patient. The same thing has been so distinctly marked in other -instances that no doubt can be entertained of those convolutions of the -brain which were situated between the coagulum and the cranium having -undergone a considerable degree of compression. It is worthy of remark -that the pulse of this person was always regular and remarkably quick -from the first examination after the receipt of the injury until the -period of his death, showing, perhaps, that the action of the heart is -not affected directly by pressure acting only on the upper surface of -the brain. - -256. Convulsive actions of the muscles, or positive convulsive fits, -are always important symptoms; yet they seem in some persons to be -dependent on idiosyncrasy, particularly when they appear early, and -after the loss of blood, in which case they are less dangerous. They -occur at different periods after the receipt of the injury, and have -been supposed to depend in general upon laceration of the substance of -the brain, although experiments on animals would seem to show that they -may be caused directly by irritation of the cerebro-spinal axis within -the skull, in which case the patients are more likely to recover. They -have been observed particularly on the side opposite to that which -is paralytic, so as to give rise to the idea that the paralysis is -dependent on injury of one side of the cerebrum, and convulsions on -injury of the other. When the effect of the mischief is so great as -to cause complete paralysis, convulsive twitches do not take place, -although they frequently precede, and may in many cases be considered -as premonitory signs, while the evil which gives rise to the paralysis -is gradually accumulating. When the paralysis is not complete, the side -so affected suffers sometimes from slight convulsive twitches, while -well-marked spasms prevail in the other, leading to the belief that, -while paralysis is an affection of only half the brain of the opposite -side, or of half the spinal marrow of the same side, convulsions are -the effect of a more general irritation, capable, however, of being -confined to a part; for partial convulsive motions do very frequently -occur without any paralysis accompanying them on the opposite side. -Several cases have occurred in which the convulsions have ceased, and -the patients recovered after the removal of a portion of bone which -was irritating the brain; but convulsions have generally been the -forerunners of death when the seat of injury was unknown and effective -relief could not be given. When they occur in cases apparently of -pure concussion, accompanied by inflammation of the brain or of its -membranes, and the patient recovers after many days of the strictest -antiphlogistic treatment, it is possible that the brain may have been -lacerated, and the cure have been effected by adhesion. Convulsions, it -must be remarked, are among the most common symptoms of inflammation of -the membranes of the brain, without any such lesion of its substance, -although they are frequently wanting. They may be expected to take -place about and after the fifth day in injuries of the head, when -inflammation of the brain or of its membranes is about to extend to -or to become continuous with the neighboring parts, and may be more or -less severe, varying from a state of partial trembling of a limb to -that of general agitation and restlessness of the body generally--from -a slight, irregular movement of the eyelids, or of the muscles of -the face, to the more marked spasmodic startings of the whole of one -side, grinding of the teeth, and contraction of the limbs. It is far -different with those convulsive movements which, at a late period, -become nearly permanent, or with rigid spasms, resembling tetanus, in -which the body is drawn in different directions, forward, backward, -or to one side. These are for the most part forerunners of death. -Examination after death, in such cases, has frequently shown nothing -discoverable beyond inflammation of the pia mater, and an effusion -of fluid, generally purulent, on the surface of the brain, or in its -ventricles, or between the pia mater and the tunica arachnoides. - -The three following cases are intended to show the different forms -of paralysis that ensue after injuries accompanied by compression or -irritation of the brain:-- - -Charles Murray, private in the 2d battalion of 1st Foot Guards, aged -thirty-three, was wounded on the 18th of June, at Waterloo, by a piece -of shell which struck him on the superior part of the _left_ parietal -bone. He remained insensible about half an hour, and on recovering from -that state, was affected with nausea and some bleeding from the left -ear, and found himself unable to move his _right_ arm and _right_ leg, -which hung as if they were dead, and had lost their feeling. Admitted -into the Minimes General Hospital at Antwerp on the 29th; he suffered -much from pain in the head, which was relieved by his being twice bled. -The paralytic affection having remained without change from the moment -he was wounded, a piece of the parietal bone, about three-fourths of -an inch long, and several smaller fragments, were extracted four days -after admission into the hospital, two perforations with the trephine -having been necessary. Immediately after the removal of the bone he -recovered the use of his right arm and leg, so far as to be able to -move them, and to be sensible of their being touched. He gradually -recovered by the 14th of August, so as to be sent to the General -Hospital at Yarmouth, never having had a bad symptom, the only defect -remaining on the right side being an inability to grasp anything in -his hand with force. The pulsation of the brain was still visible at -the bottom of the wound for about the space of half the circumference -of the crown of the trephine. September 16th, 1815: the wound has -filled up with healthy granulations, and has nearly cicatrized. A small -sinus remains at the superior part, through which the edge of the bone -can be felt. His health has been invariably good, although he has -suffered a good deal of pain twice previously to the coming away of -little pieces of bone, and toward evening he has been generally subject -to slight vertigo. Discharged cured. - -William Mitchel, of the Royals, aged forty, was wounded by a -musket-ball on the 18th of June, at Waterloo; it struck the side of the -head near the vertex, and, passing across through the sagittal suture, -fractured and depressed _both_ parietal bones. When he had recovered -his senses he suffered great pain in the part, and found that he had -lost the use of BOTH his legs, and was benumbed even from the loins and -lower part of the chest; he was often sick, and felt low and ill. On -the 28th, ten days after the battle, the trephine was applied in two -places, and the whole of the detached and depressed portions of bone -were removed. The sickness, lowness of spirits, and general illness -immediately subsided, and the loss of power in the lower extremities -gradually began to diminish, but he was not able to walk without -assistance until the first week in August. On the 10th he arrived at -Yarmouth, not having had a bad symptom after the depressed bone had -been removed; and by the end of September he was discharged, able to -walk well with the assistance of a stick. - -Mr. Keate has mentioned to me a case, in which the injury and the -paralysis were apparently on the same, or the right side. The -paralysis, although positive, was not so complete as to render -the patient quite incapable of moving the arm and leg, which were -frequently convulsed, but the convulsions, which were observable in -both, were more marked on the opposite or left side. On examination -after death, the most serious injury was found to be a fracture of the -right parietal and temporal bones, extending to the petrous portion -of the latter, and beyond it; this, with a rather large extravasation -of blood under and in the course of the fracture, appeared to be -sufficient not only to destroy life, but to have caused paralysis of -the left side, which, however, it did not do. Another extravasation, -rather less in quantity, had, however, taken place under the upper and -anterior portion of the left parietal bone, which enabled Mr. Keate -fully to account for the paralysis which took place on the right side. -According to the surgery of the French Academicians of the beginning -of the eighteenth century, this man would have been trephined or -trepanned on the left side of the head in search of an extravasation by -contre-coup; but accident or chance alone could have led to the right -spot, as it was by no means opposed to that on the other side. - -257. A simple fissure or fracture of the skull is of no more importance -than a fracture of any other bone in the body, unless it implicate the -brain; it should be managed according to the ordinary principles of -surgery. These principles, however, involve a treatment diametrically -opposite to that practiced by many surgeons, almost unto the present -day. - -If the integuments or scalp be divided, and the bone fissured, these -principles should be carried out, by endeavoring to procure the union -of the divided parts, as was generally done during the war in all -such injuries from sabre-cuts as did not quite penetrate the skull--a -practice that was found to be eminently successful, even when union -did not take place. The general treatment should be similar to that -insisted on in concussion, of which the following may perhaps be -considered a sufficient example:-- - -A soldier in Lisbon, partly in liquor, received a blow from a spade -which cut the upper part of the head across the sagittal suture, and -rendered him senseless. He soon got better, and a slight fissure or -fracture without depression was discovered. His head was shaved, -kept raised, wet and cold, and the divided parts brought together by -sticking-plaster; he was bled to twenty-four ounces, purged, starved, -and kept quiet in a dark room. Slept well, but said that his head felt -painful, as if something tight was tied around it. Pulse 96, small -and hard; bowels not open. Blood was taken from the arm to the amount -of forty ounces, when he appeared about to faint. Calomel and jalap, -followed by infus. sennæ cum magnes. sulphate, were given, and acted -well, and he was greatly relieved. The calomel was continued every -six hours. In the evening, however, the pain and tightness of the -head returned, with a pulse of 110, hard and full; these symptoms -were removed by the loss of twenty-four ounces of blood. He remained -easy until the evening of the next or the third day, when the pulse -quickened to 120, became small and hard, and he complained of severe -pain in the head. It was evident that inflammation of the brain or -of its membranes had commenced, and that it must be subdued; he was -therefore bled until he fainted, forty ounces having been taken away. -This entirely relieved him, and calomel and jalap, senna and salts were -again administered with great effect. On the fourth day he was easy, -the pulse 94, soft and full, the mouth being tender from the mercury. -The wound did not heal by adhesion, but by granulation; and under the -continuance of the starving and purging system he gradually got well -without any more bad symptoms, having been saved by the loss of one -hundred and twenty-eight ounces of blood in three days. - -The vigorous and decided abstraction of blood saved the man, and, with -the mercury, in all probability prevented the occurrence of those evils -which our predecessors sought to obviate by removing a portion of bone. -They believed the bone could not be fractured without an extravasation -taking place beneath; and some took credit to themselves for placing -wedges between the broken edges, in order to allow the escape of the -blood or of the matter which might be formed below it. That blood may -be effused, and matter may be formed, is indisputable, even under -the most active treatment; but that an operation by the trephine -will anticipate and prevent these evils, cannot be conceded in the -present state of our knowledge; and the rule of practice is at present -decided, that no such operation should be done until symptoms supervene -distinctly announcing that compression or irritation of the brain has -taken place. It is argued that when these symptoms do occur, it will -be too late to have recourse to the operation with success. This may -be true, as such cases must always be very dangerous; but it does not -follow, and it never has been, nor indeed can it be shown, that the -same mischief would not have taken place, if the operation had been -performed early. - -258. When a simple fracture, which in its slightest form is called -a capillary fissure, takes place, the dura mater must be separated -from it at that part to a certain extent, and some small vessels -must be torn through. It does not follow, however, that blood must -necessarily be poured out in such a quantity that it will not be -absorbed. Dissection, on the contrary, has established the fact that -it will be absorbed even in cases of fracture of greater extent, where -it has been seen that a larger quantity had been extravasated. As the -effusion of a larger, or of so large a quantity of blood as to prove -eventually mischievous, does not _usually_ take place, except under -other circumstances than those of a simple fracture, the ordinary -practice ought not to be to seek for that which is not likely to be -found. The dura mater is rarely separated beyond the limits of the -fracture, and it is more likely to recover without any further exposure -or interference than with it. The dura mater, however, may be separated -to a considerable extent from the bone in more severe injuries, and a -quantity of blood is often extravasated upon it. When this does occur, -the commotion or shock which occasioned the fracture, the separation -of the dura mater, and the extravasation will generally have caused -other more important although less perceptible derangements. These -show themselves after the lapse of a few days, by giving rise to -inflammation of the brain or of its membranes, of which such patients -more usually die, than of the separation of the dura mater, or of the -extravasation of a small quantity of blood. The case is no longer -one of simple fissure or fracture of the cranium, and the nature and -severity of the symptoms which have supervened must regulate the -practice to be pursued. - -259. After the receipt of a severe blow, or of a gunshot fracture of -the head, which has not even stunned the person at the moment, he may -walk to the surgeon, the wound be dressed, and he may converse with -his fellows as if nothing had happened; yet in a short time he may -become heavy, stupid, drowsy, and unwilling to move, with a slow pulse -and a pallid countenance. Inflammation has not yet had time to set -in, and extravasation has not always taken place. If the loss of a -moderate quantity of blood should relieve such a person, it shows that -congestion had occurred, perhaps on the surface of the brain under the -injured spot, on recovering from which, by the unassisted efforts of -nature, he would still be liable to inflammation. I have repeatedly -seen a sharp bleeding from an incision made to allow a complete -examination of the part in such a case, cause the restoration of the -patient to his natural state. A return of untoward symptoms during the -progress of the case does not always indicate essential mischief; -they will be removed, if of a temporary nature, by a further moderate -bleeding, by purgatives, and by greater restriction in diet, through -irregularities in which these secondary attacks most usually occur. If -the loss of blood should not relieve the symptoms, the case is probably -complicated by a separation of the dura mater, or by an extravasation -having taken place between the dura mater and the bone, or even in or -on the surface of the brain. - -260. When a fracture takes place at the anterior inferior angle of the -parietal bone, or in any part of the course of the middle meningeal -artery, it often gives rise to a more serious injury, which nothing -but an operation can remove. The artery is always in a groove, and is -often even imbedded in the bone at its lower part, and may be torn -at the moment of fracture, giving rise to a gradual extravasation of -blood on the surface of the brain, which can be borne to a considerable -extent without causing any particular symptoms, although a sudden -and considerable effusion causes immediate insensibility. When the -extravasation is gradual, the patient walks away after the accident, -and converses freely, becoming oppressed slowly, and in the end -insensible, as the last drops of blood which are effused render the -compression effective. When these symptoms occur after a wound in this -particular part, the bone should be immediately examined; if there be -no obvious fracture, and relief cannot be obtained by the abstraction -of blood, the trephine should be resorted to as a last resource; for -if there be truth in the statements so confidently made of fracture -of the inner table of the bone from concussion of the outer without -fracture, it is here especially that we may be permitted to look for -it. The hemorrhage in the greater number of these cases takes place -slowly, and the effused blood depresses the brain by separating the -dura mater from the neighboring bone--a process, however, which can -hardly occur unless the injury has been so violent as to rupture its -attachments to the bone; for the brain generally yields rather than the -attachments of the dura mater, and is depressed, the hollow or cavity -thus formed being filled up by the coagulum, which becomes thicker -and thicker until insensibility is induced. Blood effused between the -dura mater and the bone readily fills up in the first instance all the -space formed by the disruption of the membrane; for the force with -which the blood is poured out from the artery overcomes the resistance -offered by the brain, which gradually yields and sinks unto that point -at which its natural functions can no longer be carried on. If the -attachments of the dura mater be strong, and the separation which has -taken place between it and the bone be small, the blood effused is -compressed by the bone on one side, on which it can exert no influence, -and is resisted by the dura mater, which will recede no further on -the other. The wounded artery in such a case is soon compressed by -its own coagulum, and the effusion is comparatively trifling, giving -rise, according to its nature, either to the primary symptoms of -compression from extravasation, or to the secondary ones dependent in -all probability on inflammation and suppuration of the part, and of -irritation and compression of the brain beneath. If, on the contrary, -the separation of the dura mater from the bone be extensive, the -quantity of extravasated blood may be considerable and the brain will -be greatly depressed. Experience has demonstrated that persons have -recovered after large coagula have been removed; but in all these cases -the brain had not lost its resiliency, and was seen to regain its -natural level on the removal of the depressing cause, the person often -opening his eyes and recognizing and speaking to those about him; but -this does not take place when the brain remains depressed after the -blood has been removed. - -A French artillery driver was knocked off his horse by a musket-ball, -which struck him on the anterior and inferior portion of the right -parietal bone, during a charge made by General Brennier, at the battle -of Vimiera, on the British infantry under the command of the late Sir -Ronald Fergusson. I took him under my care, thinking from his freedom -from bad symptoms and the slightness of the fracture that he would -probably do well. The next morning I found him apparently dying. A -portion of bone being removed, a thick coagulum of blood appeared -beneath, apparently extending in every direction. Three more pieces of -bone were taken away and the coagulum, which appeared to be an inch in -thickness, was removed with difficulty with the help of a feather. The -brain did not, however, regain its level, and the man shortly after -died. The middle meningeal artery was torn across on the outside of the -dura mater; the wound did not pass through to the inside, and there -was no blood beneath the dura mater. The convolutions of the brain -were depressed and flattened by the pressure. - -A soldier of the 29th Regiment was struck on the right parietal bone in -a similar manner, shortly after daylight, at the battle of Talavera, -during the first attack on the hill, the key of the British position. -He walked to me soon afterward to the place where the wounded of -the evening before had been collected in the rear. Being otherwise -employed, I heard his story but could not attend to him at the moment, -and found him some time afterward insensible, with a slow, intermitting -pulse, breathing loudly, and supposed to be dying. The fractured parts -were sufficiently broken to admit of the introduction of two elevators, -by means of which they were gradually removed, together with a large -coagulum of blood which had depressed the brain. When this had been -done the brain regained its level, the man opened his eyes, looked -around, knew and thanked me. The pulse and breathing became regular; he -said he suffered only a little pain in the part, and should soon get -well. He died, however, on the third day. - -During the battle of Salamanca a soldier of the 27th Regiment was -brought to me, who had walked to the rear, and had fallen down -insensible within a few yards of the hospital station. I found a -considerable fracture, with depression at the inferior part of the -parietal bone before and above the ear. The end of the elevator -having been introduced, a small piece of bone was first raised, then -another, and a third, when a thick coagulum was exposed and removed. -The dura mater was not separated from the bone around to any extent, -and the coagulum, although thick, was not large. The brain, which had -been depressed, regained its level immediately; the man recovered his -senses, and was cured of his wound, but remained unfit for service. The -artery did not bleed after it had been exposed. - -The rule in surgery, to remove the bone in such cases, is absolute. - -261. Fractures of the skull are stated, from almost the earliest -records of surgery, to occur on one _side_ of the head in consequence -of blows received on the _other_. The facts which ancient authors -have collected and related on this point are so numerous and so well -attested that it appears almost more than skeptical to doubt their -accuracy, however seldom they may be now observed. - -A counter-fracture or fissure of one parietal or temporal bone, caused -by a blow on the opposite one, is of such rare occurrence that it is -in general unnoticed by later writers on injuries of the head. It is -not so, however, with respect to a fracture at the base of the cranium -from a blow on the vertex, or on the back part of the head--a kind -of accident which occurs more frequently perhaps than any other in -civil life--because persons who suffer from fractures of the skull do -so more generally by falling from a height, or from being pitched on -their heads, than by direct blows or other injuries. This accident -principally depends on the superincumbent weight of the body pressing -on the unsupported flat and thin base of the skull, and is but little -connected with the unyielding nature of the spine; for it occurs to as -great an extent in consequence of falls from a short distance without -any impetus, as from falls from a great height. Some of the worst -cases take place by the sufferer having been thrown from the back of a -horse by the sudden starting of the animal, without any running away. -Although in these cases a fissure may often be traced to the foramen -magnum, the great fracture is essentially distinct, extending from the -petrous portion of the temporal bone on each side, across, and between -the sphenoid bone and the os frontis, and even separating the edges of -the coronal suture nearly to the opposite side. - -A noted gambler was thrown from his horse, and pitched on the top of -his head at the door of the Westminster Hospital, late at night; he -was taken up insensible, and died shortly afterward. The skull was -fractured quite round from the vertex to the base, and from side to -side, so that the fore and back parts might have been easily separated -into halves, if the soft parts had been removed. Fractures of the base -of the cranium are generally fatal, but not always so; for some persons -live a considerable time afterward, and appear to die from other -causes; so that partial, if not perfect recovery is possible. - -H. Cochrane, forty-five years of age, fell a distance of twenty feet -upon his head, and was taken up apparently lifeless, bleeding largely -from the ears, nose, and mouth, but more particularly from the ears. -He was seen within half an hour of the accident. He was then quite -insensible; the surface of the body cold; pulse about 68, and very -feeble; in three hours after the accident he was bled to sixteen -ounces, when his pulse rose to 76, and the breathing, which before -was rather oppressed, became more free. He was ordered six grains of -calomel, followed by moderate doses of senna, till the bowels should be -relieved. - -He continued progressively mending, but in a state of stupidity, -accompanied by extreme listlessness; answered questions sullenly, and -frequently rested upon one arm without appearing conscious of pain; -the mouth was drawn to the left side, to which there had been a slight -tendency for some days; the tongue not at all affected. - -He continued under treatment for three weeks longer, soon after which -he was permitted to resume his employment, the mouth being still -drawn in some degree to the left side. His habits became silent and -solitary, but he performed his task with the greatest exactness. He was -occasionally subject to vertigo, particularly in hot weather, after -any violent exertion or taking a small quantity of beer; a pint of ale -would render him stupid or insensible. Six months afterward he was -found dead, lying in a ditch. - -_Sectio cadaveris._--The nasal bones were fractured by a blow which -had made a transverse incision in the upper part of the face. The -femur was found fractured upon the right side, and the scalp puffy -and ecchymosed on the left. On removing the skull-cap, the dura mater -appeared perfectly healthy, without any sign of extravasated blood upon -the surface. Beneath the pia mater on the left side the sulci of the -brain were filled with black blood, apparently very recently effused. -The brain was removed without the least violence, when a lesion was -found upon its inferior surface, corresponding to the petrous portion -of the right temporal bone. The dura mater in this situation was -externally of its natural structure, and adhered with its usual degree -of firmness to the bone beneath. The arachnoid and pia mater were here -deficient; the lesion consisted of a cavity about fifteen lines in -length, nine in breadth, and three in depth, coated with a light-yellow -lining, which also adhered to the corresponding portion of the inner -surface of the dura mater, which completed the walls of the cavity -inferiorly; it contained a turbid serum, in which were seen floating -numerous but exceedingly minute white globules. The portion of the -brain in this situation did not appear to have been disturbed by the -recent violence, except that from the upper part of the cavity a probe -was admitted without any resistance into the descending horn of the -right lateral ventricle, which, with the one on the opposite side, was -filled with a large quantity of bloody serum, none of which, however, -had escaped into the cavity beneath. The brain generally appeared -perfectly healthy, and not more vascular than usual. Even within a line -of the yellow deposit above mentioned there appeared not the slightest -change of structure. On removing the dura mater from the base of the -skull, indications of a former fracture were discovered, leading -vertically down through the squamous portion of the temporal bone, -whence it appeared to have been continued along the anterior part of -the petrous portion into the Vidian canal; the edges of this fracture, -both internally and externally, had been rounded by absorption; it was -met at right angles by another which ran across the base of the petrous -portion of the temporal bone. The direction of the last fracture was -marked by numerous small, rough particles of bone, which adhered so -slightly to the rest that they separated on maceration. The transverse -ligament of the second vertebra was ruptured, and the atlas forced -forward. The connection between the articular processes of the second -and third cervical vertebræ on the right side had also been separated -by the fall which had caused death. - -William Clayton, forty-four years of age, was admitted on the 31st of -July, 1841, into the Westminster Hospital, having received a blow on -the RIGHT side of his head from the handle of a windlass, by which his -skull was fractured. The fracture extended downward from the parietal -bone across the temporal, and in all probability through its petrous -portion, as blood flowed freely from the ear for the first six hours; -he was stunned for a few minutes at first, but became sensible by the -time he was brought to the hospital. The bleeding from the ear was -followed by the discharge of a fluid resembling water--which is a very -dangerous symptom, as it usually flows from the sac of the arachnoid -membrane--and afterward at intervals by a discharge of blood and -matter, particularly, he said, on coughing; he was also quite deaf, -with a little pain on the right side of the head. The bowels were well -opened, and he lost sixteen ounces of blood. On the evening of the -third of August, the fourth day after the accident, paralysis of the -muscles of the RIGHT side of the face supplied by the portio dura came -on, or was first observed. Pulse 80. He was well purged, but lost no -blood, as he was apparently weak and the pulse soft; it fell next day -to 72. Mercury was now administered twice a day until the mouth became -sore. On the eighteenth of September he was discharged, cured of the -paralysis, the wound on the head being open, and a piece of bone bare -and likely to exfoliate. October 8. Readmitted in consequence of great -headache after drunkenness, with numbness of the toes and fingers; he -was well purged, and felt relieved. He remained in the hospital for a -month, his mouth being again slightly affected, occasionally drinking -in spite of all remonstrance; he then returned to his work on the piers -of Westminster bridge. On the eighth of June several small pieces of -bone came away; and the wound nearly healed. The course of the fracture -can be traced, in consequence of the scalp having adhered to the bone, -causing a slight depression and hardness, which can be felt by the -finger, extending down to the ear. - -An hostler was thrown on his head from a horse, and was carried to -the Westminster Hospital late at night in a state of stupefaction; no -other injury could be discovered. The next morning he could answer -questions, although not always correctly; complained of pain in his -head, had bled from the ears all night, and had vomited some blood -two or three times. Pupils dilated, but they contracted on bringing a -lighted candle near them; the left eyelid more open than the right; -pulse 52; very restless, and constantly turning in bed. V. S. ad ℥xxiv. -Calomel and colocynth: salts and senna. Cold to the head. The pulse -rose to 60 after the loss of blood. 2d day. Is delirious; bleeding from -the ears but trifling; complains of pain in the head; bowels open; -passes urine freely; pulse 54, a little irregular. Y. S. ad ℥xvj gave -relief. Continue calomel, and salts and senna. 3d day. Restless all -night; headache and thirst; bowels open. V. S. ad ℥xiv relieved the -pain in the head. Pulse 56. 4th day. Restless and delirious at night; -pulse 60, regular; bowels open; headache. V. S. ad ℥xiv. No discharge -from the ears. 6th day. Slightly paralytic on the left side of the -face, tongue drawn to that side; headache, restless, delirious; feces -and urine passed unconsciously; pulse 80. V. S. ad ℥xx. Pulse rose to -100, and was weaker. Calomel, gr. iii every six hours. 7th day. Pulse -88, compressible; restless at all times, delirious at night; bowels -open, but he is more conscious of everything. 8th day. Pulse 80, small, -intermitting; occasionally slept a little, and is generally better; -bowels well purged; paralysis of the face continues. Has taken a little -farinaceous food. Continue calomel and inf. sennæ. 10th day. Improved; -slept tolerably well. 12th day. Continues to improve. Omit the calomel, -but continue the infus. sennæ. 16th day. Is better. Paralysis lessened. -Recollects he was thrown from a horse, but nothing else. Is free from -pain, but very weak. Mouth a little sore. - -After this time he gradually recovered, but was for a long time unable -to work, or to undergo any exposure. A very little more mischief, and -he would have gradually sunk, and died after the seventh day, instead -of slowly recovering. - - - - -LECTURE XVIII. - -INJURIES OF THE HEAD. - - -262. A fracture of the inner or vitreous table of the skull, as it has -been termed from its peculiar brittleness, as opposed to the greater -toughness of the outer, is a rare occurrence without some signs of -depression or fracture of the outer table, or detachment of the -pericranium. - -Mr. S. Cooper says: “One case of this kind, attended with urgent -symptoms of compression, I trephined at Brussels. A large splinter of -the inner table was driven more than an inch into the brain, and on its -extraction the patient’s senses and power of voluntary motion instantly -returned. The part of the skull to which the trephine was applied did -not indicate externally any depression, although the external table -came away in the hollow of the trephine, leaving the inner table -behind.” - -The records of eighteen centuries have produced but little information -on this most interesting subject: and if the cases were collected -which have been overlooked by authors, as well as those which have -been altogether omitted, little would be gained; it may be concluded, -therefore, that although such things have happened, they are of rare -occurrence. I have never, in the great number of broken heads I have -had under my care on many different and grand occasions, actually -known the inner table to be separated from the outer, without positive -marks of an injury having been inflicted on the bone or pericranium. -Although it is not possible to doubt the fact of fracture of the -inner table having occurred, without apparent injury to the outer, -it is very desirable in a practical point of view not to bear it too -strongly in mind; for if a surgeon should be prepossessed with the -idea that the inner table may be so readily fractured and separated -from the diploe placed between it and the outer table, and thus cause -irritation or pressure on the brain, few persons who had received a -knock on the head, followed by any serious symptoms, without fracture -or depression, would escape the trephine, and the worst practice -would be again established. An operation should never be performed -under the expectation that such an accident may have happened, unless -it be apparently required by the urgency of the symptoms indicating -compression or irritation of the brain, which cannot be relieved by -other means, and are about to prove fatal. - -It is by no means intended to imply by these remarks that a blow on the -head will not frequently detach the dura mater from the inner table by -rupturing its vessels, and thus give rise to compression or irritation -of the brain from the effusion of blood or the formation of matter; -or that the inner table may not from the same cause become diseased, -and thus lead to ulterior mischief; but these are altogether different -states of injury, and require a different consideration. - -Mr. Deane, of Chatteris, in Cambridgeshire, had occasion to examine -the head of a young man after death from a blow on the left side, just -below the parietal protuberance, there being only a _slight detachment_ -of the pericranium, but no fracture. On removing the skull-cap, a very -distinct fracture of the inner table, about three-quarters of an inch -long, was seen corresponding to the external part injured, extending -outwardly as far as the diploe, but no farther. The dura mater adhered -firmly everywhere, except at this part, and for some distance around, -a quantity of fluid blood being interposed between it and the bone. -If this man had outlived the first symptoms, he would not, in all -probability, have recovered without an operation for the removal of the -extravasated blood. - -263. Severe effects do not always take place in such cases in the -course of the first treatment, but occur afterward; or the unfavorable -symptoms, never having been entirely removed, increase so much at a -later period as to render the aid of operative surgery necessary for -the removal of the bone, in order to save life. - -M. A. Farnham, aged twenty-three, a stout, healthy-looking girl, -received a blow, two years before, from a stone falling from a door-way -under which she was passing; it struck her upon the left side of -the head at a spot an inch anterior to the parietal prominence, the -weight of the stone and the space through which it fell making the -estimated force with which it struck the head equal to sixteen pounds. -The immediate effect of the blow was insensibility, followed by acute -fixed pain in the head, which has ever since continued to mark the -seat of injury. A week after the receipt of the blow she began to lose -the power of moving the right arm, there being, however, no loss of -sensation or any disturbance of the cerebral functions. - -During the following twelve mouths the symptoms remained unchanged; -this period was spent in several London hospitals; not having -derived any relief while in any of these institutions, she became an -out-patient of the Westminster Hospital. - -The arm and leg of the right side were quite paralytic, the former, -which had previously been flaccid, having now become remarkably -rigid, its temperature being below that of the opposite side; vision, -particularly of the left eye, imperfect, the pupils, however, acting -naturally; hearing on that side also affected; memory bad; respiration -frequently slow and almost stertorous; the countenance had assumed a -dull, heavy expression, and she manifested an unusual tendency to sleep. - -April 1st, 1841.--Mr. Guthrie this day removed a disk of bone from the -exact point in the parietal region to which she referred the pain. The -portion of bone presented no evidence of disease; its thickness varied -from two and a half to four lines, the latter measurement corresponding -to the part most distant from the sagittal suture; the vessels of the -diploe bled freely, the dura mater was quite healthy, and without any -very evident motion. - -On visiting her _an hour_ after the operation, she raised the -previously paralytic arm several inches from the bed, and was able to -bend and extend the fingers. The pain in the head was considerably -less, and her countenance, before dull and heavy, was now remarkably -animated. Sensation had returned in the arm, and partially in the leg. -Her pulse was calm, and the skin cool. - -Ten hours after the operation she was attacked with rigors, followed by -pyrexia and all the symptoms of commencing inflammation of the brain. -By the immediate abstraction of blood, which was three times repeated -during the succeeding twelve hours, whenever the pain in the head or -the force of the circulation increased, every bad symptom was removed. -In the course of three days the paralysis had completely disappeared, -sight and hearing again became perfect, and after passing through a -speedy convalescence, she quitted the hospital completely recovered. - -She has since had some relapses of pain and uneasiness in the head, -but is altogether a different person, although of a very hysterical -temperament. The cicatrix on the head is firm, and she considers -herself to have been cured by the operation. - -264. The inner table is sometimes broken in a peculiar manner, and to -this attention was first drawn in my lectures, since trepanning has -ceased to be the rule of practice in all cases of fractures. It occurs -from the blow of a sword, hatchet, or other clean-cutting instrument, -which strikes the head perpendicularly, and makes one clean cut through -the scalp and skull into the brain. This kind of cut is usually -considered as a mere solution of continuity, and not as a fracture, the -bone being apparently only divided, with scarcely any crack or fissure -extending beyond the part actually penetrated by the instrument. When -the outer table alone has been divided, the wound in the scalp should -be treated as a simple incised one, and united as quickly as possible, -a practice of which I have seen several successful instances. When the -instrument even penetrates to the diploe, the same course should be -pursued; for although the external wound may not unite by the adhesive -process, and some small exfoliations may occur, it is not common for -serious consequences to ensue under that strictly antiphlogistic -plan of treatment to which all persons with such injuries should be -subjected. - -265. When the sword or ax has penetrated the inner table, the case is -of a much more serious nature; for this part will be broken almost -always to a greater extent than the outer table. It may be separated -from it, and driven into the membranes, if not into the substance of -the brain itself, the surface of the bone showing merely a separation -of the edges of the cut made into it. These cases should all be -examined carefully. The length of the wound on the top, or side, or any -part of the head which is curved and not flat, will readily show to -what depth the sword or ax has penetrated. A blunt or flat-ended probe -should in such cases be carefully passed into the wound, and being -gently pressed against one of the cut edges of the bone, its thickness -may be measured, and the presence or absence of the inner table may -thus be ascertained. If it should be separated from the diploe, the -continued but careful insertion of the probe will detect it deeper -in the wound. A further careful investigation will show the extent -in length of this separation, although not in width; and will in all -probability satisfy the surgeon that those portions of bone which have -thus been broken and driven in are sticking in or irritating the brain. -In many such cases there has not been more than a momentary stunning -felt by the patient; he says he is free from symptoms, that he is not -much hurt, and is satisfied he shall be well in a few days. - -An officer was struck on the head, in Halifax, Nova Scotia, by a -drunken workman with a tomahawk, or small Indian hatchet, which made a -perpendicular cut into his left parietal bone, and knocked him down. -As he soon recovered from the blow, and suffered nothing but the -ordinary symptoms of a common wound of the head with fracture, it was -considered to be a favorable case, and was treated simply, although -with sufficient precaution. He sat up, and shaved himself until the -fourteenth day, when he observed that the corner of his mouth on the -opposite side to that on which he had been wounded was fixed, and the -other drawn aside; and that he had not the free use of the right arm -so as to enable him to shave. He was bled largely, but the symptoms -increased until he lost the use of the right side, became comatose, and -died. On examination, the inner table was found broken, separated from -the diploe, and driven through the membranes into the brain, which was -at that part soft, yellow, and in a state of suppuration. - -Mr. B., of the 29th Regiment, when in Halifax, Nova Scotia, was struck, -in a drunken frolic, on the anterior part of the left parietal bone, -with his own sword, which was a straight, heavy one, and a wound -about two inches long was made in the side of his head through the -bone. His little finger was cut at the same time, and it was not until -the finger had been dressed that I was asked to look at the head, -which he declared had nothing the matter with it. He was vomited, and -purged, and the next morning bled, and as symptoms of inflammation of -the membranes of the brain came on or increased, the bleedings were -repeated, the quantity taken at each time being gradually diminished. -He lost 250 ounces of blood in five days, after which he gradually -although slowly recovered, some small spiculæ of bone coming away -during the cure. Returning to England, the vessel was taken off the -Scilly Islands, and he was sent to Verdun, where he remained several -years, until liberated by the peace of 1814, when he rejoined his -regiment, which had served in the Peninsula, and had returned to North -America. It was soon found that he became outrageous on drinking a very -little wine, and was odd in his manner, and had a great propensity to -set out walking for hours without apparently knowing what he was about, -or where he was going. When his regiment came immediately in front of -the enemy, he was found going over to their lines, without being aware -of what he was doing; and he was at last obliged to be sent to England, -having evidently become deranged. This gentleman has ever since been -confined in a private mad-house. His brother offered to allow the bone -to be removed; but after thirty years of derangement a recovery could -not be expected, and it was declined. If the examination I have since -learned to be proper in such cases, had been made at the time, the -inner table of the bone would have been found broken and depressed; and -he might now have been in health both of mind and body. - -I removed, in Lisbon, in the hospital appropriated to the wounded -French prisoners in 1812, a portion of bone by the trephine, which had -been fractured by a sword some months before: the wound had not healed, -and some pieces of bone were depressed. One piece, in particular, of -the inner table, was sticking in and irritating the dura mater, and -was in all probability the immediate cause of the fits from which the -patient had been suffering. He recovered. - -A British soldier received a wound at the affair of El Boden, in front -of Ciudad Rodrigo, from a sword, on the top of the head; he accompanied -me to Alfaiates, on the retreat of the army. The bone was apparently -only cut through, yet the inner table was depressed, and felt rugged -when examined with the probe. The symptoms of inflammation increasing -on the fourth day, and not being relieved by copious bleeding, I -removed a central portion of the cut bone by one large crown of the -trephine, and took away several small pieces which were sticking into -the dura mater, after which all the symptoms gradually subsided. - -266. The whole of the French wounded, who remained on the ground or -were taken prisoners after the battle of Salamanca, were under my -care, and among them there were several severely wounded by sword-cuts -received in the charges of heavy cavalry made by Generals Le Merchant -and Bock. The cerebellum was laid bare in two cases without any -immediate bad effect. In one particular case, which recovered, (after -the battle of Waterloo,) the brain was seen pulsating for several -weeks; and the statements made to me by the different officers at -Brussels and Antwerp, and afterward at Yarmouth and Colchester, -entirely confirmed the observations I had made, and the recommendations -I have inculcated on this particular point as resulting from the -practice of the Peninsular war. - -267. It would appear that too much stress is laid upon a difference -which is supposed to exist in the danger of trephining a man on the -first or on the seventh day after an accident; and that an error may be -committed in believing that the trephine is a more dangerous instrument -on the first day than on the seventh. The question is not whether the -man is to be trephined or not, but which will be the best and safest -day or time to do the operation. I do not hesitate to say the first, -believing the violence to be greater when done on parts already in -a state of inflammation, than when they are sound. When the inner -table has pierced the membranes and gone into the brain itself, the -individual will in most cases ultimately die miserably of the accident -if not relieved by art. It is less safe to let him designedly run the -certain risk of cerebral irritation, which when once excited is often -indomitable, than to remove the cause, and endeavor to prevent the -evil. If the cerebral irritation only manifested its effects on the -surface of the dura mater by causing suppuration there, delay might -be admitted; but as it usually gives rise under these circumstances -to the formation of matter on the surface, and even in the substance -of the brain, where it is deadly, “la chirurgie expectante” cannot -be allowed. Lastly, there is not more danger of a hernia cerebri, as -has been supposed, when the operation is done early, than when it is -done at a later period; on the contrary, the patient has a much better -chance of escape from hernia cerebri, and from all other evil, when the -local and the general treatment are decided and efficient. - -If, on attempting to remove a fragment buried in the brain, serious -convulsive movements should be excited, it would be proper to desist -from all further attempts to extract the splinters until the brain has -become more quiescent. - -It is necessary to recollect that the brain appears to be insensible, -or nearly so, when first exposed; and it has rarely occurred that a -serious convulsion or anything beyond vomiting has taken place on the -removal of a piece of bone from the brain; nor will any difficulty be -found in removing such small fragments as can be seen with a pair of -forceps duly adapted for the purpose. It is impossible to say at what -period of time the brain may become irritable, and no longer admit of -its being touched without convulsive movements ensuing; but when this -state of irritation has commenced, and its existence is proclaimed by -the excitement which takes place on touching the fragment of bone, the -surgeon should at once desist from all attempts to remove the foreign -body. The brain under ordinary circumstances is much more likely to -recover from an injury, all foreign or irritating matters having been -removed, than when suffering from their presence. - -268. The establishment of the principles which ought to regulate the -practice of surgery in cases of fracture with depression of the inner -table of the skull, is of the greatest importance. The principle being -laid down that it is right and proper to examine all such wounds with a -blunt, flat probe, in order to ascertain if possible whether the inner -table be depressed and broken, the question necessarily arises, what is -to be done when such depression and breaking down of the inner table -have been ascertained to have taken place? There can be no hesitation -in answering, that in all such cases the trephine should be applied, -although no symptoms should exist, with the view of anticipating them. -The old doctrine, it may be said, in regard to fractures generally, is -revived in these cases, but on a principle with which our predecessors -were not sufficiently acquainted. A patient very often survives a -mere depression of the skull; he may, and occasionally does survive, a -greater depression of the inner than of the outer table; but it has not -been shown that he ever does survive and remain in tolerable health, -after a depression with fracture of the inner table, when portions of -it have been driven into the dura mater. If cases could be advanced of -complete recovery after such injuries, they would not supersede the -practice recommended, unless they were so numerous as to establish -the fact that injuries of the dura mater and brain by pieces of bone -sticking in them are curable without an operation, and without leaving -any serious defects. There are great objections to the trephine being -applied in ordinary cases of fracture, not attended by symptoms of -further mischief; but the nature of the cases particularly referred to -having been ascertained, the practice should be prompt and decisive -in every instance in which the surgeon is satisfied that there is -not merely a slight depression or separation of the inner table, but -that several points of it have been driven into the dura mater. If -one trephine will suffice, the central point being applied close to -the edge of the middle of the wound in the bone, it should be applied -there; but if the cut be longer, and the spiculæ of bone extend upward -and downward in its length, a small trephine should be applied as near -each end as may be judged advisable, and one edge of the cut bone -should be removed by the straight saw, of which Paré and Scultetus made -such use in ancient times, and which Mr. Hey of Leeds revived in modern -surgery; or the small straight saw may be used alone, if the object -of removing a portion of bone can be attained without the trephine. -By these means sufficient room will be obtained to remove the broken -pieces of bone which are irritating the dura mater and brain. The -danger resulting from the application of the trephine, in such cases, -bears no proportion to the risk incurred by leaving the broken portions -of bone as a constant cause of irritation. - -269. There is an essential difference between a depression of the -skull in a CHILD and in an ADULT. In the child the inner table is not -brittle--it bends equally and does not break; it very often does little -mischief when depressed, and gradually recovers its level. The brain -in young persons is softer and less consistent, and can accommodate -itself more readily to pressure for a limited time, without ultimate -mischief, than the brain of an adult; so that a continuance of the most -urgent symptoms can alone authorize the application of the trephine in -children, and in young persons under fifteen or sixteen years of age. A -similar bending of the long bones in young children is often observed -at an early period in life. - -270. The propriety of dividing the scalp in an adult, in order to -examine the state of the bone beneath, when evidently depressed, thus -rendering a simple although comminuted fracture a compound one, is -a matter of very great importance, the decision of which rests upon -the still more essential point--viz., whether a depressed portion of -bone ought or ought not to be removed? This again must depend upon the -nature and extent of the depression, for many persons who have suffered -from such a misfortune have recovered without the depressed portion -being raised. It is a question of degree or extent, upon which every -surgeon must form a judgment from his own observation and experience. - -The difference between a simple and a compound fracture of the leg is -often considerable; it is more often dependent on degree. When the -fracture is nearly transverse, and the skin is cleanly divided, the -difference between it and a simple fracture of the same part is little -more than one of time. This may be the case with an injury of the head; -the difference between the two states in fractures of the skull has, -however, been much exaggerated; so much so, that no reliance can be -placed on the supposition that there is more real danger in a case of -fracture with depression in which the scalp has been divided, than when -it has been only bruised, and not divided. I admit that theoretically -it ought to be otherwise, but theory and practice do not always -correspond. In all cases in which a fracture with _marked_ depression -is known to have occurred in an ADULT, it is good practice to ascertain -the nature and extent of the depression. It is imperatively necessary -if accompanied by symptoms of compression. - -If the result of a great number of comparative trials should be in -favor of never, under any circumstances, raising a depressed portion -of bone in an adult, but of leaving it to the efforts of nature, an -incision in order to ascertain the state of parts below ought not to be -made; but as such a result is not likely to be obtained, the practice -recommended appears to be the best. - -The scalp should be divided, in such cases as may require the -operation, by a straight, crucial, or such other shaped incision as may -be found most convenient to the surgeon; but no part should be removed -which can be preserved with the hope of maintaining its life. - -271. The cranium, together with the fracture and depression, being -exposed, the question whether the trephine should be applied or not is -next to be determined. If the operation by the trephine, or that of -sawing a piece of bone out of the head, were not in itself dangerous, -there could be no hesitation about its use; but it is a dangerous -operation, especially in crowded hospitals, and ought not to be -resorted to when it can be avoided. If any ten healthy persons were -trephined in a hospital, one would in all probability die from the -effects of the operation, and three or four more might have a narrow -escape from the inflammation of the brain and its membranes, or the -other consequences which would probably ensue. It is not the admission -of air, which has been even lately supposed to do mischief, that is -to be dreaded in these cases, but the same kind of irritation which -often follows the abstraction of a piece of bone under other and more -ordinary circumstances at a later period of time. - -The following cases are illustrative of many important points:-- - -William Rogers, aged nineteen, of the 32d Regiment, was wounded on the -16th of June by a musket-ball, which entered at the inferior angle -of the left parietal bone, knocked him down, and for a few minutes -rendered him insensible. On recovering his mental powers, he found -that he was unable to speak, not so much (as he said afterward) from -the want of power to form words, as from the incapacity of giving them -sound. He was conscious of everything passing around him, and reasoned -correctly. He retired out of the reach of shot, and then lay down for -the night. On the following morning, he went to Brussels, where he was -examined and dressed. On the morning of the 18th he reached Antwerp -on horseback, very giddy, and overwhelmed with fatigue, fasting, and -watching; he was admitted into the Minimes General Hospital and put -to bed, when he soon fell into a sound sleep, which with some tea -refreshed him much. - -June 19th. The ball was found to have passed obliquely upward and -backward at least two inches, and could be distinctly felt with a -probe. It gave more the idea of having raised the outer table than -that of having depressed the inner. The defect in speech was in some -measure diminished, and this with giddiness were the only symptoms of -compression. A poultice was placed over the wound, a brisk purgative -given, and spoon diet ordered. - -20th. The pain and giddiness having increased, with annoyance from -noise and exposure to light, twenty-six ounces of blood were taken from -the arm. The following day the purgative was repeated, and the patient -was much relieved. Everything went on well, the wound was nearly -healed, and he was considered almost fit to be discharged, when, on -the 16th of July, the wound began to open; on the 18th it was dilated -and a portion of the cranium removed by the forceps; this was soon -followed by symptoms of inflammation of the brain; twenty ounces of -blood were taken immediately from the arm, purgatives and diaphoretics -were ordered, and the strictest abstinence enjoined. 23d. Venesection -was repeated, as well as the other means usually adopted to reduce high -action. 24th. Completely relieved. 26th. Another portion of the cranium -removed, the dura mater being fully exposed; the general health in the -best state. - -August 3d. Doing remarkably well; the wound healthy; the pulsation of -the brain evident; the power of speech perfectly restored. The ball yet -remains in, according to the opinion of the patient, (who is a fine, -intelligent lad,) and he thinks it has gradually descended toward the -petrous portion of the left temporal bone. Sent to England at the end -of the month, the wound being healed. - -When I saw this man at Antwerp I gave my opinion, without hesitation, -that the bone and the ball ought to have been removed in the first -instance, when he would have had a better chance for perfect recovery. -The operation, when afterward performed for the removal of the loose -pieces of bone, placed his life in great jeopardy. He was discharged -the service with the ball lodged, and it is more than probable that he -did not long survive, which he might have done if the ball had been -removed when it was first felt within the skull. - -In the following case the ball could not perhaps have been removed in -the first instance with propriety; it might, however, have been lying -on the dura mater, or near it, within reach, and the actual state of -things ought to have been ascertained, the surgeon afterward deciding -whether any further operation were necessary. - -Thomas O’Brien, 28th Regiment, aged twenty-three, was wounded by a -musket-ball on the 16th of June at Quatre Bras; the bullet penetrated -the occipital bone below and to the right of the junction of the -lambdoidal and sagittal sutures. On his arrival at Colchester, the -wound was healthy in appearance and healing rapidly. It appeared from -his own account that for some hours after the injury he was totally -deprived of sight; since that time he has been constantly more or less -affected with headaches, for which he has been prescribed occasional -cathartics and low diet. He has also been affected with pain and -weakness in both eyes, but more particularly in the right. While at -Brussels, and during his progress to Ostend, he lived very irregularly, -and was frequently intoxicated. The external wound was entirely healed -on the 20th of July, and no suspicion existed that the ball was lodged -in the brain. On the 25th matter was perceived under the scalp, and -was evacuated yesterday. To-day, the 27th, he complains of increase -of headache; pulse small and quick. V. S. ad ℥vj. Haust. cathart. -statim. 28th. In the course of this day his symptoms have become very -urgent; he is restless, with a very quick pulse; an extensive crucial -incision was made in the site of the original wound, and now for the -first time it was discovered that the ball had penetrated the brain; -several loose pieces of bone were extracted; a considerable quantity -of arterial blood was suffered to flow from the small vessels divided -in the incision. His bowels had been well opened by the cathartic. The -most vigorous treatment was continued, but the symptoms notwithstanding -increased, and he died on the morning of the 29th of July. - -The ball was found lodged nearly two inches deep in the substance of -the right posterior lobe of the brain; a considerable quantity of pus -surrounded it; some inflammation of the brain and its membranes was -observed, but much less than might have been expected. - -A. Clutterbuck, 61st Regiment, aged twenty-five, was wounded in the -back of the head by a musket-ball at the battle of Toulouse, on the -10th of April, 1814. He felt little inconvenience from the wound during -the first two days. On the 14th he complained of severe pain in the -head, giddiness, and dimness of sight; the face was flushed, pulse -hard and frequent. Twenty ounces of blood were taken from the arm, and -the wound enlarged so as to expose the cranium. The upper part of the -os occipitis was found fractured by the ball, and a circular portion -of it, about the size of a shilling, was depressed and fractured. -15th. Pain in the head much abated; no giddiness, dimness of sight, -or any unfavorable symptom; pulse still hard. V. S. ad ℥xx. To be -well purged. 19th. He was bled again this day to the extent of twelve -ounces, as a matter of precaution. 23d. Continues free from any bad -symptom. May 8th. The wound is now much contracted, and he feels no -inconvenience. A small portion of the bone still feels bare to the -probe, but the greater portion of the depressed piece is covered with -healthy granulations. No exfoliation has taken place. May 24th. The -wound is nearly healed; he is in good health and spirits, and without -inconvenience. - -This case may be properly contrasted with that of O’Brien, as showing -by the result the difference between an uninjured and an injured brain. -If the fractured and depressed bone had not been at the back part of -the head, it is probable the depressed portion would have been removed -in the first instance, as it certainly would have been after the 15th, -if the unfavorable symptoms had not yielded to the general treatment; -but the bone would then have been removed under much more unfavorable -circumstances than at first. - -The following case is related to show the extent to which blood-letting -may frequently be carried to preserve life. There having been no reason -to believe that the symptoms depended on fractured and depressed bone, -the scalp was not divided; and as the symptoms were coeval with and -not consecutive to the injury, they were therefore supposed to depend -on concussion rather than on compression of the brain. If the trephine -had been applied on the fourth day because the insensibility continued, -the additional injury would in all probability have proved fatal. If -the depletion of all kinds had been less effective, the inflammation -of the brain or of its membranes would certainly have terminated in -the effusion of lymph or the formation of matter, which the use of the -trephine would not have prevented nor removed. - -George Mills, an artillery driver, aged twenty-eight, was admitted -into the Dépôt de Mendicité Hospital, Toulouse, May 29, 1814, in -consequence of having been thrown from his horse on his head against -the ground. He had fallen on the right side of the os frontis, -immediately above the eye, where the surface of the skin appeared to -be scratched and bruised, but the bone was not depressed: he was bled -freely, but remained insensible. The next morning he was again bled -to twenty ounces, which operation was repeated in the evening. On the -29th, the temporal artery was opened, and a vein in his arm at the -same time, the breathing being strong and sonorous, the eyes closely -shut, and he lying quite insensible; the pulse before the bleeding was -quick and small; after he had lost about eight ounces of arterial and -eight ounces of venous blood, it became fuller, and the breathing was -somewhat relieved; the slightest touch gave him pain, and he shrunk -from pressure made directly above the eye. The temporal artery was -again opened in the evening, and ten ounces of blood were taken away. A -purgative and a stimulating enema were ordered, and cold was constantly -applied to the head. - -30th. He has been freely purged and appears more collected; the pulse -is still quick and small; breathing very free; the irritability -continues and he complains of pain on pressing the head. The purgative -and the enema were repeated, and ten ounces of blood were drawn from -the temporal artery, after which he attempted to speak. 31st. Passed -a good night; the pulse is quick and small; pain in the head still -great; was again bled to twelve ounces, and the purgative was repeated. -June 1st. Pulse quick; there is not so much pain in the injured part, -and he appears more sensible; was bled to twenty-four ounces, and the -purgative was repeated. 3d. Was again bled to ten ounces. From this -time until the 20th, he gradually improved, and was then discharged -cured. - -The treatment in these cases was the same, although in one there was -no fracture, and in the other two there was fracture with depression. -The broken portions of bone did not, in Clutterbuck, appear to press -unequally on the dura mater, and it was presumed that the moderate -degree of pressure which ensued from the depression might be borne -with impunity, as it did not seem likely to be accompanied by the -projection inward of any pointed pieces which might irritate the brain. -The result confirmed the supposition and justified the treatment. If -the examination of the depressed part had led to the apprehension that -such points of bone did exist, and were sticking into and irritating -the dura mater or brain, they would have been removed, in the belief -that although they might not at the moment have given rise to any other -symptoms than those which depended on the blow, the time would come -when they would scarcely fail to cause those which usually accompany -the formation of matter within the skull. If this danger should also -be avoided, the subsequent evils which have been noticed as occurring -at a later period, and which ultimately require the same operation -for the relief of the patient after months of acute suffering, might -be encountered; for although a person may temporarily recover from an -injury in which a portion of bone has been allowed to remain a source -of irritation to the brain, it does not follow that such recovery -should be permanent. If there be a doubt on the mind of the surgeon, -whether there be or be not any pieces of bone depressed and irritating -the brain or its membranes, he should wait; this is the real difference -between the surgery of the latter part of the Peninsular war and that -of the olden time. - -272. When a fracture is accompanied by depression, and the broken -portion or portions of bone would seem to be driven into the dura mater -or the brain, or to press so unequally upon them that as much mischief -is likely to ensue from leaving as from removing them, especially in -an adult or a middle-aged man, less harm will in general follow from -ascertaining the fact by dividing the scalp and removing the broken -pieces than by doing nothing, more particularly when the presence of a -foreign body has been ascertained. If there be no symptoms indicative -of mischief below the fractured part, the surgeon must then decide, -after the best estimate he is able to make, of the probable evil which -will occur from allowing the broken or depressed portions of bone to -remain. - -A French grenadier was brought to the field hospital the second day -after the battle of Salamanca; he had received a blow on the left -side of the head, probably from a piece of shell, which had caused -a contusion and swelling on the left parietal bone, with a graze of -the scalp, but without any opening communicating with the bone. This -swelling, on examination, was so soft, and the feeling of depressed -bone beneath so distinct, combined with the fact of the continued -lethargic state of the patient, that an incision was made into it, -when the bone beneath was found broken into several small pieces. On -clearing away the blood, two pieces which were loose were readily -raised and removed by the elevator and forceps, and egress given to -an ounce or two of blood, which were extravasated beneath, apparently -from the rupture of the vessels passing between the dura mater and the -bone. The patient regained his senses in the course of the night and -morning of the third day, and under a strictly antiphlogistic regimen -gradually recovered, some other small pieces of bone coming away, one -or two others apparently reuniting to the uninjured parts, showing that -it is not always necessary to remove every portion of bone which may be -broken, provided any bond of union remains, and principally that which -exists between it and the dura mater. - -These different cases stand out in bold relief as eminently successful -and opposed to those said to have been equally so under _la chirurgie -expectante_. They tend to show that however good a general rule may -be, it may admit of many and important exceptions; and they prove that -experience, aided by sound and correct observation, is essentially -necessary for the formation of a scientific surgeon. - -273. In young persons the brain will bear a greater degree of pressure -and of irritation with impunity than it will in persons of mature age. -By far the greater number of cases in which recovery has taken place -after fracture and depression of the skull with injury of the brain, -and even loss of its substance, have occurred in children or in persons -_under the adult age_; greater reliance may therefore be placed on -the powers of nature in them; and recourse may be had less frequently -to the aid of operative surgery in order to prevent mischief than in -older persons, even when the bone is fractured as well as depressed. It -will be found, and the remark is important, that the cases of fracture -and depression reported to have been successfully treated without -operation, have occurred principally in young persons. - -The result of my experience has rendered it imperative to remove at -once all portions of bone or foreign substances which have materially -injured the dura mater in adults, although no symptoms of compression -should be observed. If the wound in the dura mater should not be -sufficiently large to allow the offending body to be extracted through -it, the opening must be enlarged to enable it to be withdrawn without -further laceration. - -274. Depressed portions of bone, accompanied by fracture at the -_back_ part of the head, need not necessarily be removed in the first -instance. When the fractured and depressed bone is accompanied by -symptoms of compression in an adult, which continue after the usual -antiphlogistic means and remedies have been employed in vain, and -appear to increase rather than to diminish, the broken and depressed -portion should be raised; for although the brain will bear and -accommodate itself to pressure in many persons in a manner which could -not be either foreseen or expected, it will not do so in all; and -the removal of the bone offers the best chance for relief, whether -the mischief has arisen from the pressure made by it or occurs from -the extravasation of blood beneath. When the principal symptom of -compression is a severe fixed pain in the part, although the state of -the fracture and depression would not alone have rendered the removal -of the bone positively necessary, it is advisable to do so when this -symptom is present. - -The greatest discrimination is required in cases where the extent of -the injury is not so manifest and in which there is more room for -doubt. In most cases in which a slight or moderate degree of fracture -and depression of the skull has taken place, the symptoms of concussion -are present as well as those of compression. The symptoms of concussion -are, however, coeval with the injury, and although those of compression -may take place almost instantaneously, they more usually occur at a -later period of time. The symptoms of concussion may nevertheless -continue for days, more particularly the insensibility, or that state -which is approaching to it, complicating the case and embarrassing the -practitioner. In a child or young person the symptoms of compression -or irritation, when they appear even at a secondary period, may pass -away under further moderate depletion; but in an adult any undue -delay in giving the necessary relief, by the removal of the depressed -portion of bone, will in general be destructive to the patient. It is -the irritation caused by the depressed bone on the dura mater, and -communicated to the brain, which gives rise to the unfavorable symptoms -and to the formation of matter which follows them. - -A gentleman received a blow on the side of the head, which knocked him -down and deprived him of his senses, from which state he partially -recovered, and vomited; some stupefaction, however, remained, although -he could be made to answer by a little importunity. Pulse 62, -irregular, breathing slow, the pupils contracting under the influence -of light; the integuments where the blow was received were soft and -swollen, in all probability from an extravasation of blood beneath. -The next day the pulse was full and regular, the pupils were dilated, -vomiting had taken place several times, and the patient answered -correctly on being sharply questioned. He was bled largely, purgatives -were administered, and cold was steadily applied to the head. He was -bled the next day; on the third the left arm became paralytic, the -pupils continued dilated, and on the fifth day paralysis implicated the -left leg as well as the arm. There could now be no doubt that the brain -was suffering from compression; but as the nerves of the excito-motory -system were unaffected, and the functions of ingestion and egestion -were satisfactorily accomplished, it was thought advisable to trust to -the efforts of nature. The swelling of the scalp was painful. - -A week afterward the general symptoms were the same, or only slightly -augmented by fever; but, as the swelling of the scalp was more painful, -it was opened, and a quantity of matter was evacuated, the bone beneath -being fractured and depressed. As this operation gave some relief, it -was thought advisable to wait, with the hope that the benefit thus -obtained might prove permanent. The patient did not improve, however; -and as the symptoms of fever increased, and were accompanied at last -by rigors and great pain in the head, the depressed portions of bone -were removed, and about half an ounce of purulent matter escaped -from between the dura mater and the bone. The relief given this time -was effective, and the patient perfectly recovered. “La chirurgie -expectante” placed this man’s life in the greatest jeopardy. It was -only saved at the last moment by the aid of that surgery which ought -not to have been withheld when the paralysis, by affecting the leg as -well as the arm, demonstrated the extension of the mischief within the -head. In this instance the operation was successful, but it is not in -general so serviceable when delayed to so late a period. It is in cases -of this serious nature often a means of prevention rather than of cure. - -275. When a severe blow, accompanied by a shock, as from a fall, has -been received on the head, and the skull is so thick and strong as to -be able to resist the violence thus offered without being broken, or is -only slightly fractured, the vibration or _trémoussement_ is directly -communicated to the brain, giving rise to laceration or bruising of its -structure in various situations, to the rupture and separation of the -vessels of the dura mater from the bone to which they are attached, -and to derangement of other parts, which will in all probability be -followed by inflammation, and may even terminate in the formation of -matter under the dura mater as well as above it, and even in the brain -itself. It is said to take place by “contre-coup” when the mischief -occurs in any other part of the head than that which is struck, -numerous instances of which are given by the older French authors. They -were probably cases of laceration, the consequence of concussion of the -brain, and not relievable by the art of surgery; but the injury which -the older surgeons particularly distinguished as by “contre-coup” was -where the blow was on one side, and a fracture took place or matter was -formed in a circumscribed spot on the other; these cases did sometimes, -they say, although rarely, admit of relief by operative surgery. These -cases, unaccompanied by fracture, do not appear to take place under the -improved method of treatment by larger depletion, by antimony, and by -the early use of mercury. In the event, however, of their occurring, -there is no surgeon of the present day who would attempt an operation -of exploration on the opposite side of the head to the injury, without -some sign of mischief existing at that part; although such operation, -if done, might accidentally be followed by success. - - - - -LECTURE XIX. - -TUMORS OF THE SCALP, ETC. - - -276. When the periosteum covering the bone is bruised, or the bone is -merely deprived of this membrane, it does not follow that it should -die or exfoliate. In many instances the wound will gradually close up -and heal, as if no such accident had happened. A blow or bruise on the -head often gives rise to a swelling or tumor, from the rupture of the -small vessels passing into the cellular membrane between the scalp and -the pericranium; the tumor in these cases appears _immediately_ after -the receipt of the injury as a soft swelling, and is usually found -to contain blood, which in most instances is removed by absorption -in the course of from two to three weeks. In some cases inflammation -supervenes, and one part becomes tender and appears to point; into -this a small incision should be made to allow the blood and matter -to escape, when gentle compression should be resorted to in order to -induce the parts to unite. Swellings of this kind in new-born infants, -occurring from pressure during delivery, may be readily mistaken for -deficiencies of the occipital and parietal bones, if it were not for -the absence of all motion, which under such circumstances would be -communicated to them from the brain. The blood effused in the cellular -membrane raises the border of the swelling, which becomes harder than -the neighboring parts, while the center remains soft and yielding, -giving a sensation to the finger as if the bone beneath were wanting, -or, after a blow, the idea that the bone beneath is depressed. If -such a swelling be unnecessarily opened, considerable inflammation -and suppuration will often follow, to the great inconvenience of the -patient; this will in general be avoided by the use of a moderately -stimulating cold lotion. - -277. In other cases of tumors, which are called secondary in -contradistinction to the preceding, the patients go on well for eight, -nine, or more days, at the end of which time they complain of headache, -giddiness, nausea, restlessness, thirst, and generally of fever. A -few days more, frequently from the thirteenth to the fifteenth day, -rigors, sometimes severe, are superadded, and a swelling, if not -observed before, is now perceived on the spot where the injury had been -received, if the integuments have not been divided; or, if there be a -wound, it loses its healthy red appearance, and assumes a yellowish, -unhealthy color, which is accompanied by a thinner and more acrid -discharge. From this time the symptoms gradually increase, the patients -become delirious, convulsed, comatose, and die; and matter is found -between the skull and the dura mater, or in or on the substance of the -brain. If this secondary swelling be divided, and the fluid evacuated, -which is not good pus, the pericranium will be found detached and the -bone bare. - -It has been stated that a bone so circumstanced would not be found -to bleed on being scraped, and that, by attending to the want of -hemorrhage from the outside of the cranium, the extent of the evil -might be ascertained, and that so long as a denuded, discolored bone -will bleed on being scraped, it may be considered that the dura mater -is attached below, and that no operation should be performed. - -The essential difference between the primary and the secondary -swellings is to be found in the fact that, although the bone be -exposed, and even in some degree may have changed its color in the -primary swelling when matter has formed, the febrile symptoms will -subside after its evacuation, healthy granulations will spring up, and -little or no exfoliation will take place. In the secondary swelling -none of these favorable symptoms or appearances will take place, for -the bone is incapable of maintaining its life, and must die. If the -outer table only be implicated, it may exfoliate; but if there be -reason to believe that matter has collected beneath, on the dura mater, -the bone should be removed by the trephine. - -Inflammation of the dura mater proceeding to suppuration, or the -formation of matter between it and the bone, appears to have been a -much more common consequence of injuries of the head in former times -than at present. It is not now of frequent occurrence in London -hospitals. - -As blows on the head and the structure and functions of the brain are -the same at present as formerly, the difference in regard to such -cases can only depend on the difference of treatment. It is, in fact, -infinitely more depletory now, and therefore less operative. Blood is -taken away in larger quantities, although to this there are exceptions, -depending on the constitution of the patient, which will not always -admit of it, while the potassio-tartrate of antimony and mercury are by -most surgeons administered at an early period. - -Suppuration, or the formation of pus on the surface of the dura mater, -not being, under the strictly antiphlogistic and mercurial system, so -common as formerly, sufficient attention has not perhaps been paid -to another evil which frequently accompanied it in former times, -viz., suppuration on the surface and in the substance of the brain -itself; for the greater number of those who died with fracture and -depression of the skull, and whose cases are recorded, suffered also -from alteration of the structure or substance of the brain, and the -formation of matter within it or upon its surface. This termination -might not have taken place in a large proportion of the cases in which -it occurred if the depressed bone had been raised to its level, and the -irritation arising from undue or unequal pressure had been avoided. -It must be admitted, however, that an internal part of the brain may -receive such a shock at the moment of injury, as well as an external -part, that no treatment can arrest the progress of the mischief, -although it may be delayed; and when the patient dies, after four, -five, or more weeks of alternate hope and suffering, matter may be -found in some part of the brain where an injury was not suspected. - -Purulent matter may be formed beneath the dura mater in a confined -spot, or it may be diffused generally over the surface of the brain, in -which case the sufferer has no chance of relief. - -278. The operation of incising the dura mater, to admit of the -discharge of blood or matter from beneath, and even of puncturing the -brain, has not been much resorted to in England; this may be an error. -The records of surgery supply many cases where it might have been done -with advantage, and some in which it was done with the greatest benefit -to the patient. It is not an operation which ought to be performed -without signs sufficiently demonstrative of the necessity for doing it. - -I have seen, on the removal of a portion of bone by the trephine, -the dura mater rise up rapidly into the opening so as to attain the -level of the surface of the skull, totally devoid, however, of that -pulsatory motion which usually marks its healthy state. An opening into -it, under these circumstances, has allowed a quantity of blood or of -purulent matter to escape, proving that the unnatural elevation of the -dura mater was caused by the resiliency of the brain when the opposing -pressure of the cranium was removed. This tense elevation, its abnormal -color, and the absence of pulsation are positive signs of there being -a fluid beneath, requiring an incision into the dura mater for its -evacuation. It is a point scarcely noticed in English surgery--one -which was not in the slightest degree understood at the commencement of -the war in the Peninsula. - -A. Monro, of the 42d Regiment, was wounded on the 10th of April, at -Toulouse, by a musket-ball, which fractured the left parietal bone -slightly, without depressing any part of it. No symptoms followed -requiring more than ordinary attention until the 23d, up to which time -he had been kept on low diet, for the most part in bed, and had been -bled and purged. On the evening of that day he became feverish, and -hasty and odd in manner, and the pulse quickened; he declared himself, -however, to be quite well, and submitted to be bled and physicked with -great reluctance, calomel combined with opium being given him at short -intervals. On the 24th he complained of pain in the head, which he -said was very slight, and that upon the whole he was quite well, and -would not be bled nor have anything done. He was bled largely by force, -which lowered the strength of the pulse, but did not relieve any of -the symptoms of irritation of the brain. On the 25th he was evidently -worse, although he declared himself to be quite well; he talked a -little incoherently; the pupils were dilated; the pulse quick but -regular; the countenance was changed; he was sensible, apparently, upon -all points except that of being much worse, which he resolutely denied, -saying he was better and would soon be well. Satisfied that matter was -forming, or had formed, in or on his brain, I desired that the trephine -might be applied on the fractured part and the bone removed. This, -however, he would not permit the officers in charge to do, and they -awaited my return in the afternoon, when, finding him much worse, I -directed it to be done by force, three of his own regiment with others -attending to assist the surgeons. He called upon these men by name not -to allow him to be murdered in cold blood, declared he was getting -well, and would get well if let alone, and prayed them to avenge his -death on the doctors if they meddled with him. The surgeons were -dismayed, and requested that the operation, which they said required -great care, should be performed by me, their chief. I therefore removed -the bone; and the moment it was taken away the dura mater rose up in -the opening to the level of the surrounding bone, and remained without -any pulsatory motion. I had no doubt of matter being beneath, and that, -from his general state, the man would die. I did not therefore think it -prudent, under all the circumstances, to do more than warn his comrades -that, when dead, they would see the whole brain beneath in a state of -suppuration. He died that night; and the next day they saw the whole of -the left hemisphere soft, yellow, and covered with matter, to their -great surprise and satisfaction at the accuracy of the diagnosis. - -Absalom Lorimer, of the 42d Regiment, was wounded by a musket-ball on -the 10th of April, 1814, at the battle of Toulouse, which carried away -a small portion of the scalp just above the right temple, fracturing -the bone slightly, but without any depression. No symptoms occurred -demanding more than ordinary attention for the first fortnight, during -which period he had been bled once, purged, and kept on low diet. On -the 25th, he complained of pain in his head around the wound, shooting -to the back part; pulse 60; pupils dilated. An incision having been -made to the bone, the pericranium was found detached, and the bone -fractured, but without any obvious depression. V. S. ad ℥xx, calomel -and colocynth: as the pain continued, the bleeding was repeated in the -evening. 26th. Pain in the head greatly relieved; pulse 60; bowels -torpid. Ten ounces of blood were taken from the temporal artery, and -the calomel and colocynth, salts and senna were repeated. On the -morning of the 29th, the symptoms of compression having increased, the -trephine was had recourse to, and the fractured portion of bone was -removed: a layer of coagulated blood was found on the dura mater, which -puffed up into the opening. In the evening he became convulsed, the -pulse intermitted, and he died. On examination, a large abscess was -found in the right hemisphere of the brain, having the ventricle for -its base, with some matter on the surface of the brain, and between the -dura mater and the bone at the base of the cranium. - -On the morning of the day that I performed this operation, I had done -another of the same kind at the Hôpital des Minimes; the dura mater -rose up in a similar manner without pulsation into the opening made -by the removal of the circular piece of bone by the trephine; on -puncturing it a considerable quantity of pus oozed out. The opening -was enlarged; and the flow of matter was daily encouraged, until it -gradually diminished, and ceased with the formation of granulations, -and the drawing in and cicatrization of the part. - -279. It has been supposed theoretically that a wound through the -dura mater was particularly dangerous, in consequence of the tunica -arachnoides which lines it being a serous membrane; and that, if the -inflammation which ensued did not cease at the adhesive stage, by the -consolidation of the surface which covered the pia mater with that -which lined the dura mater, a diffuse inflammation would necessarily -follow, which might spread over its whole extent. This has not been -found practically to be the case; and if a simple wound of the dura -mater be a danger that ought to be avoided, the risk run cannot be put -in comparison with that which accompanies the continuous irritation -depending on the presence of a spicula of bone, which has passed -through the dura mater, and is irritating the brain beneath. It has -also been supposed theoretically that the danger would be diminished if -the pia mater were wounded also, as the brain would project and fill -the wound; but the accuracy of this opinion may be doubted. If the dura -mater were injured through error or design, I should not think the evil -lessened by adding to it a wound of the pia mater, and perhaps also of -the brain. - -By those who have been accustomed to the terrible injuries which occur -in military warfare, in which large portions of the brain are sometimes -exposed, and even lost, without much inconvenience following, the -exposure of or the opening into the dura mater is not considered of so -much importance as it is by those who have had fewer opportunities of -seeing such awful cases; while the formation and retention of matter -below the bones of the cranium is, on the other hand, more dreaded by -those who have often seen their ill effects than by those who have not -had many occasions for observing them; by whom, however, they are often -considered, when they do take place, to be irremediable by art. - -280. Gunshot wounds of the skull are attended by certain peculiarities. -In ordinary circumstances there is usually an external wound and a -fracture more or less comminuted, with depression; this wound will -almost always require to be enlarged by a simple incision, so as -to show the extent of the depression or the size of the broken and -depressed portions of bone. When the bone is scarcely injured, and the -periosteum is only bruised, or when the bone is even deprived of this -covering, it does not follow that it should die or even exfoliate. -In many instances the wound will gradually close in and heal, as if -no such evil had occurred; and in those which do not terminate so -favorably, the cure may only be delayed by the exfoliation of a layer -or scale of bone from its outer surface, unless the mischief should -have implicated the parts beneath. - -A musket-ball striking directly against a bone sometimes makes a hole -not larger than itself, with or without any radiating fracture; and -one large trephine, if properly applied, will often embrace the whole -of the mischief, and admit of the removal of the broken pieces. As -a center-pin cannot be used, the trephine may be made to turn very -well in most cases in a flat but thick bar of iron, having a hole in -the middle, of such a size only as will allow the polished outside -of the trephine to turn in it. Sufficient support for the instrument -will be obtained by this means until it has made a groove in the bone -for itself, when the operation may be continued as it would be in an -ordinary case after the removal of the center-pin. - -When a musket-ball ranges along the side or top of the head, it -may break the outer, and depress and fracture the inner table to a -considerable extent, for the space even of three or more inches. -The broken portions of bone may in general be removed by means of -good forceps and a straight saw; and no good reason can be given for -delaying the operation unless the nature of the injury be doubtful, -when it may be as well to wait for symptoms. It sometimes happens, -although rarely, that a ball sticks so firmly in the bone that it -cannot be extracted by working round it in any ordinary way with a -pointed instrument. The difficulty usually arises from the ball having -half buried itself in the diploe, so little of it being exposed as not -to admit of a firm hold being taken of it. The large trephine, used in -the way pointed out, has several times overcome this difficulty. The -removal of the outer table has been sufficient where the inner one has -not been driven into the dura mater; when any doubt is entertained on -this point both should be removed. - -281. A ball or other foreign substance may penetrate the brain -directly or obliquely. When the ball penetrates the brain directly, -it is not often that it can be removed, and the sufferer very rarely -survives beyond a few days, even if the ball has been extracted; more -particularly if the injury have occurred in the anterior part of the -substance of the brain; several persons, however, have recovered, in -whom the injury occurred toward the back part of the head, the ball -being allowed to remain. It will be better in all such cases to allow -the ball to remain, which it will often do for many days, until -circumstances render it necessary to endeavor to find it. When it can -be felt immediately under the surface of the brain, it ought to be -removed like any other foreign substance. - -Dr. Rogers relates the history of an excellent case, in which a young -man aged nineteen received a wound on the frontal bone, just above the -center of the left superciliary ridge, from the bursting of a gun on -the 10th of July. It was not until the 4th of August that he discovered -a piece of iron lodged within the head, in the bottom of the wound, -(from which a considerable quantity of brain had come away,) which he -extracted the next day. It proved to be the breech-pin of the gun, -three inches in length, and three ounces in weight. By the tenth of -December his patient was perfectly cured. - -When a ball strikes the head obliquely, it may enter and pass out or -lodge. Nearly all these cases die, but one occasionally escapes, and -none should be allowed to die without assistance. When the entrance and -exit of the ball are obvious, and not far distant from each other, the -splinters of bone should be removed; and if the little bridge between -the openings should be injured, the whole should be taken away by the -straight saw; an operation which cannot, however, be necessary in the -first instance, if the portion of bone be apparently sound. - -At the battle of Talavera, a soldier of the 48th Regiment was brought -to me in a state of insensibility; he had received a musket-ball on the -upper part of the right side of the frontal bone, where it had entered, -and had evidently passed backward; it could be followed by the probe -rubbing against the bone for nearly four inches. The scalp over this -point was soft, as if blood were effused below; and on dividing it, -a fracture was seen bulging rather outward. The trephine was applied -forthwith, and the bone removed, together with the ball, which only -wanted a little more impetus to have come through. The brain was -injured, and the man died two days afterward. - -A French grenadier was wounded at the battle of Salamanca by a -musket-ball, which struck him on the right side of the head, penetrated -the temporal muscle, and lodged in the bone beneath, giving rise to -symptoms of compression. On dividing the parts, I found that the ball -had fractured and driven in a part of the temporal bone, one portion -of the ball being above, and the other below the broken bone. The -upper half of the ball was readily removed, but several small portions -of bone were raised by the elevator and forceps before the remaining -portion of the ball could be drawn from under the bone, which was not -depressed, the ball having been cut in two by its edge. The dura mater -was bruised, but not torn through. The wound suppurated freely; several -pieces of bone exfoliated, and the patient was ultimately discharged in -progress toward a cure. - -A small ball sometimes becomes so flattened by striking against -the skull as to remain undiscovered when care is not taken in the -examination. A soldier was wounded at the storming of San Sebastian -by a ball on the side of the head, which was supposed not to have -lodged. The wound did not heal, a small opening remaining, although -no exfoliation took place, and the bone did not seem to be bare. On -dividing the scalp to ascertain the cause of the delay in healing, a -small ball, quite flat, was found; it had sunk down a little below the -hole left for the discharge to which by its irritation it had given -rise. - -When a larger ball or a piece of a shell strikes the head, the fracture -is usually extensive, and portions of bone, or a piece of the shell -itself, are often lodged in the substance of the brain. There is -nothing peculiar in the management of these cases, which are for the -most part unfortunate. - -282. A suture may be separated by a musket-ball, which impinges with -a moderate degree of force directly upon it, but not without great -danger. It can, however, only happen in young persons in whom the -sutures are not obliterated as they are in elderly ones; in general it -takes place when the ball happens to lodge as it were between the bones -concerned in the formation of the suture. The first case of the kind -which came under my observation occurred at the taking of Oporto. I -met with a second at Albuhera, a third at Salamanca, and a fourth in a -slighter degree at Orthez. - -A heavy dragoon was wounded at the battle of Salamanca by a musket-ball -in the body, which caused him to fall from his horse, injuring the -top of his head. Little attention was paid to him until mischief was -suspected from the lethargic state into which he fell, which could only -be attributed to the blow on the head, where a tumor was observable. -This, on being divided, showed a separation of the edges of the -sagittal suture, from which some blood flowed. Two crowns of the -trephine were applied on the twelfth day, in order to admit of the free -discharge of some blood which had been extravasated from a wound in the -longitudinal sinus, after which the symptoms subsided, and the patient -gradually recovered. - -A ball may pass apparently through the fore part of the head from side -to side without doing much mischief beyond depriving the sufferer -of sight. It does not in these cases injure the brain, but passes -immediately below it and through the back part of both orbits. In four -such cases the recovery was rapid, but the blindness was irremediable. - -283. The danger of injury to the frontal sinuses has been greatly -exaggerated, and vanishes in a great degree when attention is paid to -their structure. The uncertainty of the depth of the cavity between the -tables of the bone, and the irregularity of the exposed surface of the -inner table, which may through carelessness be mistaken for depression, -should be remembered. - -A soldier of the 29th Regiment was wounded at the battle of Talavera -by a ball, which struck him on the lower part of the right side of -the forehead, fracturing the external wall of the frontal sinus. On -examination, the ball could be felt lodged in the sinus, whence it was -readily removed by enlarging the opening, and the man recovered without -any bad symptoms. - -At the storming of Badajos, a soldier of one of the regiments engaged -at the little breach was struck by a small ball about the size of a -swan-shot; it penetrated the frontal sinus of the right side, and stuck -in the inner table, the outer being considerably injured and splintered -by the blow. The splinters having been removed, the small ball could -be seen sticking in the inner table of the bone, whence it was easily -extracted, leaving the dura mater bare beneath. He was sent to Elvas, -and recovered with a good and firm cicatrix. - -After a wound of the frontal sinus has healed, the air has been known -to raise up the integuments of the forehead into an elastic crepitating -swelling whenever the patient blew his nose, so that a compress and -bandage on the part were required for its relief; but these cases are -very rare. - -284. Wounds of the bony parts within the orbit are often attended by -the most serious consequences. A boy, nine years of age, was struck by -his playfellow with the end of a thick iron wire on the right eye, -which blackened it. There was no external wound; but as there was -some bloody chemosis at the upper part and the inside, there was a -probability of the wire having penetrated deeply, although the opening -could not be discovered by the probe. The accident had happened two -days before, but he did not think himself ill. He was well purged, and -cold water was applied externally. Two days after, he complained of -sickness, headache, and some pain over the brow. He was bled freely -from the temple of that side by leeches, and well purged by calomel -and jalap. On the sixth day his mother reported him as having been -delirious and restless all night. He was found stupefied, answering -with difficulty and incoherently; pulse very quick, skin hot and dry, -with some convulsive twitches of the face and arms; pupils slightly -obeying the influence of a strong light, but not dilated. He was again -bled freely from the temple, but his breathing became more difficult, -he fell into a comatose state, and died in the night. On examining the -head, the stiff iron wire was found to have passed under the upper -eyelid, between it and the eye, through the posterior part of the -orbitar plate of the frontal bone and into the anterior lobe of the -brain, which was softened at that part, and bedewed with matter. - -A woman, who had been struck by her husband on the left eye with a -tobacco-pipe, while preparing her frying-pan for cooking, knocked him -down with the pan, and ruptured his right eye, which was lost. She then -pulled out a piece of the pipe which was sticking in the orbit, between -the lid and upper and inside of her own eye, which was uninjured. She -complained of little but the bruise, and rather brought her husband -than herself for advice. Bled and purged, she did not complain of -anything for several days, when she said she had been very ill all -night, with nausea, headache, and shivering; with hot and dry skin, -pulse very quick, the upper eyelid paralytic; she looked very ill, -became delirious at night, and died two days after the first complaint -of serious illness. On examination, half an inch of the red waxed end -of the tobacco-pipe was found to have gone through the sphenoid bone, -by the side of the sella turcica, and to have lodged in the brain, -whence it was removed bedewed with pus, the brain being yellow and -softened around it. - -A wound of the longitudinal or lateral sinuses, allowing a free -discharge of the blood poured out, is of comparatively little -consequence. It is, on the contrary, a very fatal injury when the blood -is permitted to accumulate. - -285. A protrusion of the brain, often improperly called a fungus -cerebri, is of two kinds, and occurs at different periods of time. -The first kind is principally composed of coagulated blood, usually -appears immediately after, or within two days after, the injury, -and is generally fatal. The second takes place at a later period, -although it has occurred on the third or fourth day, and is formed for -the most part of brain. These protrusions rarely take place when a -considerable portion of the skull has been lost or removed, the brain -then being able to expand to such an extent as the inflammatory impulse -from within may render necessary. When the opening is small, and the -dura mater has not been injured, it has seldom been observed. It is -then principally when the opening in the skull has been of greater -extent than the size of one piece of bone removed by the trephine, -the dura mater having yielded either in consequence of the injury or -by ulceration, that this evil takes place; it is not, under proper -treatment, a fatal, although it is always an extremely dangerous -occurrence. - -In the first kind of protrusion, the dura mater must necessarily be -torn to some extent, and the tumor which comes through it is of a -dark-brown color, glazed and covered in general by the pia mater. -These protrusions were accompanied, in every case I have seen, by -delirium and other symptoms of inflammation of the brain and of its -membranes, and not by coma, until near the fatal termination of the -disease. I have seen them torn off by the patients themselves during -life, or before death; and satisfied myself that they all arose from -hemorrhage into the substance of the brain, probably immediately below -its surface, which became more elevated as the inflammation proceeded, -and was gradually protruded at the part where there was the least -opposition. When the tumor was torn off, little hemorrhage ensued, but -a dark-brown blood cavity was seen in the substance of the brain; and -when cut off and examined, the protruded part seemed to be covered by -the pia mater, with or without a layer of cerebral matter, and was made -up generally of coagulated blood. No case of this kind recovered. - -In the second kind of protrusion, or that which usually although not -necessarily takes place when the first or active inflammatory symptoms -are on the decline, the tumor is formed of the substance of the -brain. It has been supposed that in whatever manner a case of hernia -cerebri may arrive at a favorable termination, there must inevitably -be a loss of brain proportionate to the extent of the protrusion--a -conclusion which the experience of the Peninsular war did not confirm, -while it may lead to the establishment of an erroneous practice for -the too early removal of the protrusion. The loss of a portion of -one of the hemispheres of the brain is now known to occasion little -or no inconvenience in many instances, either to the intellectual or -corporeal faculties; nevertheless, as the precise quantity of brain -which a person may lose with impunity has not been ascertained, it may -be as well not to deprive a patient of any, provided its removal can -be dispensed with; and that it may be so dispensed with, the practice -of that war gave positive proof in several instances, by the protruded -part being gradually withdrawn within the skull, the wound having -afterward healed by the ordinary processes of nature. - -There were three cases of recovery from a protrusion of the brain after -the battle of Toulouse. - -Bernard Duffy, 40th Regiment, aged twenty-four, was wounded on the 10th -of April, and admitted into the Caserne de Calvete Hospital, on the -13th, with fracture and depression of the upper part of the os frontis. -Some portions of detached bone were removed; he was largely bled and -purged. - -On the 14th, he complained of severe pain in the head, giddiness, -dimness of sight, and drowsiness. The pupils were much dilated; pulse -60, and full. An incision was made down to the bone, and the divided -arteries were allowed to bleed freely. One perforation was made by the -trephine, and the whole of the detached and depressed pieces of bone, -which were of considerable size, were removed, one of them having -penetrated the dura mater.--15th. Has less pain in the head; pulse full -and slow; pupils dilated, with a tendency to coma, but he is sensible -when spoken to. V. S. ad ℥xxiv. Continue the purgatives.--18th. Is -less drowsy; pupils more contracted. The surface of the dura mater is -sloughy, and a small, dark-colored excrescence is rising up through -the opening in the cranium.--22d. The fungus cerebri has considerably -increased in size during the last few days; in other respects he is -doing well.--24th. The wound looks clean; the discharge is healthy. -The fungus increases in size, and is rather above the edges of the -wound; some sloughs have separated from it, and it has now a red and -tolerably clean appearance.--26th. The wound granulates regularly; -the excrescence seems to enlarge rather at the base than at the upper -part; it was touched slightly with lunar caustic without any pain -or unpleasant symptom being produced.--30th. Continues doing well. -The pupils are still somewhat dilated, but contract readily on the -admission of light; appetite good; bowels regular; and the patient -says he has no complaint. Discharge from the wound healthy; the fungus -is prevented from increasing by a slight application of the argenti -nitras every second day. He has not required any medicine for some -time past.--May 6th. The wound has closed around the fungus, which is -a little above its edges; it is touched slightly every day with lunar -caustic or the sulphate of copper. The pulsation of the brain elevating -and depressing the fungus is perfectly distinct; no constitutional -derangement. Was discharged cured to Bordeaux. - -William Donaldson was admitted, on the 13th of April, 1814, into the -Dépôt de Mendicité Hospital, having received a gunshot wound in the -head on the 10th of April, which fractured the right parietal bone to a -considerable extent. The brain protrudes; pulse quick and small; bowels -open. V. S. ad ℥xvi.--14th. The pulsation of the brain is evident, -and the protrusion increases; he complains of no particular pain; the -discharge is profuse, and of a thin, black, watery quality; pulse 90; -bowels freely open. V. S. ad ℥xvi. Continue the purgatives.--15th. -The pulse and bowels natural, the protrusion has scarcely increased; -discharge profuse, and still gleety; a small compress was laid over -the dressings, and a bandage was lightly applied.--16th. Pulse and -secretions natural; the wound looks more healthy; the discharge -something better in appearance; the fungus does not increase.--19th. -Is doing well, and does not complain of pain; functions natural; -the protrusion somewhat less; discharge good. A small quantity -of cloth has come away.--21st. Discharge improved. Continue the -purgatives.--26th. The protrusion evidently diminishes, and begins -to heal at the edges.--30th. The hernia cerebri has considerably -diminished; secretions natural; a small quantity of bone has come away; -discharge diminished.--May 4th. The wound is healing rapidly; the -patient is now permitted to get out of bed, and has half diet. Another -very small piece of bone has come away.--10th. The wound is now nearly -healed.--Between the 15th and the 25th several small pieces of bone -came away.--On the 26th, on introducing the probe, a small piece of -bone followed it; and on further examination a large piece was felt -quite loose, and was removed by incision. Discharged cured to Bordeaux. - -Gentle pressure was made on the protrusions, according to the feelings -of the individuals, in both these cases; when made too firmly, it gave -rise to swimmings and pain in the head, retardation of the pulse, -a sense of sickness and fainting, and on one occasion to syncope. -Pressure could only be borne when very lightly applied while the -protrusion was increasing, but could be gradually augmented when -it became stationary, and during its diminution and secession. The -pressure was continued until after the wound had healed. - -I had occasion, at Santander, to remove a portion of bone, including -the upper part of the lambdoidal suture of the right side, from the -head of a soldier of the Light Division, in consequence of symptoms -of irritation having come on after an irregularity in drinking. He -had been wounded by a musket-ball on the heights of Vera, which had -fractured and depressed the skull at that part some weeks before. -A piece of bone was depressed, and had irritated the dura mater at -the part; the membrane had some matter upon its surface, and was -evidently abraded. The operation gave relief, but a tumor soon sprang -up, evidently composed of brain. The patient was again bled, purged, -and starved; calomel and opium were given in moderate doses, and the -protrusion ceased to increase; about the same time it changed color, -became yellow, fetid, softer, and soon wasted away, pieces of dead -matter separating at each dressing, until it sunk within the level of -the skull; after which healthy granulations sprung up, and the wound -healed. - -In the fatal cases, paralysis, accompanied by stupor and other symptoms -of compression of the brain, invariably supervened before death. - -The preceding cases prove that persons may recover after having had a -protrusion of the brain, without as well as with the loss of a portion -of its substance, the difference in all probability between the cases -being dependent on the degree of mischief which gave rise to them. In -the fatal cases I have seen, the protrusion was manifestly a part of -the substance of the brain, and firmer than the hemisphere beneath, -which was soft, pulpy, and of a yellow and sometimes of a reddish -color, the lateral ventricle being filled with a sero-purulent matter, -pus being also spread over the surface and intermingled with the pulpy -structure, into which the brain had been changed. The protrusion was -the consequence of low inflammation of the brain; and greater caution -had been necessary during the progress of the mischief than had been -enforced. It was the observation of this, and of other circumstances -not less important, which led me to enjoin that rigid system of -management insisted upon in all cases of injury of the head. There can -be no doubt that the formation of many of these protrusions was aided -by the opening made in the dura mater, which would have restrained -their growth if it had been sound. The dura mater therefore should -never be opened if it can be avoided. - -It has been proposed to destroy protrusions of the brain with -escharotics, and by ligature; and more faith has sometimes been -placed in the knife for their early removal than in the more deferred -operations of nature. Greater reliance may, however, be placed on -the efforts of nature, assisted by a methodical treatment of the low -inflammatory state of the brain, and by such pressure at a later period -as can be borne with comfort, and persisted in with propriety. - -286. It has been supposed that abscess of the liver followed injuries -of the head in a more peculiar manner than injuries of other parts -of the body, an opinion upon which too much reliance should not be -placed; for experience has induced me to think that unless the liver -be really injured by a fall or blow, it only becomes affected in a -secondary manner, in a similar way to the lungs or other viscera, or -to the joints or other parts. The new disease in these cases is always -insidious in its nature and progress, and for the most part fatal in -its result, as has been explained at length, (Aph. 59, p. 62, et seq.) - -287. When a person has received a serious blow on the head, which -has given rise to an exfoliation of the bone, or to a very slight -depression of the skull, he is rarely restored to his previous healthy -and natural state. The scalp adheres firmly to the bone beneath, -instead of sliding loosely over it, and a deep hollow is formed, which -would imply that greater mischief had been done and a greater loss of -bone had been sustained than had actually occurred. This is the more -remarkable when pieces of bone have been removed. Major D., of the -Indian army, was wounded on the left side of the forehead, at its upper -part, by a musket-ball, at the assault of Maheidpoor. Several pieces -of bone were removed, and the pulsation of the brain was evident under -the discharge. The point of a little finger passes into the hole left -by the cicatrization of the wound, to a greater extent than might be -expected. This officer suffers from headaches, augmented or brought -on by any exertion of body or mind. He cannot bear exposure to the -heat of the sun. He can scarcely drink three glasses of wine without -feeling their effect. Persons so afflicted can bear no great exertion -of any kind. They fall down under exposure to heat. They are easily -inebriated, rendered furious by a small quantity of liquor, and often -become stupefied, comatose, or even die suddenly. In addition to these -evils, which may be avoided by care, many are subjected to fits, which -are apparently epileptic; and others suffer from such intolerable -pain in the part injured, as well as in the head generally, as to be -desirous of seeking relief by an operation, even at the risk of life. - -These injuries are often accompanied during their progress by mental -defects which time does not always remove. The memory is very often -much impaired; it is frequently defective as to things as well as -to persons. The sight of one or of both eyes may be impaired, or -even lost. Ptosis, or a falling of the upper lid, is not an uncommon -although a more curable defect. Speech is not only difficult, but -the power of uttering certain words is often lost; a language is -occasionally for a time forgotten, and a sort of conventional one has -even been adopted, under my own observation. The more serious evils -which befall these unfortunate sufferers are aberrations of mind, -rendering some degree of restraint necessary, or a state of fatuity, -which is not less distressing. These intellectual defects are often -accompanied by various states of lameness or debility, from which -there is but little hope of recovery. Pathologists have supposed that -concussion of the brain is frequently accompanied by, and may indeed -be essentially dependent on, small extravasations of blood in various -parts of or throughout the brain, not larger than the point or head of -a small pin, constituting, in fact, a derangement which, when general, -is destructive of life, and, when partial, may sometimes be the cause -of the various defects which follow injuries of the head. - -288. It is an interesting fact that a person who has been shot in -the head, or has fallen from the top of a house, so as to become -insensible, has no knowledge of the circumstance; and when, after -several days or weeks, he regains his senses, he has no recollection -of the injury, or of having received the wound; or if he should have -fallen from a height, he only remembers that he was aware he was about -to fall, but of the actual descent, or of the injury, he knows nothing. - -289. The trephine, which is worked by turning the hand, and makes -therefore only a half turn, necessarily saws unequally; but the -operator has the advantage of being able to press with it on any -particular part as the sawing of the bone draws to a close, and can -thus cut any portion of the bone which is thicker than the rest without -wounding the dura mater. The division and yielding of the last layer of -bone is very sensibly felt by the hand, and when sawing, the surgeon -can use the trephine as a slight lever with great effect, by pressing -on a particular part, or from side to side, and the inner layer of the -vitreous table may be in this manner as much broken as sawn through. -The piece to be removed should never be brought away in the crown of -the trephine, but should be raised by the forceps and lever; whenever a -rough edge of the inner table remains, it should be carefully rounded -off with the lenticular or blunt-ended instrument commonly used for -that purpose. - -290. Whenever there has been a loss of the integuments or scalp, so -that this part cannot be brought over the opening made by the removal -of the bone, some fine soft cotton should be laid on the dura mater, -so that a slight degree of support may be given to that membrane, more -particularly when it is thought that it may not be necessary to examine -it for two or three days. When circumstances appear to render a daily -inspection necessary, the cut portions of the scalp should be brought -over the opening, and retained by a slight compress and bandage kept -constantly wet and cold. The dura mater usually changes color and -becomes more red; a layer of lymph is seen adhering to it, from which -granulations arise and spring up until they touch the scalp, to which -they unite, or cicatrization takes place. When the patient dies early -from other causes, and the calvarium has been raised, the discolored -spot on the dura mater marks the place from over which the bone was -removed. I have seen this in a state of slough, and the only apparent -discoverable mark of disease. - -One of the improvements in modern surgery is to be found in the -restriction which has gradually been placed on the repeated use of the -trephine on the same person, and on the removal of large portions of -the skull. Cases are not, however, wanting in the older authors which -would appear to justify the proceeding, although it may perhaps be said -that they only show how great an extent of injury may sometimes be -committed with impunity. - -Saviard trepanned one person twenty times. Russ Martel and Le Gendre, -surgeons to the King of Navarre, say that in the year 1686 they took -away nearly both parietal bones, and the patient recovered and lived -for thirty years afterward, half his body, however, being paralyzed. -Marechal applied the trephine twelve times successfully, Gooch thirteen -times, Desportes twelve times. Saviard says that he had under his -care a woman whose parietal bones, together with a great part of the -occipital and frontal, separated at the end of two years after a -blow; the bones thus separated resembled a calvarium sawn off a dead -person. No fungus or hernia took place, and she lived for several years -afterward. - -Dr. Drummond, deputy inspector-general of hospitals, has published -the case of a seaman belonging to H.M.S. “Mutine,” who in 1845 fell -down some stone steps at Sierra Leone, receiving a contused wound on -the scalp, for which he was admitted into the Royal Naval Hospital -at Plymouth in October of the same year. The bone, which was not -supposed to have been injured, was then found to be denuded of its -pericranium to some extent, (left side of occipital.) After an attack -of erysipelas, followed by numerous purulent deposits under the scalp, -necrosis went on rapidly; there was oozing of pus from beneath the -diseased bones, and gaping of the coronal and sagittal sutures, the -brain pulsating very distinctly in the spaces. In July, 1846, he was -removed to Melville Naval Hospital at Chatham. During the six years -he has been under observation, there have been repeated attacks of -erysipelas, followed by profuse suppuration. Both tables of the bones -have suffered in some places; in others only the external. About five -square inches have been lost from the right side of the frontal, right -parietal, and squamous part of the right temporal. The whole of the -occipital to within a short space of the foramen magnum is deficient, -with the exception of about two inches in the center of the bone, -which are now undergoing the process of separation. On the left side, -Dr. Drummond adds, there has been less destruction of the bones, but -extensive caries was going on there, and fetid pus was being discharged -from several openings at the date when the case was reported, (April, -1851.) At no point was there any tendency to reproduction of bone, or -arrest of the disease. - -291. The removal of a large portion of the skull may be necessary -where the broken portions are deprived of their natural support and -connections, but as little should be taken away as possible. When the -loss of sense and motion is accompanied by fracture, and continues to -increase rather than to diminish, after the necessary and usual means -have been adopted for its relief, a piece of bone should be removed. -If blood should be found in any quantity on the dura mater, it may be -necessary to take away more bone to admit of its free discharge; for -although the gradual pressure of the brain from within will tend to -expel it, this object may not be attained in sufficient time, and the -patient may be lost. The older surgeons in these cases were anxious to -ascertain how far or to what extent the dura mater was separated from -the skull, and they often removed large portions of bone accordingly; -although their practice should not be implicitly followed, repeated -observation has shown that modern surgeons have often fallen too -much into the opposite extreme of doing nothing. When blood has -been evacuated in this manner, the parts must pass from a state of -inflammation into that of suppuration before the dura mater can again -adhere to the superincumbent bone, and care must be taken that the -matter shall have a free discharge. If symptoms of fever, followed by -those of commencing compression, should supervene from the granulations -arising from the dura mater filling up the opening and preventing -its exit, they should be excised; or if the matter should have -gravitated in a direction which does not admit of its being discharged, -the opening in the skull should be increased so as to remove the -impediment, and thereby lessen the danger. - -A layer of blood is often extravasated very thinly over the whole -surface of the brain and cannot be removed, although it may be -absorbed. It is, on the other hand, often collected in larger quantity -on the basis of the cranium, whence it will not be absorbed and cannot -be removed. It may be extravasated without reference to the part on -which the blow has been received, giving rise in the end to symptoms of -epilepsy or apoplexy, for the relief of which no surgical operation can -avail; but when a blow has been undoubtedly received on a part of the -skull, and any sign of mischief can be perceived on or in that part, -the removal of the bone is permissible. - -292. The wind of a cannon-ball has been supposed to exert some -influence on the brain when passing close to the head; there is, -however, no valid foundation for the opinion. An officer of the fifth -division was struck by a cannon-shot, during the assault of Badajos, -on the right side of the head and face. It carried away the right -eye and the whole face, the left eye hanging in the orbit, the floor -of which was destroyed. A part of the lower jaw remained on the left -side, but a great part of the tongue was gone. He had lost a large -quantity of blood, but was quite sensible. In the middle of the next -day he suffered much from the want of water to moisten his throat, -which could not be procured. After a distressing delay of three or four -hours under a hot sun, a small quantity was obtained, the arrival of -which he observed; and while I was giving directions relative to its -distribution, I felt a gentle tap on my shoulder, and on turning round -saw this unfortunate man standing behind me, a terrific object, holding -out a small cup for water, not one drop of which he could swallow. -Alone among strangers, he felt that every kindness in our power to -offer was bestowed upon him, and he contrived to write his thanks with -a pencil, which he gave me when he pressed my hand at parting at eleven -at night. I was glad at sunrise to find he had just expired. - -293. When a portion of bone is as it were sliced off with the scalp and -adheres to it firmly, the scalp and bone should be reapplied; and the -cure will often be effected without difficulty. When the portion of -bone cut off and hanging to the scalp, which is turned down, has but -little adherence, it should be removed. - -A German dragoon was brought to me in front of Madrid, who had -received a slicing cut of this kind on the top and side of the head, -which caused a portion of the scalp and parietal bone to be turned down -over the ear, uncovering the dura mater. Replaced and retained in its -situation, the flap and bone appeared to adhere, and the man recovered. -In the case of a Portuguese soldier cut down by the French cavalry in -a sortie during the second investment of Badajos, a portion of bone -cut off with a flap was quite loose, and was removed. The patient did -equally well. - -In the museum of the Royal College of Surgeons there are ten skulls -which have suffered from very severe slicing cuts. They appear to have -been collected from the burial-place of some establishment for invalid -soldiers in Germany. The portions of bone thus sliced, and they are -large pieces, were once detached, and afterward reunited a little out -of their proper places, so that the points of separation and of union -can be distinctly seen. These fissures are all in a certain state of -progress toward being filled up by bone, and the patients must have -lived some months, if not years, after the receipt of their respective -injuries; for bone is deposited apparently with difficulty and most -carefully in all such cases, so as not to irritate the membranes of the -brain. The opening in the first instance is filled up by granulations, -over which a thin skin is formed; this afterward becomes firmer and -harder, being in some cases, where the trephine had been used, a thin -but strong membranous expansion extending from one edge of bone to the -other. In others it is thicker and more solid, and in a few instances -osseous matter is deposited in its circumference, so as in part to -fill up the opening, the edges of the bony circle made by the trephine -becoming gradually thinner as they appear to grow inward. It is common -for an exfoliation to take place in such cases from the edges of -the cut bone, and from the circle made by the trephine. It has been -occasionally observed, after death, that the circular cut edge of the -bone does not become thin in the manner described, but that a sort of -ridge forms around and within it. - -When the scalp is torn down without being much bruised, and a large -flap extending from the occiput to the forehead falls down on the -shoulder, covered with blood or dirt, the flap should be cleansed and -restored to its place. When it is large, two or three sutures may be -necessary to keep it in its proper situation. The flap may not entirely -adhere under any management, but it will do so in parts; and care -should be taken to evacuate at an early period any matter which may -form by small but sufficient incisions made where required; this will -in general be above and about the ear. When the flap is much bruised, -the attempt at adhesion by close apposition will be useless until after -suppuration has taken place, when a well-regulated pressure will do -much toward expediting the cure. - -294. Erysipelas occurs in two forms: when the skin has the ordinary -redness characteristic of the complaint, and when the color of the -skin is not altered or is whiter than natural, but puffed, tense, and -shining, the inflammation being seated beneath the tendinous expansion -of the occipito-frontalis muscle. - -The general treatment should be regulated by the powers of the patient -and the state of the constitution, (Aph. 24, page 39.) The local -treatment of the first form essentially depends on puncturing the red -and inflamed skin all over with the point of a lancet, assisting the -flow of blood by warm fomentations. The punctures should be repeated, -if necessary. The second form is to be treated by incisions, perhaps -the greatest improvement of the surgery of the Peninsular war. - -The scalp in such cases is in a state of general puffiness, causing -the head to look considerably larger than usual, but without redness; -it retains the impression of the finger. Incisions are to be made in -the scalp from two to four or six inches in length, united by others, -if necessary. The scalp will often be upward of an inch in thickness, -and filled with a fluid partly serous, partly purulent. The small -arteries bleed freely, and should be allowed to do so as long as may -be desirable, when the hemorrhage should be arrested by pressure. -The head should be fomented. The essential points are, to take off -tension, and to allow the free discharge of any fluid which may be -secreted. The moment the parts around a wound have become puffy, the -surface of the wound changing from a red to a yellowish color, with -a thin discharge instead of good pus, an incision should be made -through them, and repeated, if necessary. It relieves the tension and -the irritative fever, and prevents the delirium which would follow; -which neither bleeding, purging, nor the other constitutional remedies -which the state of fever may indicate will remove. If it should be -neglected, suppuration and sloughing will extend under the tendon of -the occipito-frontalis, or the fascia of the temporal muscle, and the -greatest danger will be incurred from this additional cause. - - - - -LECTURE XX. - -WOUNDS OF THE CHEST. - - -295. Wounds penetrating the wall of the chest, and implicating any part -or portion of its cavity or contents, are among the most dangerous of -injuries. They require in their treatment a more careful attention and -a greater extent of knowledge than most others which befall mankind. -The means which the improved methods of auscultation have afforded -cause the progress of the symptoms which follow to be less obscure, -and lead to a less doubtful practice than formerly; while they render -a knowledge of this branch of medical science an essential part of the -education of a surgeon. - -296. _Incised_ or _punctured wounds_, from swords, lances, bayonets, -or knives, require a treatment _essentially distinct_ on many points -from that of _gunshot_ wounds, especially in the commencement. On this -early treatment so much depends, that details of the more serious or -more important cases are rarely found among the records of injuries -sustained on the field of battle, where so much is often to be done, -and so few are to be found to do it. - -The simplest of the more serious results from injuries not penetrating -the chest is the occurrence of inflammation, either of its lining -membrane, giving rise to what is called _pleuritis_, or of the -substance of the lung, termed _pneumonia_, or of both, constituting -what has been named _pleuro-pneumonia_; but many severe blows on the -chest are not followed by such serious consequences. - -On the 17th August, 1808, in the act of leaving the village of -Colombeira to ascend the heights of Roliça, a soldier was shot in the -leg: he jumped up three or four feet, and made a considerable outcry. -A second was struck at the same time by a ball on the shoulder, which -did not penetrate, but gave him great pain. A third received a ball on -his buff-leather belt, on the right breast. The noise made by these -two blows was unmistakable. I saw this man fall, and supposed he was -killed: the ball, however, had only gone through his belt, and made a -mark on his chest, over the cartilage of the fourth rib, the hardness -and elasticity of which had prevented further mischief. He recovered -in a short time, spat a little blood in the night, and after a large -bleeding was enabled to accompany me on the 20th to Vimiera, ready for -the fight next morning. - -A soldier was struck on the hill of Talavera,[4] on the breast-plate -by a ball, which, as he believed, had gone through his body. He was -as white as a sheet, and desperately frightened. On opening his coat, -I found the ball had indented the breast-plate, and made a round, -red mark on the skin, without going deeper. I did not see him again -for several days, until after crossing the bridge of Arzobispo, on -the retreat to Truxillo. He was then engaged in disemboweling a fine -fat wild hog, among a herd of which we had, unluckily for them, just -fallen. He recognized me at once; said that, as I told him, he had -been more frightened than hurt; that he had been bled largely and well -physicked, and after two or three days had thought no more of it. I am -bound to add that, in gratitude, he offered me a leg of the pig, which, -having nothing to eat, I could not but accept. It supplied a dinner for -three others who are now no more. - -[Footnote 4: The Duke of Wellington received a blow from a spent ball -at the same time, near the left clavicle.] - -A soldier of the 40th Regiment slipped from the ladder on which he was -attempting to scale the wall near the great breach of Badajos, and fell -on his cartridge-box, which hurt his left side so much as to render him -unable to move for some time. On the 8th of April he was much worse. -The part injured was painful to the touch; the difficulty of breathing -considerable; cough hard, with little expectoration; pulse 90, skin -hot, appetite gone, tongue white. V. S. ad ℥xvj, and aperients. 9th. -Better; pain less; expectoration more in quantity, and viscid. V. S. -ad ℥xii; antimonials. 10th. Pain still felt on coughing; expectoration -reddish; difficulty of breathing greater. Pil. cal. et antim. c. opio; -V. S. ad ℥xvj. He gradually recovered (his mouth having become slightly -sore) from what was manifestly an attack of pneumonia. A gentleman, in -1835, fell from his shooting-pony on his powder-horn, which bruised his -right side from the seventh to the last rib, and, as he said, knocked -the breath out of his body, and hurt him so much as to render him -incapable of walking from one room to another from pain in the side, -back, and thigh. No bones were broken. The pain, on the second day, -was augmented on breathing and on attempting to cough. The third day -he was purged, and blooded to sixteen ounces, which gave some relief; -but as the symptoms increased on the fourth day, he was more carefully -examined. His right side could not bear pressure. The respiratory -murmur was distinct, but accompanied by a crepitating rhonchus under -the part injured. Cough troublesome; expectoration mucous, viscid, -and of a reddish tinge. Antim. p. tart. and sulphas magnesiæ, every -four hours. V. S. ad ℥xiv. On the fifth day, the symptoms being little -altered, he was cupped on the part affected to fourteen ounces. On -the sixth, the pain was only felt on coughing, or on drawing a very -full breath; expectoration redder and thicker; pulse quicker. The -rhonchus was quite as distinct. V. S. ad ℥xij, and the medicines to be -continued. After this he quickly recovered and the natural respiration -became distinct. - -Lieutenant Cooke Tylden Patterson, of the Light Division, was struck -on the left breast by a musket-ball, on the morning of the 15th of -July, 1813, in front of the village of Vera, in the Pyrenees. He fell -on his back breathless, as if he were killed. While waiting the order -to advance, he had been reading Gil Blas in Spanish, and on receiving -it, had hastily put the book in the breast pocket of his coat. The -ball had struck this, but, unable to penetrate it, had fallen on the -ground at his feet, completely flattened on one side, and marked with -the impression of the braid of his coat. A piece of the cover of the -book, about the size of a half-crown, was driven in, and the leaves -throughout were indented by the ball. It was some days before the -effects of the blow entirely subsided. - -A soldier of the 97th Regiment was struck at the unsuccessful assault -of Fort Christoval, opposite Badajos, by a musket-ball, which went -through his brass breast-plate and coat, drove his shirt through the -skin, and against the sternum, which it was not able to penetrate. He -fell, and was supposed to be killed, but he soon recovered and ran to -the rear. The ball was found flattened between his shirt and coat. The -part of the chest was very black next day, the spot struck by the ball -being much bruised. It was necessary to bleed him largely. When the -integuments are painful, although merely bruised, the diluted tincture -of arnica is a useful application, and Scheele’s hydrocyanic acid, six -drops to an ounce of water, is said to be efficacious. - -Major Lightfoot was struck by a musket-ball on the left breast; it -went through his clothes, the integuments and the outer part of the -great pectoral muscle, and slanted inward for three inches toward -the sternum, to which distance its track could be followed. It was -evident that the ball had neither lodged nor penetrated, for no serious -symptoms ensued. In all probability it had been ejected the way it went -in by the elasticity of the cartilages of the ribs near the sternum. - -297. In order to understand, or to become in any way acquainted with -the changes from the natural structure which are going on under -derangement in the chest, even from simple injuries, it is always -necessary to have recourse to auscultation, and sometimes, although -more rarely, to percussion, if the external parts are not too tender. -Under all circumstances both sides of the chest should be examined -by the stethoscope. As the ordinary breathing of an individual is -rarely sufficiently strong to enable the auscultator to hear it with -distinctness, the patient should be desired to inspire fully and -more quickly than usual, without much effort, and without noise from -the mouth or nose, or retaining his breath. The inspiration and the -expiration are both to be carefully observed. - -When the ear is firmly and equably applied to the chest of a healthy -young person, a very distinct and long-continued sound is heard at -the moment of inspiration, and another at that of expiration. This -is called the _vesicular_ or _respiratory murmur_, and is dependent -on the air fully permeating and distending the air-vesicles of the -lungs. It has been poetically compared to the sound of a gentle gale -rustling in a thick summer foliage--to the whisper of a retiring wave -on a sandy beach in a calm day. It is soft, scarcely sonorous, equable, -and during inspiration continuous. In childhood it is louder than in -adult persons, arising probably from the greater activity of the lungs -in young than in elderly people. This is called, and especially when -perceptible in adults, _puerile respiration_, as opposed to their -ordinary, or what in old persons may be called _senile_. It is more -marked during inspiration. - -When the stethoscope is applied in the situation of the great bronchial -passages, as over the first bone of the sternum, under the clavicle, -in the center of or between the shoulder-blades, a different sound -is usually but not always distinguishable, when the patient breathes -fully, arising from the passage of the air through these bronchial -tubes. It is compared to the noise made on blowing through a reed or -quill, and is called _bronchial or tubular respiration_. When heard -in other parts of the chest, it is a morbid sound. If the stethoscope -be applied over the trachea, the sound is louder, rougher, and more -intense, and is called _tracheal_ respiration. On listening over the -trachea during speaking, the voice sounds as if it were passing into -the ear, and the words are distinct--_tracheophony_. This, if heard in -any other part of the chest, is a sign of disease, for in the natural -state the voice is heard only to resound through the chest, but the -words are not heard if the other ear be stopped. When heard, the sound -has been called _pectoriloquy_, and is supposed to imply the existence -of a cavity at that part; but the word is unnecessary, or, if used, it -means that the cavern or hollow communicating directly with the trachea -gives forth a similar or nearly similar sound, a _natural_ sound in an -_unnatural_ position. The essential difference between _bronchophony_ -and _tracheophony_ in the investigation of disease is, that in the -latter the voice apparently speaks through the stethoscope into the ear -of the auscultator, while in the former it is heard with scarcely less -distinctness, but at the distal end of the instrument. Over the larynx -it is louder, hoarser, and rougher. - -The length of the sound in inspiration, as compared with that of -expiration, has been said to be as five to two. One is louder -and longer than the other, a difference requiring attention from -the circumstance that morbid sounds of great import are heard in -inspiration, which do not prevail during expiration. When any other -difference is perceptible between them, so that they more nearly -resemble each other in duration or in intensity, or when expiration is -prolonged, some structural alteration may be suspected in old persons, -some disease in young ones. When little or no respiratory murmur can -be heard after symptoms of inflammation have existed for some time, -the case is very serious, implying that effusion into the cavity, or -condensation of the lung, has taken place to a considerable extent. - -298. The number of inspirations in a minute in the adult and elderly -persons varies from eighteen to twenty-two in a state of health: from -twenty-two to twenty-six in children. The stroke of the pulse is -generally as four to one. If the inspirations are eighteen, the pulse -will in general be seventy-two. Both may be slower, although they are -often quicker under disease. When the breathing is slower, it commonly -indicates some affection of the nervous system; when very rapid, some -important lesion within the chest. - -The theory of percussion is founded upon three elementary sounds, which -are produced when a solid, a liquid, or a gaseous body is struck; all -others are varieties of these. The sensation of resistance which is -experienced at the same time bears an exact relation to the density of -these bodies--hence the resistance when a solid substance is struck is -greater than when a gaseous one is under percussion. The liver, the -thorax in a case of pleuritic effusion, and the distended stomach after -a long fast, afford good examples of these elementary sounds. To employ -percussion successfully, it is necessary that the strokes be uniform in -force and quickness, and that the finger or pleximeter be so applied to -the surface that no space exists between them, otherwise such a sound -will be elicited as may give rise to an incorrect diagnosis. - -It having been stated that a sound lung never fills the bag of the -pleura, particularly toward the diaphragm, at least during ordinary -respiration, I requested Mr. Quekett, the Resident Conservator of the -College of Surgeons, to ascertain this by experiments on some sheep at -the moment of their being killed; and it appeared from them that the -base of the lung is always in contact with the surface of the diaphragm. - -299. In ordinary expiration the chest diminishes in size. The ribs -which have been raised recede, by the elasticity of their cartilages, -and by the return of the ligaments, to their state of rest; the -elevated muscles become relaxed, while others belonging to the lower -part of the trunk and abdomen contract. The diaphragm is relaxed, -and pushed upward by the viscera of the abdomen, pressed upon by the -muscles of its wall, if it should not be drawn upward by the attraction -of the lung, which when distended endeavors by its elasticity to -return upon itself, and to occupy less space than the capacity of -the chest will afford. The lung, invested by an elastic, special, -and transparent membrane, and covered by the pleura pulmonalis, is -composed of an immense number of air vesicles, the largest being equal -in size to the fourth part of a millet-seed. These air vesicles, -crowded together, each communicating with a fine bronchial tubule, are -separated from each other into groups by a condensed cellular tissue, -thicker where it surrounds these lobules, which alternately form, when -aggregated together, a lobe, whence it is called interlobular tissue. -An artery and vein form a very minute net-work around each vesicle. -These vesicles may become filled with water; when dilated by air, they -constitute what is called emphysema of the lung. The lung in man is -constantly applied to the internal surface of the chest, the pleura or -serous membrane covering the lung being closely applied to the pleura -lining the wall, and one surface glides upon the other, moistened by -a secretion in just sufficient quantity to effect this object. If the -lower intercostal muscles of a young animal be removed to a sufficient -extent, the lung and the diaphragm may be seen applied to the inside -of the pleura lining the rib, and _ascending_ and _descending_ in -concert, the lungs moving vertically, not horizontally. The diaphragm -ascending, covered by its pleura, is in a similar manner applied to the -lower part of the wall of the chest, which had been filled by the lung -during inspiration. After death the lung remains closely applied to the -pleura, recedes on an opening being made into that membrane, and may -collapse, provided no adhesions exist to prevent it. - -300. When inflammation of the pleura takes place, the gliding motion -is not effected silently, but with a peculiar noise, called by the -French _frottement_. When the lung is inflamed, the respiratory murmur -is changed in that part, or is overcome by a peculiar sound, which can -be distinctly investigated by the ear--_rhonchus crepitans_. Hence the -great value of auscultation. - -In the following observations it is not intended to give a history of, -or even the whole of the symptoms and consequences of inflammation -of the pleura and the lungs; but only to draw attention to such of -the principal facts as it may be necessary to consider when these -inflammations and their consequences are caused by external injuries. - -Acute idiopathic inflammation of the pleura usually commences by -rigors, preceded perhaps by some signs of general uneasiness, which -soon become those of great febrile excitement. Pain is early felt in -the side in the course of the sixth, seventh, and eighth ribs, or at -the point corresponding generally to the seat of the inflammation. -It is usually sharp and darting, is called a stitch, occupies rather -a small space, (the _point de côté_ of the French,) and is always -increased by drawing a full breath or by coughing. The breathing is -short, from the disinclination to fill the chest, by which the pain -would be increased; it is hurried, and sometimes takes place as if -by jerks, from the necessity for its repetition, in consequence of -the smallness of the quantity of air admitted at each attempt. When -the attack is very severe the patient tries to breathe with the -healthy side only, the lower ribs of the affected side being moved -but slightly, and with evident caution. If the inflammation have been -caused by extreme violence, pain will also be felt, particularly at the -part injured. - -When inflammation has affected the pleura covering the diaphragm, -especially when caused by external violence, the pain will be felt -lower down, so as to lead to the suspicion that it is also abdominal. -When jaundice supervenes, it occurs from the extension of disease -through the substance of the diaphragm, as is occasionally seen in -wounds implicating the chest, the diaphragm, and the liver. - -A cough is not a constant accompaniment of the first stage of disease; -when present, it is usually dry, slight, infrequent, and does not -attract attention, unless accompanied by a thin, frothy mucous -expectoration, indicating the presence of bronchitis; of pneumonia, if -reddish. The patient usually lies on his back while the pain is severe, -and has a great indisposition to turn fully on to the affected side. -At a later period, when effusion has taken place, the pain usually -subsides, and he turns on the side affected to relieve the difficulty -of breathing, caused by the pressure of the fluid on the sound lung -through the bulging of the mediastinum; but the manner of lying, or -_decubitus_, is of little importance, and should be subservient to the -feelings of the patient, who is sometimes comfortable only when raised -to nearly an erect position. - -When the complaint is not subdued at an early period, an effusion of -serous fluid, more or less in quantity, takes place. The whole cavity -of the side affected has been known to be filled in from twenty-four -to forty-eight hours, giving rise to symptoms dependent on the degree -to which the effusion has taken place; _this_ is the evil which in -injuries penetrating the cavity of the chest is most to be feared. When -the external wound has been closed, or is so partially closed as not -to allow the escape of the effused fluid, it is commonly the immediate -cause of the death of the patient. Its secretion and early evacuation -are therefore the most important points to be attended to in wounds of -the chest. - -The respiratory murmur becomes less distinct as soon as the pain -prevents the ordinary distention of the affected side of the chest, -and diminishes the quantity of air which usually penetrates the lung -in any given time. As soon as a thin layer of fluid commences to be -thrown out between the pleuræ, this murmur becomes fainter, and when -it is complete, it ceases. If the patient can bear percussion, the -side affected yields a dull, dead sound instead of the ordinary clear, -sonorous one of health. The position of the patient when erect, by -causing the fluid to descend, may allow of the respiratory murmur being -heard at the upper part of the chest; and it may be perceived in front, -but not behind, when he lies on his back, until the cavity is filled, -when the sound altogether ceases. At the spot in the back corresponding -to the root of the lung, or at any other point at which a previously -formed adhesion may retain the lung against the wall of the chest, some -respiratory murmur may yet be distinguished, until this part of the -lung shall also have yielded to the general compression, so as to be -temporarily impervious, or have become solidified under the continuance -and extension of disease. While this is taking place in the affected -side, the other lung is called upon to make up the work of aerification -of the blood; it labors harder, its functions become more energetic, -and that side of the chest is more distended; the respirations become -quicker, fuller, and louder, and the vesicular murmur is said to -resemble that of a child--in fact, to be _puerile_. - -When the lung begins to be compressed by the circumambient fluid -and the respiratory murmur ceases, a peculiar modification of -the respiration through the large bronchial tubes may be heard, -constituting _bronchial_ respiration. It occurs in pneumonia, in -pulmonary apoplexy, and in tubercular disease when the lung is -solidified. When the voice is heard through the stethoscope in these -complaints, the peculiar sound emitted is called _bronchophony_. - -In pleuritic effusion, the voice, when carefully examined, sometimes -obtains a character not previously noticed, but of comparatively little -importance, called _œgophony_, a sound which may be easily confounded -with bronchophony, of the latter of which it is a modification more -often alluded to than observed. Laennec says: “Simple œgophony consists -in a peculiar resonance of the voice, which accompanies or follows the -articulation of words. It appears to be sharper than natural, more -acute and somewhat silvery, vibrating, as it were, on the surface of -the lung more as an echo of the voice than as the voice itself. It -rarely enters the tube of the stethoscope, less frequently traverses -it completely. It has besides another peculiar character, which is -constant, and from which I have taken its name. It is a trembling, -bleating, or shaking sound, like that of a goat, the tone of which -animal it greatly resembles. When it occurs near a large bronchial -tube, as in the root of the lungs, a more or less marked bronchophony -is often superadded.” This sound may pervade the whole side; it is -usually, however, most distinct near the inferior angle of the scapula, -the patient being erect. It only exists where the effused fluid is -small in quantity, and is never a dangerous symptom; its return, -after it has been present and has disappeared, is a sign that a part -of the effused fluid has been removed. It is a sign principally of -value in distinguishing between pleuritis and pleuro-pneumonia and -pure pneumonia, in which latter disease it is not heard, as in that -complaint fluid is not thrown out into the cavity of the pleura. - -301. In pneumonia or inflammation of the substance of the lung, as -distinct from any implication of the pleura, which, however, most -frequently obtains after blows on, and in cases of penetrating wounds -of, the chest, the symptoms differ. The ordinary febrile symptoms are -similar to those of pleurisy, only more intense; they usually precede -for a day or two the local symptoms of difficult respiration, pain, -and cough. The dyspnœa varies in different people. In some it is only -a slight embarrassment of breathing, admitting of partial removal -by accelerating the number of the respirations, which are augmented -from twenty to thirty, forty, and upwards, and in children to sixty -and seventy, marking a great degree of distress and of extent of -inflammation, from which, when they are so frequent, persons rarely -recover. The patient can scarcely speak or lie down, and is obliged to -be supported in that which he finds to be the least uneasy position. -Pain is not always present; it is even said to be more frequently -absent when the substance of the lung is affected, and not the pleura. -That pain is not a necessary concomitant of pneumonia, is admitted, but -that it is usually present, and with great intensity in many cases, -cannot be doubted. When present, it is usually an early symptom, deep -seated below the sternum, under the breast, extending to the scapula. -When in the sides it is more acute and fixed, and is probably conjoined -with the pain of pleurisy. - -The pulse is quick and sharp, occasionally full and hard, at the -commencement of this complaint in young and healthy persons, although -it is sometimes small and weak from the beginning, where there is -little general power; but this rarely occurs in cases of injury, and is -not to be relied upon in opposition to other symptoms. - -The _cough_ is usually dry in the commencement of idiopathic pneumonia, -rarely recurring by paroxysms, and is without any particular -indication; it is soon, however, accompanied with a slight mucous -expectoration, which, after some twenty-four or forty-eight hours, -begins to assume certain and peculiar characters of the utmost -importance as indicating the existence and the different stages of the -disease. On the second or third day the expectoration becomes bloody. -Each sputum, spit, or _crachat_ of the French is composed of mucus -intimately combined with blood--that is, not simple streaks or striæ -of blood, as in catarrh; nor is it pure blood, as in hemoptysis. Each -sputum is either of a yellow, or rusty, or even red color, according to -the quantity of blood intimately mixed with the mucus. These sputa are -at the same time tenacious and viscous, adhering so intimately together -as to form a homogeneous transparent whole, readily gliding, however, -from the basin in which they are held on sufficient inclination being -given to it. At this period or stage of the disease, the sputa adhere -strongly to each other, but the mass is not sufficiently viscid to -stick to the sides of the vessel. When no further change takes place -in the sputa the inflammation rarely passes beyond the first stage of -obstruction or engorgement, or swelling. When they attain to a more -viscous state, and adhere to the inside of the vessel in which they -have been received, the progress of the inflammation to the second -stage, or that of hepatization, may be feared. In almost every case -where the viscidity of the expectorated matter increases, respiration -becomes dull or bronchial, percussion of the chest yields a duller -sound than before, and the inflammation has attained its highest -degree. The expectoration, after being some time stationary, changes -its character. If the complaint is to terminate by resolution, or by -death, or to pass into a chronic state, the redness and viscidity -gradually diminish, and at last disappear. If the rust color and -the viscidity should return, there has been a relapse, which the -reappearance of the other symptoms will show. When the inflammation -is of the most serious nature, and about to terminate fatally, the -expectoration diminishes, and at last ceases. In some cases it only -diminishes because it cannot be discharged; it accumulates in the -trachea, in the larynx, and in the bronchi, until the patient is -destroyed. In some rare cases the matter secreted is spit up nearly to -the last, and in others, still more rare, the approach of death in the -last stage is characterized by a brown expectoration which cannot be -mistaken for either of the others which preceded it. If the pneumonia -pass into the chronic state, the expectoration becomes yellowish, or -somewhat greenish, and at last is purely catarrhal. - -Delirium is not an uncommon symptom when the inflammation of the lung -is intense in persons of powerful constitutions, particularly during -the exacerbation of fever in the night. It yields with the other -symptoms when relief is obtained. When, however, it comes on at a later -period of the complaint, or when the accompanying fever is not purely -inflammatory, or in persons weakened by exhaustion and privation, it is -usually a fatal symptom if continued. When mild, it often occurs after -repeated and efficient bleedings, which have subdued, but not entirely -removed the disease; and yields to opiates and gentle stimulants, by -which the pain is removed, although it sometimes remains in a milder -degree than before. - -The ear discovers, soon after the commencement of the disease, that -the natural murmur cannot be distinctly heard, it having been at first -partly obscured, and after a time entirely superseded by a peculiar -noise, called a crepitating or crepitous rattle or rhonchus. In its -purest state it has been likened to the sound of a lock of hair -rubbed close to the ear, or to that made by rumpling a fine piece of -parchment; or again, to that which is produced by what under ordinary -circumstances is called the crepitation of salt, when scattered in -small quantities on red-hot coals. This crepitating rhonchus is heard -at first in a small part of the lung, generally at the lower rather -than at the upper part; it marks the first stage of the disease. It -is not of long continuance; the vesicular murmur is either restored, -or the crepitating rhonchus ceases to be heard, in consequence of the -second stage to this, or that of hepatization, having commenced; the -small air-vesicles are no longer pervious; the sound of the breathing, -which is now heard, is that of the air more forcibly driven into the -larger bronchial tubes causing _bronchial respiration_, which is no -longer a vesicular or crepitating, but a whiffing sound, like that -caused by blowing forcibly through a quill, or as if little gusts of -air were blown in or blown out. The voice betrays to the ear of the -auscultator another sign; it descends into the pervious bronchi, and -being conveyed to the ear through the solid lung, gives rise to that -peculiarity of voice called _bronchophony_, a correct knowledge of -which can only be acquired by repeated observation. - -When the inflammation of the lung is confined to a small and -deeply-seated spot, auscultation may not at first reveal the evil; -or it may possibly be overlooked, through the sound part of the lung -becoming more active, and giving forth in consequence a stronger and -more puerile breathing, which may mislead the listener. - -When the vesicular murmur cannot be heard, when the _rhonchus_ or -_crepitating râle_ or sound is not present, and bronchial respiration -and bronchophony only can be distinguished, the case is one of great -anxiety and danger. The second stage of hepatization is passing into -the third, or purulent infiltration, of which auscultation shows no -further signs, although the matter secreted may be expectorated, in -proof of what has taken place. Pus is thus formed, which it is steadily -maintained by some pathologists is not deposited in the form of -abscess, but is infiltrated throughout the parenchymatous substance of -the lung, finding its way into larger bronchial tubes, or being poured -out from some parts of their secreting surface; the accuracy of this -statement, however, as a rule, may be doubted, from some dissections -having proved the reverse. - -302. The effects of inflammation of the pleura are well marked; the -first is to diminish, if not to annul, the secretion of the exhalation, -or halitus, by which it is lubricated; so that its surfaces can no -longer glide without noise upon each other. The patient is often -made aware of the difference by some uneasy internal sensation; the -auscultator, by a rubbing or creaking sound emitted as the inflamed -pleuræ, no longer smooth and polished, rub against each other, and -become covered by a thick, effused matter, although not actually -separated by a liquid. It is a sound which cannot exist after -separation has taken place by the intervention of a fluid, or after -adhesions have formed; it is, therefore, an early and transitory sign, -is frequently interrupted, and returns, as if by jerks, three or four -times repeated in succession. The pleura when inspected, after being -attacked by inflammation, shows at first but little sign of derangement -on its serous surface. It quickly, however, exhibits numberless small -vessels, carrying red blood, which are principally seated in the -sub-serous cellular tissue, reddening the membrane more deeply in one -part than another. These soon begin to take on a new action, leading -to the deposition of coagulable lymph or fibrin, which adheres to the -inflamed surfaces. These deposits soon assume the determinate form -of very thin layers, constituting what are called false membranes; -while a serous or sero-purulent effusion takes place, even to filling -the cavity of the chest, and which may or may not be ultimately -absorbed. When coagulable lymph is first deposited, and about to form -a false membrane, it is soft, of a grayish-white color, and does not -possess any appearances of organization. Red points are, after a -time, perceived in it, which soon become red lines or streaks, on the -surface. This organization of the lymph does not depend on the period -which has elapsed from the commencement of the complaint. It is seen -in the first day of the disease in some cases; it is altogether absent -in others, and depends much on the state and habit of the patient. -The lymph is sometimes deposited in small drops or spots; in others, -in patches of a greater or less size, varying according to the extent -of the inflammation which has produced them. When a false membrane is -once fully formed, it becomes itself a secreting surface, and may go on -augmenting its thickness to so great a degree as materially to diminish -the cavity of the chest. I have seen the pleura with a solid deposit -of this kind much more than an inch in thickness. In general, it is -found in distinct layers, superimposed one upon the other. Whatever may -be their thickness, they commonly admit of being separated from each -other. The false membranes thus formed, resembling areolar tissue in -their properties, may ultimately become cartilaginous, and even bony. -When simple adhesions form between the pleuræ, they become lengthened -with time; and, although they impede the motion of the lung at first, -and may give rise to some uneasy sensations, they gradually become -elongated, and give no further inconvenience. The fluid thrown out -is serous; is often mingled with flocculi or lymph, which are seen -floating in it; it is therefore more or less turbid, resembling whey. -It is often nearly colorless and transparent; when the consequence of -injury, it is often tinged with blood, forced out from the capillary -vessels of the pleura, or of the false membrane, if not caused by the -deposition of the fluid coagulated in the first instance after the -receipt of the injury. - -The quantity of fluid thus thrown out varies from an ounce to several -pints; it gravitates according to the position of the patient, -unless, when from old adhesions between the pleuræ, it is confined -to particular parts. When the cavity of the pleuræ is free, and the -fluid is in quantity, it compresses the lung, and diminishes its size -by pressing or squeezing the air out of it; it is thus pressed toward -the vertebral column, and so greatly diminished in size and augmented -in density as to be useless for the purposes of respiration. While the -lung is undergoing this compression to its utmost, the mediastinum also -yields, and bulges into the opposite side of the chest, carrying the -heart more or less with it; so that when the left side of the thorax is -thus affected, the heart is seen and heard to beat on the right. The -diaphragm now yields in turn, more on the left than on the right side, -from the obstacle to its descent afforded by the liver. The intercostal -muscles and ribs resist the internal pressure for a considerable length -of time, even for weeks; they at last, however, yield; the ribs may -even turn a little outward, while the interspaces in thin persons are -said to fill out, so as to render that side of the chest nearly smooth, -the size of that side, when measured, being larger than the other, in -some instances even by two inches, but this rarely occurs unless the -fluid within is purulent, and the disease of long standing. - -303. After a time, and particularly in wounds of the chest, the -effused fluid becomes purulent, the lung, compressed to a small, -flattened surface, adheres to the spine by what was its root, if no -adventitious attachments have retained it in a different position; and -the pleura has become a thick, yellowish-white, irregular, honey-combed -sort of covering for it, as well as completely lining the chest. -The serous as well as the purulent effusion are both free from any -unpleasant odor; unless a kind of gangrene has taken place, when the -latter becomes very offensive, and of a greenish-black color, as well -as the substance of the false membranes extending to and sometimes -beneath the pleura covering the condensed lung, into which openings -have even thus been made. - -In some cases the surface of the pleura is covered with small -tubercles, some as large as a filbert; in others it appears to have -a reticular or honey-combed appearance; and in particular cases, -large irregularities or excavations may be observed in it when much -thickened, being evidently spots of ulceration, which, if they had -proceeded, would have ended by allowing passage to the matter outward, -until it formed an external abscess, implicating in all probability one -or more of the ribs; thus giving rise to an exfoliation which, by being -separated internally, might in time be the cause of further mischief, -if not previously covered by a thin layer of false membrane. When -chronic pleurisy succeeds to a more acute attack, or they alternate -with each other, particularly after penetrating wounds of the chest, -several layers seem to be laid down one upon the other. This deposit -is never so thick upon the pleura pulmonalis; nevertheless it is thick -enough in most instances to prevent the lung from again dilating, -the substance of it being generally quite permeable to, although so -compressed as to be deprived of, air. It is then flattened, drawn -upward toward its root against the mediastinum and spinal column, -unless by some previous adhesion such a course has been prevented, and -it adheres, as it has been often known to do, to the side of the chest. -As that adhesion may occur in more than one spot, so may the effusions -or deposits take place between them, constituting circumscribed sacs, -and rendering the case more complicated. - -304. The changes which take place in the structure of the lung in -pneumonia are three in number: 1. Engorgement. 2. Hepatization. 3. -Purulent infiltration. The formation of an abscess or vomica, and -the occurrence of gangrene, may be omitted, as well as of chronic -disorders, in the views about to be taken of the disease from injury. - -In the first stage of inflammatory obstruction, or that of engorgement, -the lung has assumed externally a livid-red or violet color. It is -heavier and firmer than in its healthy state, and the natural feeling -of crepitation, although greatly diminished, is not extinct. The lung -retains the impression of the finger, and pits on pressure as if it -contained a liquid, although air-bubbles can yet be distinguished -in it, and its cellular or spongy texture is still to be observed. -On cutting into it, a quantity of sanguineous or turbid fluid flows -from it, mingled with numerous minute air-bubbles. In some places -the color of the incised surface is darker and more compact, showing -that some progress has been made toward the stage of hepatization. It -nevertheless tears with greater facility than in a healthy state. - -In the second stage, or that of the red softening of Andral, the -hepatization of Laennec--the latter term being in most common use, -from the lung assuming somewhat the appearance of liver in solidity -and weight--the lung does not crepitate, no air-bubbles pass out of -it, but a thick, bloody fluid exudes on pressure, and it sinks for the -most part in water. The color is somewhat less red or violet than in -the first stage, and lighter and more varied in color when cut into. -The openings of the larger vessels and of the bronchi, when cut across, -are observed as white specs; the interlobular tissue is thicker and -more marked in lines running in different directions; while many little -granular points can be discovered, especially with a glass, apparently -of a more solid material than the surrounding parts. - -The word solidity, or solidification, is sufficiently explanatory in -contradistinction to the naturally pervious and crepitating state of -the lung. Andral believed that hepatization arises from an excessive -congestion of blood, and not from any deposition of lymph. It is not -easy, however, to understand, in the present state of our knowledge, -how acute inflammation can go on for three or more days without -secretion and deposition being added to congestion. That hepatization, -or impermeability to air, may take place in the typhoid pneumonia in -twenty-four hours, and that it as suddenly seems to be removed, is -hardly conclusive, as it shows merely that a thoroughly well-loaded -lung ceases to be permeable to air until a part of the load shall have -been displaced. - -When the lung, inflamed to the second stage, or that of hepatization, -is about to be restored to a state of health, a slight crepitation or -crackling begins again to be heard at the end of each inspiration; -and as this increases, (the rhonchus crepitans redux of Laennec,) the -bronchial respiration and voice gradually, or after a time, diminish, -until they entirely disappear; while a mucous râle or rattle commences, -the index of that free expectoration by which pneumonia usually -terminates. - -In the third stage of morbid change, or that of purulent infiltration, -the lung is of a lighter color, from the intermixture of a new matter -in its substance, although in the first degree it preserves its -firmness and granular structure. The new secretion is of an opaque, -straw or yellow color, and puriform in its nature. This is discoverable -more particularly in spots; but as the disease proceeds, it pervades -the whole substance of the lung, which becomes softer and more moist, -and is easily broken down by the fingers, the granular structure having -disappeared. It is more or less a purulent sort of sponge, in which all -of the lung that can be perceived under a strong light may be resolved -into small blood-vessels, bronchial tubes, and interlobular septa. - -These three degrees or stages of inflammation may be met with in the -same lung, for the most part gradually intermingling one with the -other. The lower part of the lung being ordinarily first affected, -is usually the seat of the purulent infiltration of the third stage; -while in the tubercular affection, which ends in phthisis, the disease -commonly begins in the upper part. - -Resolution or recovery from even this, the last of the morbid changes -which have been observed, may take place, although it is less likely to -do so after idiopathic than traumatic inflammation, in which the lung -was previously healthy, and the constitution unimpaired. - - - - -LECTURE XXI. - -GENERAL BLOOD-LETTING, ETC. - - -305. The first and most essential remedy in the treatment of pleuritis -and pneumonia from injury is bleeding, which should be resorted to in -every case, whenever the febrile excitement is really inflammatory. -All old people, under such circumstances, unless in a cachectic state, -bear at least one bleeding well; they often bear more; and no fact is -more important, in opposition to the opinions commonly entertained on -this subject. In young people, who have not been reduced in health -and strength by privations and hard service, the bleeding should be -repeated until the desired object has been effected; the quantity -required to be drawn in inflammation, particularly after _injuries_, -is often very great. It may almost become a question, in some cases, -whether a patient shall be allowed to die of the disease, or from loss -of blood; for convalescence is rapid in proportion as the inflammation -is of small extent, and has been early subdued. As the first stage -of pneumonia only lasts from twelve hours to three days before it -passes into the second, and the second from one day to three before -matter begins to be deposited, no time should be lost to prevent these -evils taking place, if the patient is to be saved, without incurring -a risk, from which few escape with health, even if life be ultimately -preserved. Bleeding in inflammation of the pleura, in _young_ and -_healthy_ persons, should therefore be effected with an unsparing -hand, until an impression has been made on the system--until the -pain and the difficulty of breathing have been removed--until the -patient can draw a full breath, or faints; and the operation should be -repeated, from time to time, every three or four hours, according to -the intensity of the recurrence, or the persistence of the essential -symptoms. The pulse does not often indicate the extent or severity -of the inflammation, although it often expresses the amount of the -constitutional irritability of the person. It is sometimes exceedingly -illusory as a guide, and is never to be depended upon in the earlier -stages of disease, when accompanied by pain and great oppression of -breathing. Whenever the pulsations of the heart are proportionally -much stronger than those of the arteries, we may bleed without fear, -and with the certainty of finding the pulse rise; but if the heart -and pulse are both weak, the abstraction of blood will almost always -occasion complete prostration of strength, and may be fatal. - -306. When many years ago in charge of a regiment of infantry, on the -top of the Berry Head, the outermost point of Torbay, the men thus -greatly exposed were attacked by pneumonia. According to the practice -taught in London, I bled my patients three and four times in the first -forty-eight hours. I first drew sixteen ounces, then fourteen, then -twelve, then abstracted, as the complaint continued, eight ounces; gave -tartar emetic, so as to keep up nausea; then calomel, antimony, and -opium, and lost my patients. I examined the bodies of all, and found -that they had lived to what is now called the third stage of pneumonia, -combined in almost all with pleuritis, with effusion, and the formation -of false membranes. The disease was essentially a pleuro-pneumonia, -varying in different degrees, as the pleura or the lungs were -principally affected; and I saw with regret that the disease had not in -any way been arrested; that the means employed had been insufficient. -What was to be done? My sixteen ounces of blood were increased to -thirty, but it would not do. It was evident that, to succeed, no limit -should be placed to the abstraction of blood in the first instance, but -the decided incapability of bearing its further loss. Every man was -therefore bled, when he came into the hospital, until he fainted, and -the bleeding was repeated every four hours, or even oftener, as long as -pain or difficulty of breathing remained; under this improved practice -all recovered. - -The lesson learned at Berry Head was not forgotten during the five -subsequent years passed in British North America. The men were as -healthy, the winds were sharper and colder, the vicissitudes of all -kinds greater. Rum was cheaper, newer, and stronger than the gin of -Torbay. The local inflammations were often as severe, whether of the -pleura or of the lungs, and by no means less so of the bowels. A -grenadier, some six feet three inches high, broad, and well framed -in proportion, had drank a gallon of rum during the afternoon, and -very narrowly escaped, even with the loss of nearly as much of his -blood, abstracted in a few hours. His first bleeding was into the -washhand-basin, until he fainted, lying on his back, and the bleedings -were repeated as soon as he began to feel pain, and whenever he felt -a return of the pain he used to put his arm out of bed to have the -vein reopened, for Jack Martin was a very gallant fellow. This is -given as an extreme case, to be borne in mind under circumstances -somewhat similar, particularly after injuries. In common cases of -well-marked pleuritis from injury in strong and _healthy_ persons, -it is now not unusual to abstract blood by those who rely on its -efficiency, until the pain and difficulty of breathing are relieved, -or fainting is about to take place. The patient should be raised in -bed, the opening in the vein should be large, the flow of blood free. -The quantity will vary from sixteen ounces to three times that amount -in different people; but the important point is to repeat it as soon -as the pain or difficulty in breathing returns. It rarely happens that -one bleeding, to whatever extent it may be carried, will suffice to -remove the symptoms; and recurrence should be had to this remedy as -often as the pain and oppression require, and THE FORCE OF THE HEART -will bear it, especially during the first two or three days. It will -often be necessary to have recourse to it in smaller quantities for -the next four or six days, and again in less quantity on any return of -the inflammatory symptoms. Where the patient is likely to faint, he -should be bled in the recumbent position; and as it is advisable to -take away a sufficient quantity of blood, great care should be taken, -by arresting its flow for a time, by giving stimulants, by admitting -fresh air, and by sprinkling with cold water, to prevent syncope, -which is sometimes dangerous in elderly persons, who may be subject to -and who are not readily recovered from it. In the second stage of the -complaint, profuse and repeated bleedings do not answer as well; they -do not remove the evil which has occurred, although they may prevent -its increase. Blood should then be drawn in such quantity only as will -relieve the action of the heart, restless under its efforts to propel -the blood through a hepatized lung. The quickness of pulse, the cough, -the difficulty of breathing, must now be aided and relieved by other -means; for although the pulse is not a certain indication, on which -dependence can be placed in the early stage of this complaint, the -breathing generally is; and as long as the respiration is oppressed, -blood should be carefully abstracted, until it becomes manifest -that the effect has been to quicken the pulse, while it materially -diminishes its power, when it is forbidden. - -307. A cupped and buffy state of the blood, together with a firm -coagulum, is a satisfactory proof of the propriety of bleeding in -the first stage of the disease; but after the effect of mercury on -the system has been produced, it cannot be depended upon with the -same degree of certainty. When the propriety of further venesection -is doubtful, the greatest advantage may be obtained from the use of -leeches and from cupping, particularly in cases of injury to the -chest. Leeches may be applied by tens and twenties at a time; and when -they have ceased to bleed into a warm bread and water or evaporating -poultice, they may be replaced by as many more, until the pain and the -oppression are removed. Cupping is always to be had recourse to when -leeches cannot be obtained, and, when well done, it is frequently to be -preferred; cupping to sixteen ounces will usually be found equivalent -to forty or more leeches. Both these means often relieve to a greater -extent, with less general depression, than a smaller quantity of blood -taken from the arm, and are, therefore, at such times more advisable. -When blood cannot be obtained from the veins, the arteries must furnish -it; and both temporal arteries have been opened with the best effect in -injuries of the chest, when blood could not be obtained from the arm, -or from the external jugular vein. - -308. The effects of bleeding were of old found to be different under -different circumstances and in different climates. Asclepiades -remarks that while phlebotomy was fatal at Rome and at Athens, it was -beneficial in the Hellespont. Nevertheless, at a much later period, -Baglivi says: “In Romano, phlebotomia est princeps remedium in -plenritide.” - -In the Crimea blood-letting has not been so favorably viewed, nor found -so serviceable nor so necessary; although the abstraction of smaller -quantities than those indicated above, and less frequently repeated, -has been found eminently beneficial, the difference being dependent on -climate and the impaired vigor of the sufferers. - -The remedy first to be administered, and most to be depended upon -in the first stage, is tartar emetic, which usually gives rise to -vomiting, purging, and possibly to sweating; it should not be omitted -because such effects are produced in the first instance. After a few, -perhaps three or four doses, the vomiting usually ceases, the stomach -tolerates its introduction, and its gradual increase from six to nine, -twelve, twenty, or more grains in the twenty-four hours, is often borne -not only with impunity, but with great advantage. Vomiting and purging -are not desirable, as the effects of tartar emetic are more rapid and -beneficial when they give rise to no particular evacuation beyond that -of general perspiration. The most valuable remark of Laennec on its -use is, “that by bleeding we almost always obtain a diminution of the -fever, of the oppression, and of the bloody expectoration, so as to -lead the patients and the attendants to believe that recovery is about -to take place; after a few hours, however, the unfavorable symptoms -return with fresh vigor; and the same scene is renewed often five or -six times after as many venesections. On the other hand, I can state -that I have never witnessed these renewed attacks under the use of -tartar emetic.” He further says that the same favorable results do not -occur from its use in pleurisy or in inflammation of serous membranes, -as in pneumonia. - -309. Mercury is a remedy of the greatest importance in serous -inflammations, such as pleuritis, although of less value than tartar -emetic in the first stage of pneumonia, than which it would appear to -be more efficient in the later period of the stages of hepatization -and infiltration, though some physicians place entire confidence on -its efficacy in all. It is of most value when combined with opium. -Some suppose that the opium merely prevents the irregular action of -the mercury; others, in some papers printed in the journals for 1801, -state that opium has a distinct curative effect, being capable, when -given in large doses, of subduing inflammation, and more particularly -of allaying pain, relieving the cough and irritation, and of procuring -sleep; in which opinion I fully concur. Opium is highly advantageous in -irritable and nervous persons, and will frequently relieve the nervous -pain, the pleurodynia which remains after pleuritis, when nothing else -succeeds. Calomel in large doses is usually preferred to all other -forms, but a difference of opinion has occurred as to what is a large -dose; whether two, three, four, six, ten, or twelve grains are large -doses, and whether they shall be given every one, two, three, four, or -six hours. It has been attempted to solve this question by supposing -that in highly inflammatory cases in healthy persons, from three to -six, and even to twelve grains, may be given twice or three times a -day, with better effect than smaller ones more frequently repeated; but -this has not been made manifest. - -In cases less inflammatory or complicated with gastric derangement, -the disease assuming more of a general than of a local character, -the excretions being vitiated, the skin dry and hot, and the tongue -loaded, from gr. iss to gr. iij of calomel, combined with three -grains of Dover’s powder, may be advantageously given every second or -third hour, the great object being to affect the gums as quickly as -possible. This is not effected in some cases by any of the quantities -given until after a considerable lapse of time, while in others it is -accomplished by less than half a dozen grains of the remedy. It has -not been ascertained that twenty-four or forty grains given in two or -four doses in twenty-four hours will affect the mouth more rapidly -than three grains every two hours for the same time, neither is it -less liable to cause irritation; while the third or half a grain of -opium given every two hours seems to keep up the effect of that remedy -with great advantage. It does not materially signify which method is -adopted in strong and healthy persons, although the smaller doses -are most satisfactory to all parties when the patient is weak and -irritable, while the large and less frequent doses often excite great -apprehension. It is argued that calomel in large doses never causes the -dysentery nor the severe ptyalism produced by smaller doses; that it -acts more quickly, and that after giving twenty grains, and repeating -it in six hours, any other medicines may be given without interfering -with it, although the strictest attention must be paid to diet, -generally confining it to very small sups of warm whey. Very serious -derangements do, however, follow the exhibition of the large as well -as of the small doses, inasmuch as it is impossible to know beforehand -what quantity will cause a severe salivation or diarrhœa, which it may -be difficult to arrest. - -310. It may be concluded that, of the two heroic internal remedies, -tartar emetic and calomel, recommended for the cure of inflammation of -the chest, tartar emetic is the more appropriate for inflammation of -the lungs or pneumonia, provided it be not accompanied by symptoms of -gastric inflammation; in which case its use should be superseded by -leeches to the epigastrium, and saline aperients, lest the irritation, -vomiting, and purging should increase the evil. But care must be taken -that one inflammation shall not be allowed to increase, while attention -is principally paid to the other, and symptoms of irritation, the -_gastro-enterite_ of the French physicians, are not to be mistaken for -gastritis. Mercury, in the form of calomel, is more to be depended upon -in inflammation of the pleura, over which, as well as over inflammation -of serous membranes in other parts of the body, it exercises a -remarkable influence. - -311. Blisters are never useful during the continuance of acute -inflammation of the chest, although their use is indicated when the -patient is much exhausted, the pulse weak, and the breathing continues -difficult; or in cases in which the disease proceeds slowly, or is -becoming chronic, when they often do much good. The same may be said -of dry cupping, mustard poultices, and other cutaneous rubefacients, -such as the ol. terebinth. used hot, which often do much good in -the commencement and termination of slight attacks, or of their -supervention on chronic disease, or after injuries. - -In the acute stages simple drinks only should be allowed. As soon -as the inflammatory action has subsided, the lightest farinaceous -nourishment, gradually augmented by the addition of broths, jellies, -eggs, fish, and lastly of animal food, should be substituted. The -temperature of the room ought to be moderate and equal. - -Inflammation of the lungs frequently terminates by the deposition of -a white or lateritious sediment in the urine, which is considered a -critical evacuation, not however to be relied upon, unless accompanied -by a remission of the important symptoms. A moderate diarrhœa and a -profuse perspiration are also signs of a favorable crisis. - -312. Inflammation of the chest has been hitherto considered as -accompanied by inflammatory fever as an essential character, but -this is by no means always the case. In large cities, and among -troops after hard service, in which they have been subjected to much -privation, and in certain epidemics, the accompanying fever often -partakes of a low or typhoid character, and becomes infinitely more -dangerous. This modification of disease I have known from my earliest -years, in different climates, in all of which it proved most fatal. -It is a disease formed of a local inflammation accompanied by general -symptoms of a low asthenic type of fever, combined with those of marked -derangement of the stomach, intestines, or liver, as shown by a dry -black, or red black, or brown tongue, offensive breath, diarrhœa, -vomiting of a dark-colored or greenish fluid, watery or sanious -expectoration, great thirst, headache, a feeble and quick pulse, low -delirium, and great prostration of strength. It was marked, on the -banks of the Guadiana, by the discharge of lumbrici by the mouth and -by the anus. This disease has always appeared to arise from peculiar -circumstances, and to disappear when they ceased to exist; such as -great privations and exposure to cold and fatigue, the use of ardent -spirits without sufficient food, bad air, or other depressing causes. -It is sometimes epidemic. The fever is typhoid, the local inflammation -latent, and the symptoms of it masked. It may be complicated with -inflammation of the stomach and intestines; it may occur in cases of -erysipelas, or after wounds or injuries attended with large secretions -of purulent matter, or with other complaints. While the symptoms of low -fever are general and well marked, those of the latent affection of the -lung are not so prominent or even observable. The patient complains -but little, and sometimes not at all, of his chest, until attention is -drawn to it by a slight cough, and difficulty of respiration, attended -by a character of countenance which usually indicates embarrassment -in the functions of the lung. It may be brought on by a common -non-penetrating injury of the chest. - -In typhoid pneumonia, general bleeding, if admissible, is to be had -recourse to with extreme caution, even in young and robust persons. -Local depletion is oftentimes useful, and perhaps ought to be alone -relied upon. The great dependence is on calomel and opium, and after -such local depletion as may be thought advisable, counter-irritation -by blistering, and the administration of stimulants, such as camphor, -ammonia, and wine, in small and repeated quantities. Mild aperients -only should be employed, and anodyne injections are frequently useful. -While auscultation has thrown a clear and steady light on the nature -of the mischief which is going on, it has added little or nothing -dissimilar to the practice pursued some forty years ago. The nature of -the hepatization or solidification which takes place in the lung in -typhoid pneumonia has given rise to some difference of opinion among -morbid anatomists, who incline to believe, from the rapidity with -which it takes place, and with which it is sometimes removed, that it -depends more on passive congestion, and on a typhoid alteration of the -state of the blood, than on an altered action in the vessels of the -part. This opinion does not seem to be fully supported by dissection, -unless it be generally admitted that gray hepatization, and the third -stage of disease of the lungs in pneumonia, mean simple congestion. - -When the patient survives the imminence of danger in which he is placed -by the attack of the disease, and the expectoration becomes copious, -with great emaciation, quick pulse, and hectic fever, a slight infusion -of senega or of cinchona with ammonia, with a mild and well-regulated -diet, and change of air and climate, answer best in aiding recovery. - -A typhoid pleuritis is presumed to exist, as a distinct disease from -typhoid pneumonia, although the analogy between them is admitted to be -close; like it the disease is latent and more frequently pointed out -by the sinking of the powers of life than by any new suffering. The -signs of effusion may be discovered on auscultation, and the treatment -is essentially similar; blistering and counter-irritants being perhaps -more useful, if time be granted for their application. - -313. Empyema, _from_ εν, _in_, _and_ πυον, _pus_,--a name given to -all collections of fluids in, and to the operation for evacuating -them from, the cavity of the chest. Empyema is not a special disease, -but the result of another; commonly of acute or chronic pleurisy, or -of injuries of the chest, which give rise to inflammation, ending -in suppuration. When it occurs from the effusion of a serous fluid, -constituting a local dropsy, it is usually the result of disease of -the heart, or of the great vessels, and is accompanied or preceded by -symptoms indicating the existence of those complaints, in which case -it is not likely to be benefited by any operation. The disease is then -denominated hydrothorax. The serous fluid is generally transparent, -although more or less tinged with blood, when thrown out in persons who -die within a few days after receiving a wound of the chest. It may, and -does occasionally, contain in these cases a large quantity of blood; -but an early effusion of blood is not uncommon in very acute cases -of pleuritis. It is usually more or less turbid when the result of -ordinary inflammation, although the presence of albuminous or purulent -matter is not constant. Whether colorless, transparent, turbid, or -purulent, it remains free from fetor, unless gangrene has occurred -internally, or some communication with the atmosphere has taken place -by an external opening. - -While the fluid remains transparent, the appearance of the pleura is -little changed, but when it has become turbid in any great degree, or -flocculent, or purulent, the pleura has lost its natural appearance. -In its simplest character, when the fluid is puriform, particularly -if the inflammation have not been very active, it is covered with a -layer of whitish inorganic sediment, which can be scraped off by the -scalpel. This is sometimes quite red, as if loaded with blood which had -been deposited upon it. Whenever pleuritic symptoms continue beyond the -ordinary period of about three weeks, or, after a temporary abatement, -are followed by those of effusion, which are not in turn removed, the -occurrence of empyema may be suspected. - -Empyema may form from a pulmonic abscess bursting, or a gangrenous -spot being detached and falling into the cavity of the pleura. An -abscess in the liver or other parts may also communicate with the -pleura, and abscesses formed from injury or otherwise in the wall of -the chest may also give rise to it. It is usually, however, caused by -acute inflammation, by penetrating injuries, or by the introduction -of foreign substances. It should, however, be borne in mind that when -it occurs from wounds, the external opening must have healed, or the -complaint would be simply a wound in the chest, with a discharge from -the cavity of the side affected. A true surgical case of empyema, -following an injury of the chest, in which the wound has healed, is not -to be ascertained but by the same means as in a case arising entirely -from internal causes, unless the protrusion of the cicatrix should -indicate the presence of matter behind it. - -314. The symptoms by which the termination of inflammation in effusion -may be known: are dyspnœa, or difficulty of breathing, which is greater -when the effusion has taken place rapidly, less when it has been -gradual; subsidence of pain; inability to lie on the unaffected or -sound side, which subsides, or is entirely removed, after the operation -has been performed and the fluid evacuated, although it should be -replaced by air in consequence of the lung being unable to resume its -natural position. When the effused fluid has filled one side of the -chest, that side is evidently enlarged, and this can be distinctly -seen when the dilatation does not exceed half an inch, measuring by -a tape from the spinous process of a vertebra behind to the center -of the sternum. The ribs are nearly, if not quite, immovable, and -partially raised, offering a strong contrast to the active motion of -the ribs on the other side. The intercostal spaces in these persons -may be more or less filled up, rendering the whole surface smooth and -soft. In some very severe cases the external parts become edematous, -so that the ribs cannot be felt, and this sign, although not always -present, is certainly pathognomonic when it takes place at a late -period of the disease. When the effusion is into the left side of the -chest, the heart is frequently pushed over with the mediastinum to -the right side, and its pulsation can be seen and felt to the right -side of the sternum; or it may descend with the diaphragm into the -epigastrium--changes which are not so extensive or remarkable when the -effusion is into the right side, as the liver materially impedes the -descent of the diaphragm, and the heart is already in the left side, -in which it is sometimes raised rather than depressed. It is said -that if the hand be placed over the affected side, while the patient -speaks with a tolerably loud voice, and a strong vibration is felt in -the part, the case is not one of empyema; but this is as uncertain a -sign and as little to be depended upon as the dullness on percussion -which sometimes takes place under the sternum in empyema. The cough -and expectoration offer nothing peculiar, unless a communication exist -between the lung and the cavity of the chest, when the expectoration -in general becomes very fetid and disagreeable. The febrile symptoms -depend on the activity of the previous disease, and the rapidity with -which the effusion has taken place. - -Night-sweats, it has been supposed, never accompany the hectic fever -of empyema, unless there be tubercles in the lungs or pleura--a remark -which cannot be depended upon. - -315. Two symptoms have been insisted upon by older authors as -distinctive of effusion in the chest, which more modern ones are -disposed to doubt, particularly in the early stages of the disease. -One is an edematous swelling of the back, the other a protrusion of -the intercostal spaces. A third may be added when the effused fluid -is blood, which is that the edematous swelling becomes ecchymosed, or -red, or bruised looking, from the effusion of blood into the cellular -membrane beneath the skin, over the whole space occupied by the blood -within. That the first two symptoms do assuredly indicate the presence -of pus, cannot be doubted; and that the third is a sign that the -effused fluid is blood, has not been disproved; but it must be borne in -mind that they are late, not early symptoms, and the operation should -not be delayed until they are present, if other signs should appear to -demand its performance. Valentin was the first to notice the ecchymosis -of the side and back when the chest was full of blood, a sign which -Larrey particularly insists upon, but which certainly does not appear -so early as to be distinctive, when other symptoms exist which almost -render it certain. The swelling does not arise from transudation of -matter through the pleura, but from irritation transmitted through it, -as in any other deep-seated abscess. Dilatation of the chest is usually -an early symptom, although a considerable effusion may exist without -it, or with but a slight elevation of the intercostal spaces. When the -complaint is distinct, these spaces are elevated to a level with the -ribs, so that the surface becomes perfectly smooth and equal; a farther -protrusion is a very rare occurrence. Effusion indeed of serous fluid -to a considerable extent, so as to displace the heart, may take place -without the intercostal spaces being elevated, which is only believed -to occur when the intercostal muscles have become paralyzed. When the -matter has been evacuated, the muscles recover their tone, and the -intercostal spaces reappear. - -In all cases of empyema in which the lung is so bound down by adhesions -that it cannot be expanded by the continued process of respiration, -a cure can only be accomplished by an alteration of the form of the -affected side of the chest, by which its cavity is diminished, and -often nearly obliterated. This is an effort of nature. The pleura -changes its character, becomes so thick as materially to diminish the -cavity, the diaphragm ascends, the heart leans to that side in many -instances, the spine curves, the ribs thicken and become flatter, and -close in upon each other, abolishing the intercostal spaces. - -_Treatment._--As long as the febrile symptoms consequent on the -inflammation continue to any extent, medicines will be of but little -avail, and counter-irritants should be avoided. When they have -subsided, purgatives and diaphoretics may be tried, in combination -with tonics and a light but good nourishing diet. Blisters applied -frequently upon a large surface often do good. When these means fail, -the operation must be resorted to. - -316. It has not been satisfactorily decided whether the operation -for empyema was first performed on Phalereus, Jason, or Prometheus; -it is therefore said of all three that, being expected to die of an -abscess in the lungs declared to be incurable, they went into battle -for the purpose of getting killed; but being only run through the -body, they all recovered, in consequence of the escape of the purulent -matter through the holes thus made. The operation was performed by -Hippocrates and his successors, by the knife, by caustic, and by the -hot iron. Ambrose Paré was the first who recommended a trocar and -canula, and many instances of success in all ways are recorded. The -modern methods are by the trocar and canula, and by incision. Whenever -auscultation, percussion, or succussion give reason to believe that a -fluid is collected, which medicine has not been nor is able to remove, -the simple operation by the trocar and canula should be performed. If -fluid should pass through the small canula generally used by way of -exploration, a larger one may be introduced in its place if thought -advisable. In ordinary cases, the little wound should be closed -immediately after the evacuation of the fluid; it usually heals without -difficulty, and the operation may be repeated if necessary. Care should -be taken that the point of the instrument is perfectly sharp, or it -may separate the thickened false membrane from the inside wall of the -chest, and, by pushing it before it, prevent the fluid from passing -through the canula when the trocar is withdrawn. - -317. The place of election, in England, for a _puncture_, in ordinary -cases, is usually between the fifth and sixth ribs, counting from -above, and between the sixth and seventh from below, and at one-third -the distance from the spinous processes of the vertebræ, or two-thirds -from the middle of the sternum. If there should be any protrusion of -the intercostal spaces, it may be a rib or two lower down. The point -of the instrument should be introduced a little nearer the lower than -the upper rib, and pressed on until all resistance has been overcome. -It is entered nearer the lower rib to avoid the intercostal artery, -and yet not touching the rib lest it should induce a too forcible -contraction of the intercostal muscles, by which the operator might be -inconvenienced. - -If the person should be very fat, or the puffing of the integuments -considerable, it may not be easy to feel the ribs, in which case even -recourse should not be had to incision. When the arm is placed by the -side, and bent forward at a right angle so that the hand rests on the -ensiform cartilage, the inferior angle of the scapula will correspond -in general, but not always, with the interval between the seventh and -eighth ribs at the back part. The attachment, however, of the last -of the true ribs, the seventh, to the xyphoid cartilage, can always -be ascertained in front, and an error of importance cannot well take -place, as the object in making a puncture by measurement is to avoid -the diaphragm. Freteau, of Nantes, says that he performed the operation -on the left side between the tenth and eleventh ribs, and on the right -side between the ninth and tenth in more than thirty dead bodies, and -always opened into the cavity of the chest, commencing the incision -close to the edge of the latissimus dorsi muscle, or about three inches -and a half from the spine--an operation which in this place should -be done by incision, and not by the trocar. When there is reason to -believe that there is an extraneous body to be extracted, such as a -ball, the place of election is of importance, as it is desirable it -should be a little above the diaphragm in order to facilitate its -extraction; for although, by carefully shifting the position of the -patient, a ball or a piece of bone may be brought to rest against the -opening, it will not be easily taken hold of unless it lie upon the -diaphragm, a point which will be hereafter further elucidated. When an -external swelling indicates the presence of matter, and there is reason -to believe it communicates with the inside of the chest, the opening -should be made into the tumor, and is then called the “operation by -necessity,” which is not an uncommon occurrence after gunshot wounds. -It is not, however, always done in the most convenient place, and -should then be repeated lower down, which will also be sometimes -necessary in consequence of the matter collected in this way being cut -off by adhesions from the general cavity. - -When the operation by incision alone was performed, the success was -certainly not great. In modern practice (after the operation by -puncture) it has been much greater, which may be attributed to the -operation having been had recourse to at an earlier period, or about -the end of the third week. After wounds penetrating the chest which do -not admit the effused fluid to flow out, it should be done much earlier. - -It is possible that both sides of the chest may be affected; but both -sides may not be punctured in succession, for an error in puncturing -both, or even the sonorous or sound side instead of the dull or -affected side, has been almost immediately destructive of life. - -318. The admission of atmospheric air into the cavity of the chest -during this operation has been much deprecated, and many inventions -have been recommended for its prevention, but it is scarcely possible -to prevent some air getting in. It is often seen to do so; it has been -proved by auscultation to have done so, and is usually absorbed in a -few hours. In one case which I saw it gave rise to distressing symptoms -from pressure on the lung, but was removed by a common syringe, to -the great relief of the patient. In all these cases two things must -be considered: Can the compressed lung expand so as to fill the chest -when the fluid is withdrawn? The answer must be, in many cases it is -so bound down by adhesions that it can dilate but slowly, if at all. -If it be asked whether a vacuum is formed in the chest, the answer -will be, no; and it will then be admitted, on consideration, that air -always finds its way into the chest, and never does harm to persons -in health. When mischief does ensue after an operation or an injury, -it usually occurs from the irritation caused in a particular state -of constitution, and not from the admission of air. A change in the -appearance of the discharge has been frequently found to follow, and -to depend upon, an accidental derangement of stomach, and to return -to its more normal state on the derangement being removed. If the -wound into a cavity can be closed and healed, the air will remain with -impunity until absorbed. If the wound cannot be healed, unhealthy -inflammation may be propagated from it to the whole cavity with which -it communicates, but this is not the effect of the admitted air. - -Dr. H. M. Hughes has published several cases of pneumothorax in the -first part of the of the volume of “Guy’s Hospital Reports” for 1852. -In the sixth case, which he calls a genuine example of pneumothorax -from rupture of one or more of the vesicles of an emphysematous lung, -the patient died speedily; and, on examination, he says: “It is also an -interesting fact that no evidence of inflammatory action existed in -the pleura, as it indicates that air in a healthy serous membrane does -not excite inflammation;”--a Peninsular dogma I have been forty years -inculcating, and which I trust is at last admitted as an established -fact. How long it may be before it is generally taught, is another -matter; for surgeons, like other men, often adhere with tenacity to -preconceived opinions, however erroneous, particularly as they advance -in life and have ceased to desire to learn more than they already know. - -319. In all cases of _serous_ effusion, there can be little doubt that -the fluid should be wholly evacuated and the wound closed. When the -fluid is _purulent_, a permanent drain should be early established. It -is not, however, common for the operation to be repeated several times -without the serous discharge becoming purulent; and, in such cases, it -usually becomes necessary at last to allow the wound to remain open -until the discharge shall cease of itself. Whenever more than one -opening is necessary, and the first is made between the fifth and sixth -ribs, the succeeding ones should be made lower down; so that when it is -thought right to leave the last puncture to become fistulous, it may be -made as near the diaphragm as may be thought consistent with the safety -of that part. - -When a doubt exists as to the probability of more than one puncture -being sufficient, and it seems likely that a third, or even more, will -be required, the surgeon may anticipate this necessity by introducing a -piece of soft gum-elastic catheter through the canula into the chest to -the extent of about three inches, enough being left outside to admit of -its being secured by tapes and adhesive plaster; through this a certain -quantity of the fluid may be drawn off daily until it ceases to be -discharged. The elastic tube bends with the heat, and applies itself to -the inside of the ribs. If the lung should rub against it, which can be -ascertained by a blunt probe, the elastic tube should be removed, and -the external wound kept open by a softer plug. In all these operations, -care should be taken to prevent the occurrence of inflammation. The -accession of pain in the part, of difficulty of breathing, of fever, -should be met by the abstraction of a few ounces of blood by cupping, -by dry-cupping, by mercury in small doses, by rest, by diet, etc., and, -if a tube have been introduced, by its removal. - -The propriety of injecting stimulating or even simple fluids into -the cavity of the chest has been often advocated, and as frequently -repudiated. Warm water or milk and water is certainly admissible, and -has been found very useful, particularly when there is an adventitious -cause keeping up the irritation, which may possibly be brought to the -opening by the sudden abstraction of the injection. Pieces of cloth -and bits of exfoliated bone have been floated out by throwing in an -injection of tepid milk and water. The opening, in a case of this kind, -should be made between the eleventh and twelfth ribs behind. - -Dr. Wendelstadt, of Hersfield, in the year 1810, in the twenty-third -year of his age, suffered an attack of pleurisy, which became chronic, -and ended in effusion. After severe suffering for six months, he was -able to attend to his professional duties. The ribs of the right -side protruded, but the intercostal spaces did not; the whole side -was motionless on respiration taking place. The circumference of the -chest continued to increase, and fluctuation within became evident -on succussion. In June, 1819, having undergone another attack of -pleurisy, he submitted to the operation for empyema, as offering some -hope of preserving life. When a pint of fluid had been discharged, -the wound was closed, and he experienced great relief. The next day -a third of a quart was taken away twice in the day, and on the third -day as much more; but he thought this was too much, as he became -greatly exhausted, and feared that suffocation was impending. He was -recovered by stimulants. On the fourth day the fluid was thicker in -consistence, and fetid, and continued more or less so for a fortnight. -It was then allowed to flow as it would at each dressing. Astringent -injections were used for six weeks, but were then abandoned, and he -gradually recovered his strength. Thirteen years afterward, in 1830, -the wound was still open, discharging twice a day, sometimes only half -a drachm, sometimes three or four ounces daily. The right side had -altogether shrunk, and did not move on inspiration; he had no cough, -and was otherwise in good health; a piece of a rib became loose, and -was removed at the end of thirteen years, when the report of the case -terminated, the patient being in health. - -It may be remarked on this case, that the admission of air did no harm; -that the lung remained compressed; that the whole side thickened and -flattened, as a consequence, so as to obliterate the cavity; but the -cure would not have been effected even then, if the piece of carious -rib had not been discovered and removed. - -Mr. Winter, secretary to Admiral Sir C. Napier, was wounded by two -musket-balls, one in the arm, while the other entered between the -inferior edge of the left scapula and the thorax, which it penetrated, -fracturing a rib in its progress, and lodged. He fell, and spat up some -blood, and as symptoms of inflammation supervened in twenty-four hours, -he was bled largely; this was repeated frequently until these symptoms -were subdued. He was after a time sent to the Marine Hospital, Lisbon, -in a miserable plight, suffering from hectic fever, with a flushed -face, hot skin, glassy eye, great prostration of strength, cough, -restlessness, dyspnœa, and copious night-sweats. The wound discharged -a watery, sanious, fetid matter in quantity, and he was unable to do -anything but eat, and for food he had a great craving. From this state, -under good treatment, he gradually recovered his strength, and on the -18th of June, 1834, a piece of the rib was removed. The wound remained -open with a great purulent discharge, which kept him in a reduced -state; a little more than one year after the injury, he reached London, -and was taken into the Westminster Hospital. The left side of the chest -was flattened and contracted, and the lung was doing very little in -the respiratory way; the wound discharging a quantity of matter, which -he could readily evacuate by making the opening the dependent point, -but not otherwise. On enlarging the external wound, so as to make the -opening into the chest direct, I found a round-pointed gum-elastic -bougie could pass into it for four inches, and, on bending it down, for -six inches more, it having to pass over a thickened pleura, and false -membrane of an almost cartilaginous nature, for the extent of an inch, -before it could be felt to be in a large cavity. As it did not appear -that he had any chance of recovery, unless another opening were made -lower than the sixth rib, in a more dependent position, I proposed -the operation, but he would not submit; and after a time he left the -hospital and went into the country, where he died. - -A non-commissioned officer, of the 2d Division of cavalry, was wounded -at the battle of Albuhera, on the 10th of July, 1811, in several -places, by the lances of the Polish cavalry; one of these penetrated -the left side of the chest behind, immediately below and in front of -the inferior angle of the scapula. He spat and coughed up blood, and -lost so much from the wound that he became insensible, the bleeding -having been stopped by a part of his shirt being bound upon it tightly -by means of his woolen sash. Brought to the village of Valverde, my -attention was drawn to him some days afterward, in consequence of the -difficulty of breathing having increased so that he was obliged to be -raised nearly to an upright position, as well as from his inability to -rest on the part wounded, round which a dark-blue inflammatory swelling -had taken place, the wound having closed. An incision being made into -it, a quantity of bloody purulent matter and clots of blood flowed from -it. The incision was then enlarged, so as to allow of a direct opening -into the cavity of the chest, which was kept open. The relief was -immediate. He was removed to Elvas, apparently doing well, some three -weeks afterward. - -This case offered the nearest approach I have seen to the ecchymosed -edema described by Valentin as accompanying effusions of blood into the -cavity of the chest; and, as well as the following, is an instance of -operations, not by election, but by necessity. - -A French soldier had been wounded at Almaraz by a musket-ball, which -went through the right side of the chest, in a line nearly horizontal -from a little below and to the outside of the nipple, backward. The -first symptoms having subsided, he gradually descended the Tagus to -Lisbon, where, after some months of continual discharge, the wounds -closed, first the back, and then the front. He did not recover his -strength, always looking sickly, and suffering from pain, difficulty -of breathing, and other inconveniences, which did not prevent his -walking about in the confined space to which he was doomed as a -prisoner of war. My attention was drawn to him in consequence of an -obvious fullness of the intercostal spaces, of the great difficulty -of breathing, and of a puffy inflammatory swelling which was forming -around and at the seat of the wound in front. Through this I made -an incision into the cavity of the chest, the walls of which, on -introducing the finger through the opening, appeared to be very much -thicker than usual. A large quantity of pus was discharged, and the man -was relieved, but this amelioration was not of long continuance, and he -gradually sank and died. On opening the body, the inside of the wall -of the chest was found to be half an inch in thickness, in consequence -of a firm deposition on the pleura, of a yellowish-ash color, -honey-combed or ulcerated, as it were, in plates, particularly where -the opening had been made. The lung was shrunk up from the anterior and -lower part of the chest, but adhered to the wounded part behind, and -was covered by a layer of false membrane of considerable thickness. The -wound through the lung could not be distinctly traced, from its being -diseased throughout. - -At Santander, in October of the same year, 1813, I received some eight -hundred wounded in the affairs of Le Saca, Vera, etc. One of the -Light Division had been shot through the left side of the chest: the -posterior wound had closed, but a sufficiently large quantity of matter -was discharged through a small anterior one to show that there must -be some depot from which it proceeded. The wound was laid open into -the cavity of the chest, and free vent given to a quantity of matter. -Some small pieces of rib were discharged, and a bit of something like -the cloth of his coat also came away. He could lie on either side, and -hopes were entertained of his recovery, until after I left Santander -in December, to join the army in France, when he suffered a relapse of -inflammation, and died. - -A soldier of the German Legion was wounded at Waterloo by a lance -between the sixth and seventh ribs of the left side. He spat up much -blood for several days, and was carried to Antwerp, where he remained -for several months, suffering from great difficulty of breathing and -other distress in his chest, which recurred from time to time, although -the wound had healed. He was admitted into the York Hospital, Chelsea, -in the spring of 1816, in consequence of an attack of inflammation, -of which he died. On examining the body, the lung of the right side -was found to be greatly inflamed, and full of purulent fluid, which -caused his death. The left or wounded side was found to contain a small -quantity of pus, the cavity being very much diminished by the great -thickening of the pleura and the falling in of the ribs, which were -thicker, greatly flattened, and changed in form; the lung, shrunk or -collapsed, was covered by a thick adventitious membrane, and bound down -against the spine, leaving a long, small space between the pleuræ, -which once had doubtlessly been full of matter. The mediastinum and -heart appeared to lean toward the left side, aiding in this manner in -the obliteration of the cavity, which must take place if a permanent -cure be effected in empyema. I have seen two cases in which this -obliteration appeared to be complete: one in a soldier, who had been -wounded in the chest; the other in a gentleman, the subject of empyema, -in private life. In both the spine was also distorted, the side wasted, -the nipple lower than the other. The breathing of the opposite side was -more marked and developed. It might have been called puerile. - -320. _Pneumothorax_ means an effusion of air and of the matter of a -tubercular abscess from disease into the cavity of the chest, or from -an injury or a wound in the lung. When pneumothorax is the consequence -of disease of long standing, the patient may be sensible of a sudden -pain, which does not abate, and which is accompanied by an equally -sudden increase of the difficulty of breathing, for which he cannot -account. He feels relief by lying on his back or on the affected side, -rarely on the other, although the difficulty of breathing may increase, -so as to render the further continuance of life doubtful, while the -prostration of strength is considerable. The muscles of respiration are -all in rapid and powerful action; the heart is displaced to the right -side when the complaint attacks the left, and it will be displaced -somewhat to the left when the right is affected; in some cases it -even descends into the epigastrium, or is otherwise removed from its -natural situation, even toward the axilla, although the left side is -supposed to be more obnoxious to this complaint than the right. The -pulse becomes exceedingly quick and small, countenance pale, nights -sleepless. The affected side is oftentimes evidently dilated, and the -intercostal spaces may be less marked, or partly filled up, when the -respiratory motion given to the parts under ordinary circumstances is -seen to be deficient. But these differences, as well as that which can -be obtained by comparing both sides by measurement, are not so marked -as when the cavity is filled with fluid, of which in pneumothorax there -is always a small quantity effused. - -_Percussion_, beginning from above, in the erect position, will give, -in cases in which it is ascertained that respiration is null, a clear -tympanitic sound, as low as the level of the fluid, when it changes -abruptly to a dull sound, or that indicating the presence thereof. -If the patient be then placed in the recumbent position, the clear -sound can be heard above, the dull one below, demonstrating the change -in the situation of the air and fluid. _Auscultation_, in addition -to the absence of respiration, when the chest is fully expanded, -discovers no respiratory murmur; but a peculiar sound called _tintement -métallique_, or metallic tinkling, is heard at intervals, particularly -on the patient’s coughing, speaking, or breathing. It may be imitated -by dropping a pin into a large wine-glass, but it more nearly resembles -the sound of a jew’s-harp in the hands of a child: once heard it cannot -be mistaken. It is a sound distinctive of pneumothorax. - -“Mr. Cornish, a medical practitioner, having suffered an attack -of pleuritis, nearly expired from suffocation on Monday, the 29th -December, 1828. He was lying on his right side, breathing most -laboriously; countenance sunk; pulse between 130 and 140; had had no -sleep for many nights. The action of all the respiratory muscles was -painful to behold; no perceptible difference in the size or shape -of the two sides. The _right_ emitted an extremely dull sound; the -_left_ sounded hollow throughout. The apex of the heart was beating -rather to the right of the right nipple. The respiration was loud and -rattling in the _right_ side; metallic tinkling distinct in the _left_; -expectoration muco-purulent, with specks of blood, and many black -particles. Mr. Guthrie, who saw him for the first time, made a short -incision between the sixth and seventh ribs, and cautiously opened the -pleura, when a rush of air issued forth with a hissing noise, strong -enough to have extinguished several candles. The patient turned on his -back, breathed with comparative freedom, and expressed his gratitude -for the operation. No fluid issued from the wound when made a dependent -opening. On the 31st, the difficulty of breathing and the metallic -tinkling had returned, the wound having closed. The wound was reopened -and enlarged; the pulse fell to 120; the metallic tinkling ceased to be -heard; the patient took some nourishment and an opiate at night. - -“Jan. 1st, 1829.--Has slept several hours; breathing easy; pulse -reduced in frequency; appetite good. A canula was placed in the wound, -when large quantities of air came through it on each expiration; the -heart beat two inches nearer the central line of the thorax than -before. During the night he became greatly oppressed, and died next -day. On raising the sternum, the heart was found rather to the right -of the median line of the chest. The left lung was collapsed to -one-fifth of its natural dimensions. The vacant space was filled with -air, and about fourteen ounces of turbid serous fluid. The pleuræ -costalis and pulmonalis presented marks of inflammation of a few -weeks’ standing--viz., some thin false membranes, which were easily -separated by scraping with the scalpel. There were no marks of more -recent pleurisy. A tube was inserted into the trachea, and air blown -into the lungs. The left lung expanded to a certain extent, and air was -heard to bubble out, when an aperture was immediately recognized at the -division between the two lobes, through which the air rushed forth and -extinguished a taper that was held near it. The aperture was circular, -fistulous, and capable of admitting a crow-quill, and was found to -communicate with a very small excavation, formed by the softening down -of some tuberculous matter; into this small excavation a bronchial tube -was seen to enter. Thus, the communication between the trachea and the -cavity of the chest was distinctly traced. The left lung presented some -trifling tuberculation, but was not materially diseased.” - -William Griffin, aged eighteen, was admitted into the Westminster -Hospital on September 14th. Ten days before his admission into the -hospital he discharged a pistol against the left side of his chest, -causing a wound corresponding to the middle of the eighth rib, from -which a very small quantity of blood escaped. The medical practitioner -who was called to him at the time _passed a probe to the extent of -four inches_ into the wound. The wound had nearly cicatrized, but he -became the subject of acute pain, diffused over the whole of the left -side of the chest, accompanied by fever and frequent cough, dyspnœa, -and inability of lying on the right side. After the lapse of a week he -was transferred by his surgeon to the medical wards under Dr. Roe, at -which time he had begun to expectorate purulent matter of an extremely -fetid character, occasionally mixed with blood. His respiration was -hurried, the right side of the chest expanding much more freely than -the left; the lower three-fourths of the affected side were dull on -percussion; tubular respiration could be detected at the upper part, -but at the lower no air appeared to enter; well-marked modifications of -voice existed over the whole of that side of the chest. By measurement -no difference in the relative size of the chest was observed, but -the intercostal spaces of the left side remained motionless daring -expiration. The heart could be felt feebly pulsating at the epigastrium. - -October 15th.--He suffered from a violent paroxysm of coughing, -during which great dyspnœa suddenly came on. He sat propped up in bed; -respiration was almost ineffectual, his face livid and covered by a -cold, clammy sweat, pulse scarcely perceptible at the wrist, and his -extremities were becoming cold. On examining the chest, the left side, -before quite dull, now afforded tympanitic resonance on percussion, -which, together with the total loss of respiration and the presence -of metallic tinkling, proved the existence of pneumothorax. A trocar -was introduced between the sixth and seventh ribs, and was followed by -an escape of gas with about five drachms of pus, both of a very fetid -character; the canula becoming obstructed, a larger one was then passed -through the opening, but not more than half an ounce of pus escaped; -it was then withdrawn, and found to be blocked up by what appeared to -be disintegrated lung. Being greatly relieved, no further attempts at -evacuating the fluid were then made. - -At night, during a paroxysm of coughing, six ounces of fetid pus -escaped by the opening, after which he felt relieved. A second gush of -sanious fluid, to the amount of five ounces, containing small masses of -sloughing membrane, subsequently took place. Cavernous respiration at -the upper half of the lung, mixed with gurgling and metallic tinkling. -Expectoration muco-purulent and offensive. - -21st.--Has somewhat improved, but suffers from accessions of fever -toward evening, and perspires very profusely during the night; the -cough is less frequent, and he expectorates freely, the sputa being of -a purulent, fetid character. Scarcely any discharge from the side. - -Nov. 5th.--Has remained in nearly the same condition until yesterday, -when he ceased to expectorate, and has since become much worse; his -skin is now intensely hot; face flushed; tongue brown and coated; pulse -jerking, but feeble and frequent; the opening in the chest has quite -healed. - -A second opening was now made about an inch external to the former one, -and a canula introduced, but not more than one ounce of pus escaped, -the instrument becoming blocked up by portions of sloughing tissue; -during a paroxysm of coughing, which occurred a few hours afterward, -several ounces of fetid sanguineous pus were forced through the wound. - -16th.--Since the last report he has been slowly sinking--is emaciated -to an extreme degree. The wound originally produced by the pistol-ball, -as well as those made by the trocar, have become fistulous, so that -during respiration the air passes into the chest, and is expelled -with as much freedom as that passing by the trocar. Expectoration has -continued very copious, about a pint and a half having been passed in -every twelve hours; large sloughs have formed upon the nates and hips, -his intellect wanders, and he has frequent syncope. Died on the 5th of -December. - -[Illustration: - _A._ Section of the lung, made vertically. - _B._ Section of the abscess communicating by the sinus, - _C_, with the circumscribed cavity, - _D_, in which the bullet had been lodged after its entrance by the - sinus, _E_. - _F._ The sinus by which the ball had passed into the pleural cavity, - _G_. Opposite the 7th and 8th ribs the lung is quite adherent. - _H._ The ball.] - -_Sectio cadaveris._--The pleural cavity of the left side contained -about ten ounces of purulent matter mixed with blood, and floating in -it were numerous masses of white, curd-like matter, at the bottom of -which, in the angle formed by the diaphragm with the spine, was found -a pistol-ball partly covered by albuminous matter and discolored. -Fluid injected into the left bronchus was found to issue freely from -an opening at the most depending part of the lung, communicating with -a small cavity, the interior of which was lined by the same thick -membrane met with in cases of chronic phthisical disease; from the -upper part of this cavity two other sinuses were formed, the one -passing externally and terminating by an adhesion of the lung with the -ribs at the point where the ball had entered; the other was longer -and more tortuous, passing deeply in the substance of the lung, and -ending in a large abscess capable of containing five or six ounces of -pus. The lung was at its lower part firmly attached to the ribs by -intervening false membrane, while the upper part was free, and had -become compressed toward the spinal column. The substance of that part -of the lung not involved in the abscess was infiltrated with pus, and -the greater number of the bronchial tubes were filled up by masses of -curdy matter similar to those found floating in the effused fluid. The -natural division of the lung into lobes was quite destroyed by the -pleuritic adhesions of one to the other, while the pleura lining the -parietes was covered by rugged layers of false membrane of irregular -thickness, but readily detached. No trace of tubercular deposit -could be found, and the lung of the opposite side was quite healthy. -Since the first publication of these cases the operation has been so -frequently and, in many instances, so successfully performed, as to -leave no doubt of the advantages to be derived from it. - -321. Lord Beaumont was wounded by a pistol-ball on the 13th of -February, 1832, when standing sideways. It entered the right side of -the chest a little below the nipple, appeared to pass under the lower -end of the sternum, just above or about the xyphoid cartilage, and -to have lodged in the cartilage of the last of the true ribs of the -left side near its junction with the bone, in consequence of a round -projection at that part resembling a pistol-ball, but which, on being -exposed, showed only a knob of cartilage which might have been a -natural formation; no further steps were therefore taken. The injury -had been received about four o’clock--it was now five; he could lay -flat on his back; had little or no pain or oppression.--Seven o’clock: -Breathing became oppressed, and accompanied by pain; vesicular murmur -distinct in both lungs; pulse 96; bleeding to thirty-two ounces.--Nine -o’clock: Difficulty of breathing; the pain greater; was again bled -until the pulse failed, although he did not faint; the relief -great.--Half-past ten: Oppressive breathing again returned; pulse very -low and quick; thirty-six leeches applied; relief obtained.--Half-past -twelve: Thirty-six more leeches.--Half-past two: Thirty leeches were -again applied. In all, four pints of blood were taken from the arm, and -one hundred and two leeches were applied to the chest, the bleeding -being encouraged afterward; during the first ten hours live grains of -calomel and four of the compound extract of colocynth had been given, -and now forty minims of Battley’s solution of opium were administered. - -14th.--Eight o’clock: Slept after four o’clock; on waking took an -aperient draught, and is much easier; pulse 120, soft, small, and -weak.--Three P.M.: On the dyspnœa returning twenty-one leeches were -applied, and the oppression was relieved; an enema given, which acted -freely.--Half-past twelve: A returning oppression relieved by eleven -leeches; calomel repeated, and thirty minims of solution of opium. - -15th.--Eight A.M.: Slept at intervals; little or no expectoration, no -blood; thinks he would faint if he sat up in bed; pulse 130, soft, -small, and weak; little pain; lies tolerably flat; respiratory murmur -distinct on both sides.--Nine P.M.: Oppression returned; twenty-four -leeches; repeat calomel and colocynth; an enema, after which the bowels -became free.--Evening: Six grains of calomel, and opium draught. - -16th.--Eight A.M.: Had forty-eight leeches applied at intervals twice -during the night; slept at intervals, and is easier; no pain in the -chest; pulse 108.--Evening: An enema; six grains of calomel, and one -grain of opium. - -17th.--Eight A.M.: Slept during the night, and is better; pulse 108, -soft; breathes freely; no pain.--Evening: Has had leeches applied -twice during the day, making in all 245, and each time with relief; an -enema,--calomel and opium as before.--Twelve at night: More oppression, -and, as the pulse was fuller and quicker, a vein in the arm was opened, -but only four ounces of blood could be obtained. - -18th.--Eight A.M.: Slept at intervals, although very restless; pulse -120, fuller; oppression in breathing returning; bleeding to twenty -ounces, which caused him to faint; senna draught.--Evening: Has been -much relieved by the bleeding; blood cupped and buffy; twenty leeches; -enema; calomel and opium. In the night, at two o’clock, the dyspnœa -returning, twenty-two leeches were applied, and thirty minims of -solution of opium given. - -19th.--Eight A.M.: Easier, quieter, better; pulse 110, soft; can -lie quite flat on his back. The wound discharged so little that the -external parts were dilated inward toward the sternum, until the -pulsation of an artery could be seen, perhaps the internal mammary, -which it was not thought advisable to disturb; respiratory murmur not -distinct at night; enema; calomel, opium, and twenty leeches. - -20th.--At three in the morning, being greatly oppressed, thirty leeches -were applied, and at eight o’clock twenty more, which quite relieved -him, but left him in a state of great exhaustion, sick, and faint. A -little arrow-root relieved the faintness; discharge from the wound -free, and accompanied by _air_; bowels open.--Ten at night: Calomel, -and forty minims of the solution of opium. - -21st.--Eight A.M.: Has now, for the first time, a hope of life: pulse -112, soft; no pain; can turn on his side, but fears to hurt himself; -wound discharges freely; has had a small piece of bread for the first -time.--Four P.M.: Restless, but better; senna and sulphate of magnesia -mixture.--Eight P.M.: Oppressed; pulse 120; twelve leeches; calomel, -and thirty minims of the solution of opium, at night. - -23d.--Oppression at night relieved by six leeches; slept afterward; -breath slightly affected by the mercury, which was omitted in -consequence; ten grains of the compound extract of colocynth given at -night, with thirty minims of the solution of opium. - -25th.--Free from pain; breathes easily and without difficulty; can -turn in bed with ease; slept well; the discharge from the wound is -free; takes farinaceous food, oranges, tea, etc. He gradually improved -until the 13th of March.--On the previous Friday, the 9th, he removed -from Bond Street to Mount Street; and on the 13th, amused himself by -washing all over in a small back room without a fire; caught cold, and -acquired a troublesome cough, which was quieted on the 14th, at night, -by opium.--On the 15th, A.M., it was evident that some mischief had -been done; pulse 120; breathing difficult; was bedewed with a cold -sweat; respiratory murmur indistinct on both sides; on the left, not -heard below the fourth rib; although the whole side sounded sonorously, -it evidently contained air, the _tintement métallique_ being very -remarkable. The wound having closed very much, and the distance to -the left cavity of the pleura under the sternum being considerable, a -piece of sponge tied around the eye of a small gum-elastic catheter was -introduced, so as to enlarge the track of the ball, and give passage to -the air from the left side of the chest. This was done at five o’clock -P.M., and at ten, on its being withdrawn, air rushed out in a very -manifest manner, to his great relief. The metallic tinkling, which was -distinct before the instrument was withdrawn, instantly ceased, but -could be reproduced by closing the opening. The small gum catheter was -therefore reintroduced with the eye projecting beyond the sponge, and -retained, air passing through it; cough very troublesome. - -March 17th.--Better; pulse 100; bowels open; cough easier; -expectorates freely a _rouillée_, or reddish muco-purulent matter. - -18th.--Easier and better; breathing on the left side not heard below -the fourth rib; discharge free; the permanent gum catheter taken out, -but passed in daily. After this he slowly recovered, and continued to -enjoy good health until the summer of 1854, when he died of what was -supposed to be ulceration of the stomach, being an admirable instance -of the treatment to be followed in such cases. When there is not an -opening to enlarge, one should be made with the trocar. - -It has been stated by the latest writers on pneumothorax, that -tympanitic resonance on percussion, and the absence of respiration, are -not pathognomonic signs of pneumothorax, as these physical signs may -exist without it, and pneumothorax may exist without them. The metallic -tinkling, in addition to the absence of all appearance of disease in -the abdomen, will be conclusive of the presence of this disease. - -322. Emphysema, from εν and φυσαω, to inflate; the diffusion of air -into a part of or throughout the cellular tissue of the body. It -has been said to take place after a wound of the chest, but without -an injury of the lung, from the air passing through the wound into -the cavity during inspiration; and by accumulation and subsequent -compression under the act of expiration, giving rise to all the -symptoms of the disease; a complaint more theoretical than real. - -Emphysema, as a medical disease, is opposed to the surgical disease, -in not being an extravasation of air into the cavity of the chest, -but a dilatation of the air-cells formed for its reception. It is of -two kinds, _Vesicular_ and _Interlobular_--vesicular when dependent -on the enlargement of one or more air-cells; interlobular when, from -the sudden rupture of an air-cell, the air has found its way into the -interlobular structure of the lung. A third and very rare kind has been -added, in which air, being extravasated under the pleura, has raised it -in the form of a pouch. The morbid appearances these diseases afford, -and the symptoms they give rise to, do not fall within the range of -surgical skill; and are not frequently within the controlling power of -medical science and ability. - -Emphysema is free from redness, and is distinguished from edema, or -the swelling containing a serous fluid which is also colorless, by its -not pitting on pressure, or retaining the mark of the finger. It is, -on the contrary, elastic; and the displacement of the air, on pressing -on the part, gives rise to a peculiar noise, resembling the crackling -of a dry bladder partly filled with air on its being compressed, -usually called crepitation. This swelling extends as the air introduced -increases in quantity until the whole of the areolar tissue of the body -may be fully distended. - -Emphysema most commonly occurs from fractured ribs, a point from one -or more of which abrades the surface of the lung. Through the opening -thus made, the air escapes into the sac of the pleura, and thence by -the side of the broken part of the ribs into the cellular membrane. -The distress in breathing arises from the air being diffused over the -surface of the lung, which it gradually causes to collapse under the -pressure exercised by the act of expiration; while, at the same time, -the mediastinum yielding, the opposite lung suffers in a similar way, -although to a less extent, until the aerification of the blood is so -greatly obstructed as at last to interfere with life, unless relief be -obtained by the equalization of the pressure made on the lung by the -compressed air in the cavity of the pleura, with that exercised on the -inside of the lung through the glottis. - -In ordinary but not severe cases of fractured ribs, a slight degree -of emphysema is frequently observed over the injured part, implying -that the lung has been wounded; such a case requires the application -of a compress, wetted with a little spirit and cold water, retained by -a bandage. The great art in the treatment of broken ribs by compress -and bandage consists in their proper application, which can only be -ascertained by the feelings of the patient. The application of a broad -flannel bandage, so as to restrain the motions of the chest, and to -cause the sufferer to breathe by the diaphragm, has been recommended -from the earliest periods of surgery; but many persons with injured or -broken ribs cannot bear the pressure of a bandage, while others derive -much ease from its use. A tight bandage generally disagrees when the -injury has been sustained at the lower part of the chest, and is more -frequently useful when the fracture is above the fifth or sixth rib. - -When the emphysematous swelling extends so as to invade a considerable -portion of the body, the further diffusion of air should be prevented -by punctures made through the skin in such places as may be thought -necessary, and in extreme cases even by incisions; but these are -things more often spoken of and written about than practiced, or than -are even necessary. - -323. Mr. J. Bell had so alarmed all military surgeons by stating, in -his able discourses on the Nature and Cure of Wounds, that emphysema -was “peculiarly frequent in gunshot wounds of the chest, both at the -orifice of entrance and of exit of the ball,” that they thought of -little else. They could not withstand the brilliant manner in which -this remarkable error--for error it is--was expressed. To such of us as -had served in the first part of the war in Portugal it was no longer -a bugbear; we slept in peace after the battles of Roliça and Vimiera, -of Corunna, of Oporto, and Talavera--laughing, perhaps, a little at -the credulity of the surgical portion of mankind; for the opening made -by a musket-ball rarely admits of emphysema. A slanting wound made by -a pistol-ball may sometimes give rise to it. After long and tortuous -wounds made by swords or lances it is seen more frequently, but then it -takes place shortly after the receipt of the injury. - -A soldier, at the battle of Albuhera, was wounded in the right side -of the chest by a sword, which had passed slantingly under the -shoulder-blade, from which injury he did not suffer much, until the -whole side as well as the body and neck began to swell and impede -his breathing, which was effected with some difficulty and with any -ease only when sitting up. The external wound was enlarged until I -could distinctly hear the air rush out and see the part where the -weapon had penetrated between the ribs; upon which he declared himself -relieved, when the wound was closed by compress and bandage. It did -not unite, however; active inflammation of the cavity of the chest -ensued, requiring frequent and considerable losses of blood for its -suppression. At the end of three weeks the man was sent to Elvas, in a -favorable state for recovery. - -324. When an opening is made into the cavity of the chest in the dead -body, the lung recedes from the pleura lining its wall, for some -distance; it is said to collapse; but this does not take place in -anything like the same extent in the living body; and if the continued -admission of air through the wound be prevented, it scarcely takes -place at all; or, should it have done so, the air is usually absorbed -and the lung quickly recovers its natural dimensions and functions. -Neither does a wound in the chest, when kept open, usually cause this -collapse to the extent which it is generally supposed to do in the -living body. The lung can be seen in motion and performing its office, -although imperfectly, as it does not fill the cavity of the pleura. -When the lung has been wounded by a ball actually going through its -substance, it does not necessarily collapse; and abrasions or deeper -injuries of its surface lead to no such result. To cause the complete -collapse of a living lung, its surface must be compressed by a fluid, -as in empyema, or by confined air, as in emphysema or in pneumothorax. - -In extreme cases, when the patient can no longer lie down, but sits -up, supported, in the greatest agony of respiration, approaching to -suffocation, the face and lips swollen and blue, the pulse almost -imperceptible and countless, an opening should be made into the chest -by a small trocar and canula, for the purpose of evacuating the highly -compressed and compressing air, and to allow the expansion of the lung -after its evacuation. When this compressed air has been drawn off, as -in the case of Lord Beaumont, the compressing power being removed, the -lung expands in part, if not entirely, in spite of the breach in it, -and the mediastinum and heart return to their natural situation, the -distress in breathing is removed, the failing circulation is restored, -and the opposite lung resumes its functions. - -The course then to pursue in such extreme cases is merely to puncture -the chest, evacuate the air, withdraw the canula, and close the -opening. The life of the patient having been thus saved, time is -given for the wound in the lung to heal under the usual inflammatory -processes, provided it will do so without a recurrence of the mischief. -This, if it should take place, must be met by another puncture, or the -opening in the chest should be made permanent in order to equalize the -pressure of the air in the cavity. - -The incisions (the “_taillades_” of the French) into the cavity of the -chest formerly recommended, should only be resorted to when the means -indicated have failed, which they will rarely do when combined in the -first instance with an antiphlogistic treatment, aided by sedatives, -and if necessary by cordials. - -The advantages to be derived from auscultation in these cases are -evident. Its value has been sufficiently shown, and the ear or the -stethoscope should be resorted to at least three times in every -twenty-four hours, in every case, however trifling it may appear to be, -until the absence of danger has been ascertained. - - - - -LECTURE XXII. - -SIMPLE INJURIES OF THE CHEST, ETC. - - -325. The most _simple injury_, perforating the wall of the chest, is -a stab by a triangular sword, a small knife, or other weapon, which -may or may not abrade the surface of the lung, and which is usually -attended by little pain, although it often gives rise to considerable -alarm. It might be supposed that a very slight wound of the lung would -be followed by some expectoration of blood, but this does not always -take place; and although its presence may be considered demonstrative -of the injury, its absence is no proof of the contrary; for a -considerable injury from a stab or from a musket-ball may be inflicted, -with scarcely any sign of blood in the matter expectorated. If the -pleuræ are in their natural state, a small quantity of air may enter -the chest, but the opening will require to be direct and tolerably -large before the lung will separate or shrink from the wall on that -account; if adhesions should have been previously formed between the -pleuræ preventing it, they will be for the advantage of the sufferer. - -In a simple incised wound, injuring the lung perhaps extensively, as -supposed from the bleeding from the mouth, no examination by probes or -other instruments need or ought to be made as a general rule; but the -wound should be immediately closed by sutures after the external parts -have been sufficiently examined to satisfy the surgeon that no portion -of the offending instrument has been broken off, or other extraneous -matters are sticking in the part. - -The advantages derived from the closure of punctured wounds of the -chest in former times led to the practice of sucking them by the mouths -of irregular practitioners, generally the drum-major of the regiment, -when the patient was a soldier; and the consequences, although in some -instances apparently miraculous, were in others quite as unfortunate. - -That bleeding may take place from the lung into the cavity of the -chest is indisputable, but little or no blood will escape through a -small wound; and its continuing to flow from such a wound will be a -presumptive if not a conclusive proof that some artery external to -the pleura has been wounded. Sucking, under ordinary circumstances, -of a small wound, unattended by bleeding, does good by attracting the -natural fluids to the parts, and thus causing them to swell so as to be -placed in apposition in the most advantageous manner for their reunion. -Punctured wounds of small size, therefore, may be sucked chirurgically -if any one be willing to do it, after which a bit of gold-beater’s -skin, or dry lint, should be placed upon the wound, supported by a -compress covered by adhesive plaster; these dressings should not be -removed for several days. - -326. The patient should lie on the wounded part, as a general rule, -if he can conveniently bear it, not for the purpose of allowing any -effused blood or fluid to flow out, unless some particular reason -require the precaution of keeping the wound open, but to allow the -pleura covering the lung to be as closely applied as may be to the -pleura lining the wall of the chest, with the hope that the adhesive -process may take place between these parts, and by this means cut off -the wound from the general cavity of the pleura, a proceeding due to -the practice of the Peninsular war, yet so little attended to at the -present time by some teachers of surgery, who seem to confound the -practice thus recommended in incised wounds penetrating the cavity of -the chest with that which should be adopted in gunshot wounds, that few -students obtain even a reasonable degree of knowledge on this subject. -Teachers are entitled to prefer any mode of treatment they please, but -they should be careful not to neglect the opinions of others, whose -authority, derived from experience, they are bound at least to notice, -even if it should be to disapprove. - -327. _Incised_ wounds of even greater extent ought not to be examined -by the probe or finger; no disturbance of any kind should be permitted -unless the cartilage or bone be injured. The external parts should be -brought together as closely as possible, so as to facilitate in every -way their union, and the processes which it is desirable should go on -within. The external parts or skin and cellular membrane cannot be kept -in perfect and continued apposition without sutures, and the proper -method of proceeding is to sew up the wound in the skin with a needle -and fine silken thread in a continuous manner, including absolutely -nothing but so much of the cut edges as will retain the thread; a -small piece of gold-beater’s skin or lint should then be laid over the -stitches and retained by a compress and adhesive plaster. - -In a _simple_ case of this kind little or nothing is effused into -the cavity or secreted from the membranes of the chest, which will -interfere with the processes which may have happily begun, and which -it is desirable should be aided by the absolute quiescence of the -patient, to whom no medicine should be given which may render any -movement of the body necessary. It was formerly supposed that the -greatest object to be attained was the prevention of inflammation, and -a man was no sooner stabbed by his opponent than he was blooded and -purged by his surgeon, regardless of the necessity which existed for -perfect rest and the presence of a certain amount of inflammation, in -order to enable nature to carry on those processes which are essential -for the restoration of the injured parts. This inflammation should be -allowed to commence without interference and to continue in a moderate -degree until the object shall have been effected. It should only be -interrupted or subdued when it is supposed to be about to exceed that -degree which experience has pointed out as likely to be useful. - -328. When the most courageous persons are wounded in parts essential -to life, there is more or less alarm or shock created by the injury; -although it has been gravely argued that a man does not always know -when he is actually shot or run through the body. A continued state of -anxiety and depression after an accident of this kind is a disagreeable -accompaniment of the injury, during which little should be done -beyond the giving a little cordial, and quieting the apprehensions of -the patient, leaving him to rest, if possible, after the necessary -applications have been made. If a gradual improvement take place, if -the pulse rise, if the patient resume more of his natural appearance, -and that state of commencing excitement which is denominated reaction -follow, hope may then be entertained. The general symptoms, as long as -they continue within ordinary bounds, are of little importance; the -local ones, significative of action commencing in the injured part, -are, however, to be carefully watched. They are those of inflammation -of the pleura, and it may be of the lung. This inflammation begins -slowly, and a day may elapse before it is well marked; for, when -persons have died within the first few hours after such injuries, -the pleura has often shown but little sign of inflammatory action. -Auscultation should always be resorted to from the moment of injury, -and constantly used throughout the treatment. Whenever it is concluded -that adhesion between the two pleuræ has failed to take place, the -direction to lie on the wounded side ceases to be of importance. Until -this period no food whatever should be allowed, and thirst should be -allayed by small quantities of water. - -329. A punctured, incised, or gunshot wound, going fairly through -both cavities of the chest, is usually believed to be quickly if not -immediately mortal--an opinion generally correct with respect to wounds -made by musket-balls, although it is certainly not the case with regard -to punctured wounds, and does not always occur in those made by pistol -or musket-balls. - -Sergeant-Major Richards, of the 29th Regiment, received thirteen sword -or bayonet wounds, and other injuries, on the heights of Roliça, on the -17th August, 1808--one particularly through each side of the chest, -between the ribs, as if the small-sword had made a wound of larger -size than usual. He had distinguished himself greatly in covering the -body of his commanding officer, and was beaten down before the British -column, which had been repulsed, could rally and recover its ground. -He was an object of particular attention to me, for the few minutes -he lived after I saw him; he had coughed up a little blood, and died -gasping, as if suffocated, the chest laboring on each side to do its -work in vain. His commanding officer, Colonel the Hon. George Lake, lay -dead by his side, killed instantaneously by a musket-ball, which passed -from the upper part of the left through the right side of the chest. - -A French gentleman, fencing with his pupil in July, 1834, received a -blow under the right axilla in a very violent lunge, whereby the button -of the foil was broken off, and the foil itself passed into and through -the back part of the thorax, the point coming out between the sixth and -seventh ribs on the left side near the angles. There was but little -bleeding. The chief symptoms were those of great inflammation of the -contents of the cavity, which gave way to full and repeated bleeding -from the arm, with perfect rest and almost starvation. He recovered -very favorably, and was quite well in about eight weeks. He remains -well, and is following his profession as a teacher of fencing. - -330. When an incised wound into the chest is large and direct, injuring -the lung, two very important points usually demand immediate attention. -The first is to relieve the oppressed state of the breathing; the -second, to suppress the bleeding. - -In large penetrating wounds of the chest, with injury of the lung, it -has been observed that the patient has breathed most easily when the -external wound has been covered; and has been hardly able to breathe -when it was opened, which is attributed to the air getting into that -side of the thorax in inspiration, instead of entering the lung by the -trachea. If the wound admit of being well closed, the difficulty of -breathing diminishes; adhesion may take place, and the inflammatory -action within the chest may terminate; but if the inflammatory symptoms -continue, adhesion does not take place, and the secretion and effusion -of a quantity of serous fluid are the consequence. This secretion of -fluid is the natural consequence of inflammation which has passed the -stage of adhesion, whether the injury of the chest have occurred from -a stab or from a gunshot. It is the leading fact in the treatment of -these injuries, hitherto disregarded by writers on this subject, but -on the proper management of which, in both instances, a successful -result principally depends. If the closure of the wound lead, in the -course of a few days, to the re-establishment of the breathing, and -the antiphlogistic means employed to the cessation of all urgent -inflammatory symptoms, adhesion has most likely taken place, or is -about to take place, in the neighborhood of the wound, and the patient -will in all probability recover without much further suffering. If -this should not occur, and effusion take place, the wound should be -reopened, or the fluid otherwise evacuated. - -A soldier of the 9th Regiment was wounded at Roliça, in 1808, by the -point of a sword in the left side; it penetrated the chest, making -a wound somewhat more than an inch long, through which air passed -readily, accompanied by a very little frothy blood, which was also spit -up on any effort being made to cough, leaving no doubt of the lung -having been injured, that viscus appearing to be retained against the -wall of the chest. As the edges of the wound could not be accurately -kept in apposition by adhesive plaster, two sutures were applied -through the skin, and the man was desired to lie on the injured side, -with the hope that adhesion might take place, as there appeared to be -no effusion of blood into the cavity. He was freely bled on each of the -two days following the receipt of the wound, and gradually recovered. - -A French soldier was brought into the village after the battle of -Vimiera, wounded by a sword in the right side of the chest. He said he -had lost a good deal of blood; was very pale; pulse small; extremities -cold; breathing hurried and oppressed; had spit up some blood. On -removing the handkerchief, a gaping wound presented itself, an inch -and a half long, through which the cavity of the chest could be -seen, the lung having receded. The wound did not bleed. As adhesive -plasters would not keep the edges of the skin in perfect contact if he -attempted to move, they were sewn together, and after the application -of a compress he was much relieved. The next day all the symptoms were -alleviated, and after the supervention of some serious inflammatory -symptoms, he was forwarded to Lisbon, for embarkation for France, in a -fair state of recovery. - -It was the successful results of these cases which led to the closure -of all such wounds in the first instance, with the hope of preventing -thereby the extension of the inflammation to the whole sac of the -pleura, which in many instances it succeeds in doing; and thus that -which was done in the first instance from apparent necessity, rather -than scientifically adopted, became a rule of practice, which may be -laid down as a principle to be followed in similar cases. When persons -thus wounded are neglected, the wound remains open, and the cavity of -the pleura passes into a state of suppuration, after all the symptoms -of acute pleuritis or of pleuro-pneumonia have taken place. - -331. If the union of a large incised or other wound by the adhesive -process does not take place, a bloody, serous fluid oozes out from -under the dressings, if the oppression of breathing should not have -led to their removal; the patient is relieved by the discharge, which, -after a time, as the case proceeds toward recovery, will become less in -quantity and more purulent in quality. - -If the union of the divided parts should take place externally, and -the general as well as local symptoms become more urgent, there can -be little doubt of a collection of some kind having taken place, and -then auscultation and percussion, if the latter can be borne, become of -the greatest importance. From the moment the wound is closed the ear -becomes the most important guide; the only one in fact to be depended -upon as to what is going on within the chest. The case is one of -pleuritis, perhaps of pleuro-pneumonia, and hence the reason that the -symptoms and treatment of these complaints have been more fully noticed -than might be considered to appertain to the province of surgery. -The effusion of a bloody, serous fluid comes on, after a penetrating -injury, from the third until the seventh or ninth day, by which time -the cavity of the pleura may be filled; puncturing the chest between -the sixth and seventh ribs at the point of election, or reopening the -wound, should be early resorted to for its evacuation. - -A picket of Portuguese infantry being surprised by a sudden rush of -French cavalry from the town, during the first unsuccessful siege of -Badajos, were nearly all sabred. The survivors were brought to me. Two -had been run through one side of the chest, and one through both sides; -the last died a few minutes after I saw him. The other two seemed to -be nearly in a similar situation from loss of blood by the mouth and -from the wounds. These were immediately closed by stitches, compresses, -and adhesive plasters. A little hot brandy and water was given to -each, and they were laid aside without hope of recovery. They did not -die, however; the breathing became more easy, the distress less, and -the pulse more distinct; reaction after a time took place. The next -morning, the siege being abandoned, they were removed to Elvas, where I -afterward heard they were doing well. - -A soldier of the Third Division of Infantry, under the command of Sir -James Kempt, was wounded at Waterloo, by a straight sword or sabre, -which penetrated the left side of the chest. He fell, and lost a -considerable quantity of blood from the mouth as well as from the -wound, and was supposed to be dying. On showing some signs of life, the -wound was covered by a part of his shirt; and on his arrival at the -Elizabeth Hospital in Brussels, four days afterward, it was closed. -On the ninth day, when my attention was drawn to him, he was sitting -up in great distress, from difficulty of breathing, his hand pressed -upon the wounded part, the cicatrix of which was red, swollen, and -projecting. I recommended the assistant-surgeon in charge to open this -with an abscess lancet, which he did, giving vent to a very large -quantity of bloody and purulent matter, to the great relief of the -patient for several days, although he did not ultimately recover. - -The advantage derived from the closure of the wounds in these cases -was manifest. It relieved the breathing, and caused the hemorrhage -to cease, aided, in all probability, by the exhausted state of the -patients. The relief to the breathing was at the moment the most -essential point, the wounds of entrance being nearly two inches long, -and the free admission of air quite unopposed; the lung had receded -from the opening. - -332. _The important question of hemorrhage_, in cases of incised wounds -admitting of being accurately closed, remains for consideration. In -many instances, the quantity of blood effused is trifling, and in -others, although greater, it is absorbed without being productive of -evil. In a third class, the quantity extravasated is larger than can -be absorbed, although it does not flow in an inconvenient or dangerous -manner through the wound, and may ultimately become coagulated and -adherent to the diaphragm and spine in the angle between them, when the -patient lies long on his back. In the worst or most alarming cases, the -loss of blood is and has been so great that its suppression offers the -only chance for the continuance of life. It is between these two last -cases only that a difference of opinion exists as to the treatment to -be pursued: one party desiring that the effused blood, if moderate in -quantity, should be allowed to discharge itself, the wound being kept -open; the other, that under all circumstances, whether the quantity -of blood poured out be small or great, the wound should be closed, -and the result awaited. The right course is, I apprehend, to remove -all the blood which can be evacuated by position, provided it can be -done without danger to the patient, rather than to allow it to fill -the chest; but as the bleeding vessel in the lung cannot readily be -got at, if seen, nor be secured by ligature with advantage, it is -advisable, if the bleeding continue, to close the wound, and allow the -cavity of the pleura to be filled, until the lung shall be sufficiently -compressed to cause the hemorrhage to cease, if the person survive -so long. The first object is to save life; after that, if time be -given, the next will be to relieve the loaded cavity. After the wound -has been closed, and the patient has so far recovered that reaction -has begun to take place, it may be concluded that the bleeding has -ceased. The chest should then be most carefully auscultated from day -to day, so that its respiratory state may be known, particularly with -regard to the increase of effusion, which will then be serous. This -will not take place until after the third, and not perhaps before the -fifth or sixth day, in any considerable quantity; when, if it should -have occurred, the wound should be reopened, or another opening made -at the most convenient place for the evacuation of the effused blood -and serum. It is probable that the wound of the vessel in the lung -which furnished the blood will be closed in five or six days: while -it is of great importance that the lung should be early relieved from -pressure, that it should be allowed to expand, and not be bound down -by false membranes; which will be the case if the compressing fluid be -not removed, and the inflammatory symptoms subdued. There is no object -to be gained but the suppression of the hemorrhage by retaining the -blood and serum within the chest; while the probability of a return of -the bleeding is not great after an opening has been made, and the blood -and serum have been evacuated, although much mischief will inevitably -follow the effused fluids remaining too long. - -Repeated observation has shown that in sabre-wounds penetrating the -chest and lung, which have not united, and from which no excessive -hemorrhage has occurred, a great discharge of serous fluid usually -takes place from the cavity, which, gradually diminishing, becomes -purulent, and at last ceases, without the function of the lung being -destroyed; while, if the wound had been early closed, and the fluid -collected too long retained, the functions of the lung would be -impaired, and a counter-opening, for the relief of the resulting -empyema, may be unavailing. Whenever, therefore, the adhesive process -between the pleuræ has failed, and great effusion has taken place, the -sooner it is discharged the better. - -In addition to the closure of the wound, it is desirable to arrest -the hemorrhage by other means, if possible, such as the abstraction -of blood from the arm to such an extent as it may be considered the -patient can bear, the administration of the acetate of lead with opium, -turpentine, matico, or the mineral acids; and the external and internal -use of cold or iced water, if it can be borne. If there be reason to -believe that a rib or ribs have been injured--that any extraneous -body is inclosed in the wound--or, from its appearance, that it will -certainly reopen, an incision should be made in the part injured, for -the purpose of giving the necessary assistance. The cure, however, will -not only be assisted, but mainly effected, by procuring a depending -opening by means of the small trocar and canula introduced as low down -as auscultation will authorize; the introduction of this instrument -will give the desired information on the one hand, and do little or no -harm on the other. - -A soldier of the 3d Regiment of Infantry was wounded by a lance at the -battle of Albuhera, in the left side, between the fifth and sixth ribs; -and was thrown down, bleeding from the mouth and from the wound, which -was afterward closed by his comrades, by confining upon it a piece of -his shirt folded up for the purpose. Brought to the hospital, at the -village of Valverde, he appeared ten days afterward to be dying from -difficulty of breathing. On enlarging the opening in the integuments, -a quantity of blood, partly fluid, partly coagulated, issued from the -cavity of the chest. The wound was kept open to allow the discharge of -this, and of a reddish, watery fluid, which, after a few days, became -purulent. At the end of three weeks I sent him to Elvas, doing well, -and with but little discharge from the wound. - -A heavy dragoon, of the German Legion, was wounded at the battle of -Salamanca by a sword, which penetrated the cavity of the right side -of the chest, between the sixth and seventh ribs. He fell from his -horse, and lost a considerable quantity of blood from the mouth and -from the wound. On examining the wound next day, a black coagulum -was seen filling up the orifice, the cellular membrane around being -considerably ecchymosed, and little doubt existed that the oppression -in breathing under which he labored was caused by blood effused into -the cavity. On separating the edges of the wound with a director, -several ounces of blood, half fluid, half coagulated, were evacuated -by making the external opening, which was enlarged, quite dependent. -The lung was then seen in contact with the external opening of the -wound, having expanded as the pressure of the blood was removed -from it. The wound was closed simply by lint, compress, and adhesive -plaster, without bandage; the man was largely bled, and placed upon his -wounded side on the ground, being the most comfortable position, in -some degree relieved from the oppression in breathing. Two days after, -the wound discharged freely a reddish-colored watery fluid, evidently -from the cavity of the chest, the exit of which was aided by keeping -the wound generally dependent. This continued for several days, the -fluid gradually becoming less in quantity, and purulent; under careful -management he was able to go to the rear, nearly well, by the end of -October. - -333. On the subject of the ecchymosis, which Valentin considers to be -a pathognomonic sign of effusion of blood within the chest, he says: -“It is very dissimilar to that which occurs after a blow or wound, -and which takes place shortly after the accident, beginning around -the wound, if there be one, and extending from it. The patient also -complains of pain when the bruised part is pressed by the fingers. -These characters are not observed in the ecchymosis, the sign of -effusion, which always takes place near the angles of the lower or -false ribs descending toward the loins. Its color is identical with -that which appears on the abdomen of persons some time after death, -a bright violet, (_violet très éclairci_.) It appears about ten days -after the receipt of the injury, sometimes later.” The same sort of -thing, he thinks, takes place when the cavity of the chest is filled -with pus, but that edematous swelling is without discoloration. - -334. In order to be explicit on points so important as those of which -I have treated, I have thought it right to lay down certain general -conclusions, subject to occasional deviations:-- - -_a._ All _incised_ or _punctured wounds_ of the chest should be closed -as quickly as possible by a continuous suture through the skin only and -a compress supported by adhesive plasters, the patient being afterward -placed on the wounded side--a precept which is absolute only with -respect to _incised_ wounds capable of being united by suture in the -manner directed. - -_b._ As soon as the presence of even a serous fluid in the chest -is ascertained to be in sufficient quantity to compress the lung, -a counter-opening should be made in the place of election for its -evacuation by the trocar and canula, which may be afterward enlarged; -unless the reopening of the wound should be thought preferable, which -will not be the case unless it should be low in the chest. - -_c._ If blood flow freely from a small opening, the wound should be -enlarged so as to show whether it does or does not flow from within the -cavity. If it evidently proceed from a vessel external to the cavity, -that vessel must be secured by torsion or by a ligature applied on it, -all the other methods recommended being simply surgical absurdities. - -_d._ If blood flow from within the chest in a manner likely to endanger -life, the wound should be instantly closed; but as the loss of a -reasonable quantity of blood in such cases, say from two to three -pounds, will be beneficial rather than otherwise, this closure may be -delayed until syncope takes place or until a further loss of blood -appears unadvisable. - -_e._ If the wound in the chest have ceased to bleed, although a -quantity of blood is manifestly effused into the cavity of the pleura, -the wound may be left open, although lightly covered, for a few hours, -if the effused or extravasated blood should seem likely to be evacuated -from it when aided by position; but as soon as this evacuation appears -to have been effected, or cannot be accomplished, the wound should be -closed. It must be borne in mind that the extravasation which does -take place is usually less than is generally supposed--a point which -auscultation will in all probability disclose. - -_f._ If the cavity of the pleura be full of blood, and the oppression -of breathing and the distress so great as to place the life of the -patient in immediate danger from suffocation, the wound should be -reopened, if it have been closed, or freely enlarged, if small, to such -an extent as will allow a clear evacuation of the effused blood. It -has been supposed that in such a case the lung does not sufficiently -collapse, and the bleeding is therefore continued because the vessel -cannot contract; but the lung will usually collapse under pressure of -the air, unless prevented by previously-formed adhesions, when the -hemorrhage may possibly cease--instances of which are said to have -taken place, and the practice should therefore be borne in mind. - - - - -LECTURE XXIII. - -WOUNDS OF THE CHEST, ETC. - - -335. Gunshot wounds of the chest, penetrating the cavity, are always -exceedingly dangerous. After the battle of Toulouse, on the 10th of -April, 1814, one hundred and six cases of wounds in the chest in -officers and soldiers, in all of whom the cavities were not penetrated, -were received into hospital. Between the 12th of April and the 28th -of June thirty-five died, fourteen were discharged to duty, and -fifty-seven were transferred to Bordeaux to proceed to England, some to -die, some to be pensioned, but few in all probability to return to the -service--being an ultimate loss of nearly one-half, if the fifty-seven -cases sent to England could be traced. M. Menière, in giving an account -of the wounded carried to the Hôtel-Dieu of Paris, in the three -remarkable days of July, 1830, where every case was immediately taken -care of, says forty cases were received into the hospital; of these -twenty died; he states the case of ten more, seriously wounded, who -recovered; and he gives the names of seven more, in six of whom the -cavity of the chest was not perforated, and alludes to three wounded -by small-swords, who recovered--the loss being thus one-half, even if -the rest happily and perfectly recovered, which may be doubted, thus -showing that with the ablest assistance the Hôtel-Dieu of Paris could -afford the loss was one-half. After the battle of Waterloo the loss was -much greater; with the army on the Sutlej the loss was deplorable, in -consequence of the want of a sufficient number of medical officers and -of means--a state of destitution to which I have drawn the attention -of the directors of the East India Company in the strongest possible -terms, but which they will not rectify, but which will some day, I -hope, become the subject of Parliamentary discussion, and, I doubt not, -of public reprobation. That the wounds of the chest with the army in -the Crimea will afford a more satisfactory result, cannot, I fear, be -expected, and for similar reasons. - -336. When a musket-ball fairly passes through the cavity of the chest, -the orifice of entrance is round, depressed, dark colored, and more or -less bloody in the first instance; the orifice of exit is generally -more of a rugged slit or tear than a hole. The alarm is great, and the -powers of life are much depressed. The wounds may or may not bleed; the -sufferer may spit up more or less blood; respiration may be difficult, -countenance pale, extremities cold, pulse variable--symptoms dependent -on particular constitutions and circumstances connected with the extent -of the injury. - -It has been said that balls are apt to run round the body, coming out -at a point opposite to that at which they entered, without penetrating -the cavity of the chest; this, whenever it does take place, is a rare -exception to a general rule, dependent on the ball being reflected from -something solid which it cannot penetrate, such as a button, a piece of -money, a rib, etc. If the ball run under the integuments exterior to -the fascia covering the intercostal muscles, it is usually marked by a -tenderness in its course on touching the part and a discoloration of -the skin. A ball may, however, run between two ribs for some distance, -injuring the muscular structures between them without penetrating the -cavity, in which case, after the first moments of alarm have passed -away, the symptoms indicative of a penetrating wound either cease or do -not occur, although those of inflammation of the pleura or lung may and -often do follow to a considerable extent. - -When the ball cannot be traced, the absence of symptoms, after the -first period of alarm has subsided, will enable the surgeon to form -the surest prognosis; their absence, however, cannot too certainly be -relied on. - -A ball will occasionally rebound from the sternum, leaving merely -a black mark; from the spongy nature of that bone in which they -frequently lodge, they require the application of the trephine. If a -ball should be felt through a wound in the sternum, the broken portions -of bone should be removed by the small saw or by the trephine, and the -ball extracted. - -337. An enlargement of the wound, the “_debridement_” of the French, -does no harm beyond the pain it occasions, unless there be something to -be removed, when an incision becomes necessary, in many instances, for -the removal of extraneous bodies or for the evacuation of blood, etc. -When a wound from a musket-ball appears likely to have penetrated the -cavity of the chest, and is too small to admit the end of the finger, -the opening ought to be enlarged so as to allow its introduction as far -as the ribs, in order to ascertain whether those bones have sustained -any injury, or whether anything is lodged exterior to or within them. -It is not necessary that a man should be cut simply because he has been -shot; and an enlargement of the wound should be of no greater extent -than is absolutely necessary for the purpose intended. When pieces of -shell, or of a sword or lance, are broken off and partly lodged in -the cavity of the thorax, which is more likely to happen when they -enter through the large muscles of the back, they will require larger -incisions to give room for their removal. Great praise was given of -old to Gerard, surgeon-in-chief of La Charité in Paris, who, having -perceived that a small sword, after going through a rib, was broken -off close to it, thought it advisable to make an incision through -the intercostal muscles into the chest, and then to introduce his -forefinger, armed at the end with a thimble, with which he pressed back -the point of the broken blade. In a case of this kind, the surface and -outer edge of the bone should be removed, until the piece of steel can -be firmly seized and withdrawn by a fine pair of pincers or pliers. - -When a ball sticks firmly between two ribs, it requires some care -to remove it, as the rib both above and below may be more or less -interested, although not actually fractured. The attempt should be -made during inspiration, when the lower rib should be depressed, and -some thin but not sharp-pointed instrument like an elevator should be -gently pressed around and under the looser edge of the ball, in order -to extricate it. - -When a musket-ball fractures a rib, there ought to be no hesitation -about the propriety of enlarging the wound, to allow the splintered -portions of bone to be removed. It is possible that in doing this some -pieces of cloth or other matters may be extracted, which might else -glide into the cavity of the thorax, or stick in the lung itself. - -A soldier of one of the regiments on the left of the position of -Talavera was brought to me, wounded by a ball in the left side of the -breast; it had struck the sixth rib, and passed out about four inches -nearer the back. As the point of the finger indicated the presence of -broken bone, I enlarged the anterior wound, and then found that the -ball had driven some spiculæ of bone into the surface of the lung, -which appeared to have been previously attached to the pleura costalis -at that part. These having been removed, together with a piece of coat -which had been carried in with the ball, a small, clean wound was left, -which gradually healed up, the man accompanying me on the retreat over -the bridge of Arzobispo. - -338. When a ball impinges with force on the center of one of the ribs, -and passes into or through the chest, the bone is usually broken into -several splinters of different lengths, some of which frequently -accompany the ball in the commencement of its course, or are even -carried into the substance of the lung, together with a part of the -wadding of the gun, or of the clothes of the patient. These should if -possible be extracted if they can be seen, and the sharp ends of the -rib rounded off. When the ball fractures a rib on passing out of the -chest, the splinters are driven outwardly, and should be removed by -incision. - -339. When a ball strikes a cartilage of one of the ribs, it does not -punch out a piece as it were, but merely divides and passes through -it, bending it inward, rarely tearing away a portion. The parts of -the cartilage thus bent and turned inward are to be drawn outward, -and replaced by the end of the finger, a bent probe, or other curved -instrument. - -A ball, when striking obliquely but with force on the chest, will -frequently penetrate, and then run round, between the lung and the -pleura lining the wall of the chest, for a considerable distance, -before it makes its exit. In this case the lung may be only slightly -bruised, without the pleura pulmonalis or costalis being more than -ruffled. In others the lung shows a distinct track or hollow made by -the ball. A shade deeper, and the ball penetrates, and forms not a -hollow, but a canal. The patient in all these cases spits blood, and -the first symptoms are severe; they frequently, however, subside, and -are not always followed, under proper treatment, by effusion, although -it may always be expected. - -340. When a ball fairly passes through the lung, it leaves a track -more or less bruised, which continues for a time to bleed according to -the size of the vessels which are injured, thus making a wound more -dangerous as it approaches the root of the lung where the vessels -are largest. More or less blood is spit up, or, if effused, it -gravitates in the chest, until it rests on the diaphragm or other most -depending part, according to the position of the patient. If it should -be in quantity, the filling up of the chest may be ascertained by -auscultation, if the wound be closed. As the quantity of effused blood -increases, the lung becomes more and more compressed, until at last -the hemorrhage ceases under pressure, if the wound be covered; and the -patient is saved for the moment, unless he should die of asphyxia, from -the lung on the other side being also compressed through the bulging of -the mediastinum on it; to prevent which, if possible, the wound should -be reopened or enlarged, so as to take off the pressure of the effused -and perhaps coagulated blood. If the person wounded shall have suffered -formerly from inflammation, and the lung has adhered in consequence to -the wall of the thorax, at the parts where the ball enters and goes -out, the cavity of the chest will not be opened, and the track only -of the ball will communicate with the external parts, unless the ball -shall have perforated some of the large vessels, when he will continue -to bleed by the mouth. The pressure of the blood effused into the track -of the ball, which may become coagulated, will sometimes suffice, under -even these circumstances, to effect the suppression of the hemorrhage -which the loss of blood, the faintness of the patient, and the weakness -of the circulation, under proper treatment, will materially assist in -rendering permanent. - -General Sir G. Lowry Cole, G.C.B., was struck at the battle of -Salamanca, on the 22d of July, 1812, by a musket-ball, which entered -immediately below the clavicle, fractured the first rib, and, inclining -inward, came out through the scapula behind; as he spat blood for -three days, the upper part of the lung was shown to have been injured. -The ball appeared to have passed so close to the under part of the -subclavian artery that the greatest fears were entertained for his -safety; more particularly as a marked difference in the size of the -pulse was perceived in the left arm, which did not exist before. He -remained three days on the field of battle, in a Portuguese officer’s -tent I always carried with me. Under repeated bleedings, and the -strictest antiphlogistic treatment, several splinters having come away, -and a large piece of the rib and of the scapula having exfoliated, he -gradually recovered, so as to be able to resume the command of the -Fourth Division in October at Madrid. The subclavian artery never -resumed its power, and the radial always beat less forcibly on the left -side. He perfectly recovered his health, the respiratory murmur of the -lung being natural. He died suddenly in 1844, from rupture, I believe, -of an aneurism of the abdominal aorta. - -A dragoon of the King’s German Legion, shot in a nearly similar manner -on the same occasion, suffered more severely: the clavicle and first -rib were splintered to a greater extent, and he lost a large quantity -of blood by the mouth. The splinters having been removed, after -enlarging both wounds for that purpose, and the inflammatory symptoms -subdued, he appeared to be going on favorably for three weeks; when, -having eaten some meat obtained irregularly, he suffered what seemed -to be a bilious attack of vomiting and purging, attended by fever and -oppression in the chest; an ipecacuanha emetic having been given with -full effect, relieved him much. During the efforts to vomit, the wounds -discharged a quantity of sero-purulent fluid, a piece of the cloth -of his coat, and another of bone, which had gone in with the ball, -and in all likelihood had been lying with the matter at the bottom of -the chest. After this he slowly recovered. This case is peculiarly -instructive. - -General Sir Andrew Barnard, G.C.B., was wounded when in command of the -Rifle Brigade, at the passage of the Nivelle, on the 10th November, -1813, by a musket-ball, which entered between the second and third -ribs, in front of the right side of the chest, passed directly through -the cavity and through the shoulder-blade, from under the integuments -covering which it was removed. He not only felt but heard the sound of -the ball as it struck him, and he fell from his horse. Blood gushed -from his mouth, and continued to do so until after he was completely -exhausted by bleeding from the arm to the amount of two quarts. He was -again bled at night, and the subsequent morning, which relieved all -the material symptoms. During six weeks he suffered from difficulty of -breathing and cough, and from night-sweats. Some pieces of bone and -cloth came away from the wounds, with a free discharge in the first -instance, which gradually diminished until the wound closed. In eight -weeks he was able to resume his command. - -More than forty years afterward I found the lung pervious; the -vesicular murmur could be freely heard even up to the situation of -the wounds, to the internal parts of which it may be concluded the -lung adhered, from the sound conveyed to the ear on auscultation. He -suffered little or no subsequent inconvenience from the injury, and -died in January, 1855, aged 82. - -_Case of Major-General Broke, by himself._--Toward the close of -the battle of Orthez, on the 27th of February, 1814, a musket-shot -struck me between the second and third ribs on the right side, near -the breast-bone. I was then on horseback, being aid-de-camp to -Lieutenant-General Sir Henry Clinton, commanding the Sixth Division. -The sensation was precisely as if I had been struck a violent blow with -the point of a cane, but it did not unhorse me. I was attended in a -very short time by the surgeon of the 61st Regiment, when, on removing -my clothes, the air and blood bubbled out from the wound as I drew my -breath. The surgeon, turning me on my face, discovered the ball to -be lodged under the thin part of the blade-bone. This he cut through -and extracted the ball, and with it pieces of my coat, waistcoat, and -shirt, which were lodged between the ribs and the blade-bone. This -occurred about four P.M. I was then removed to the town of Orthez, a -distance of about three miles, and in the course of the afternoon the -veins of both arms were opened in at least seven different places, but -scarcely any blood came away; breathing became exceedingly painful in -a day or two, and I felt nearly suffocated, when, in the evening, my -brother, Sir Charles Broke Vere, arrived with my friend, Mr. Guthrie, -who examined me carefully. The agony of drawing breath was such that -I could scarcely endure it. He opened one of the temporal arteries, -and desired that it might be allowed to bleed without interruption. -He afterward left me to visit some other wounded men, and returned in -about three hours, when I told him that I felt relieved, and had much -less of the suffocating pain in breathing. He then opened the other -temporal artery, directing as before that its bleeding should not be -checked. I shortly after that dropped asleep, and on waking could -breathe freely; my recovery was progressive from that time, the wound -in front, where the ball entered, being the first closed; but both were -healed at the end of about eight weeks, and in about ten I was able to -rejoin the army at Bordeaux. - - H. G. Broke, _Major-General_. - -He is now, in 1855, in perfect health, the respiratory murmur being -free all over the chest. - -The Duke of Richmond, then Earl of March, was wounded by a musket-ball -at the battle of Orthez, while at the head of his company in the 52d -Light Infantry. He was standing at the moment with his right face -toward the enemy. The ball entered that side of the chest, between the -fourth and fifth ribs, nearly in a line with the lower edge of the -scapula. He fell to the ground with great violence, and was speechless -for some time. He stated to me at a subsequent period that the -sensation he felt at the moment was as if he had been “_cut in two_.” - -On immediate examination there was no other opening to be found but the -_one_ where the ball had entered; nor were the medical officers able to -feel the ball anywhere under the skin or under the muscles. - -The wound having been dressed he was laid on a door and removed to -Orthez, about three miles from the scene of action, during which he -complained of excruciating pain, extending from the wound to the top -of the os ilii on the same side, the pain being much aggravated by -frequent and severe cough, with copious expectoration of frothy mucus, -and much florid blood; respiration hurried; countenance pale. - -The moving him to Orthez occupied nearly three hours; a great part of -the ground being very rough and broken, the men could not well step -together, and the consequent unavoidable shaking and jolting caused him -much pain. On his arrival at Orthez, he was extremely languid, with a -tendency to syncope. Pulse feeble; extremities rather cold. - -Seven in the evening: After having been faint for an hour, he -became hot and restless; pulse 108, and full; skin more hot, and -the respiration short and more hurried. After he was placed in bed -hemorrhage from the wound took place to a very considerable extent. -Eight ounces of blood were taken from the arm. (Could bear no more.) - -15th inst., nine A.M.: After the bleeding he became more quiet, and -had less pain; but he has since become very restless, and the pain -returned, with a full, hard, and frequent pulse. The wound has again -discharged a very considerable quantity of blood. Bleeding repeated as -before. - -Nine P.M.: Deputy-Inspector Thomson and Staff-Surgeon Maling examined -the wound. Mr. Maling introduced his finger (the whole length) between -the ribs into the wound without any interruption to its progress, and -without being able to reach the termination of the passage of the ball; -and Dr. Thomson then passed a probe (its whole length) straight into -the chest, with a similar result; thus leaving no doubt on the minds of -all present that the ball had passed directly into the posterior part -of the chest. - -Midnight: The blood last taken is very buffy; and there has again been -an _immense discharge_ of blood, etc. from the wound; the sheets, -mattresses, etc. are saturated with it; and on the floor, under the -bed, there is a large pool of blood which had soaked through the -bedding. Pulse 114, low and frequent; cough and expectoration as -before; pain violent, and great restlessness. Repeat the bleeding. - -_Mem._--Perhaps enough has now been stated to show the nature of the -wound; and any further detailed statement of his lordship’s sufferings, -or the treatment of his case, would be unnecessary. On the latter -point, however, it may be mentioned that, exclusive of the _general -treatment_, he was bled _seven times_ between the evening of the -27th of February and the morning of the 2d of March, the _cough_, -_expectoration_, _breathing_, _pain_, _etc._ being much relieved by -each bleeding. - - A. Hair, M.D. - -Mr. Guthrie saw the Earl of March on the same day as Colonel Broke, -and suggested that no further efforts should be made to find the ball, -while the treatment adopted should be steadily pursued; and in 1846, -he pointed it out lying under the edge of the base of the scapula. His -grace is now, 1855, in good health, and the chest, well formed, sounds -clearly and healthily in every part, even at the point injured. - -341. The ball in passing through the lung, in these cases, destroyed -the life of that part only which it touched; and although air would -pass out at the time, this would not be of long continuance. The wounds -being kept covered, the lung did not and does not usually, in similar -instances, collapse or recede from the wall of the chest, but quickly -recovers its state of expansion, however impaired it may be at the -moment by the injury. The track made by the ball gradually suppurates -and heals, leaving merely a depression or cicatrix on the surface -attached around or in part to the wall of the chest by adhesion. The -track through the lung may be readily seen in such cases after death; -although during life it interferes so little with the respiratory -murmur as not to be observable, unless by its greater distinctness, -from the thinness of the intervening parts. - -Mrs. M. was wounded by a small pistol-ball, which entered on the right -side from behind, between the seventh and eighth ribs, just under the -arm when hanging down, and passed out in front over the cartilage of -the sixth rib, more than an inch from the pit of the stomach. She had -not spit blood, and the ear declared the lung to be pervious to air -at the wounded part, which raised a hope that the ball might not have -penetrated the cavity, although it might have injured the pleura. -As she suffered great pain twenty-four hours after the injury, the -breathing being oppressed, Mr. Adams bled her into a hand-basin, -until about to faint. She lost nearly thirty ounces of blood, but her -symptoms were quite relieved, so as to render any other bleeding during -her treatment unnecessary. At the end of the third day she spat a very -little blood after removal in a carriage to another lodging, and then -gradually recovered. After four different stethoscopic investigations, -I came to the conclusion that the ball had not struck the lung in the -first instance, although the lung adhered to the pleura costalis, and -suffered from some abrasion or ulceration at that point, which gave -rise to the expectorated blood. - -These cases are instances of wounds of the upper part of the lung, -which are in general more dangerous than those of the lower, from the -vessels being larger, and from the greater difficulty with which any -extravasated blood or fluids can escape. They also prove that when -blood is poured out in small quantity, it may be absorbed, but what -that quantity may amount to is doubtful. - -342. In cases in which the external opening or wound does not -communicate freely with the cavity of the chest, the principal danger -arises from the inflammation of the pleura ending in effusion, which, -if not evacuated, leads to the loss of the individual. _It is the great -fact to be attended to in the treatment of pistol wounds of the chest, -or those made by small balls which do not pass out._ All the persons I -have seen die from small balls have died with the affected cavity more -or less full of fluid. The post-mortem reports of all persons killed -in England in duels by wounds through the chest, unwittingly attest -this fact, as well as the insufficiency of the surgical treatment they -received; and the necessity, for the future, for its amendment. It is -in these cases that the stethoscope is most valuable--its frequent use -indispensable. When the respiratory murmur ceases to be heard except -at what is the upper part of the chest, whatever the position of the -patient may be, it is full time to enlarge the original opening, or to -draw off the fluid by the trocar and canula. - -Laennec thought that when a considerable effusion took place in -pleuro-pneumonia, filling the posterior part of the chest when the -patient lay on his back, it nevertheless diffused itself over the -whole surface of the lung; but dissection has shown, in cases of -wounds, that the fore part of the lung may be applied to the anterior -part and sides of the ribs, while a serous effusion fills the hollow -behind, the respiratory murmur being distinctly heard above it. It -is the most important fact to ascertain, particularly in pistol or -small penetrating wounds of the chest, in which the opening is not -sufficiently large to allow any fluid effused to run out. - -Sir C. B. was wounded by a pistol-ball in the back, which passed into -the chest through the lower part of the lung of the right side, and -lodged on the inside of the wall of the chest in front of the same -side, sticking in and against a rib, but giving rise to no external -marks or signs of mischief at that part, so as to admit of an operation -for its removal. The inflammatory symptoms having been restrained, -it was nevertheless obvious that the cavity of the chest was full of -fluid, and that the oppression in breathing arose from it, and not -from the injury done to the lung. The stethoscope was then unknown, -the ear was not in use; my older colleagues were obstinate; they would -not hear of an operation for enlarging the wound into the chest; and -as our patient was, unfortunately for him, shot in London, instead of -at the pass of Roncesvalles, or on the bridge over the Bidassoa at -Irun, we let him die on the eighth or ninth day, without all the aid -which surgery might have given him. It is possible he would not have -recovered under any circumstances, from the ball having lodged, and -from his advanced age. - -A soldier of the Fifth Division of Infantry was wounded at Toulouse by -a musket-ball, which entered between the fourth and fifth ribs of the -right side, near the sternum, and came out behind nearly opposite, -fracturing the ribs, the splinters of which were removed. The first -symptoms of inflammation, having been in some degree subdued by the -sixth day, were followed by those more immediately indicating effusion; -such, particularly, as great oppression, difficulty of breathing, -and inability to lie in the recumbent position, which induced me to -introduce, after a little pressure, a gum-elastic catheter into the -posterior wound, through which a quantity of red, serous fluid was -withdrawn, exceeding, perhaps, three pints by measure. On the removal -of the catheter the discharge of fluid ceased, and, under a strict -antiphlogistic treatment, the man gradually recovered, so as to be -sent to England in the following June. If the symptoms of oppression -had returned, I should have repeated the operation perhaps lower down. -Auscultation, if it had been then known, would have smoothed away many -doubts and difficulties. - -A soldier of the 40th Regiment was wounded at Toulouse on the 10th -of April by a musket-ball, which entered about two inches below the -nipple of the right breast, passed through the cavity and the lung, and -came out behind at a nearly opposite point, injuring the ribs above -and below, without entirely destroying their continuity. He was bled -largely on the morning of the 11th, and again at night. On the 12th -the bleeding was repeated; some small pieces of ribs were extracted -from both orifices, and some part of his dress from the anterior -one. He spat blood when he coughed, and respiration was difficult. -Calomel, opium, and antimony were given in pills every six hours, -and the bleedings were repeated daily, and sometimes oftener, for -the first eight days, during which time a free discharge, at first -serous, afterward purulent, took place from the wound, after which -the inflammatory symptoms subsided; the cough became easier, the -expectoration less, and free from blood; breathing easy. The calomel -was omitted; a mild farinaceous diet was allowed instead of a little -gruel, and a very little bread and milk. In a fortnight the wounds -began to heal. On the 1st of May, some small pieces of rib were removed -from the anterior wound, after which both gradually closed, and he was -forwarded to Bordeaux on his way to England in the beginning of June, -cured. - -Corporal Dunleary, of the 69th Regiment, was wounded on the 16th of -June, 1815, at Quatre Bras, by a musket-ball, which entered the -thorax, fracturing the seventh rib on the fore part of the right side, -and lodged. He said he had lost a large quantity of blood from the -mouth, and some from the wound, between that and the 19th, when he was -brought to the hospital in Brussels. The pulse was then quick and hard, -respiration difficult and anxious, and a bloody discharge issued from -the wound on every respiration; bowels confined since the accident; was -bled to forty-four ounces; saline purgatives, with calomel, antimony, -and opium, were given until the 29th of June, when the wound discharged -good pus. From this time, at different periods for six weeks, he lost -ninety-two ounces more blood, being strictly placed on milk diet. -Several pieces of rib exfoliated. He was sent home on the 31st of -August, declaring himself quite as well as ever he had been in his -life; the ball remaining undiscovered. - -A soldier of the Fusilier Brigade was struck by a musket-ball on the -right side of the front of the chest, at the battle of Albuhera; it -entered between the fifth and sixth ribs, passed through the lungs, -and lodged. Three days afterward, when the first symptoms were in part -subdued, he complained of pain in a particular spot, nearly opposite -to where the ball had entered, at which part something could be felt -deeply seated. An incision being made, the ball was found lodged in the -intercostal muscles between the ribs, whence it was easily removed. A -considerable discharge of reddish-colored serum followed, with great -mitigation of the symptoms, after which, under strict treatment, the -man recovered, and was sent to Elvas with every prospect of a cure. - -Lieutenant-Colonel Harcourt and Major Gillies, of the 40th Regiment, -were both shot through the chest, at the head of the regiment, at -the successful assault of Badajos; the wounds were as nearly similar -as possible, from before directly backward. They were taken to the -same tent, and treated alike with the same care by the late Mr. -Boutflower, the surgeon of the regiment, with whom I saw them daily. -The inflammatory symptoms ran high in both. In Major Gillies, a tough -old Scotchman, they could not be subdued, and he died, at the end of -a few days, of pleuro-pneumonia. Colonel Harcourt slowly recovered, -and died Marquis d’Harcourt, near Windsor, more than twenty-five years -afterward, suffering little or no inconvenience from his chest, when I -last saw him. - -Captain Cane, 23d Fusiliers, was wounded at the affair of Saca Parte, -in front of Alfaiates, in 1812, by a musket-ball, which struck him -below and a little to the outside of the left nipple, fractured the -rib, and entered the chest, giving rise to the sensation as if the ball -had passed diagonally downward and backward to the loins of the same -side. He spat blood, and was very faint. The next day he could scarcely -breathe, was in great pain, continued flushed and anxious; pulse 100. -He was bled into a washhand-basin until he fainted, and every day -afterward, some days twice, to a less extent, for ten days, and once -again until syncope was induced, on an accession of symptoms after an -imprudence in taking a little wine, which nearly smothered him, he -said. Some pieces of flannel shirt, of braces, coat, etc. were removed -from the wound, and several portions of bone gradually followed, -together with a quantity of matter, which continued to flow from May -until the end of the following September, when the wound healed. - -On the 23d Jan., 1821, I had an opportunity of examining this -gentleman. My report says, he is never free from a little pain in -the loins, where the ball is supposed to be, and cannot take a full -inspiration without pain in the chest; expectorates more or less -constantly, and occasionally a little blood about once in three or -four months in half congealed lumps. Cannot ride or take any exercise -because it brings on the pain. The cicatrix shows a large, deep hole, -and the deficiency of the rib is well marked. The side of the chest is -altogether contracted and flatter; the heart has been moved behind the -sternum; the beat of the apex being on the other side of the xiphoid -cartilage, and that of the heart, as a whole, is more indistinct than -usual. In other ways in good health. It is possible that the ball may -be lodged in or be retained by layers of coagulable lymph in the angle -formed between the diaphragm, the ribs, and the spine. - -William Downes, of the 11th Regiment of infantry, aged thirty-three, -was wounded by a musket-ball, on the 31st of August, 1813, in the -Pyrenees; it fractured the fourth rib of the left side, passed through -the chest, and came out behind through the scapula. He spat a good -deal of blood, although little flowed from the wound. The next day -he was bled largely twice, to relieve the bleeding from the lung, -and was sent to Passages, where he was bled daily; and thence, a ship -being ready, to Santander, where he arrived on the 14th of September. -A free, bloody, purulent discharge took place from the anterior wound, -but little from the posterior, and he expectorated a bloody, purulent -matter, and occasionally a little blood. Toward the end of September -the sanguineous expectoration ceased; but the soft parts of the chest -had sloughed and separated under an attack of hospital gangrene, from -which he had a narrow escape during the month of October. The wound in -the chest gradually closed during the month of November; and on the -14th of December he was discharged convalescent, his health tolerably -good, but his breathing by no means free; no expectoration. The left -arm was impaired in power, in consequence of the mischief done to the -muscles of the fore part of the chest and shoulder by the hospital -gangrene. The chest was altogether somewhat flattened and shrunk, but -there did not seem to be any diseased action going on within. - -_Case of Lieutenant-Colonel Dumaresq, aid-de-camp to Lord Strafford, -by himself._--While turning round, after a successful charge of -infantry, at Hougomont, on the 18th of June, 1815, I was wounded by a -musket-ball, which passed through the right scapula, penetrated the -chest, and lodged in the middle of the rib in the axilla, which was -supposed to be broken. When desired to cough by the medical officer who -first saw me, almost immediately after receiving the wound, some blood -was intermixed with the saliva. I became extremely faint, and remained -so about an hour and a half, after which I rode four or five miles to -the village of Waterloo, where I was bled, which relieved me from the -great difficulty I had in breathing; this difficulty was accompanied -by a severe pain down my neck, chest, and right side. I was much -easier until the evening of the 19th; but in the course of the night, -the difficulty of breathing becoming much greater, and the spasmodic -affection having very much increased, I was bled seven times, until the -middle of the next day.--20th. I continued better, but was then seized -with the most violent spasms imaginable in my neck, chest, and stomach. -I could scarcely breathe at all, and was in the greatest possible -pain; I was again bled twice very largely, and my stomach and chest -fomented for a length of time with warm water and flannels. I passed a -very tolerable night, and continued pretty well until two o’clock the -following day, when I was again very largely bled, by which I was very -much relieved. I continued pretty well, and free from much pain; but my -pulse having very much increased, and having a good deal of fever, on -the 23d I was bled again; after this I continued free from much pain or -difficulty of respiration, and on the 26th was removed into Bruxelles, -when I came under your care. I forgot to mention that when I was so -violently attacked I had two lavements most vigorously applied; salts, -etc. proving of no avail, took digitalis, commencing with ten drops -every four hours, increasing to fifteen from the second day. - -N.B.--Up to this period, the 2d of July, the devil a bit have I eaten. - - While with fat mutton-chops, and nice loins of veal, - You stuff your d--d guts, your hearts are all steel. - Oh! ye doctors and potecaries, you’ll all go to hell, - For cheating our poor tripes of their daily meal. - H. Dumaresq. - -The ball in this case was lodged in the rib, which ultimately became -thickened around it. He recovered with good health, but with occasional -spasms in the chest; and died of apoplexy, in Australia, twenty-five -years afterward. His doggerel lines show the buoyant and unconquerable -spirit of a soldier, who knew that his chance of recovery was small. It -was a most gallant, a most friendly spirit. Peace to his manes. - -If the ball had caused a greater degree of irritation, I was prepared -to cut down upon the rib, and remove a part of it, if necessary; for -I have seen balls so situated slip from their lodgment, roll on the -diaphragm, and cause general inflammation, suppuration of the cavity, -and death, which must almost always ensue in such cases, unless the -ball can be removed, and the matter evacuated by an operation to be -hereafter described. - -General Macdonald, of the Royal Artillery, was present at Buenos Ayres, -when a bombarder of that corps received a wound from a two-pound shot, -which went completely through the right side, so that when led up -to the general, who was lying on the ground, he saw the light quite -through him, and supposed he was of course lost. This, however, did not -follow, and some months afterward the man walked into General (then -Captain) Macdonald’s room, so far recovered from the injury as to be -able to undertake several parts of his duty before he was invalided; -thus proving the advantage of a shot, however large, going through -rather than remaining in the chest. - - - - -LECTURE XXIV. - -Appearances After Death, Etc. - - -343. The appearances after death differ materially even in apparently -similar wounds. - -A French soldier, shot through the right side of the chest at the -siege of Badajos, died in December, 1812, in Lisbon, apparently of -consecutive phthisis. The ball had gone through the chest from before -directly backward; the posterior wound was closed; the anterior one -was fistulous, and discharged a small quantity of matter, of which he -spat up daily a large quantity until he died. The lung was diseased -throughout, and contained several vomicæ or small abscesses, from which -the matter expectorated was secreted. The track of the ball was nearly -filled up, although the part immediately around was harder than usual. -The lung adhered in many places to the wall of the chest, which was -much flattened. - -In other cases, portions of wadding, of leather belts, of splinters of -different lengths, pieces of buttons, and even balls, have been found -loose in the chest, showing the necessity for an especial and decided -treatment. - -A French soldier was wounded by a musket-ball at the battle of -Waterloo; it penetrated the chest, fracturing the second rib, then -passed through the lung, and went out behind in nearly a straight line, -close to the spine. Left on the field of battle for five days before -he was brought to Brussels, he was nearly dead with difficulty of -breathing and other symptoms of inflammation, from which he recovered -in the course of the next ten days, under repeated bleedings and -the strictest antiphlogistic regimen. At the end of this time, when -apparently doing well, an accession of inflammation and of all his -bad symptoms took place, destroying him at the end of four weeks -from the receipt of the injury. On dissection, the lung was found -adherent to the chest by false membranes of some thickness, with a -quantity of purulent fluid in the cavity. The track of the ball was in -a suppurating state, and two pieces of rib were found in the center -of its course. The whole of the lung appeared to be filled with a -sero-purulent fluid, which could be readily squeezed out. - -John Roth, of the 5th battalion of the 60th Regiment, aged twenty-nine, -had been wounded by two balls, one on the 10th of April, 1814, at the -battle of Toulouse, which grazed the left temporal bone; the other had -gone through the upper part of the right chest, in the Pyrenees, the -autumn before. Both wounds had healed. He was seized on the 8th of May, -after a little intemperance, with pains in his body and joints, pain in -the chest, and cough, with bloody expectoration; skin hot, tongue foul, -and bowels confined. On the 9th he was bled, and purged by calomel, -antimony, and salts. On the 10th symptoms augmented, pulse 120, small, -and wandering, but no pain in the head. Repeat the medicines. Head -shaved and cold applied; bleeding to ten ounces. 11th. Every symptom -increased; great pain on touching the chest; pulse 126; skin hot. On -the 12th passed his urine and feces involuntarily; and on the 13th he -died, his body being covered by petechiæ. - -The head, on examination, showed pus under the dura mater, at and -behind the situation of the wound he had received. The right lung -adhered to the walls of the chest where the ball had entered and passed -out, the track made by it being very visible, indurated, and inflamed, -from the last attack: the parts otherwise sound; no fluid in the cavity. - -Mr. Drummond was wounded by a pistol-ball in the back, low down, about -two inches from the spine, and three inches from the inferior angle -of the scapula; it was afterward found to have entered between the -eleventh and twelfth ribs, and to have _passed between the base of -the lung and the diaphragm_, abrading the former, and passing through -the latter into the abdomen, ultimately lodging in the fat under the -skin, over the cartilage of the eighth rib of the left side, nearly -at an opposite point in front. From the absence of all symptoms of -shock and alarm, it was hoped by some that the ball might have run -round, but on the removal of the little ball its course could not be -traced. This occurred on Friday. On Saturday morning at five o’clock -he suffered great uneasiness and difficulty of breathing, accompanied -by a particular catch or jerk in respiration, indicating a wound of -the diaphragm. The stethoscope and the ear attested the clearness of -the respiratory murmur in every part of the chest, which sounded well, -and I was satisfied the lung was not materially injured; twelve ounces -of blood were drawn with difficulty from both arms. At ten o’clock, -the jerk and difficulty of breathing being greater, the left temporal -artery was opened, as no blood could be drawn from the veins; five -ounces only could be obtained; a dose of calomel and a senna draught -had been followed by the discharge of a teaspoonful or two of blood, -leaving no doubt on my mind that the ball had penetrated the cavity -of the abdomen, as well as of the chest, and that a bowel had been -injured. With a constitution apparently unequal to bear an inflammation -of the most dangerous character, or the remedies necessary to subdue -it, the prospect was but melancholy. Thirty-six leeches were applied -around the wound in front, but they drew little blood. Pulse from -108 to 112. Dr. Hume, Mr. B. Cooper, and Mr. Jackson were added in -consultation on Monday at twelve, when the jerk became worse, the -oppression in breathing greater. Muriate of morphia, half a grain; at -two, bled to twelve ounces; blood very buffy; calomel, two grains, -opium, half a grain, every two hours. In the evening, bleeding, -repeated to fourteen ounces; no more would flow. Tuesday morning, at -five, bled again to twelve ounces. The ear now indicated effusion for -the first time. It was not, however, in sufficient quantity to render -the evacuation of the fluid necessary. After this he gradually sank, -and died on Wednesday morning. He lost on the whole fifty-six ounces of -blood. On examination after death, it was found that the ball, after -entering the cavity of the chest, had slightly abraded the left lung -at its lower and inferior edge, which was covered by recent lymph, -the lung being internally sound. The left side of the chest contained -nearly a pint of red-colored serum. The ball had perforated the -diaphragm, grazed the fat of the left kidney, passed through the great -omentum below the stomach, to the part where it was extracted, injuring -apparently no important organ in the abdomen in its transit, but giving -rise to an effusion of blood from some small vessel which had sloughed, -the blood being partly coagulated and partly diffused to the amount -of many ounces; its loss appeared to have been the immediate cause of -death. - -A gamekeeper’s gun burst at the Red House, Battersea, and a small -part of the lock entered the middle of the left arm, and passed -upward into the axilla, where it could not be traced by Mr. Keate, -who saw him within an hour after the accident. The symptoms which -followed were those of inflammation of the chest, and were subdued by -active treatment; the wound healed, and he returned to his occupation -in Wiltshire. Having exposed himself to the night air some weeks -afterward, the inflammation of the chest returned, and he died. On -opening the thorax, one edge of the bit of iron was found impacted -in the surface of the lung, the other edge was rubbing against the -inside of the sixth rib, which was nearly worn through by the constant -friction it underwent during respiration; there was also a mark on the -pericardium as of a cicatrix, and of a graze on the surface of the -heart. - -Among the French prisoners in Lisbon, in the spring of 1813, I saw a -man in whose chest a ball had entered midway between the fifth and -sixth ribs, and lodged; from this a constant and considerable discharge -of purulent matter took place. The ball was found after death lying -between the diaphragm and the spine, surrounded by coagulable lymph, -and adhering by its envelope to the spine and diaphragm at the angle -formed between them; there was a very thickened pleura costalis; the -lung was shrunk and attached by membrane almost equally thickened -across the chest, the lower part of which was filled in the upright -position by the discharge, which was only evacuated in quantity when -the opening of the wound was made dependent. - -A case was met with after the battle of Waterloo, among the French -wounded, which was somewhat similar. A portion of rib had been -driven in, and the assistant-surgeon was aware that the ball could -occasionally be felt. The man died at the end of a fortnight, the -cavity containing a quantity of sero-purulent bloody matter. The lung -had been injured by the ball, which had fallen loose into the cavity of -the chest. - -344. The removal of splinters of bone, or of other foreign bodies from -the lung, has occupied the attention of surgeons from the earliest -periods, and some of them proposed to draw a piece of cambric or other -things through the chest, for the purpose of removing them. These -extreme measures have been abandoned; but there can be no doubt of the -propriety of removing as many of these causes of irritation as can be -either seen or felt. If the ball have broken a rib, the orifice of -entrance especially should be enlarged as early and as carefully as -possible, so as to give an opportunity for the removal of the splinters -and of all angular points of bone which may be turned inward. A little -addition to the original opening can do no harm, and if the lung should -not collapse, or should it be adherent, it will enable the surgeon to -see whether any splinters are impacted in it, and to remove them. It -is possible that the end of the finger even may be introduced, and the -lung felt, if it should not have receded too far; as it is insensible -to such an operation, no evil will ensue; but all probings with small, -sharp-pointed instruments should be avoided. That wadding, buttons, -pieces of cloth, and of bone have been frequently coughed up, I have -had experience; but although it is said that even balls have been thus -brought up, I have not had an opportunity of seeing them. - -An officer was wounded by a musket-ball on the 9th of July, 1745; it -passed through the chest, entering in front, fracturing the seventh -rib near its junction with the cartilage attaching it to the sternum, -and passing out behind near the angle of the same rib, which it -again broke, together with the one immediately below it. M. Guerin -enlarged the openings of entrance and of exit to the extent of nearly -two inches, by dividing the pleura, the intercostal muscles, and the -integuments from within outward. Several splinters of the rib injuring -the lung were removed, the smallest of which might be half an inch -or six lines long, by two wide. A tent was then passed through the -wound. The patient suffered much, and spat a great deal of blood; pulse -feeble, extremities cold. He was bled three times the first night, -and twenty-six times during the first fifteen days, the seton being -retained in the chest the whole time. On the twenty-second day, a -piece of cloth was felt by the finger, after removing the seton, and -was extracted; a splinter was also felt, but so deeply that it could -not be removed without enlarging the incision. As the inflammatory -symptoms were re-excited, he was bled for the twenty-ninth time. On -the thirtieth day these symptoms had so much increased that the seton -was withdrawn, under the impression that it was doing more harm than -good, and the thirty-first bleeding was effected. The next morning the -patient complained of something pricking him within, and the parts left -between the two original wounds, after the incisions which had already -been made, were divided. The chest was now open from the articulation -of the head of the rib with the sixth and seventh vertebræ behind, -nearly to the cartilage in front; and the whole course of the ball was -seen; it had made a groove in the surface of the lung, in the substance -of which a splinter was sticking. This was extracted, and the wound -dressed simply, after which the patient gradually improved, and was -quite cured in four months. - -The two first incisions for the removal of the splinters were -necessary. The tent or seton drawn through the chest was an error; -and although the fortunate result of the case depended probably on -the removal of the splinters of bone sticking in the lung, few would -survive the formidable operation performed for their removal. The case -is suggestive and instructive. - -345. When the lung can be seen through the opening made by the ball, -or after some moderate enlargement for the purpose of removing any -splintered pieces of rib or any spiculæ which can be felt or seen, the -object is attained. I have not had experience of the utility of large -incisions for the purpose of making the lung more visible, although the -importance of extracting foreign substances in the first instance is -inculcated, provided their situation can be ascertained. - -A Spanish soldier, wounded at the battle of Toulouse, was brought to -me the same evening, shot through the right side of the chest, between -the fifth and sixth ribs, one of which was fractured, the ball passing -out nearly opposite behind. On removing the splinters by the aid of -an incision, I found that the lung was adherent to the inside of the -chest, and was enabled to withdraw from within the lung some splinters -of bone and a part of his coat. He left Toulouse apparently doing well; -but natives of warm climates rarely suffer from such severe attacks of -inflammation as those of northern habits and constitutions. - -A soldier of the German Legion was wounded at the battle of Waterloo, -the 13th of June, 1815, by a musket-ball, which entered between the -seventh and eighth ribs in front, about two inches from the sternum on -the right side, passing out behind. He died in York Hospital, Chelsea, -in the month of January following, where he was taken after some -drunken fits, which induced an attack of pneumonia. A fistulous opening -existed, and had discharged a little matter, which was gradually -diminishing; the sinus was from six to seven inches long, extending -into and nearly through the base of the lung, and was lined by a -mucous membrane, the lung around being thickened to the extent of from -a quarter to half an inch. There was but little fluid in the cavity, -although the lung on both sides showed signs of recent inflammation, -without which he would in all probability have recovered. The orifices -of entrance and of exit through the lung adhered to the walls of the -chest, thus separating the track of the ball from the general cavity -of the pleura, which would in all probability have led to his ultimate -recovery, if it had not been for his intemperance. - -346. When a ball, or portion of bone, leather, cloth, wadding, or -other foreign substance is driven into the cavity of the pleura, it -usually gives rise to fatal results, constituting, therefore, cases of -the greatest importance, to which attention has not been sufficiently -given, but on which too much cannot be bestowed, if life is to be -preserved by the art of surgery. The neglect of these cases has -probably arisen from the insufficiency of the means of ascertaining -their nature--an insufficiency which auscultation has in some measure -removed, and which the science of surgery may still further diminish. -The presence of a ball, a piece of bone, or of any other substance, -lying upon or rolling about on the pleura covering the diaphragm, must -give rise to more or less irritation and inflammation, and consequently -to suppuration, or the formation of matter upon the surface of that -membrane in its thickened state, until, in all probability, the foreign -substance has been removed or the person has wasted away and perished. - -A dragoon of the King’s German Legion was wounded between the eighth -and ninth ribs at the battle of Salamanca. The ball had entered -and lodged; the symptoms were severe; the breathing laborious. As -the discharge from the wound was not free, I enlarged the opening, -removed some scales of bone, a bit of cloth which stuck between the -ribs, the lower of which was broken, and evacuated a great quantity -of bloody-colored fluid, not purulent. After a few days the discharge -became purulent, and, as he felt something, as he thought, roll -within him, which he supposed might be the ball, I contemplated -again enlarging the wound, so as to be able to see whether anything -were loose in the cavity; but a sudden relapse of inflammation, from -drinking some brandy, carried him off. On examination, the ball was -found lying loose on the diaphragm in the chest, and might, with some -enlargement of the wound, have been extracted. - -A French prisoner of war, who had been wounded near Almaraz by a -musket-ball, which had lodged in the left side of the chest, was sent -to Lisbon in 1812, with a considerable discharge through the wound, -and died there. The ball was found in the angle formed between the -diaphragm and the spine, enveloped in coagulable lymph, by which it was -attached to the spine; there were some splinters of bone inclosed with -it. - -A soldier of the 29th Regiment was wounded at Talavera by a -musket-ball, which penetrated the right side of the chest, between -the fourth and fifth ribs, and lodged. He died the day after, and on -opening the body, I found that the ball had passed through the lung, -and was lying loose on the ribs behind, near the union of the diaphragm -with the spine. - -Major-General Sir Robert Crawford was wounded at the foot of the -smaller breach at the storming of Ciudad Rodrigo, by a musket-ball, -which passed through the posterior fold of the armpit and entered the -side of the chest in the axilla by a small opening or slit, apparently -too small to allow a ball to pass through. I saw him a few minutes -afterward with Dr. Robb, under whose care he remained, when, from the -general anxiety manifested, I was satisfied as to the severity of the -injury. The symptoms were not at first urgent, but their continuance -and augmentation, in spite of the most rigorous antiphlogistic -treatment, led, in a few days, to his death. On examination of the -body, the ball was found lying on the diaphragm; the cavity of the -chest contained a large quantity of very turbid serum; false membranes -had formed on the lung, which was compressed toward the spine, and at -the upper part retained the mark of an injury as from a ball which had -not had force enough to penetrate and lodge. - -Baron Larrey has had the good fortune to meet with some remarkable -cases of this kind. In the first he did not see the man for some weeks -after the wound had been inflicted, the ball entering at the upper -edge of the fourth rib, about an inch from its junction with the -cartilage. By means of a bent and flexible sound introduced through the -wound, he distinguished a hard, metallic substance at the bottom of -the cavity of the chest, which he supposed to be the ball, nearly in -the situation of the place where the operation for empyema is usually -performed. This operation having been done, about twelve ounces of pus -escaped, and the ball was discovered rather flattened. It was easily -removed with the aid of a pair of polypus forceps. After this there was -every prospect of recovery, until the patient, having unfortunately one -day drank too much brandy, was attacked by enteritis, and died. - -William Barrett, of the Life Guards, a middle aged, muscular man, of -full habit, was wounded by a musket-ball at the battle of Waterloo; -it fractured the third and fourth ribs behind on the left side, and -broke the left arm. He was brought to Brussels, where the inflammatory -symptoms were subdued by repeated general and local bleedings, and the -other ordinary but strictly antiphlogistic means, during the first six -weeks, by which time the external wound had nearly closed, and no trace -of the ball could be perceived. At the end of this time, Staff-Surgeon -Collier, now Inspector-General of Hospitals, under whose care he was, -and who furnished me with these particulars of the case, which I saw in -Brussels, finding that his symptoms became worse, that he had rigors -and evening exacerbations, and that the difficulty of breathing had -increased almost to suffocation, decided on opening into the cavity of -the chest and following the course of the ball. This he did by a deep -incision, which enabled him to remove some pieces of the ribs, which -were denuded but not detached. A bag-like protrusion was then felt -between the ribs near their angles, which was opened, and nearly two -pints of thick, fetid pus escaped, the relief which followed being as -complete as sudden. The wound was dressed from the bottom, and every -means adopted, except introducing a tent, to prevent its closing, but -in vain; the opening closed, and matter again collected, requiring a -second incision for its removal. Between these two operations small -bleedings were resorted to most beneficially. A short gum-elastic -catheter was introduced into the cavity of the chest after the second -incision; very little matter, however, was secreted. From this time he -gradually recovered, and was sent to England, cured, in November. - -347. The presence of a ball, rolling about on the diaphragm, can now be -ascertained by means of the stethoscope at an early period, so as to -admit of an operation being undertaken with confidence for its removal; -while the knowledge acquired by auscultation or percussion, of the -filling of the chest by fluid, whether serous, bloody, or purulent, is -at the same time incontestibly demonstrated. The presence of a ball, -or of any other foreign body, decides the question as to the place -where the opening into the chest should be made. On this point the -information derived from the practice of the French surgeons in Algeria -is valuable. - -M. Baudens, whose labors I again refer to with great pleasure, says -that he has also seen splinters of bone and even a ball, surrounded by -a cyst formed by the pseudo-membranes of inflammation, cut off from -the general cavity, and confined in the angular space formed behind -between the rib, the diaphragm, and the spine. In one case, M. Baudens -introduced a _sonde à dard_, such as is used in the high operation -for the stone, between the second and third ribs, and made it project -behind between the eleventh and twelfth. He then cut down upon it, and -extracted a ball and some splinters of the rib. The wound thus made -was then closed, the upper one being sucked dry daily by a pump. The -patient recovered in forty days. - -A., 54th Regiment, was brought to the hospital at Algiers, on the 22d -of October, 1833, wounded eleven days before by a ball, which, having -broken the right clavicles was lost in the chest, without any sign of -effusion having taken place; he appeared to be going on well, until -suddenly he complained of pain about the middle of the sixth rib, -which could not be removed by the means employed, and was accompanied -by a great discharge from the wound. On the 10th of November he died. -The clavicle and the first rib had been fractured, and an abscess -had formed behind them, the size of a hen’s egg, containing several -splinters of bone, which had stuck in and afterward separated from the -lung. The ball had passed from above downward and outward, forming a -sinus, which terminated at the middle of the sixth rib, to which this -part of the lung was attached; the posterior three-fourths of this -canal were closed; the anterior fourth contained two splinters of -bone, one of which was about to fall into the abscess in front. The -sixth rib was broken, although it had not been perceived during life; -and a small digital cavity was formed at this part in it by the ball, -surrounded by portions of lymph, floating loosely from its edges; from -this the ball had been detached, and had given rise to the inflammation -which destroyed him. The ball had fallen on the diaphragm, where it was -lying loose, surrounded by a quantity of purulent matter. - -M. Baudens says himself, and rightly, that the operation of opening -into the chest should have been performed in the eleventh intercostal -space, and that the wound in front should have been enlarged. - -M. Baudens relates another case, in which the posterior wound, -situated near the angle of the tenth rib, had healed, the anterior -one, half an inch below the clavicle, giving issue to an abundant and -weakening suppuration. The lung above this was permeable to air, but -the respiratory murmur could not be heard below it. To draw off this -offensive fluid, he adapted an empty caoutchouc bag to a gum-elastic -canula, which he affixed against the orifice of the wound, and thus -sucked out six pints in five days. Some days later the wound behind -reopened, and a piece of bone was discharged from it, which saved the -man’s life. Two years afterward he was seen in good health. - -The desire to have as dependent an opening in the chest as possible in -these injuries has been manifested by all surgeons of experience; and -the interspaces between the ninth and tenth, and between the tenth and -eleventh ribs, have been often selected for this purpose; but as the -operation was formerly done with the trocar, the abdomen was as often -opened as the thorax, and death was frequently thus caused, even if it -would not have been occasioned by the disease. To prevent, or to avoid -this evil, M. Baudens advises its being performed at three fingers’ -distance from the spine, by incision, and he says he has frequently -done it with success, although he does not give any circumstantial -directions as to the operative method to be pursued. I therefore caused -several experiments and dissections to be made in the workroom of the -College of Surgeons by Mr. Quekett, with the following results:-- - -348.--1. That a trocar and canula pushed in between the eleventh and -twelfth ribs, in a diagonal direction upward, on a line with the angle -of the ribs generally, will in the _dead body_ invariably enter the -cavity of the chest without injuring the diaphragm. - -2. That the same operation performed on the _living body_ would, in -all probability, if done at the moment of expiration, first enter the -thorax, then pierce the diaphragm, and thus open into the cavity of -the abdomen,--a difference in result to be explained by reference to -the anatomy and physiology of the parts concerned; showing that this -operation, when required on man, should always be done cautiously by -incision, and not by puncture with the trocar and canula. - -On examining the lower part of the chest from within, after removing -the pleura, the diaphragm is seen forming the boundary between the -thorax and the abdomen, commencing from the transverse process of the -first lumbar vertebra, and forming an arch under which the upper part -of the psoas muscle passes, (the ligamentum arcuatum proprium.) From -this part extends another aponeurotic arch along the lower border, -to the end of the last rib, called the _false ligamentum arcuatum_, -(ligament cintré du diaphragme of Cruveilhier,) which is nothing -more than the upper edge of the anterior layer of the aponeurosis of -the transversalis muscle, folded upon itself in all its extent. The -diaphragm is afterward attached to the lower border of the twelfth, -and in succession to the eleventh, tenth, ninth, eighth, seventh, and -sometimes to the sixth, ribs, counting from below upward. The external -intercostal muscles are distinctly seen between the ribs, extending -from the spine until they meet and are concealed by the fibers of -the internal intercostal muscles, near the angles of the ribs. The -vessels and nerves, after passing on the external intercostal muscles, -subsequently run between them and the internal ones. - -The lower intercostal arteries arise from the aorta on each side, and -before they enter the space between the ribs give off a branch passing -backward to the vertebral canal and the posterior muscles of the spine. -The eleventh and twelfth intercostal arteries, covered at first by the -pillar of the diaphragm, ascend on leaving the vertebræ to reach the -under edges of the ribs, and are accompanied by a vein and nerve. The -tenth intercostal artery, and those immediately above it, run almost -horizontally, and nearly in the mid-spaces of the ribs, as far as -their angles, at which part a small artery is commonly given off, which -descends from the main trunk at an acute angle to the rib below, and -may be injured in opening into the chest, and be perhaps mistaken, in -operating, for the intercostal artery itself. From the angles each -artery runs in a groove in the under edge of the rib as far as the -anterior third, when they all become very much diminished in size, -and, leaving the grooves, run in the middle of the intercostal spaces, -until lost in their different anastomoses with the branches of the -epigastric, phrenic, lumbar, and circumflexa ilii arteries. - -In making an opening into the chest between the tenth and eleventh, or -between the eleventh and twelfth ribs, the artery will not be injured, -provided the opening be made below the middle of the intercostal space, -which is wider between the eleventh and twelve ribs than between those -above it. The vein is situated above the artery, and proceeds to the -vena azygos major on the right, and to the smaller azygos vein on the -left side. - -The intercostal nerves are the anterior branches of the dorsal -nerves, and lie below the arteries under the pleura upon the external -intercostal muscles, until they approach the angles of the ribs, where -they enter between the layers of the intercostal muscles. - -It is worthy of observation that the pleura is necessarily continued -over the inside of the twelfth rib to line the different attachments of -the diaphragm, and that an incision may always be made into the chest -above this point, if done carefully. - -On removing the integuments of the back, covering the muscles and -the lower ribs, the broad expanse of the _latissimus dorsi_ muscle -is brought into view, extending from the ilium and spine upward -and outward, and covering all the parts of importance beneath in -the operation to be described. On the removal of the lower part of -this muscle the _serratus posticus inferior_ is seen, of a somewhat -quadrilateral form, arising by a thin aponeurosis common to it and to -the latissimus dorsi, from the spinous processes of the three superior -lumbar vertebræ and the two inferior dorsal, and proceeding upward and -outward to be inserted by four flat, tendinous digitations into the -four lower ribs. - -If this muscle be separated from its origins and turned outward, or -divided in the middle, and its two portions reflected, the posterior -spinal or long muscles running in and filling up the groove or hollow -of the side of the spine will now be distinctly seen, composed chiefly -of the sacro-lumbalis and the longissimus dorsi muscles, sometimes -called as a whole the _erector spinæ_ or the _sacro-spinal_ muscle. -This, which forms a thick mass over the beginning of the tenth, -eleventh, and twelfth ribs, is not to be divided or interfered with -beyond a very few at most of its external fibers; the opening into the -chest about to be made should begin at its external edge and go through -the external intercostal muscle, which is now exposed on a plane below -it. - -The eleventh and twelfth ribs, unlike all those which precede them, -except the first, have only one surface of articulation with the -corresponding vertebræ, to which they are attached, instead of two -facettes articulating--one with the body of the vertebra above, the -other with that below. They form, particularly the twelfth, a more -acute angle with the spine than the other, which gives to them their -greater degree of obliquity, while the freedom of their cartilaginous -extremities enables the twelfth, particularly, to be depressed or -separated by a moderate force from the rib above to a greater extent -than at any other part, by which means a foreign body of larger size -may be removed from between them more readily than elsewhere. - -349. _Operation._--The eleventh and twelfth ribs having been distinctly -traced, and the obliquity of their descent from the spine having been -clearly made out, the patient ought, if possible, to be placed on a -stool, with the upper part of the chest supported by a pillow on a -table before him. An incision should then be made over the intercostal -space between these ribs, three inches long and slightly curved, -through the integuments down to the latissimus dorsi muscle, and as the -mass of long spinal muscles is usually three inches in width, and can -in general be seen, the incision should commence two inches from but -between the spinous processes of the eleventh and twelfth vertebræ, -and be continued obliquely or diagonally downward in the course of the -interspace between these ribs. The latissimus dorsi and the serratus -posticus inferior muscles having been divided at the upper part where -they cover the longissimus dorsi or the long spinal muscular mass -alluded to, its edge becomes apparent; from this point the latissimus -and the serratus are to be further divided downward. The external -intercostal muscle being thus exposed, its fibers should be scratched -through or separated in the middle of the interspace between the ribs, -which can now be seen as well as felt. A director should be introduced -below the muscle, on which it may be carefully cut through, as well as -any fibers of the internal intercostal muscle which may extend as far -as the wound thus made. The pleura will then be exposed, and if the -cavity of the chest contain fluid in any quantity, it can scarcely fail -to project in such a manner as to convey to the finger the assurance -of its being beneath. An opening may then be carefully made into it at -the upper part of the incision close to the external vertical fibers -of the spinal mass of muscles, _at the moment of inspiration_, and -on the existence of fluid being ascertained by its discharge, the -opening should be enlarged by a director previously introduced under -the pleura, the patient being desired to draw a full breath at the -time, in order that the diaphragm may descend as low as possible. If -there should not be any fluid in the chest, the diaphragm, in ascending -during expiration, may be applied to the inside of the pleura lining -the chest as high even as the fifth rib, counting from above, and might -easily be divided with the pleura, if great care were not taken to make -the opening during the process of inspiration. - -In all cases of wounds of the chest, in which auscultation points out -the presence of a ball rolling loose on the diaphragm, this operation -should be performed for its removal, and may save the life of the -sufferer. It would, perhaps, have done so in the case of Sir Robert -Crawford. At a later period the presence of a foreign body, perhaps, -can only be known by the sounds or defect of sounds which may be -observed at the back part of the chest, in which the ball or other -foreign bodies lodge or become enveloped by matters confining them in -that situation. - - - - -LECTURE XXV. - -HERNIA OF THE LUNG, ETC. - - -350. _Hernia of the lung_, as a consequence of a wound in the chest -which has healed, is a complaint of rare occurrence. It appears to take -place when the intercostal muscles have been much injured and are -deficient, the opening through them being merely covered by the common -integuments which have yielded to the pressure exerted from within. It -has been supposed that it might be mistaken for the thinning of parts -from the formation of matter within, or empyema. The early occurrence -of the abscess after the receipt of the injury forbids the supposition, -while the ear, applied to the protruded part which is most prominent -during EXPIRATION or coughing, perceives not only a crepitation, felt -equally by the touch, but the natural respiratory murmur stronger, -softer, but less vailed and more like the sound given out by a -pulmonary lobule inflated close to the ear, but without enlargement of -the part. - -A portion of lung will sometimes protrude during the efforts made by -the sufferer to breathe, particularly in expiration, when the wound -is left open and the lung is sufficiently free to admit of it. When -protruded, it sometimes happens that the efforts of nature are not -sufficient for its retraction, and it remains filling up the opening -into the thorax. A large portion of lung is rarely protruded, except -through an opening which readily admits of its return; but when the -wound is small, the return of a portion of protruded lung, when it -is not positively strangulated, should not be interfered with. The -surface of the lung is but little sensible; touching it causes no -apparent pain, and its adhesion to the edges of the cut pleura is -more advantageous than its separation from it. It should, therefore, -be allowed to remain or be only so far returned, if it can be so -managed, as to rest within the edges of the divided pleura and fill -up the gap made by the incision, over which the integuments should be -accurately drawn and retained. The adhesion of the lung to the pleura -costalis arrests the inflammation, and may prevent its progress to -other parts of the cavity. That the inflammation may extend farther -into the substance of the lung, is possible, but when the sufferers -are otherwise healthy, the chance of evil from pneumonia is less than -from inflammation of the general cavity. Whenever the protruded lung -has been completely returned, more inflammation has followed than where -it has been allowed to remain under the precautions recommended. Three -cases were brought under my notice at Brussels, after the battle of -Waterloo, which were not interfered with, greatly to the advantage of -the patients. It is rare, however, to see a protrusion of the lung -after a gunshot wound. - -The protruded lung, when left uncovered and unprotected, soon loses its -natural brilliancy, dies quickly, shrinks, and becomes livid, without -being gangrenous. In such cases the protruded part may be removed, but -it should never be separated at its base from its attachment to the -pleura costalis by which it is surrounded. - -351. _Wounds of the diaphragm_ were known to the older surgeons -from the time of Paré; they were aware that these wounds were not -immediately, although generally, mortal. They knew that the viscera -of the abdomen did sometimes pass through such wounds into the cavity -of the chest, but they did not know that a wound of the diaphragm -never closes, except under rare and particular circumstances; that it -remains an opening during the rest of the life of the sufferer, ready -at all times to give rise to a hernia which may become strangulated -and destroy the patient, unless relieved by an operation as yet -unperformed, but to which attention is especially directed--a fact -first pointed out by me early in the war in the Peninsula. - -A soldier of the 29th Regiment was wounded at the battle of Talavera, -and died in four days after the receipt of the ball, which went through -the chest into the liver. I found, on examining the body, an opening in -the central part of the diaphragm of an oval shape, the edges smoothing -off as if they were inclined to become round; this opening was nearly -two inches long, evidently ready to allow either the stomach or the -intestines to pass through it on any exertion. - -Captain Prevost, aid-de-camp to Sir E. Packenham, was wounded by a -musket-ball, on the 27th September, 1811, on the heights of Saca Parte. -It penetrated the chest from behind, splintering the ninth and tenth -ribs of the left side, and made its exit a little below and to the -right of the xiphoid cartilage. A good deal of blood was lost from -the posterior wound, but he did not spit up any. He was carried to -Alfaiates, and there he threw up a small quantity of bloody matter by -vomiting. The posterior wound was enlarged and continued to discharge -some blood, the intercostal artery being in all probability wounded. -Sixteen ounces of blood were taken from the arm, giving great relief, -and the bowels were opened by the sulphate of magnesia. - -Sept. 29th.--Bleeding to eighteen ounces; on the 30th he was bled again -to thirty-two ounces, from which great relief was obtained; he fainted, -however, on making a trifling exertion to relieve his bowels. - -Oct. 1st.--Accession of symptoms as yesterday, relieved by bleeding in -a similar manner; bowels open. - -3d.--The inflammatory symptoms recurred this morning, and were again -removed by the abstraction of sixteen ounces of blood. Beef-tea. - -5th.--Passed a sleepless night, and was evidently suffering from -considerable internal mischief; wandered occasionally; pulse quick, -120, and small; felt very weak and desponding. A little light, red wine -given, with beef-tea and bread; opium night and morning. - -6th and 7th.--Much the same; pulse always quick, with much general -irritability. - -15th.--The wounds discharged considerably, particularly the posterior -one; has a little cough; pulse continues very quick; spasms of the -diaphragm troubled him for the first time, and caused great pain and -uneasiness; they were relieved by opium in large and repeated doses. - -On the 18th the spasmodic affection of the diaphragm and the pain -returned with great violence, so as to threaten his dissolution, which -took place on the 20th. - -On examination, I found that the ball had passed through the under part -of the inferior lobe of the left lung, and through the pericardium -under the heart, through the tendinous part of the diaphragm, and -into the liver, before it made its exit. The wound in the lung was -suppurating; the matter and fluid from the cavity of the chest had -a free discharge by the shot-hole; the edges of the wound in the -diaphragm were smooth as if cicatrized, leaving between them an -elliptical opening an inch long. The injury to the liver was through -the substance of the anterior part of its right lobe; the matter having -a free discharge, and generally slightly yellow, as if tinged with bile -in small quantity. The skin did not show a yellowish tinge, neither -were the conjunctivæ discolored. - -A soldier of the 23d Regiment was wounded at the same affair, by a -musket-ball, on the right side; it fractured the sixth rib, from three -to four inches from the sternum, and passed out behind, between the -ninth and tenth ribs, near the spine. The rib being fractured, the -splinters were removed after an enlargement of the wound by incision, -when the opening into the cavity of the chest was manifest, air being -discharged freely from it. The shock in the first instance was great; -but after a time reaction took place, and he lost a considerable -quantity of blood in six bleedings during the first sixty hours. The -discharge, at first serous and bloody, gradually became purulent, and -the occurrence of jaundice showed that the diaphragm and liver had in -all probability been injured. Under the administration of calomel, -antimony, and opium, this symptom was gradually disappearing, when I -left him to rejoin the army. He was sent to the rear at the end of ten -weeks nearly well. - -On the day preceding the battle of Fuentes d’Onor, in 1811, Sergeant -Barry was wounded in the chest. The ball entered close to the nipple -of the left breast, and passed out at the back, between the eighth and -ninth ribs. The anterior opening of the wound soon healed, but the -posterior one did not do so for a considerable period, when he became -affected by such severe cough, with expectoration, that his medical -attendant deemed it proper to reopen it. The symptoms were relieved, -and portions of his shirt and jacket were discharged. After this -his health improved so rapidly as to enable him soon to rejoin his -corps. The wound in the back repeatedly opened and healed--generally -at intervals of twelve or fourteen months; but for five or six years -it ceased to do so. His appetite was small and delicate; flatulence -was much complained of; and if the stomach at any time happened to be -overloaded, vomiting occurred. He died of mortification of the left -leg, January 4th, 1833. - -On examination, the whole of the stomach and the greater part of the -transverse arch of the colon were found in the left cavity of the -chest, having passed through an opening in the diaphragm extending -about three inches in a transverse direction, near the center of the -dorsal attachments of that muscle. The peritoneum lining the diaphragm -was firmly attached to the parts passing through it. - -The wound in this instance was through _muscular_, not tendinous parts. -The preparation is in the museum at Chatham, No. 63, Class 6. - -A French soldier was admitted into the Gensd’armerie Hospital at -Brussels, in consequence of a wound from a musket-ball, at the battle -of Waterloo, which entered behind between the eighth and ninth ribs, -near the spine, and lodged internally. After many severe symptoms -and much suffering, he died on the 1st of December, worn out by the -discharge, which often amounted to a pint daily, for the free exit of -which the external wound had been early enlarged. On examination, the -lung was slightly ulcerated on its surface, opposite to where the ball -had entered, and a little matter contained in a sac had formed between -it and the wall of the chest. That the ball had gone on was proved -by the fact of there being an opening in the tendinous part of the -diaphragm, through which a portion of the stomach had passed into the -chest, from which it was easily withdrawn. The ball could not be found -in the abdomen; in all probability, it had passed into the intestine -and had been discharged per anum, as has happened in other instances. - -James Wilkie, 12th Light Dragoons, aged thirty-four, was suddenly -attacked, at four P.M. of the 6th September, 1815, with violent pain -in the umbilical and epigastric regions, accompanied with nausea -and great irritability of stomach; pulse small, rapid, and regular. -Assistant-Surgeon Egan visited him half an hour after the attack, bled -him freely, and caused the abdomen to be fomented with hot water; a -large blister was applied to the seat of pain, an ounce of castor-oil -was given, and emollient and laxative clysters were occasionally -administered. At night the symptoms abated, and he slept about three -hours. The next morning his countenance exhibited that appearance of -haggardness and anxiety which have always been alarming indications; -pulse feeble and rapid; the pain severe; at noon he vomited from two -to three ounces of black, fetid blood in a fluid state; the pulse -became very feeble. At four P.M. the pain increased, he ejected from -his stomach from four to six ounces of dark, fluid blood that had less -fetor; and at six the same evening he expired in pain. - -This man, on the 18th of June, at Waterloo, received a punctured wound -from a sword, which entered about an inch below the inferior angle of -the scapula on the left side, penetrated the thorax, appeared to have -passed through the diaphragm, the point of the weapon coming out on the -opposite side of the chest between the first and second false ribs. The -wounds were quite healed, and he apparently enjoyed good health, when -he arrived from Brussels in August. - -_Appearances on dissection._--On opening the abdomen, the whole of the -intestines, with the exception of the duodenum, were in a high state of -inflammation. On tracing the duodenum upward a very small portion of -the stomach was found in its natural situation; while, on opening the -thorax, a large spherical tumor was seen in its left cavity, containing -two quarts or upwards of black, fluid, fetid blood. This sac was soon -seen to be the stomach, which had protruded through the aperture in -the diaphragm, by which it was so firmly embraced as to render the -communication between the portion of the stomach in the thorax and -that in the abdomen impervious to each other. The hernial sac and its -contents were supported by the diaphragm. The left lung exhibited a -shriveled, contracted appearance, as if its function had been impeded -by the pressure of the sac and its contained fluid. The cicatrix and -the course of the sword were well marked. The cardiac and pyloric -orifices of the stomach were in the natural cavity. - -S. Fletcher, 31st Regiment, wounded at Sobraon on the 10th of February, -1846; died at Chatham, February, 1847. On opening the thorax, the -greater part of the stomach, and a foot and a half of the transverse -arch of the colon, with the omentum attached, were found in the left -pleural cavity. There was an opening in the diaphragm with a rounded -margin two inches and a half in diameter, two inches to the left of the -œsophagus. The stomach, colon, and omentum adhered firmly, at one part, -to the pleura covering the diaphragm and lining the ribs to the extent -of a few inches, although otherwise loose and free in the cavity. The -parts in the aperture of the diaphragm were free from adhesions, and -the finger passed easily through the opening from below upward. Two -cicatrixes were to be seen on the left side of the chest--one between -the eleventh and twelfth ribs, close to the transverse processes of the -vertebræ; the other between the eighth and ninth ribs, three inches and -a half from the cartilages. The preparation is in the museum at Chatham. - -352. These cases confirm the fact that wounds of the diaphragm, whether -in the muscular or the tendinous part, never unite, but remain with -their edges separated, ready for the transmission between them of any -of the loose viscera of the abdomen which may receive an impulse in -that direction. That parts of these viscera do pass upward and back -again, cannot be doubted; and it is probable that incarceration may -take place for a length of time before strangulation occurs from some -sudden and distending impulse giving rise to it. - -When the solid viscera of the abdomen are injured, as well as the -diaphragm against which they are applied in their natural situation, -the wound may sometimes be considered a fortunate one; for the liver or -spleen may adhere to the opening in the diaphragm and fill up the space -between its edges. - -A wound of the diaphragm may be suspected from the course of the -ball, particularly when it passes across the chest below the true -ribs. It is necessarily accompanied by an opening into the cavity -of the abdomen, and is by so much the more dangerous. The symptoms -will partake of an injury to both, although they are principally -referable to that of the chest, and are those of intense inflammation, -accompanied by a difficulty of breathing, which in the case of Mr. -Drummond was a peculiar sort of jerk; in that of Captain Prevost it -was more spasmodic. The risus sardonicus, hiccough, pain on the top -of the shoulder, and loss of power of the arm, which were all more or -less present, in all probability depended on some larger fibrils of the -phrenic nerve being wounded. The treatment should be antiphlogistic, -with a free external opening for the discharge of matter. The accession -of jaundice shows an injury to the liver; vomiting of blood or its -passage per anum indicates a wound of the stomach or intestines. - -353. When the patient recovers, the probability of a hernia taking -place into the chest through the diaphragm should be explained to him. -If any reason should exist for the belief that it had occurred, he -should be doubly cautious as to eating and drinking in small quantities -only, and remaining in the erect position for some time after each -meal; he should carefully avoid a stooping posture and all muscular -exertion or straining. If symptoms of strangulation should come on, an -opening made into the abdomen would appear to offer the only chance -for life. The hernia may perhaps be drawn back into its place in the -abdomen; but if firm adhesions have formed between the protruded parts -and the edges of the opening in the diaphragm, the case must be treated -as one of adherent strangulated rupture in any other part, by a simple -division of the stricture in the most convenient situation. The opening -should be a straight incision through the wall of the abdomen, large -enough to admit the hand, immediately over the part where the diaphragm -is supposed to be injured. It should be closed by a continuous suture -through the skin. This operation, now for the first time recommended, -although apparently formidable, cannot be compared as to danger with -the incisions of twelve and fourteen inches long through the wall of -the abdomen, which have been in some instances successfully made for -the removal of diseased ovaria. - -354. _Wounds of the heart_ are for the most part immediately fatal. -Many persons have, however, been known to live for hours, nay days, -and even weeks, with wounds which could scarcely be otherwise than -destructive; and several cases are recorded in which the cicatrixes -discovered after death, in persons known to have been wounded in the -vicinity of the heart, have shown that even severe wounds of that most -important organ are not necessarily fatal. As our knowledge of the -nature of the injury inflicted can never be distinct, it follows that -every wound should be considered as curable until it is unfortunately -proved to be the contrary. - -355. _Auscultation_ and _percussion_, and principally auscultation -of the whole precordial region, have afforded means of judging of -injuries of the heart which were not formerly known. A vertical line, -coinciding with the left margin of the sternum, has about one-third of -the heart, consisting of the upper portion of the right ventricle, and -the whole of the left, on the left. The apex of the heart beats between -the cartilages of the fifth and sixth left ribs, at a point about two -inches below the nipple and an inch on its external side; or, if one -leg of a compass be fixed at a point midway between the junction of the -cartilage of the fifth rib on the left side with the rib and sternum, -and a circle of two inches in diameter be drawn around, it will define -as nearly as possible the space of the precordial region occupied by -the heart while uncovered, except by the pericardium and some loose -cellular texture. In the rest of the precordial region it is covered, -and separated from the walls of the chest by the intervening lung. - -If the chest of the dead subject be transfixed with long needles, -it will be found that the center of the first bone of the sternum -corresponds with the lower edge of the left subclavian vein and to -the arch of the aorta crossing the trachea, the center of the second -bone to the upper edge of the appendix of the right ventricle, and -the center of the third bone to the right side of the right auricle, -the right ventricle being lower down. A needle penetrating the chest -at the costal extremity of the fifth rib, close to the upper edge of -its cartilage, will touch the septum of the ventricle. The apex of the -heart is an inch and a half below this, and inclined to the left side. - -The semilunar valves of the pulmonary artery correspond to a spot a -little below the center of the third bone of the sternum. The aortic -valves are a few lines below and behind the pulmonary. The mitral -valves are a little lower, and still more deeply seated. The pulmonary -artery, after touching the sternum, inclines to the left, and is found -close to the sternum between the second and third ribs. The aorta -ascends to the first bone, and crosses it to form the arch. - -One-third of the heart, consisting of the upper part of the right -ventricle and of the whole of the right auricle, is beneath the -sternum; the remainder of the right, with the left ventricle and -auricle, are to the left side of that bone. - -356. On applying the ear to the precordial region, the patient being -in the erect position, two sounds are distinguishable in a healthy -heart--one duller and more prolonged, the other clearer and shorter; -between these there is scarcely an appreciable interval. The period of -repose is sufficiently marked before the first or duller sound returns. -Of the time thus occupied, one-half is filled up by the first or dull -sound, one-quarter by the second or sharp sound, one-quarter by the -pause or period of repose. - -Twenty-nine theories have been proposed, each accounting for the sounds -of the heart. The theory of Dr. Billing appears to prevail at present, -which supposes that the sounds thus heard “are caused by the valves, -which, being membranous, each time they resist the reflux of the blood -are thrown into a state of sudden tension, which produces sound.” - -The impulse of the heart, as far as it can be felt by the touch, -depends much on the position in which the body is placed. In the -erect position, it is heard between the fifth and sixth ribs. In -the recumbent posture, the impulse is almost imperceptible. It is -perhaps more observable when the body is turned on the right side, -but decidedly more so when it is turned on the left. A clearer sound -proceeds from a thin, and a duller sound from a thick heart; a sound of -greater extent from a large heart, and a sound of less extent from a -small one. A more forcible impulse is given by a thick heart, and one -more feeble by a thin one; the impulse is conveyed to a longer distance -from a small heart. - -From a clearer sound we believe in the probability of an attenuated -heart, but we argue its certainty from a clearer sound joined with -a weaker impulse. A stronger impulse denotes the probability of a -hypertrophied heart, but we argue its certainty from a stronger impulse -with a diminished sound. - -The terms endocardial and exocardial are used to designate the -alterations which take place in the sounds of the heart under -disease--endocardial when they occur within the heart, and exocardial -when they take place upon its surface. The endocardial murmur of -disease, or bellows-sound, takes the place of and is substituted in -certain cases for the first or second, or even for both the healthy -or normal sounds. The exocardial murmur of disease is heard with the -normal sounds, but confusing and overpowering, sometimes overwhelming, -them by its rubbing or crumpling noise. The natural sounds exist, -although rendered imperceptible by the greater distinctness and nearer -approach of the unnatural or unhealthy ones. - -The heart apart from the pericardium never moves without a sound; the -pericardium apart from the heart never gives out one. Under disease -the heart gives out the natural sound, diminished, exaggerated, or -modified, or it may be totally altered. The sounds given out by a -diseased pericardium must always be new, (there being no old ones,) -and are described as rubbing, or to-and-fro sounds. The pleura, when -diseased, being a serous structure, like the inner membrane of the -pericardium, gives out less marked but somewhat similar sounds (the -“_frottement_” of the French) in particular stages of disease. - -The alterations in the ordinary sounds constituting the endocardial -murmurs of the heart under disease depend principally on the altered -state of the endocardium, or membrane lining its cavities; the sounds -given off, and called exocardial, on an altered state of the serous -membrane of the pericardium, reflected over the outer surface of the -heart. The endocardial or bellows-sound, when it accompanies the -normal sounds of the heart, may result from any kind of derangement -affecting the internal membrane of that organ, particularly rheumatic -inflammation, or from any force which may compress its cavities; or -it may depend on the altered quality of the blood, from anemia. It -should be present after excessive hemorrhages have greatly reduced -the powers of the sufferer. When this murmur or sound occurs after -injury in the vicinity of the heart, and is accompanied by fever, it -indicates inflammation of the lining membrane, although no local pain, -no palpitations, no irregular movements of the heart be present. - -When a murmur or sound is heard of a different kind, possessing the -character of friction, of surfaces moving backward and forward on each -other, or to and fro, it is the sign of inflammation of the membrane -covering the heart, as well as of that lining the fibrous external -tissue of the pericardium. The signs of both external and internal -inflammation may be present at the same time, and they frequently are -in cases of acute rheumatism. - -357. When the heart is supposed to be wounded, even without much loss -of blood, there is fainting; palpitation; irregular movement or total -cessation of its action; coldness of the extremities; ghastliness -of countenance, succeeded by great anxiety; a sense of anguish; an -intermission or cessation of pulse, followed, if the patient should -survive, by reaction, which renders it very frequent and sometimes -increases its impulse; while the anxiety is increased by pain, -sometimes intolerable, referred to the part. These symptoms imply a -serious injury, although they may not all be present, and many of them -differ in intensity. If the patient should survive, the ordinary sounds -of the heart will return, with more or less irregularity, accompanied -after a few hours by the endocardial murmur, although something like -it may perhaps be observed from the first period of injury. The -friction or attrition sound, indicating the presence of inflammation -of the pericardium, may be absent; it will not be discernible, if a -layer of blood be effused into the cavity of that membrane; while -the natural sounds of the heart are rendered more indistinct as the -heart is separated from the walls of the chest by the effusion which -distends the pericardium, and impedes the regular action of the heart, -but cannot compress it, as an empyema does the lung. If inflammation -take place without an effusion of blood, the friction sound will be -heard, and will usually continue even after some effusion of serum and -of lymph has occurred, as the quantity of serum secreted is rarely -sufficient to prevent the effused and attached portions of lymph from -rolling against each other. - -The presence of a larger quantity of fluid may be more distinctly -known by percussion, if it can be borne in cases of injury, the -degree and extent of the dullness being the measure of its existence -and accumulation. It may extend over a part or over the whole of the -precordial region, reaching as high as the second, or even the first -rib, beneath the sternum, and even under the cartilages of the ribs of -the right side. - -358. That the heart when wounded is capable of recovery by the -permanent closure of the wound, in a few rare instances, is -indisputable; and it would seem, from a consideration of the different -cases which have been recorded, that such recovery takes place in -consequence of there being but little blood discharged through -the wound, or into the cavity of the pericardium, or into that of -the pleura. The absence or the cessation of the hemorrhage by the -contraction of the wound, or the formation of a coagulum, is the first -step toward a cure, and it was to one or other of these circumstances -that most of those who survived the injury for several days or weeks -owed their existence for the time, although they usually died from the -effects of inflammation, more of the inner lining and outer covering -than of the substance of the heart itself. - -If the wound be inflicted by a musket or pistol-ball, it cannot be -closed, although pressure may be made upon it for a time, so as to -suppress the external flow of blood. If this should succeed, it is more -than probable that the hemorrhage will continue internally, and that -the patient may die after much suffering, principally from oppression, -caused by the escape of blood into the cavity of the chest. - -If the wound be a stab, the external opening may be accurately closed, -and the escape of blood prevented; but as the pressure of the blood -in the pericardium is unequal to restrain the action of the heart, -blood forced out through the opening fills the cavity of the pleura, -and causes suffocation, unless from some accidental circumstance the -opening in the heart becomes obstructed, and the bleeding ceases. - -If all the circumstances be considered, there can be no doubt of the -propriety of closing the wound in the first instance, if the flow of -blood be excessive and appear likely to endanger life. It seems to be -as little doubtful that the wound should be reopened after a time, -if the danger from suffocation be imminent. The relief obtained by -the escape of a little blood may be efficacious, while it does not -necessarily follow, although it is more than probable it will be so, -that its place will be occupied by a further extravasation of blood, -which will prove fatal. It is a choice of difficulties, and death from -hemorrhage is easier than death from suffocation. - -In the case of the Duc de Berri, whose right ventricle was wounded, -and who died from loss of blood, Steifensand reprehends Dupuytren -for having opened the external wound every two hours, to prevent -suffocation; but if death were actually impending from the filling of -the cavity of the chest being about to cause suffocation, there was -nothing to be done but to give relief at all hazards. - -359. When the sufferer has recovered from the imminent danger attendant -on the infliction of the injury, and the pericardium is believed to -be so full of blood or of serum as to prevent in a great measure the -movements of the heart, it has been proposed by Baron Larrey to open -the pericardium by the following operation--equally, as he thinks, -applicable in an ordinary case of hydrops pericardii:-- - -“An oblique incision is to be made from over the edge of the ensiform -cartilage, to the united extremities of the cartilages of the seventh -and eighth ribs. The cellular tissue being divided with some fibers of -the rectus and external oblique muscles, there remains only a portion -of the peritoneum called its false layer, above the pericardium, which -can be seen after the division of all the intervening cellular tissue, -projecting between the first and second digitations of the diaphragm. -Into this the bistoury is to be entered, with the precaution of doing -it with the edge turned upward, and directed a little from right to -left, to avoid the peritoneum. The smallest portion possible of the -anterior border of the diaphragm is next to be divided, where it is -attached to the inner part of the cartilage of the seventh rib. The -internal mammary artery is to the outside. The patient should be placed -perpendicularly, and supported on his bed, which inclines the anterior -part and base of the pericardium to the fore part of the chest.” - -Skielderup recommends this operation to be done by first trepanning the -sternum a little below the spot where the cartilage of the fifth rib -is united to that bone, at which part the periosteum lining it offers -considerable resistance, and should not be divided by the trephine. -Below this there is a triangular space formed by the separation of the -layers of the mediastinum, free from cellular tissue, and tending a -little more to the left than to the right. The apex of this triangle is -opposite the fifth rib; its base touches the diaphragm. The bone having -been removed, the patient is made to lean forward, when the projection -of the pericardium will enable the operator to feel that a quantity of -fluid is within, and to open it with safety. - -360. J. Dierking, a stout, muscular man of the 3d Regiment of German -Hussars, was wounded at the battle of Waterloo by a lance, which -penetrated the chest between the fifth and sixth ribs, and was then -withdrawn. He fell from his horse, lost a good deal of blood by the -mouth, and some by the wound, and was carried to Brussels without any -particular attention being drawn to the injury. His strength not being -restored, while he suffered from palpitations of the heart, and other -uneasy sensations in the chest, he was sent to England to be invalided; -and in November, 1815, was admitted into the York Hospital, Chelsea, in -consequence of an attack of pneumonia, of which he died in two days, -without attention being particularly drawn to the cicatrix of the wound. - -On examining the body, I found that the lance, having injured the edge -of the cartilage of the rib, passed through the inferior lobe of the -left lung, the track being marked by a depressed, narrow cicatrix. It -then perforated the pericardium under the heart, and sliced a piece of -the outer edge of the right ventricle, which, being attached below, -turned over and hung down from the heart to the extent of two inches, -when in the fresh state, the part of the ventricle from which it had -been sliced being puckered and covered by a serous membrane like the -heart itself. The lance then penetrated the central tendon of the -diaphragm, making an oval opening, easily admitting the finger, the -edges being smooth and well defined. It then entered the liver, on the -surface of which there was a small, irregular mark or cicatrix. The -heart in front was attached to the pericardium by some strong bands, -the result of adhesive inflammation, but the general appearance of -the serous membrane showed that this had not been either great or -extensive. The pericardium was not thickened. - -If this man had lived long enough, he might have furnished an instance -of hernia of the stomach or of intestine into the pericardium. The -preparation is in the military museum at Chatham, Class 1, Div. 1, -Sect. 7, No. 156. - -[Illustration: - - _a_, right ventricle; - _b_, left ditto; - _c_, right auricle; - _d_, left ditto; - _e_, aorta; - _f_, pulmonary artery; - _g_, coronary ditto; - _h_, a portion of the cartilages of the ribs seen on the inside; - _i_, a portion of the diaphragm; - _k_, the pericardium. - - 1, a portion of the pericardium reflected to show abnormal adhesions - to the surface of the heart; - 2, aperture of wound through the diaphragm and the pericardium; - 3, pendulous slice off the substance of the right ventricle; - 4, puckered cicatrix of the wound of the ventricle.] - -That the heart, when exposed, is insensible, or nearly so, to the -touch, was known to Galen and to Harvey. Galen is said to have removed -a part of the sternum and pericardium, and to have laid his finger -on the heart. Harvey did the same to the son of Lord Montgomery, who -was wounded in the chest. Professor J. K. Jung not only introduced -needles into the hearts of animals, but also galvanized them without -disadvantage, although Admiral Villeneuve is supposed to have died -suddenly from running a long pin into his heart, which scarcely left -the mark of its entrance. - -That persons may die from the shock of a blow on the heart, need -not be doubted, and that they do die when little blood is lost, is -admitted. History preserves the fact that Latour d’Auvergne, Captain of -the 46th demi-brigade, who had obtained the honorable title of “Premier -Grenadier de France,” fell and died immediately after receiving a wound -from a lance at Neustadt, in the month of July of the sixth year of the -Republic; it struck the left ventricle of the heart near its apex, but -did not penetrate its cavity. He was, however, sixty-eight years of age. - -361. In wounds of the heart, all extraneous matters should be removed, -if possible, and all inflammatory symptoms should be subdued by general -bleeding, by leeches, by calomel, antimony, opium, etc. The chest -should be examined daily by auscultation. If the cavity of the pleura -should fill with blood, it ought to be evacuated to give a chance for -life, and if the pericardium should become permanently distended by -fluid, it should be evacuated. - -_Lacerations and ruptures of the heart_ have frequently taken place -from blows or other serious contusions. - -Ollivier, who devoted much time to reading and collecting the -observations made by different writers on the injuries of the heart, -says: “That of forty-nine cases of spontaneous rupture of the heart, -thirty-four were of the left ventricle, eight only of the right, -two of the left auricle, three of the right, and that in two cases -both ventricles were torn in several places; and that these results -were in an inverse proportion to those which occurred after blows or -contusions; the right ventricle being ruptured in eight out of eleven -cases, the left ventricle three times; the auricles being also torn in -six of these eleven cases; the ruptures not being confined to one spot, -but taking place occasionally in several different parts, or even in -the same ventricle.” In eight of these cases he had noticed, the heart -was ruptured in several places. That a spontaneous rupture may be cured -as well as a wound, seems likely, from a case reported by Rostan, of -a woman who died after fourteen years’ suffering with pain about the -heart, and was found to have the ventricle ruptured. A cicatrix was -observed to the left side of the recent rupture, half an inch in extent -in every direction, in which the new matter was evidently different -from the natural structure of the heart. - - - - -LECTURE XXVI. - -WOUNDS OF THE INTERNAL MAMMARY ARTERY, ETC. - - -362. _Wounds of the internal mammary and intercostal arteries_ have -so much occupied the attention of theoretical surgeons, and so many -inventions have been broached for the suppression of hemorrhage, -particularly from the latter, that it becomes consolatory to know that -bleeding from these vessels rarely takes place; that the inventions -are more numerous than the case requiring them, and that no notice -need be taken of them, they being as unnecessary as they are useless. -I have never had occasion to see a distinct case of hemorrhage from an -internal mammary artery, but if bleeding should take place from a wound -in its neighborhood, of a nature to lead to the belief that it came -from this vessel, the wound should be enlarged until the part whence -the blood flows can be ascertained, when, if it be from that artery, -the vessel should be twisted or secured by ligatures, and if these -methods should be impracticable, the wound should be closed and the -result awaited. - -The following method of operating for the application of a ligature on -this vessel has been proposed by M. Goyraud. It may be done with ease -in the three first intercostal spaces, it offers some difficulties -in the fourth, is very difficult in the fifth, and is scarcely to be -done lower down. An incision two inches in length is to be made near -the side of the sternum from without inward, at an angle of forty-five -degrees with the axis of the body. The middle of this incision should -be three or four lines distant (a quarter of an inch) from the bone, -and in the center of the intercostal space, within which the vessel -is to be found. The skin, cellular substance, and the great pectoral -muscle having been divided, the aponeurosis of the external intercostal -muscle with the muscular fibers of the inner intercostal muscle are to -be separated and torn through with a director, until the artery and its -two venæ comites are laid bare at the distance of three lines from the -edge of the sternum, lying before the fibers of the triangularis sterni -muscle, which separates these vessels from the pleura. A bent probe, or -other proper instrument, can then be readily passed under the artery. -The vessel can only be secured in this way when injured at the upper -part of the chest; below this it must bleed into the cavity, unless -there be an open wound. - -363. The _intercostal artery_, although often injured, rarely gives -rise to hemorrhage so as to require a special operation for its -suppression; but whenever it does so happen, the wound should be -enlarged so as to show the bleeding orifice, which should be secured by -one ligature if distinctly open, and by two if the vessel should only -be partially divided. The vessel is sometimes so small as to be easily -twisted, or its end sufficiently bruised as well as twisted, to arrest -the hemorrhage. It lies between the two layers of intercostal muscles, -and in the middle of the ribs it runs in a groove in the under part of -each. - -I have had occasion to twist and bruise the end of an artery bleeding -in an intercostal space, and I have tied the vessel under the edge of -the rib; but I have not met with any of the great difficulties usually -said to be experienced in suppressing a hemorrhage from this artery, -when the wound was recent, and the parts were sound; no reliance should -be placed on the hypotheses often entertained on this subject. - -When the parts are unsound, and the hemorrhage is secondary, greater -difficulty is sometimes experienced in arresting it, because the -ligature easily cuts its way through the softened parts, and styptics -are liable to fall into the cavity of the chest. - -The late General Sir G. Walker, G.C.B., after scaling the wall of -Badajos, with the fifth division, was wounded by a musket-ball, which -struck the cartilages of the lower ribs of the right side, broke the -bones, penetrated the chest, and then passed outward. He remained in -Badajos under my care during the first three weeks, with many of the -other principal officers who were wounded; and overcame the first -inflammatory symptoms in a satisfactory manner. After I left him the -wound sloughed, some part of the cartilages separated, and one of the -intercostal arteries bled, although the bleeding was arrested once by -ligature, and afterward, on its return, by different contrivances; each -time it reappeared his life was placed in considerable jeopardy from -it and the discharge from the cavity of the chest, which was profuse. -The bleeding was ultimately arrested by the oil of turpentine, applied -on a dossil of lint, and pressed on the bleeding spot by the fingers -of assistants until the hemorrhage ceased. He recovered after a very -tedious treatment, with a considerable flattening of the chest, and a -deep hollow at the lower part of the side, whence portions of the rib, -and of the cartilages had been removed. - -A young man, aged fifteen, was wounded by small shot in the chest, -between the first and second ribs, and near the sternum, at the -distance of about forty-eight paces. He ran about six hundred paces, -fell, and died thirty-eight hours afterward. On opening the injured -cavity of the thorax, it was found to contain twenty-eight ounces -of blood, the lung having collapsed to one-fourth its natural size. -An opening on its upper part corresponded to the external one in -the paries; but the track of the shot could not be traced into its -substance for more than two inches and three-quarters; a lacerated spot -was, however, perceived at the lower edge of the sixth rib, about two -inches from its head, at which part the intercostal artery was found to -be torn through; the shot could not be found, and there was no opening -in the skin behind. - -The discussions which took place on this case led to the statement of -an anatomical fact--that when a man is standing erect, a line drawn -horizontally from the upper border of the second rib in front would -touch the upper edge of the fifth rib behind, and that very little -inclination, viz., an inch and a half, was necessary to make the shot -wound the intercostal artery of the sixth. Auscultation would have -made known the extravasation, and relief might have been given by an -incision over the spot where uneasiness was felt; for the loss of blood -was not sufficient of itself to destroy life, unless some other injury -had been sustained, which was not perceived. - -364. _Wounds of the neck_ which are made with swords, or by knives -or razors, by persons attempting to destroy themselves, are to be -treated on two great principles. The _first_ is, not to place the -parts in contact until all hemorrhage has ceased, lest the patient -be suffocated. In the mean time, while any oozing continues, a soft -sponge should be placed between the edges of the cut. When the larynx -or trachea is obstructed by a quantity of blood, it may be sucked out, -or drawn up by an exhausting pump, and it may be advisable in some -cases to introduce a tube. If the trachea be cut across, a stitch -will be necessary to keep the ends in contact. The _second_ is, to -keep the divided parts in contact afterward, by position and bandage, -but not _by suture_. If the œsophagus be wounded, nourishment should -be administered by a gum-elastic tube introduced through the nares -into the stomach. It is almost unnecessary to add that the artery, if -wounded, should be secured by ligature. A hole in the internal jugular -vein may be closed by a thread passed around it when raised by a -tenaculum. - -Captain Hall, of the 43d Regiment, was wounded by a ball which passed -between the upper part of the back of the larynx and the termination of -the pharynx, without causing much further inconvenience than the loss -of voice. In this instance it must have been the superior laryngeal -nerve that was injured, and not the recurrent, yet the voice could only -be heard in a whisper, and was not completely recovered for years. If a -ball should lodge in the trachea, it must be removed by the operation -of laryngotomy or tracheotomy, if the original wound cannot be -enlarged; although Birch, says Christopher Wren, hung up a man wounded -in this way by the heels, when the ball dropped out through the glottis -and mouth. General Sir E. Packenham, who was killed at New Orleans by -a ball which went through the common iliac artery, had been twice shot -through the neck in earlier life. The first shot, which went through -high up from right to left, turned his head a little to the right. -The second shot, from left to right, brought it straight. My kind and -excellent friend had ever afterward a great respect and regard for the -doctors and a strong feeling for the wounded. The recollection of that -regard, and the advantages derived from it, have made me sometimes -think it might be advantageous for the unfortunate as well as for the -doctors if every general could be at least shot once through the neck -or the body, before he was raised to the command of an army in the -field; for there is nothing like actual experience of suffering to make -men feel for their fellow-creatures in distress. A Minister at War -would not perhaps be the worse for a little personal experience in this -matter. - -365. _Wounds of the face_ made by swords or sharp-cutting instruments -should be always retained in contact by sutures. When the cut is of -small extent, and not deep, the skin only should be included by the -thread, and that in the slightest possible manner, and the part -supported by adhesive plaster and bandage. When the cheek is divided -into the mouth, one, two, or more sutures may require to be inserted -more deeply, but the deformity of a broad cicatrix will in general be -avoided, by carefully sewing up the whole line, taking the very edge -of skin only; and a cut in the bone or bones of the cheek should not -prevent the attempt being made to unite the external wound over it. - -Incised or even lacerated wounds of the eyelids and brows should be -united by suture, as far as can possibly be done in the first instance, -by which a subsequent painful operation may be avoided; great care -should be taken in doing this; the suture must be inserted through -the eyelid, and a leaden thread is often the best, the first being -introduced at the very edge of the lid, and two, or as many more -afterward as may be necessary. They may remain for three or more days, -as circumstances seem to require. If the eye be wounded, any part -protruding beyond the sclerotic coat should be cut off with scissors; -but the eye, however injured, should not be removed unless the ball -be detached in every direction, or destroyed. The treatment should -be strictly antiphlogistic, in order to prevent suppuration of the -eyeball, which may in general be effected, if too much injury have -not been done to it, and if the treatment be sufficiently decided and -well continued. These observations apply to the nose and ears, and -all parts not actually separated--or, if separated, for a short time -only--should be replaced in the manner directed, and every attempt -made to procure reunion. If this should fail, surgery may yet be able -to yield assistance by replacing the loss by a piece of integument -dislodged from the neighboring parts--a proceeding requiring a separate -consideration. Injuries from musket-balls are often attended by -considerable laceration, particularly when near the eyelids. Whenever -this occurs, the parts likely to adhere should be brought together by -suture, after any splinters of bone which may present themselves, or -can be seen or felt, have been removed from the holes made by the ball. -If the bones should be broken, and not splintered, they will frequently -reunite under proper management. - -366. _Wounds of the eye_ from small shot are remediable when these -small bodies lodge in the cornea or sclerotica, whence they may be -removed by any sharp-pointed instrument. When a shot or piece of a -copper cap is driven through the cornea, into the iris, or lies in the -anterior chamber, it should be removed by an incision to the extent of -about one-fourth or one-fifth of the cornea, near its junction with the -sclerotica, but in these cases a cataract, if not amaurosis, frequently -results. When the shot passes through all the coats of the eye, it -can neither be seen nor removed with safety; vision will be lost, -much pain may be endured, and the eye will frequently be destroyed by -suppuration, or by a gradual softening, and ultimate diminution in -size. A contused wound from a large shot which only injures the coats -of the eye, but does not perforate them, will oftentimes be cured by -a proper antiphlogistic treatment, which in all cases should be most -strictly enforced, although loss of sight is a frequent consequence -after such injuries. - -When a ball lodges behind the eye, it usually causes protrusion, -inflammation, and suppuration of that organ. If it be not discovered -by the usual means, its lodgment may be suspected from the gradual -protrusion and inflammation of the eye itself. If it be discovered, -it should be removed together with the eye, if such proceeding be -necessary for its exposure. If suppuration have commenced in the -eye, a deep incision into the organ will arrest, if not prevent, the -horrible sufferings about to take place, and allow of the removal of -the offending cause. If the eye remain in a state of chronic disease -and suffering, a similar incision will give the desired relief. If the -chronic state of irritation affect the other eye, the incision and -sinking of the ball of the one first affected or injured is urgently -demanded, and should not be delayed. If the back part of the eye be -left with the muscles attached to it, a stump remains, against which an -artificial eye may be fitted, so as sometimes to render the loss of the -natural one almost unobservable. - -367. I have several times seen both eyes destroyed and sunk by one -ball, with little other inconvenience to the patient; one eye sunk, -the other amaurotic, and both even amaurotic, almost without a sign -of injury, by balls which had passed from side to side through both -orbits, but behind the eyes. When the eye becomes amaurotic from a -lesion of the first branch of the fifth pair of nerves, the pupil does -not become dilated; the iris retains its usual action, although the -retina may be insensible and vision destroyed. This was well shown in -the case of the late Major-General Sir A. Leith, who was wounded by -a sword in the forehead, this nerve being divided. It has so often -occurred as to leave no doubt of the fact, and of the error formerly -existing on this point. - -368. Penetrating wounds implicating the bones of the face are always -distressing. When the bones of the nose are carried away, there must -always be some deformity remaining, although there is oftentimes but -little suffering. When these bones are merely splintered and depressed, -great pains should be taken to keep them properly elevated. If the -duct of the parotid gland be implicated by an incised wound, care -should be taken to divide the cheek into the mouth, if it should not -have been already done, and to keep the incised wound open until the -external one is closed. If a salivary fistula have formed externally, -from inattention or otherwise, it must be treated according to the -ordinary methods adopted in such cases. When a wound of the gland -itself becomes fistulous, and weeps, which is a rare occurrence, it -will be best treated by actual or potential cauterization, if moderate -pressure should fail. When these wounds are of some extent, they are -often followed by partial paralysis, in consequence of the seventh -pair of nerves being injured, when the mouth is drawn somewhat to the -other side. When the lachrymal bones or sac are injured by balls or -swords, the tears usually continue through life to run over, and give -inconvenience, although much good may be done by early attention to the -injuries of this part. Wounds injuring the upper jaw are oftentimes -followed by much suffering, and by permanent inconvenience. - -General Sir Colin Halkett, G.C.B., was wounded on the 18th of June, at -Waterloo, when in front of his brigade, which was formed in squares -for the reception of the French cavalry, by a pistol-ball, fired by -the officer commanding them, which struck him in the neck, and gave -him great pain, but without doing much mischief. A second shot shortly -afterward wounded him in the thigh, and he was obliged to leave the -field toward the close of the day, by a third musket-ball, which struck -him on the face, when standing sideways toward the enemy. It entered -a little below the outer part of the cheek-bone on the left side, -and, taking an oblique direction downward and forward, shattered and -destroyed in its course several of the double teeth in the upper jaw, -fracturing the palate from its posterior part, forward to the front -teeth. The ball then took a direction obliquely upward, destroying -the teeth of the opposite side of the upper jaw, which bone it also -broke, and lodged under the fleshy part of the cheek. These wounds gave -great pain, and until the ball was removed, the left ear was totally -insensible to sound and all external impressions, although the general -suffered much from distressing noises in his ear. These subsided on the -removal of the ball some days afterward. - -The treatment of this wound, however, was most painful; the extraction -of several pieces of bone was necessary at different times, during -the three following years, before the wounds were finally closed. -Considerable derangement of health followed, the deafness remains; and -the general has ever since been subjected to attacks in the head of an -increasing and most distressing nature. - -369. Wounds of the lower jaw are perhaps more common, and are certainly -more troublesome than those of the upper; they are more difficult of -management, and, for the most part, end in greater deformity, unless -particular care be taken to prevent it, and then only in very severe -cases, by operations which were formerly not in use, but which the -intrepidity of the surgeons of the present day have deprived of all -their terrors. I mean the methodical division of the soft parts, -the sawing off and removal of the broken pieces of bone, and the -rounding off of those parts of the jaw which may remain irregular and -pointed. M. Baudens has given two good examples of the success of -this proceeding during his campaigns in Algeria. In the first case, -the ball entered at the middle of the left cheek, and came out by the -side of the spinous process of the seventh cervical vertebra. The -ascending ramus of the lower jaw was broken into numerous splinters. -M. Baudens divided the soft parts down to the bone, entering the -straight bistoury four lines, or the third of an inch, below the -articulation of the jaw with the temporal bone. He then carried it -downward, and a little obliquely forward, so as to terminate it in the -fibers of the masseter muscle, about half an inch below the base of -the bone. This incision was begun below the seventh pair of nerves, -and exposed the parotid gland divided vertically at its middle part. -The splinters were removed, a part of the pterygoideus internus muscle -was divided, and a projecting point of bone attached to it sawn off. -He then separated the attachments of the buccinator, temporal, and -pterygoideus externus muscles, divided the ligaments, and removed the -coronoid and articulating processes, taking care to avoid the fifth and -seventh pairs of nerves. The bleeding from two arteries was suppressed -by twisting their ends; and the parts were afterward brought together -by sutures, which remained for eight days. A month after the operation -the patient ate solid food, and in six weeks was cured. In the second -case, the ball entered near the left commissure of the lip, and came -out behind on the side of the middle of the neck; three inches of the -jaw were splintered, the ends of the bone being sharp and angular. In -order to remove the splinters, and to prevent the evils anticipated, -M. Baudens divided the lip from the angle downward and outward, below -the base of the bone, as far back as the edge of the masseter muscle. -He then separated the flaps, and sawed the jaw across, first near the -symphysis, and then behind, outside the attachment of the masseter. The -facial artery was twisted, four sutures were inserted, and the jaw duly -supported. The patient was bled twice, and in six weeks was cured; at -the end of that time he could eat solid food. After the healing of such -wounds, mechanical means are often necessary to enable the sufferer -to eat and to live without causing disgust to his neighbors and his -friends. - -It is said there are fifteen men in the Hôtel des Invalides, in Paris, -wearing silver masks on the lower part of their faces, in consequence -of injuries of this kind. - -Colonel Carleton was an instance of a ball fracturing the jaw directly -through its body, near where the masseter muscle is attached on both -sides; the jaw was broken into three pieces, besides splinters; several -teeth were knocked out, and the tongue very much hurt. By sawing off -the splinters both from within and without, and by cleansing and -supporting the parts with great care, he recovered after a length of -time, the deformity after such a wound being much less than might be -expected. - -370. Incised wounds of the tongue do sometimes give rise to hemorrhage -somewhat difficult to restrain, particularly if it occur a few days -after the receipt of the injury, when the tongue is swollen and -painful. It does not so frequently occur after gunshot wounds. As -the vessels of one side do not communicate with those of the other, -any bleeding which continues after the artery of one side has been -properly secured, can only take place from a wound of the artery -of the other, which must then also be tied. This should be done by -drawing the tongue as far as possible out of the mouth by a flat pair -of forceps, which may be easily effected at an early period, when -it is not tender and painful. At a later date, and under difficult -circumstances, various styptics, such as the mineral acids, nitrate of -silver, etc., will be useful. The actual cautery has been recommended, -but I have never seen it used in such cases. - -371. One of the most curious instances of the lodgment of a foreign -body in the face occurred in the person of Captain Fritz, at Ceylon; -his gun burst in his hand, and drove the iron breech into the forehead, -whence it descended into the nares, and, at the end of a year, part of -it made its appearance in the mouth, through the palate. He died eight -years afterward, having suffered much inconvenience from the offensive -discharge it occasioned. When the iron was removed, it had obviously -injured no part of any material importance to life. I have seen balls -descend in this way into the throat and soft palate, and have removed -them from both places with success, and from the hard palate with equal -surprise and advantage to the patient. I have known a ball lodge in the -superior maxillary sinus for months, and even for years, before it was -removed, or the death of the patient proved the fact. - - - - -LECTURE XXVII. - -STRUCTURE OF AN INTESTINE, ETC. - - -372. If an intestine be divided circularly in any part, its walls will -be found to be composed of three principal coats or tunics, which -are--commencing from the inside--the mucous, the muscular, and the -serous or peritoneal, each being separated from the other by a layer of -areolar tissue. A diagram thus made would show a transverse division of -the intestine, and eight distinct if not all different parts. Beginning -from without, viz., serous or peritoneal, areolar or sub-serous; -longitudinal muscular, areolar; transverse muscular, areolar or -sub-mucous, and epithelial. The mucous coat in man has a peculiarity -not observable in animals, of ledges or shelves projecting into its -cavity. - -When the mucous coat of the duodenum is examined with the naked eye, -the first part of its course presents a tolerably smooth appearance, -gradually, however, becoming irregular in transverse folds, which are -so numerous, marked, and regular in the jejunum and ileum as to have -obtained from the earliest times the name of valvulæ conniventes. They -are most strongly marked in the jejunum, and gradually disappear toward -the lower part of the ileum, the inner surface of the large intestines -being still smoother than any part of the small, although large pouches -or cells are formed in the colon by a peculiar arrangement of the -muscular coat. These valves never extend completely round the inside of -the intestine, and rarely more than half or two-thirds, although they -sometimes bifurcate. They have a velvety appearance, which has obtained -for this coat the name of villous as well as that of mucous. - -Valvulæ conniventes are peculiar to man; none exist in the -ourang-outang or chimpanzee. In the frog there are valvular folds, -appearing, at first sight, like the valvulæ conniventes of the human -subject; but, on a careful examination, they are found to be mere -elevations, without villi. In the tortoise there are similar folds, -running however in a longitudinal or opposite direction. In the -rhinoceros the mucous membrane is raised up into villiform processes, -somewhat like the valvulæ conniventes, or large villi; but they are -not villi, as each process is covered with other projections which -really are villi. A valvula connivens consists of two layers of mucous -membrane and sub-mucous tissue, but the muscular coat is not continued -into it. - -373. When examined microscopically, the velvety appearance is found to -consist of innumerable small processes which have been called villi, -each villus being composed principally of a very thin, transparent -_basement_ or _germinal membrane_, forming a sheath or case, inclosing -within it an artery, a vein, a capillary plexus, and an absorbent -vessel termed _lacteal_. A nerve has not been discovered, although -it is presumed to exist. These villi are longest in the duodenum, -and gradually diminish in number and in size from 1/25 to 1/50 of -an inch. Between these villi or projections, holes or openings are -observable, termed the follicles of Lieberkühn, who first described -them; they resemble inverted villi, being in some instances as deep -as the villi are long. Unlike the villi, they are found throughout -the intestines. The villi in every part in common with all mucous -membranes are covered, and the follicles are lined by epithelium, which -in this instance is the columnar, situated on the basement membrane, -each column being attached by its pointed extremity. A layer of this -epithelium extends between the villi, down to the lower part of each -follicle, each column being, generally speaking, shorter and rounder -than when covering the villi. - -The office of the epithelium of the villi has been stated to be -_protective_, that of the follicles to be _secretive_. A villus, when -duly magnified, is seen to have a bulbous extremity without an opening, -and to be covered by epithelium when the intestine is in a state of -quiescence, uncalled upon for any purpose of digestion. When digestion -commences, the epithelium, according to the researches of Mr. Goodsir, -is separated and thrown off. As the chyme begins to pass along the -small intestine, an increased quantity of blood circulates in the -capillaries of the gut. In consequence of this increased flow of blood, -or from some other cause, the internal surface of the gut throws off -the epithelium of both villi and follicles, which is intermixed with -the chyme in the cavity of the gut. The cast-off epithelium, forming -19/20ths of the covering of the villus, is of two kinds, that which -covers the villi, and which from the duty it performs may be termed -_protective_, and that which lines the follicles and may be termed -_secretive_, each column having a nucleus situated at some part of it, -and bulging out that part. - -The villi being now turgid with blood, erected and naked, and covered -by the chyme mingled with the cast-off epithelia, commence their -functions. The summit of the villus becomes at first somewhat flattened -and crowded under the basement membrane with a number of newly-formed -and perfectly spherical vesicles, varying from 1000 to less than 2000 -of an inch in size. Toward the body of the villus or the inner edge -of the vesicular mass, minute granular or oily particles are situated -in great numbers, and gradually pass into the granular texture of the -substance of the villus. As the process advances lacteal vessels are -shown passing up from the root of the villus, subdividing and looping -as they approach the spherical mass, which in this stage has become -more distinctly vesicular, although no distinct communication can be -detected between them. The blood-vessels and capillaries shown in -injected preparations are now seen colored red with their own blood, -and running up to the basement membrane, looping with each other -immediately beneath it, and ending in one or more venous trunks. The -vesicles, quite distended and grouped in masses, push forward the -membrane, and give to it by these inequalities an appearance resembling -that of a mulberry. - -The minute vesicles above noticed fulfill the important office of -absorption, by drawing into their cavities through their walls, by a -process called _endosmosis_, that portion of the chyme necessary to -form chyle; when filled with it they burst or dissolve, their contents -being thus discharged into the texture or substance of the villus, fit -to be taken up by the granular vesicles interspersed among the terminal -loops of the lacteals, and communicating with their trunks, running up -from the root of the villus in their center. Absorption is thus shown -to be effected by closed vesicles, and not by vessels opening on the -surface of the villus. - -The _débris_ and the contents of the dissolved chyle cells, etc. pass -into the looped net-work of lacteals, as in other lymphatics. When the -gut contains no more chyme, the flow of blood to the mucous membrane -diminishes, the development of new vesicles ceases, the lacteals empty -themselves, the villi become flaccid, and the cast-off epithelium is -reproduced, apparently from the nuclei in the basement membrane, in -the intervals of digestion, showing that this function should only be -induced at regular periods, the presumed special use of the epithelium -being to prevent, in a measure, the absorption of any effete or other -matters which might exert a deleterious influence oh the system, -the epithelium of the follicles now secreting a mucus which may be -considered protective. - -In the large intestines there are no villi, but the whole surface is -covered with follicles which must be capable of absorbing as well as of -secreting, as it is ascertained that persons can be nourished and kept -alive for many weeks by nutritious enemata which do not pass into the -small intestines. - -374. On examining the mucous membrane of the stomach, its follicular -structure is immediately seen, the follicles resembling much in -appearance those of the intestine; but in the stomach minute tubes are -found opening into the bottom of each follicle, fulfilling in all -probability a different office, the follicles being lined by columnar -epithelium, the tubes by spheroidal or glandular epithelium; it is -therefore presumed that the gastric juice is secreted by the tubes, -the mucus by the follicles. The tubes differ in the middle and lower -parts of the stomach, by being longer or more deeply seated, and more -numerous as they approach the pylorus, showing in all probability a -difference of function between the upper and middle, and the pyloric or -lower extremity of the organ. - -The intestines are supplied with glands, not apparently for the -purposes of absorption, but of secretion; these require attention. They -are the duodenal of Brunner, the agminated of our countryman, Nehemiah -Grew, and of Peyer, and the solitary, which are found in the lower part -of the small and in the whole course of the large intestines. - -The _glands of Brunner_ are situated at the commencement of the -duodenum, within an inch of the pylorus, and are not visible until -the serous and muscular coats have been removed from without. They -appear to the naked eye like the little white eggs of an insect. Under -the microscope each little gland is found to be lobulated, very much -resembling a small portion of a salivary gland or pancreas, each lobule -having an excretory duct, which unites with those from other lobules -to form one larger one opening on the mucous surface of the bowel. The -lobules themselves are made up of vesicles, within which the secretory -cells are discernible. - -The _agminated_ glands of _Grew_ and _Peyer_, by the latter of whom -they were more minutely described, occur in oval patches at irregular -distances throughout the jejunum and ileum, and are situated on the -side immediately opposite the part where the mesentery is united to the -bowel. Each gland resembles somewhat a Florence oil-flask in shape, the -small end or mouth, which is more or less pointed, projecting through -among the villi or the follicles. They are composed of cells, supplied -by capillary vessels, which Mr. Quekett says have the peculiarity -of being unsupported by areolar tissue, and are termed by him, in -consequence, _naked_. These are the glands which are found more or -less diseased after phthisis and fevers which have terminated fatally. -The oval form of the patches is retained, although considerably raised -above the general surface of the mucous membrane, and when injected -the parts around are more vascular, the ulcerated portion being less so -than usual. - -The _solitary_ glands are best seen in the cœcum and appendix -vermiformis. They are well developed in the fœtus, projecting slightly -above the mucous membrane. Each gland may be considered as one of -the agminated form much enlarged, and when the free surface is very -flat, an opening may be easily seen in the center. These glands also -are frequently the seat of ulceration in fever and dysentery, and -particularly in phthisis. The follicles partake of this disease, and -the whole mucous coat may be destroyed. In some cases there is an -attempt at healing, and the edges of the ulcers become more vascular -and even villous. - -The sub-mucous areolar tissue--the tunica nervosa of Haller, the -_fibrous lamella_ of Cruveilhier--separating yet connecting the mucous -with the muscular coat of the intestine, is composed of the yellow -elastic and of the white or non-elastic fibers, the latter of which -predominate. It is more firmly connected with the mucous than with the -muscular coat, and in it the blood-vessels and nerves are supported -prior to their distribution in the mucous membrane. This sub-mucous -tissue or structure prevails also in the stomach, and is often much -altered by disease, becoming thicker, and assuming a more dense and -sometimes an almost gristly hardness. It is an important part in the -surgical treatment of wounds of the intestines, being firmer, stronger, -and more elastic in reptiles, and more distinct in carnivorous than in -herbivorous animals or in man. - -375. The muscular coat of the intestines is in two layers, the internal -being composed of fibers running transversely, the outer fibers running -longitudinally; they are thickest in the duodenum and rectum. They are -of the _involuntary_ or unstriped kind, as opposed to the _voluntary_ -or striped, which are of large size, and characterized by striæ running -transversely and longitudinally. - -The involuntary fibers, on the contrary, are much smaller in size, -are always more or less flattened, and present no trace of striæ or -stripes, although the interior appears granular, with an occasional -nucleus. The heart is a remarkable exception to this rule, being an -involuntary organ, with striped fibers differing in size, resembling in -this respect those of a voluntary muscle. - -The peritoneal coat is formed of the white fibers, under a -structureless or basement membrane, covered by tesselated epithelium, -constituting a serous and secreting membrane. - -376. Wounds and injuries of the abdomen are essentially of three -kinds--1. Affecting the paries or wall. 2. Opening or extending into -its cavity. 3. Wounding or injuring its contents. - -The wall of the belly is, when severely hurt, liable to a permanent -defect, as the ordinary result of a severe bruise. It is the formation -of a ventral rupture. A division of the wall to any extent by a -sharp-cutting instrument is usually followed by a similar consequence; -and it never fails to occur in the openings made by a musket-ball -penetrating into or passing through the cavity. - -Captain Tarleton, of the 7th or Royal Fusiliers, was struck on the -left iliac region by a large, flat piece of shell, at the battle of -Albuhera, in 1811. The surface was not abraded, although the iron -caused a very severe and painful bruise; the whole of that side of the -belly became quite black, and the remaining part much discolored. Some -months afterward he drew my attention to the part, and I then found -that the whole of the muscular portion of the wall had been removed -by absorption to the extent of the immediate injury from the piece -of shell, the tendinous parts alone remaining under the integuments. -These protruded on any effort, constituting a circular-shaped ventral -rupture, with a large base, which required the application of a pad and -bandage for its repression. - -Mr. Smith, a deputy-purveyor, received a blow on the side of the fore -part of the belly from the end of a spanker-boom, which knocked him -down, and gave rise for some time to much inconvenience. He showed the -part to me in Lisbon, in 1813, in consequence of the formation of a -ventral hernia to the extent of the spot originally injured. In neither -of these cases was such a result expected; no rupture of the fibers of -the muscles was distinguished at the time, and it was supposed that the -sufferers would recover without any permanent defect. The absorption of -the muscular fibers was therefore a subsequent process; whether this -result may or may not be prevented in similar cases by a more active or -a longer-continued treatment, with the early application of a retaining -bandage, is yet to be ascertained. It may be that some muscular fibers -were actually ruptured and others bruised in these cases; but the -extent of the absorption was greater than the apparent injury would -seem to have warranted. - -Abscesses form from neglected injuries of this kind, and give rise to -the most serious apprehensions of their bursting into the cavity of -the abdomen, which, however, they very rarely do. The safety of the -peritoneum and its capability of affording sufficient resistance to -the progress of the matter through it seem to depend upon the strength -of the fibrous structure on its outer or muscular side; the inner or -really serous surface being very delicate, and offering but little -resistance to the application of any moderate degree of force. - -An officer, whose name I forget, was wounded at the assault of Ciudad -Rodrigo, in 1812, by a musket-ball, on the left side and fore part of -the abdomen, near the crest of the ilium: it made a wound about four -inches in length, cutting away the muscles of the abdominal wall so -deeply as to lead to the exposure, and, as I feared, to the ulceration -of the peritoneum, when the sloughs should separate. Under these -circumstances, although not belonging to my division, I took him with -me from the field to the divisional hospital at Aldea Gallega, some ten -miles from the battlefield. Granulations sprang up, however, from the -bottom and sides of the wound, which gradually closed in and healed -without further difficulty. - -377. It has been supposed theoretically, to be a matter of importance -to discriminate between the orifice of entrance of a ball passing -through the abdomen or its wall, and that of its exit. Practically -speaking, it is a matter of indifference; the part on which the ball -impinges is usually distinguished by a more circular and depressed -appearance, while the opening of exit more frequently resembles a tear -or slit, the edges of which are rather disposed to protrude. - -A ball striking obliquely against the wall of the abdomen has been said -to run sometimes nearly round under the skin, or between the muscles -and the peritoneum, a proceeding upon the recurrence of which little -expectation need be placed. It may, however, do something of the kind -for a considerable distance, passing even over or between the spinous -processes of the vertebra behind. In such cases, when they actually -occur, the course of the ball will usually be marked by a line on the -skin, more or less of a reddish-blue color; and the constitutional -alarm, if it should occur at all, will subside early. A ball may, -however, pass under and between the muscular layers of the wall of the -belly, (or run nearer to the peritoneum for several inches,) giving -rise to great anxiety, until the sloughs have separated from the -openings of entrance and of exit, at which parts they prevail to a -greater extent than in the middle of the track of the projectile. In -some few instances an opening will require to be made in the middle of -this track or course of the ball, for the evacuation of pus or of other -extraneous matters which may be detained in it. - -When a ball lodges in the wall of the abdomen and is deeply situated, -it sometimes escapes notice, and when found is often better left alone -unless it prove troublesome. When it approaches the surface, it may -be removed if it cause inconvenience. When removed after the lapse of -twenty or more years, I have found some dense cellular membrane forming -a sac around and adhering to the ball, which is usually more or less -flattened and irregular. - -378. Injuries of the wall of the abdomen from cuts or stabs affecting -the muscular and tendinous parts are said to be frequently troublesome, -and even dangerous, from their giving rise to pain, vomiting, and -severe general derangement. This only occurs when suppuration takes -place, and, from some accidental circumstance, the matter does not find -a ready exit, but collects between the muscles, or within or under -their aponeurotic sheaths. This is indicated by the pain and swelling -of the part, proceeding sometimes to the formation of an abscess, which -ought to be prevented, if possible, by an early enlargement of the -wound, so as to remove the cause of irritation, and the obstacle to the -free discharge of the secreted matter. If the swelling should become -prominent in a more convenient situation than the spot of injury, it -should be opened at that part. - -In these and in all other serious injuries of the abdomen, the -recumbent position, with a relaxed state of the muscles, should -be observed for several days at least. The antiphlogistic plan of -treatment should be fully enforced, especially by leeching, bleeding, -and spare diet, and in due time the part should be supported by a -proper bandage. - -The late General Sir John Elley was wounded in the last charge of heavy -cavalry at Waterloo, by the point of a sabre, which entered nearer -the extremity of the ensiform cartilage than the umbilicus, causing -a wound about two inches in length, penetrating the stomach. From -this he recovered in due time without any severe symptoms, but with -a small hernia of that organ, which remained until his death, giving -rise occasionally to some gastric inconvenience when he did not keep a -gentle pressure on it by a retaining bandage. - -379. Severe blows, or contusions from falls or from the concussion of -foreign bodies, may give rise not only to injury of the internal parts -of the abdomen, followed by inflammation, but to rupture of the hollow -as well as of the more solid and fixed viscera, and death. - -William Fletcher, of the 18th Hussars, a healthy man, thirty-seven -years of age, received a kick from a horse, immediately above the os -pubis, on the 15th of April, 1810, (about a league from Cartaxo, on -the Tagus;) great tension of the belly soon followed, with excessive -pain and vomiting. The pulse rose rapidly. He was bled to syncope -twice during the day, to the extent of sixteen ounces each time. In -the evening he was removed to Cartaxo, and taken into hospital; the -pain continued, accompanied by retching, without much vomiting; the -abdomen was constantly fomented with hot water, and injection was -thrown up, and two ounces of infusion of senna with salts were given -every two hours. In spite, however, of the most active treatment, he -died on the 17th. On dissection, the peritoneum was found to contain a -large collection of fluid, partaking of a fecal character; the bowels -appeared to have suffered to the greatest extent, and a laceration was -discovered in the ileum. - -A child, just able to walk, was placed under my care in the Westminster -Hospital, in consequence of its having received some injury on the -side of the belly, from having been tossed up into the air by its -father with his right hand, and caught in its descent in the crutch -formed by the thumb and fingers of the left, on the thumb of which it -unfortunately at last fell; this caused the child great pain, which was -soon followed by considerable swelling and inflammation of the belly, -of which it died. On examination after death, the small intestine was -discovered to have been ruptured by the end of the thumb, from which -extravasation of its contents into the abdomen had ensued. - -The first effect of a rupture of the intestine must be the -extravasation of such gas as may be contained in or secreted from it, -giving rise to the sudden swelling, as well as to the sudden effusion, -of part of its contents, but which, from the support of continuity, -and of the general pressure of the abdominal parietes, is perhaps more -gradually poured out. The rapid swelling and tension of the belly is -perhaps then a distinguishing symptom of a rupture of the intestines. - -A Spanish soldier was brought to me, near the conclusion of the battle -of Toulouse, in consequence of having been struck obliquely by a -cannon-shot on the right side of the abdomen and back, which appeared -to be badly braised, although no abrasion of the skin had taken place. -The shock was great, however; he was unable to move his limbs, and -appeared likely to die, which he did in fact, in the course of the -night, having passed bloody urine, but without any reaction having -taken place. On making an incision through the skin, which was then -quite a blue black, although not torn, all the soft parts were found -reduced to a state approaching to the appearance of jelly; the spine -was injured, the right kidney ruptured, and the cavity of the abdomen -full of blood. - -A soldier of the 40th Regiment was struck by a ricochet cannon-shot, -on the last day of the siege of Ciudad Rodrigo. He saw the ball, which -destroyed his left forearm so as to render amputation necessary, -strike the ground a little distance from him, before he was himself -injured. He thought, from the sort of shock he received, that it had -also struck his belly; but this I should not have credited, if it -had not been for a bruise across the umbilical region without actual -abrasion of the integuments, on which account my attention was drawn -to him on the fourth day after the injury, at the hospital of Aldea -Gallega. He had been bled in consequence of complaining of pain, and -because of the quickness of pulse and the fever which had ensued, and -which were attributed to irritation after amputation. The belly was -swollen and tender under pressure. Calomel, antimony, and opium were -given: he was bled again, and blisters were applied. The stump took -on unhealthy action, and he died a fortnight after the receipt of the -injury. The abdomen, when opened, was found to contain a quantity of -opaque serous fluid, mixed with shreds of coagulable lymph. The omentum -and intestines were of a dark color, and loaded with blood, distinctly -indicating the chronic state of inflammation which had taken place. - -If the injury should not destroy the patient, but prove sufficient to -give rise, after several weeks, to effusion into the cavity, the fluid -should be evacuated by the trocar. - -When the fixed viscera are ruptured by severe blows, such as those -received by falls or from cannon-shot, the sufferers usually die from -hemorrhage and not from inflammation. The arm has been carried away, -and the liver ruptured without almost a sign of injury to the skin of -the abdomen, death ensuing from hemorrhage. - -380. When an incised wound is made through the wall of the abdomen -to any extent, except perhaps in the linea alba, the muscular parts -are rarely found to unite in a more perfect manner than when they are -ruptured and bruised. In those cases in which I have tied the common -iliac artery by an incision on the face of the lateral part of the -abdomen, the patients recovering afterward, the incision through the -muscular wall did not remain united, although union appeared to have -taken place in the first instance, and a herniary protrusion formed in -the course of the greater part of the line of the wound. - -The constant occurrence of this non-union, except by skin and cellular -membrane, led me to repudiate the introduction of ligatures through -other parts for the purpose of keeping them in apposition, as it does -not lead to the permanent cohesion of the parts, while it exposes the -sufferers to all the dangers which the irritation of sutures commonly -occasions, thus offering another instance of the improvement surgery -owes to the war in the Peninsula. - -Chelius recommends “several flat ligatures to be introduced through -the skin and muscles, the needle being placed close to the muscular -surface of the peritoneum.” Graëfe (section 514) is declared to be of -the same opinion, he recommending, however, that a soft tape should be -substituted for a ligature. Reference is made to Weber in support of -this practice, to which Mr. South, the translator, does not raise any -objection. - -381. In all simple wounds of the wall of the belly of moderate extent, -the edges of the wound should be brought together by means of a small -needle and a fine silk thread passed through the skin and the loose -cellular membrane only which is in contact with it, by a continuous -suture without puckering, in the manner a tailor would fine-draw a hole -in a coat. This gives a certain degree of support to the parts beneath; -and if proper attention be paid to maintain a well-regulated, relaxed -position of the muscles, no great separation takes place in wounds of a -reasonable extent, and little or none in a wound of smaller dimensions. -An effective support should be also given by strips of adhesive plaster -extending to some distance around the body; a bandage rarely does good, -and will assuredly do mischief, unless it be very carefully applied and -watched, so as only to give support and not to make undue pressure. The -position of the patient is of the greatest importance; its essential -object is to bring the edges of the incision, and especially of that in -the peritoneum, as nearly as possible in apposition, so that the space -between them may be more easily filled up by the opposing peritoneum -forming the anterior layer of the omentum, or by the outer covering -of the intestine if the omentum should not intervene. This is to be -effected by the gentlest inclination of the body toward the wound which -may be supposed capable of keeping these parts in apposition; for -although the omentum and intestines are often capable of undergoing -a considerable degree of motion from side to side, independently of -that peculiar wormlike movement on themselves which in the intestines -is called peristaltic, they very frequently do not wander from place -to place in the manner which has been sometimes attributed to them, -but remain, under proper care, so far stationary as to admit of the -cut edges of the wounded peritoneum adhering to the healthy peritoneum -opposed to them, when they will be retained in contact with it. The -serous surfaces of the peritoneum which are in contact with each -other soon offer on one part, and accept on the other, the process -of adhesion through the medium of lymph or fibrin deposited between -them. If this adhesion take place, it extends for some little distance -from the wounded part, which it thus closes up and cuts off from all -communication with the general cavity of the belly; the previous -admission of air--the bugbear of surgeons of the olden times--being -of no sort of consequence. The adhesive process is the effect of -inflammation extending to a certain point, and ending in the deposition -of fibrin. When it exceeds this, the secretion of a quantity of serous -fluid, together with threads of flocculent matter, marks the excess of -inflammation; it is diffused over more or less of the peritoneum lining -the wall of the belly, covers its contained viscera, and prevents that -adhesion from taking place which is the safeguard of the patient. - -382. Absolute quietude is no less to be observed. It must, however, -be steadfastly continued; the slightest alteration of position should -be forbidden. Motion should not on any account, nor for any reason -whatever, be allowed, if it can by any possibility be avoided. In -the position in which the patient is placed he should be rigorously -maintained until adhesion has been effected or all hope of it has -passed away. The practice of the older surgeons was to purge such -persons vigorously, in order to remove from their bowels any peccant -matters that might be in them; in the same manner they recommended -persons should be purged who had undergone the operation for -strangulated hernia--both which proceedings the experience of the -war enabled me to condemn, as being not only contrary to the right -medical treatment of such cases, but to the physiological and surgical -principles on which it ought to be founded, a condemnation the accuracy -of which is now universally admitted, although the source from which it -is derived is not so universally acknowledged. No purgative medicine -whatever should be given to a person with a penetrating wound of the -abdomen. No food should enter his mouth; and no more water even should -be allowed than may be found requisite to moisten the lips and allay -any intolerable thirst which may ensue. This precaution need not be -carried out so strictly if it could be readily ascertained that an -intestine was not wounded; but as this knowledge, however satisfactory -it would be, cannot always be obtained, and ought not in the generality -of instances to be sought for, the restriction should be fully observed -if possible. In all cases of injury of the belly there is more or less -shock, alarm, and anxiety. It is sometimes remarkably great, even -when the mischief has not been considerable. When little or no injury -has been inflicted on the intestines, the natural and usual action of -expelling the contents is generally delayed beyond the time at which -in health it would in all probability have occurred. When nature shall -point out by the sensations of the patient an inclination to perform -this function, it may be assisted by an injection of warm water or -of any mild laxative which may facilitate the process and prevent -any unnecessary action of the abdominal muscles, against which the -patient should be cautioned. The attendants should be forewarned that -the position of the patient is not to be interfered with under any -circumstances, the necessary arrangements being made by bedsteads of -a proper construction, or by other simple means which are sufficiently -well known. - -383. The custom of directing a man to be bled forthwith, as well -as purged, because he has been stabbed, was another error much in -esteem by the older surgeons, but which experience did not sanction, -and it could not therefore be approved. The abstraction of blood -before reaction has taken place delays its occurrence as well as the -commencement of that inflammatory stage which is to be so salutary in -its result in favorable cases. It tends to prevent the agglutinative -process from taking place, and thus aids the diffusion of inflammation -over the whole surface of the peritoneum. The general abstraction of -blood is to be ordered, and regulated as to quantity by the symptoms -of inflammation which may accompany or follow reaction. The quantity -of blood required to be taken away in these cases is usually large, -particularly at an early period. With the army in the Crimea, the -abstraction of large quantities could not in general be borne and has -not been found serviceable, nor has it been found so necessary to -repeat the bleedings as in persons more favorably situated. It is, -however, often a nice point to determine when blood enough has been -abstracted with advantage, as too much may be taken away as well as too -little--the former being marked, after death, by the general diffusion -of a slight degree of inflammation, without the concomitant sign of -effusion of serum. Leeches applied in considerable number will often be -found more beneficial, particularly at a late period, when the sufferer -may not be able to bear a general abstraction of blood. The patient, -after leeches have been once applied and their good effect has been -ascertained, will often ask for them himself on the recurrence of pain -or on its increase; and from twenty to sixty, or even eighty, may be -applied in some instances of great danger with advantage. - -The pulse is by no means a guide in the management of these cases; a -small, low, and sometimes not even a hard pulse being more strongly -indicative of an overpowering state of inflammation than is a quick -and full pulse; much more depends on the pain, the anxiety, and the -general oppression than on the apparent state of the circulation. -Before general and local bleeding cease to be employed with advantage, -calomel, antimony, and opium will render essential, nay, most -important, service. - -The extensive incisions made of late years into the abdomen for the -removal of ovarian tumors, with fair success, confirm what I have -constantly repeated in my lectures for the last thirty-five years, that -penetrating wounds of the abdomen, without injury to the viscera, when -properly treated, are not so dangerous as they were generally supposed -to be. - -384. In penetrating wounds of the belly, the offending instrument -frequently passes in for a considerable distance, sometimes separating -or pushing the viscera aside without injuring them, at others -inflicting upon them wounds more or less severe. In fatal cases of -stabs from knives and sharp instruments, the intestines have been -usually injured by the point, although when the lapse of three or four -days before death takes place, the small wound is not readily perceived. - -W. Carpenter, private, 1st battalion, 43d Regiment, was accidentally -wounded, March 19th, 1812, by a comrade, the small end of a ramrod -entering about two inches below the navel, passing in a direction -upward, penetrating the second lumbar vertebra, and protruding an inch -and a half on the opposite side. - -On examining the wound, the ramrod was found firmly fixed in the bone. -It was endeavored at first to extract it by a gentle turn, making -extension at the same time, but this failed. Force was then applied on -the opposite side, by fixing the broad end of a ramrod on the point of -the protruding one, which was laid bare by an incision, when by a smart -stroke with a stone it was driven back and removed. Bleeding to twenty -ounces. - -March 20th.--Has slept several hours during the night; passed urine two -or three times; suffers slight pain occasionally on turning himself in -bed; has the perfect use of his lower extremities; pulse rather full; -skin cool; repeat bleeding to twenty ounces. - -22d.--No evacuation since the 20th; pulse rather full; bleeding to -twenty-two ounces; sulphate of magnesia, one ounce. Seven o’clock A.M.: -Medicine operated three or four times; feels no pain in passing water. - -23d.--Has passed a good night; wounds dressed; is allowed a small -proportion of bread with his tea. - -28th.--So far recovered as to be able to be removed to Elvas.[5] - -That a blunt instrument, like the small end of a ramrod, should be -forced between the loose viscera of the abdomen without wounding any -of them, may be easily conceived, but that balls or sharp-pointed -swords should do so, is not to be understood so easily. Ambrose Paré, -our own Wiseman, Ravaton, Lamotte, Muys, and others, however, have -related instances of this kind, in which the patients recovered in an -inconceivably short space of time; but these and other recoveries of a -similar nature must be considered as exceptions to general rule. - -[Footnote 5: He marched with his regiment, in the summer, to -Valladolid, and was drowned in the Douro.--G. J. G.] - -385. Wounds penetrating the wall of the belly, when made by cutting or -lacerating instruments, or by musket-balls, are usually followed, if -to any extent, by a protrusion of some portion of the contents of the -cavity, generally of the omentum or intestine, if not of both. This -may take place at the rounded orifice of entrance of a ball, as well -as at the more slit-like opening of exit, which, if the patient should -recover, becomes closed by a thin tendinous-like expansion, under the -cicatrix formed by the common integuments. These soon yield to the -general pressure on the abdominal cavity, and admit of the formation -at the part of a ventral rupture, requiring the application of a -restraining bandage. - -386. When a piece of omentum only protrudes, the direction given by -the latest writers on surgery is, that it shall be returned into the -cavity of the abdomen whence it came, the finger following to ascertain -that it is quite free; after which the wound is to be carefully closed -by sutures applied close to the peritoneum, so that the omentum -may not again protrude through it. Having objected already to the -manner of employing the suture, I now object to the treatment of the -omentum, and do not approve of its being so dextrously returned by -the finger within the peritoneum to its natural loose situation. I -desire, on the contrary, that it may be retained between the cut edges -of the peritoneum, but without the slightest pressure or possible -strangulation, in order that by its retention it may more readily -adhere to these edges, and thus form a more certain barrier against the -extension of inflammation than is likely to take place when moving -at liberty in the cavity of the abdomen, however closely it may be -supposed to be applied to the inner surface of its paries. - -It sometimes happens that a portion of omentum is altogether without -the cavity of the abdomen, and the opening through which it has -protruded seems too small to allow its restoration to the cavity. -The latest authors on this subject recommend a blunt director to be -introduced between the upper edge of the wound and the protruded -part, be it omentum or intestine, or both, upon which a blunt-ended -bistoury is to be passed into the cavity as far as the enlargement of -the wound seems to require, after which the director and the bistoury -are to be withdrawn together. I altogether dissent from this. It is -scarcely ever necessary to enlarge the opening in the peritoneum, -the obstacle to reduction being situated in the tendinous expansion -or aponeurosis of the wall of the belly, a slight division of which -will give sufficient space for the restoration of the protruded part -in almost every instance. I have unavoidably opened into the cavity -of the peritoneum, and have seen it done in other instances, but no -inconvenience follows small openings not exceeding a quarter of an inch -in length, when they are properly covered over by the healthy parts. -It is therefore important in all cases to have as small an opening as -possible in the peritoneum, and certainly no addition should be made to -the size of a small opening if it can by any possibility be avoided, -however indifferent half an inch, more or less, may be in the length of -a large one. All protruded parts, whether omentum or intestine, should -be gently cleansed with warm water, and the fingers of the surgeon -should be wetted in a similar manner, the mesentery being returned -first if protruded, then the intestine, and lastly the omentum; the two -former under all circumstances; the latter not so, if it be adherent -or inflamed, torn or jagged, or in a state of suppuration or gangrene. -It should in these cases be left to itself, and treated in the most -simple manner; a ligature should never be applied to it, neither should -it be spread out and cut off, as was formerly recommended, as it will -gradually retract and be withdrawn into the cavity of the abdomen. If -suppuration should take place in its substance, and the swelling of the -part lead to its constriction, or the formation of matter under the -integuments or between the layers of muscular or tendinous fibers, -these may be carefully divided. - -Evan Thomas, aged seventeen, was admitted into the Westminster -Hospital, Sept. 1st, 1828, having been stabbed with a dinner-knife -immediately above the umbilicus; the wound was three-quarters of an -inch long; the omentum protruded and could not be returned until the -skin, cellular membrane, and fascia had been divided; the opening in -the peritoneum was then distinctly seen, against the inside of which -the omentum was left, the wound in the skin being sewed up by the -continuous suture. In the evening he was bled to sixteen ounces, and, -as he had thrown up his dinner, an enema only was administered. On the -2d, the belly being tense and slightly painful, although he was not in -constant pain, the blood drawn before being buffy, twenty-two ounces -more were taken away, a purgative enema administered, and, as the bowel -was not believed to be injured, four grains of calomel and six of the -compound extract of colocynth were given, with a draught of senna and -salts every four hours. 3d. The bowels open; no pain and scarcely -any uneasiness on pressure; abdomen soft. No food; barley-water and -gruel; pulse 84. On the 6th the sutures were removed, the wound having -reunited. He was then made an out-patient, having a comfortable home. - -A soldier of the Second Division of Infantry received several stabs -from a lance in different parts of the body, at the battle of Albuhera, -as the lancers rode past him, while lying on the ground, one only being -of any importance: it was on the right side and lower part of the -belly, and through it a portion of omentum protruded. On this being -reduced, the epigastric artery, which had been divided, bled freely; a -ligature was readily applied, and the wound closed by the continuous -suture. The patient, after undergoing a very rigorous treatment, -recovered. - -A Spanish soldier was wounded in a scuffle in Madrid, in 1812, at -the gate of the British Hospital, near the Prado, into which he was -brought, with a wound on the right side of the abdomen, near and below -the umbilicus, through which a portion of omentum protruded about -the size of a small orange. As this could not readily be returned, I -carefully enlarged the wound at its under part, some three or four -hours afterward, by dividing the skin, and then found that it was -the aponeurotic or tendinous expansion of the muscles going to form -the sheath of the rectus, which prevented the return of the omentum -into the belly; on the division of this part it slipped back without -difficulty, but as it did not recede further than the peritoneum I -left it there, and closed the wound, which was about an inch long, by -sewing it up in the manner described. He was bled and starved, and was -delivered up to the proper authorities out of danger, with his wound -nearly healed, when the army evacuated the place. - -A Spanish soldier was wounded at the battle of Toulouse by a -musket-ball, which passed in on one side and came out at the other, -carrying with it a portion of omentum which gradually became as large -as an orange, in which state I saw it four days after the accident. -Little had been done; he had not suffered much pain, although the -abdomen was tender; he had vomited; passed blood with his motions; -was feverish and ill. I visited this man every three or four days; -he suffered from privations of every kind, yet each time I found him -better. The protruded omentum gradually diminished in size, and was at -last drawn into the wound in the abdomen and covered by granulations. -He left Toulouse before me, nearly well. - -If the omentum be greatly bruised or injured it may be cut off, and the -vessels tied if bleeding; but it should not be returned further than -the edges of the peritoneum, over which the external wound is to be -closed. - -Ravaton wrote a hundred years ago: “The views of a surgeon must be -very confined who advises the application of a ligature to the omentum -when protruding from the cavity of the belly in a healthy state. It -is a cruel and deadly maneuver, contrary to reason and experience. -To restore it to its place is so simple, just, and reasonable, that -I am surprised it does not occur to every one. The reduction is -easily effected. It is sometimes difficult to retain the reduced part -except by sutures. I admit that when the omentum is strangulated, -gorged with blood, black, and about to become gangrenous, the result -of its restoration to the cavity may be doubted: yet experience has -demonstrated that it is the safest mode of proceeding, taking care not -to close the wound entirely, but to leave an opening at the lower part -to give vent to any effusion or suppuration that may take place.” - -387. When a portion of intestine is protruded without being wounded, -it is to be returned, whatever may be its state, unless it be soft -and unresisting between the fingers, of a dull blue or black color, -and to every surgical eye deprived of life or mortified. At any state -previous to this (to Englishmen) almost certainly fatal condition, it -should be restored into the cavity of the abdomen. When a portion of -intestine is thus returned, three directions are given by most modern -surgeons, and especially by Chelius, section 517, on which his English -editor makes no comment; and which may therefore be considered to be -those which are commonly taught in London, but of which I entirely -disapprove. The first is, that the peritoneum is to be divided in cases -where an obstacle is interposed to the return of the intestine; this I -aver to be less necessary for the intestine than for the omentum. The -second is that, “after the reduction, the forefinger must be introduced -into the cavity of the belly in order to ascertain that the intestines -have not passed into the interspaces of the muscles”--a precaution -which is unnecessary, and may do much mischief. The third is, that the -patient is then to be placed “in such a posture as that the intestines -should least press against the wound,” to which direction I object. The -surgeon should certainly take care that the intestine does not pass -between the layers of muscle, nor anywhere else than into the cavity of -the belly. So far, however, from the intestines being pushed away from -the cut peritoneum, the most favorable position for it would be to be -applied against the edges of the cut membrane, and even rising up for -the least possible distance, without or above it, the great object to -be desired being to facilitate adhesion by as perfect an apposition of -these parts as possible, while the external wound is accurately closed -by the continuous suture, and duly supported by adhesive plaster, -compress, and a bandage, provided it be methodically applied. The next -best thing which can happen is that, every part being relaxed, and the -patient perfectly quiescent, the intestine should press so steadily and -yet so gently against the wounded peritoneum that it will be kept in -constant apposition with it without protruding through it. - -A soldier of the Artillery was stabbed in two places, in 1812, with a -long knife, by a townsman, late in the evening, and was carried into -the hospital for the sick and wounded French prisoners in Lisbon. The -wound in the belly was situated somewhat more than an inch to the right -side of the umbilicus, and was about an inch in length from above -downward; through it a considerable protrusion of small intestine, -without any omentum, had taken place. This was distended by flatus, -and of a dark-brown color when I first saw it, some time after the -receipt of the injury. The bowel being constricted by the tendinous -expansion of the muscular fibers, the latter was carefully divided by a -blunt-pointed curved bistoury passed under its upper edge, and resting -on the back of the nail of the forefinger, by which the intestine was -guarded; the flatus having been pressed out of the intestine, which -was gently washed with warm water, it was restored to the cavity of -the abdomen. Of the part which had apparently first protruded, the -peritoneal coat and a few fibers of the longitudinal layer of muscle -were divided to the extent of half an inch, the remaining portion of -the gut being unhurt. The skin was then sewed up by a fine continuous -suture, and adhesive plaster and a compress duly applied. A good deal -of alarm was evinced, the pulse was very small, and the man faint. -The other wound was in the back, about half an inch in extent, and -near the inferior angle of the right scapula. It appeared to be a -penetrating wound, but not giving rise to any peculiar symptoms, he -was placed in bed on his back, with his legs raised, and the body -slightly bent. Early the next morning, the officer on duty found it -necessary to bleed him largely, to forty ounces, according to my -directions, on account of pain which had come on in his bowels and in -his back, accompanied by difficulty of breathing, the skin being hot -and the pulse quick and hard. The cellular membrane around the wound -in the back was emphysematous; there was a slight cough, accompanied -by an expectoration slightly tinged with blood. The bleeding removed -the essential symptoms, but the pain and difficulty of breathing -returning next day, it was repeated to eighteen ounces, with an equally -good effect. It was necessary to repeat it on the third, fourth, and -fifth days, when the pain ceased to return, and the pulse, instead -of being small and hard, became softer and fuller. The bowels were -open naturally on the third day, and the emphysema had gradually -disappeared, no food being allowed, and very little drink for some -days, and then only in small quantities of the simplest kind. The -threads were removed with scissors on the sixth day, and the man was -free from complaint, although very weak, at the end of five weeks. - -Madame Doucet was applied to a hundred years ago, by a soldier, who -having been struck by a halbert, had a wound made across his abdomen -from above the ilium, through which a quantity of intestine protruded, -which he carried in his hat, enveloped in his shirt. Having had to walk -between three and four miles, in the heat of July, to the old lady, his -bowels were as dry as parchment by the time he arrived. She therefore -bathed them in warm milk and water until they became soft and natural -in appearance, returned them into the cavity of the belly, and sewed -up the wound with a well-waxed silken thread--thus setting an example -which ought to be followed in 1855. The man recovered. - -388. When the protruded intestine is wounded, the case is complicated, -and much depends on the size of the wound. A mere puncture, or a -very small cut, is often of no consequence, and does not require any -treatment; the bowel should merely be returned to the cavity of the -belly, and the symptoms of inflammation closely watched, and, if -possible, steadily subdued. - -It is advisable, in investigating this subject further, to consider the -abdomen as devoid of cavity during life and health, the contained parts -being so gently pressed upon by the containing and retaining muscular -parietes around as to enable them all to carry on their ordinary -functions, unless suffering from some derangement, exclusive of that -which might arise from a deficiency of the pressure usually exercised -upon them; but that this pressure can, or generally will, prevent the -effusion of the contents of a bowel when ruptured, if the wound be half -an inch in length, or that it will prevent the extravasation of blood -from an artery or vein of moderate dimensions, if torn, is contrary to -facts now considered indisputable, as I have frequently had occasion -to verify. That a mere puncture of the intestine does not allow the -effusion of air, much less of the contents of the bowel, is not -doubted. When the contents of the bowel have been poured out, without -an external opening in the paries through which they might escape, -inflammation and death have ensued at no long distance of time. When -blood is poured out from the great vessels, as in rupture of the liver -or spleen--of which instances will be adduced--the general cavity may -be filled; but when the injury is less extensive, or the lesion less -important, the blood usually gravitates toward the back or sinks into -the pelvis. It is possible that blood may be effused in small quantity, -and be then confined, under the general pressure of the wall of the -abdomen and the resistance offered by its contents, to a particular -spot, whence it may be absorbed after coagulation; or, by commencing -decomposition, give rise to irritation, and be discharged through the -external wound, if one exist, or through the bowel with which it may -happily be in contact. - -A soldier, belonging to the Second Division of Infantry, was wounded -by the Polish Lancers at the battle of Albuhera, in several places -slightly, and in the abdomen severely, a penetrating wound having been -made an inch long, between the umbilicus and the crest of the ilium on -the left side. Brought to me the day after at Valverde, the edges of -the wound were stitched together and dressed simply. He said it had -bled freely at first, and was then painful. Treated antiphlogistically -and sharply, the inflammatory symptoms gradually subsided. The bowels -were relieved by gentle aperients, there being no reason to suppose -they had been wounded. A small, oval swelling was soon perceived under -the wound, which was tender to the touch, indicating mischief of some -kind. The edges of the wound, which did not unite fully, although -they were retained in contact, at last separated, and allowed about a -wineglassful of bloody matter to pass out, which reduced the swelling -and removed the uneasiness and pain of which he complained. After this -he gradually recovered, and was discharged to Elvas, and thence to -Lisbon. - -389. Whenever large effusions of blood have occurred, the sufferers -have usually been lost, from the occurrence of peritoneal inflammation. -That small ones may be absorbed, cannot be doubted. I have seen -instances of their having been discharged by the bowel, although I have -never been so fortunate as to see a general formation of matter from -effusion, and to have opened the abdomen for the evacuation of its -contents with success; nevertheless, I do contemplate that such cases -may occur, and surgery may come to their relief with good effect. - -The important conclusions to be deduced from the observations of -those who have made experiments on the intestines of living animals -are--First, that wounds not exceeding four lines in length, (or the -third part of an inch,) no matter what their direction may be, are not -so apt, as might be supposed, if left to themselves, to be succeeded by -extravasation of the contents of the intestinal tube; and that, in the -majority of cases, nature, properly aided by art, is fully competent to -effect reparation. Secondly, that wounds of the bowels to the extent -of six lines, whether transverse, oblique, or longitudinal, are almost -always, if not invariably, followed by the escape of the contents of -the bowel, and the consequent development of fatal peritonitis. It may, -therefore, be concluded, from experiments made on animals, as far as -they can be relied upon with reference to man, that every wound in the -bowel, of such an extent as shall not admit of its being temporarily -filled up by the protrusion and eversion of its internal or mucous -coat, which always takes place as an effort of nature to close the -wound, ought, if possible, to receive assistance from art, and that can -only be given with advantage in the first instance. - -Mr. Travers tied a thin ligature firmly round the duodenum of a living -dog; the ends were cut off, the parts returned, and the external wound -properly closed. On the fifteenth day, the cure being completed, the -dog was killed. A portion of omentum, connected with the duodenum, was -lying within the wound, and the folds contiguous to the tied part of -the intestine adhered to it in several points. A slight depression was -observed around the duodenum, the internal or mucous surface of which -was more vascular than usual; a transverse fissure marked the seat of -the ligature. “The lymph,” Dr. Gross observes, “which is effused upon -the external surface of a bowel, consequent upon such an operation, -gives the part at first a rough, uneven appearance; but, if the animal -survive several months, it is generally no easy matter to determine -the seat of the injury from the external appearance of the part. -Internally, the cicatrization is almost as complete, the continuity of -the mucous membrane being everywhere established, leaving scarcely even -a seam at the original seat of constriction. The rapid manner in which -the ligature cuts its way from without inward obviates the evils which -might arise from the occlusion of the passage. In an experiment, in -which the dog was killed upon the eleventh day after the application of -the ligature, the canal of the bowel was completely restored, and the -bond of connection between the divided parts was firm and organized.” - -Similar effects are produced when a small ligature is applied around -the edges of a wound from two to three lines in diameter, provided -it be drawn with sufficient firmness not to slip off. The process of -reparation is not, however, so speedily completed, owing to the breach -being much wider than when a ligature is simply placed around the tube. -The mucous membrane requires a longer period for its reproduction, and -the quantity of lymph deposited around and inclosing the ligature is -proportionally greater. - -390. The idea of sewing together, and thereby restoring the continuity -of a wounded bowel, is attributed to four master surgeons, as they were -called, of Paris, in the thirteenth century, who, having united their -efforts for the relief of the sick poor in that city, procured, it is -said, a portion of the trachea of an animal, one end of which they -introduced into the upper part of the divided bowel, and the remaining -piece into the lower, and then brought the divided ends into contact, -and retained them by as many sutures as appeared to be necessary. Their -writings, in which this operation is described, are lost. Peter de -Argelata, who lived about the middle of the fifteenth century, says -that Jemerius, Roger, and Theodoric supported the intestine by a canula -of elder-wood, while Gilbert de Salicetti condemns both the use of the -trachea and the elder-wood tube, and recommends, if anything be used, -that it should be the dry and hardened bowel of some animal. These -ancient surgeons believed that a transverse division of the intestine -was necessarily a fatal injury, and only resorted to the methods they -recommended when the division was less complete. Duverger de Maubeuge, -in the beginning of the eighteenth century, apparently unaware of what -had been done before his time, brought forward this method of the four -masters as an invention of his own. He cut off a portion of mortified -intestine in a case of strangulated hernia, introduced a piece of the -trachea of a calf, brought the divided intestine over it, and fastened -it by a suture. The trachea was passed on the twenty-first day, and the -external wound was closed by the forty-fifth, the patient recovering. - -Ramdohr, a German surgeon, who lived in the early part of the last -century, seems to have been the first to join the ends of a divided -bowel by introducing the upper end within the lower. He removed two -feet of mortified intestine in a case of strangulated hernia--performed -this operation on the ends of the bowel, retained the parts by -stitches, and his patient perfectly recovered. Heister says the -mortified parts were in his possession. (Haller, _Disputat. Anatom._, -vol. vi., _Observ. Med. Miscel._, 18.) Since his time, many of the -most eminent surgeons of France, Italy, America, and Great Britain -have turned their attention to this subject; but the conclusion at -which I have arrived is that the continuous suture is, in all cases of -serious injury, the most simple and the best. - -391. In making a continuous suture, a fine needle and a waxed silken -thread should be introduced through the gut, beginning on the inside -close to one end of the cut part, and bringing it out on the peritoneal -surface a little more than a line distant from where it entered. The -needle is then to be carried to the opposite side through the bowel -from without inward, and the sewing thus continued until completed, -each stitch being about the sixth part of an inch asunder, and about -that distance from the edge of the cut. The threads or stitches -should not be drawn close until the whole are inserted, when, on -being drawn moderately tight one after another, the cut edge of the -intestine should be turned inward by a blunt probe, so that the -peritoneal surfaces shall be in contact under the stitches and in the -best situation for union, the mucous coat forming a ridge within, the -outside being perfectly smooth, the stitches not being too tight, while -the end may be secured by a knot made by a turn of the thread over the -needle. This done, the intestine should be returned into the cavity -of the abdomen, and events awaited. Recoveries more frequently follow -wounds of the colon than of the jejunum or ilium; but the result must -always be doubtful, being dependent on many causes which the surgeon -can neither foresee nor control. - - - - -LECTURE XXVIII. - -TREATMENT OF INCISED WOUNDS, ETC. - - -392. When an incised wound in the intestine is not supposed to exceed a -third of an inch in length, no interference should take place; for the -nature and extent of the injury cannot always be ascertained without -the committal of a greater mischief than the injury itself. When the -wound in the external parts has been made by an instrument not larger -than one-third or from that to half an inch in width, no attempt to -probe or to meddle with the wound, for the purpose of examining the -intestine, should be permitted. When the external wound has been made -by a somewhat broader and longer instrument, it does not necessarily -follow that the intestine should be wounded to an equal extent; and -unless it protrude, or the contents of the bowel be discharged through -the wound, the surgeon will not be warranted in enlarging the wound -in the first instance to see what mischief has been done. It may be -argued that a wound four inches long has been proved to be oftentimes -as little dangerous as a wound one inch in length; yet most people -would prefer having the smaller wound, unless it could be believed that -the intestine was injured to a considerable extent. Few surgeons, even -then, would like to enlarge the wound to ascertain the fact, unless -some considerable bleeding or a discharge of fecal matter pointed out -the necessity for such an operation. When the wounded bowel protrudes, -or the external opening is sufficiently large to enable the surgeon to -see or feel the injury by the introduction of his finger, there should -be no difficulty as to the mode of proceeding. - -393. A puncture or cut which is filled up by the mucous coat so as to -be apparently impervious to air does not demand a ligature. An opening -which does not appear to be so well filled up as to prevent air and -fluids from passing through it cannot usually be less than two lines -in length, and should be treated by suture. When the opening is small, -a tenaculum may be pushed through both the cut edges, and a small -silk ligature passed around, below the tenaculum, so as to include -the opening in a circle, a mode of proceeding I have adopted with -success in wounds of the internal jugular vein without impairing its -continuity; or the opening, if larger, may be closed by two or more -continuous stitches made with a very fine needle and silk thread, cut -off in both methods close to the bowel, the removal of which from the -immediate vicinity of the external wound is little to be apprehended -under favorable circumstances. The threads or sutures will be carried -into the cavity of the bowel, as has been already stated, if the person -survive, and the external part of the wounded bowel will either adhere -to the abdominal peritoneum or to one or other of the neighboring parts. - -When the intestine is more largely injured in a longitudinal or -transverse direction, or is completely divided as far as or beyond the -mesentery, the continuous suture is absolutely necessary. - -394. When the abdomen has been penetrated, and considerable bleeding -takes place, but not from the intestine, it is necessary to look for -the wounded vessel. When it comes from one of the mesenteric arteries -or from the epigastric, the wound is to be enlarged until the bleeding -artery be exposed, when ligatures are to be placed on its divided ends -if they both bleed, the external wound being accurately closed. I have -seen the epigastric artery tied several times with success. - -A Portuguese caçador on picket was wounded at the second siege of -Badajos in a sally made by some French cavalry. He had three or four -trifling cuts on the head and shoulders, and one across the lower part -of the belly on the right side. He bled profusely, and, when brought -to me, had lost a considerable quantity of blood which came through -a small wound made by the point of a sabre. This wound I enlarged -until the wounded but undivided artery became visible; upon this -two ligatures were placed, and the external wound was sewed up. The -peritoneum was open to a small extent, but the bowel did not protrude; -and the patient (not being an Englishman, and therefore not so liable -to inflammation) recovered after being sent to Elvas. - -A soldier of the same regiment, cut down at the same time, died as soon -as he was brought into camp, having been severely wounded in the chest -and abdomen. He was said to have died from hemorrhage, from a wound in -the belly, two inches in length, made by one of the long-pointed swords -of the French dragoons. I had the curiosity to enlarge the wound, and -found one of the small intestines had been cut half across, another -part injured, and that the blood came from an artery which had been -opened by the point of the sword in going through the mesentery, which -wound had caused his death. - -395. When this operation cannot be done successfully or with advantage -to the patient, whose life is in jeopardy from the continued drain, -the wound should be closed by suture, and a compress laid over it and -retained by a bandage methodically applied for the purpose of aiding -the muscular parietes in keeping up that pressure on the viscera which -may be useful in arresting the flow of blood from the wounded part. If -the bleeding continue, or, having been arrested, should recur, and -the belly become in consequence distended, the sutures being evidently -so tense as to be likely to cut their way out, or if the blood should -ooze out between the stitches, they may be in part removed in order -to give immediate relief. When the belly becomes very painful, tense, -and manifestly full after a punctured wound, and not tympanitic from -the extrication of air or the distention of the bowel by it, the wound -should be enlarged to allow the evacuation of the extravasated blood, -which cannot be absorbed when in such quantity. The orifice of a small -gunshot wound, which is not sufficiently direct to communicate with the -cavity and to allow the issue of blood extravasated in the quantity -alluded to, should be enlarged to such an extent as to effect that -object. - -396. Blood effused in moderate quantity, and circumscribed by the -pressure exercised upon the contents of the abdomen by its parietes, -may readily be evacuated by the wound, provided it be sufficiently -open; and the patient may recover, if the inflammation which must -necessarily ensue should not be communicated along the peritoneum -throughout the cavity, or if it should be subdued in time. If the blood -be in small quantity, it coagulates, and may be absorbed; but if in -such a quantity as cannot be absorbed, or from any other cause which -may prevent its removal by this means, it becomes after a time a source -of irritation, and nature sometimes commences early to cut it off from -the general cavity by surrounding it with fibrin--a result which, -however desirable, can rarely be expected. - -When extravasated blood is thus cut off from the general cavity, and -cannot be absorbed or be by accident carried off through an opening -in the bowel, a change takes place by which it ceases to be bland -and harmless, and causes it to excite inflammation and its ordinary -consequence, suppuration, if the patient survive so long. This -occurs, for the most part, after the first inflammatory symptoms -have subsided, from the tenth to the twelfth, or even to a later, -day, when the renewal of irritation is accompanied by an increase of -the general symptoms, by a more local pain, and by a circumscribed -swelling of some part near the wound, in which fluctuation may perhaps -be distinguished even during the existence of the general tenderness -of the whole abdomen. Under such circumstances, when it is proposed -to make an incision into this part, if it should be thought advisable -to do such an operation, it may safely be preceded by an exploring -needle or a very fine trocar and canula, which will demonstrate the -fact of the purulent and sanious depot, without doing in such a case -perhaps any mischief, if the expectations of the surgeon should not be -realized. If the exploring needle should show that a bloody, purulent, -or other fluid is really distending the abdomen, no doubt ought to be -entertained about enlarging the original wound and making a depending -opening. - -Ravaton, in his twenty-fifth observation, relates the case of a soldier -who was wounded five days before by the point of a sabre, to the -right of the umbilicus. When the man was brought to him, the belly -was swollen, hard, and very painful, with vomiting, hiccough, etc., -announcing the approach of death. Believing that the abdomen contained -a fluid, either effused or secreted, he made an opening into the cavity -immediately above Poupart’s ligament or the outside of the internal -opening of the ring of the right side, when, finding that nothing came -from the cavity, he passed his finger upward along the iliac vessels, -and, after tearing up some membranous adhesions, evacuated a pint of -coagulated blood and fetid, serous fluid. He then introduced a dossil -of lint into the wound to keep it open, fomented and oiled the belly, -round which he applied a bandage, and placed the patient on his face. -The bad symptoms diminished during the night, and the patient declared -himself better in the morning. From the fifth to the tenth day of the -wound he was in extreme danger. On the eleventh, the bed was inundated -with a purulent matter of an almost insupportable smell. The cavity -of the abdomen was injected and cleansed, the ordinary dressings -applied, and the greatest cleanliness observed. He was subsequently -dressed three times a day in a similar manner; portions of omentum -were occasionally drawn away with the forceps. His strength was well -supported by every kind of nourishment. The night-sweats continued -until the thirty-third day, and on the seventy-second he was discharged -from the hospital, cured. The discharge at first was serous, and only -became purulent on the sixth day after the operation. - -Thomas M’Mahon, 76th Regiment, aged twenty-two, was admitted into -the Garrison Hospital, Portsmouth, upon the 13th of June, 1845, with -all the symptoms of strangulated inguinal hernia of the left side, -of two days’ standing, for which the usual operation was performed. -Everything went on favorably till the morning of the fourth day after -the operation, when he made a sudden effort to go to the close-stool, -which was immediately followed by the descent of a considerable portion -of intestine and omentum, accompanied with profuse hemorrhage from a -small artery on the surface of the intestine, which was taken up and -tied, and the parts returned into the abdominal cavity. The greatest -excitement followed, with all the symptoms of acute inflammation. -These were treated by general bleeding to the extent of fifty ounces, -and sixty leeches to the abdomen, with other antiphlogistic remedies. -On the morning of the seventeenth day from the performance of the -operation, a piece of intestine came away with the fecal contents of -the bowels, after which the patient experienced relief in all his -symptoms, and appeared to gain health and strength, and after a time -the wound seemed disposed to close, three weeks after the sloughing -of the intestine. On the sixth day afterward the evacuations ceased, -attended with acute tenderness of the abdomen, which began to swell -fast. The means adopted had not the slightest effect, and the patient -was considered past relief, unless it could be obtained by an external -opening. I accordingly made an incision over the site of the former -wound, and carefully opened the intestine, to the extent only to -allow the tube of the stomach-pump to be inserted, when there was an -immediate discharge of flatus and some feculent matter, and the patient -expressed himself relieved. By the further use of the stomach-pump -apparatus, I was enabled to extract a quantity of feculent matter by -the artificial opening, and after some hours the patient was completely -relieved from the dangerous symptoms he was suffering from. The -artificial opening was left patent for two months, when the bowels -again gave evidence of acting naturally. The artificial wound was not, -however, closed till the 22d of August, 1845; a week after the bowels -appeared to act freely and naturally. - -The patient from this time got well and strong, and was discharged to -his duty on the 10th of October, 1845, since which period he continued -to perform all the duties of a soldier most efficiently, without -experiencing any inconvenience to his general health or constitution, -until the 6th of October, 1846, when he died of inflammation of the -brain, at Fort George, in Scotland. On dissection, the abdominal -viscera, including the intestinal canal, appeared perfectly healthy; -but on a minute examination of the portion of small intestine (found -to be the ileum) situated in the inguinal region of the side operated -upon, directly opposite to the cicatrix of the external wound, it -was discovered to be firmly attached to the abdominal parietes, by -an adventitious membrane, to the extent of two lines, which then -diverged, and formed itself _into a canal of a funnel shape for about -five inches and a quarter in length, of a homogeneous structure, which -united itself with the continuous intestinal tube_. By this wonderful -provision of nature the healthy functions were uninterruptedly carried -on, and permanently continued, without any pain or detriment to the -patient’s general health. On appearance, Jan. 23d, 1847. - - A. Maclean, M.D., late Surgeon, 76th Regiment. - -Cases of extravasation or of effusion, terminating by the formation of -a sac, pouch, reservoir, or _foyer_ surrounding it, while the rest of -the cavity remains free from inflammation, are so rare in natives of -our northern climates that I am indisposed to infer that they do take -place, except as very accidental circumstances. The fact that such -things do take place should be borne in mind, and surgery should not -be wanting in giving its aid, under all well-considered and reasonable -circumstances. It is easier to do nothing than to think and to act. - -The general treatment to be pursued in the acute period of all these -cases of inflammation has been sufficiently marked--antiphlogistic to -the utmost extent consistent with propriety, by bleeding, leeching, and -cupping; the repeated administration of enemata; the early exhibition -of mercury and opium, and subsequently of gentle aperients. - -397. Continental surgeons, and by pre-eminence Baron Larrey, who is -followed on this point by most French surgeons, inculcate the necessity -of enlarging the wounds made by a musket-ball in the wall of the belly, -although the Baron is particular in confining it to the muscular -parts; M. Baudens, one of the latest writers on the subject, points -out the additional tendency this gives to the formation of hernia, and -furnishes therefore the soundest reason for not doing it without an -especial cause. When a slip of the muscular or tendinous structures -interferes with the quiescence of the wound; when it is desirable to -introduce a finger to make an examination; when it is necessary to -divide a portion to allow the restoration of protruded parts, no one -will doubt the propriety of the direction. But when neither these nor -any other good or sufficient reason can be given for such an operation -as that of enlarging the wound (_débridant la plaie_) simply because -it has been usual so to do, at the risk of making a large hernial -protrusion instead of a smaller one, it is unnecessary. It gives rise -to some bleeding, but that is really nothing; it makes a cut instead of -a hole, by which nothing essential is gained; and as this enlargement -of the wound can always be accomplished when it may become necessary -from a sufficient cause, such interference, especially on the fore part -or the sides of the abdomen, may be safely omitted. - -398. When a musket-ball, passing across the abdomen, comes out behind -through the thick muscles of the back, with perhaps a slit-like -opening in the skin, through which some urine, and perhaps fecal -fluid or matter may also pass, such wounds should be enlarged both -superficially and deeply. There is here an object to be gained, and -the operation is necessary. There is no objection to its being done -when it is even supposed that these fluids or matters are likely to -be soon or ultimately discharged through it, as it is desirable that -any secretions or effusions which cannot be evacuated by the natural -passages should have every reasonable opportunity offered of making -their escape. - -399. When it is obvious, from internal hemorrhage, or from the -discharge of fecal matter, or from the introduction of the finger, by -which it can be felt, that a large hole or rent has been made in an -intestine, the wound should then be enlarged so as to allow its being -brought into sight, when the edges should, if required, be smoothed, -and the continuous suture applied in the manner directed, Aph. 391. - -400. When a musket-ball penetrates the cavity of the belly, it may -pass across in any direction without injuring the intestines or solid -viscera. It usually does injure one or the other, and it has been -known to lodge without doing much mischief. The symptoms are generally -indicated by the parts injured, although in all the general depression -and anxiety are remarkable; their continuance marks the extent if not -the nature of the mischief. - -The following cases of the survivors of hundreds who died under -similar wounds, during the war beginning with the battle of Roliça in -Portugal, in August, 1808, and ending with that of Waterloo, in June, -1815, may be read with a melancholy interest, as showing what sometimes -will happen in a few rare instances, and even then as more dependent on -the wantonness of nature than on the united efforts of science and of -art. - -A soldier of the brigade of heavy cavalry, under General Le Marchant, -advancing in line to charge the French infantry at Salamanca, on -which occasion the general was killed, was struck by a musket-ball, -which entered in front, between the umbilicus and the ilium of the -left side and came out behind on the opposite side above the right -haunch-bone, thus traversing the body. The bowel protruded in front, -but was uninjured, and was easily restored to its place. He remained at -the field hospital with me for the first three days and was rigorously -treated, as well as afterward in the San Domingo Hospital, where he -gradually recovered, and was ultimately sent to the rear. - -Captain Slayter Smith, of the 13th Dragoons, being engaged at Campo -Mayor, on the 25th of March, 1811, was shot by a pistol-ball, which -entered at the left hip, three inches and a half from the junction of -the ilium with the sacrum, an inch and a half below its crest, and came -out about three inches below the navel, and one inch to its right side. -He felt a terrible shock, but did not faint or fall from his horse. - -“There was a protrusion of bowel from the wound in front of about -three inches; but little blood issued from it. The hemorrhage from the -wound in my back was very copious. A French officer, with three or -four of his men, were so near me that he called out ‘Rendez vous, mon -officier,’ to which I replied, ‘Pas encore, monsieur,’ and rode away -with my bowel in my hand. - -“I reached the field hospital shortly afterward, when the protrusion -was returned without enlarging the orifice, and _no_ stitch was put -into the wound then or afterward. It was dressed merely with lint and -adhesive plaster. I begged earnestly for a glass of Madeira, which, -after a little hesitation on the part of the surgeon, was given to me; -but they afterward thought it necessary to bleed me; but little blood -followed the insertion of the lancet. This was the _only_ time I was -bled. In the morning I found the bed saturated with blood, which had -trickled through to the floor, and had escaped from the wound behind. - -“Before a month had elapsed I and all the wounded were removed to Elvas -on _bullock-cars_, and a desperate journey it was. - -“On my arrival, inflammation began in the wound in front, accompanied -with great swelling and pain. The swelling was laid open and a quantity -of matter was evacuated, followed by an angry-looking protrusion, -which was carefully washed with warm water, and poulticed; when the -inflammation had subsided, the wound was dressed as before, with lint -confined by adhesive plaster. When the protrusion was touched by the -hand I experienced a nauseous and disgusting sensation, to which in -comparison the application of the knife or lancet was a flea-bite. - -“I arrived in England in June, and in September went to Brighton. Soon -afterward I felt terrible pains in the _right_ side of my back, in a -line with the wound, through the ilium, or rather above it, where a -kind of tumor formed. For several days I suffered agony from it; and -one night, completely worn out, I fell into a long and deep sleep, and -awaking late in the morning I found all pain and excrescence gone, and -nothing remaining but a tenderness of the part on pressure with the -finger. I underwent much from violent spasms in the stomach, which I -never had before I was wounded. I recovered, however, sufficiently -to rejoin my regiment the following spring in the Peninsula, and was -soon afterward again wounded in a skirmish by a spent shot in the left -shoulder, which, however, was of no moment, though I was compelled -to return to England on sick leave, in October, 1812, as the spasms -increased with greater severity, incapacitating me from doing my duty, -and at times rendering me totally helpless. - -“I now gradually recovered my health, and in the spring of 1815, -accompanied the 10th Hussars to Belgium, and served at Waterloo. - -“My health gave way again in 1821, and I certainly was in a precarious -state for three or four years, but I gradually recovered, and by dint -of great care and attention to diet I am now (1853) in robust health, -and can take the strongest exercise with impunity.” - -John Richardson, of the 1st Royal Dragoons, was wounded at the battle -of Waterloo by a musket-ball, which entered two and a half inches -above the umbilicus, and passed out on the left side, close to the -lumbar vertebræ. He threw up a considerable quantity of blood, and the -stomach was so irritable that nothing would remain on it. He complained -of pain, which cut him right across, as he termed it; his eyes were -suffused and face flushed; had headache; pulse 130. Thirty ounces of -blood were taken from the arm, emollient injections thrown up the -rectum, and poultices applied to the wounds. - -June 20th.--Some blood came away with the injections during the -night; great pain in the right side and shoulder; saline draughts are -returned tinged with bile and blood; pulse 130. Bled to sixteen ounces; -injections and poultices continued. - -21st.--A draught was ejected mixed with blood, and a quantity of -bilious fluid; diarrhœa during the night; the feces were mixed with -blood; pulse 120; skin hot. Bleeding to twelve ounces; blood sizy. - -22d.--Slept a little during the night; had several alvine evacuations -of a bilious fluid mixed with blood. The tension of the belly is not so -great. He still complains of pain. Tea remains on his stomach. Bleeding -to twelve ounces; fomentations and poultices to the belly; chicken and -beef broths; injections frequently. - -24th.--Feels considerable relief from the tension of the abdomen having -subsided; threw up his tea and a quantity of clotted blood this morning. - -26th.--Had a bad night; pulse 125, and full. Complains of great pain in -the hepatic region, and backward toward the spine. Bleeding to sixteen -ounces. ℞.--Hydrarg. chlorid. gr. iv; conf. rosæ. gr. ix; to be made -into two pills, one to be taken twice a day. - -30th.--Vomiting in the night, mixed with blood; tea, etc. remain on the -stomach this morning; pulse 108. - -July 5th.--The adnatæ have a yellow tinge; in other respects he is -doing well. ℞.--Chlorid. hydrarg. gr. x; extr. colocynth. comp. ʒj: to -be made into ten pills, one to be taken three times a day. - -20th.--The wound perfectly healed; is cleaning his accoutrements, -boots, etc. Was discharged on the 28th of July, perfectly recovered. - -Owen M’Caffrey, aged thirty-three, first battalion 95th Regiment, -was wounded on the 18th of June at the battle of Waterloo, by a -musket-ball, which penetrated the cavity of the abdomen on the right -side, about midway between the superior anterior spinous process of -the ilium and the linea alba. When admitted into the Minimes General -Hospital three days after, he was in the most deplorable state; the -whole abdomen was tense and exquisitely tender; the pulse small and -wiry; vomiting incessant, with hiccough and ghastly visage. From this -period to the 24th, he was thrice largely blooded, and the strictest -antiphlogistic plan was laid down and rigidly adhered to. Laxative -injections were administered, the whole of the abdomen was frequently -fomented, and opiates were administered to allay the irritability of -the stomach, and to procure ease and rest. On the 25th the wounded -intestine sloughed, and the feces escaped by the external orifice, _the -adherence of the two surfaces of the peritoneum_ preventing any, even -the smallest portion, getting into the cavity of the abdomen. - -26th.--The high inflammatory action having been reduced, milk, rice, -and sugar, and the farinaceous part of the potato were allowed. - -July 1st.--No very alarming symptom remains. Half a fowl ordered for -his dinner, and the greatest attention to personal cleanliness directed -to be paid. - -7th.--Strength slowly but gradually returning. The action of the large -intestines is daily kept up by stimulating injections. - -14th.--Progress to recovery satisfactory. The injections are daily -repeated, and the discharge by the natural passage increases. The wound -contracts and looks healthy. Is enabled to sit up, and has recovered -his cheerfulness. - -28th.--Still improving; ultimately recovered. - -The situation of the ball was never ascertained. - -A soldier of la Jeune Garde Imperiale was struck by a ball, which -entered to the right and a little below the umbilicus and passed out -on the left or opposite side, about two inches above the crest of the -ilium. It was supposed to have passed along the canal of the great -arch of the colon. Fecal matter, much tinged with bile, passed by both -openings. The symptoms of inflammation were severe for the first few -days, but gradually yielded to the means employed, when the bowels -began to act regularly by the aid of mild injections, and the discharge -from the wounds gradually lessened; the man was much reduced, but -otherwise in good health, and was sent to France from Brussels, nearly -well. - -A soldier of the Third Division of Infantry was wounded during the -assault of Ciudad Rodrigo, by a ball which entered and lodged in the -left side of the back, about midway between the spine and a line drawn -to the upper part of the crest of the ilium, from which opening the -contents of the bowel were discharged. Left among the dead and those -who were supposed to be dying at the field hospital, in the rear of -the trenches, I sent him, with all those of different corps who were -wounded, to my own hospital at Aldea Gallega, some ten miles off. Here, -under a sufficiently vigorous treatment, of which bleeding, starvation, -and quietude were the prominent features, he gradually recovered. On -the fifth day the ball passed per anum, and on two or three different -occasions afterward portions of his coat, flannel shirt, and breeches. -Fecal matter passed readily through the wound, while the bowels were -gently solicited by common injections for some time; but the wound -gradually closed in, and the man regained his health, and was sent to -the rear with a slight colored discharge from the wound, not quite free -from odor. - -Ensign Wright, 61st Regiment, was wounded by a musket-ball, on the -morning of the 10th of April, at Toulouse. The ball passed through the -abdominal parietes on the right of the linea alba, nearly half way -betwixt the umbilicus and the pubes, and lodged. Sense of debility, -tremor, nausea, small, feeble pulse, and pain in the lower part of the -abdomen were the immediate symptoms. - -Peritonitic and enteritic symptoms of considerable violence having -begun to manifest themselves on the 11th, copious and repeated -evacuations of blood were made by order of Mr. Guthrie, the Deputy -Inspector-General in charge of all the wounded. Fomentations were -applied to the belly; abstinence in food and drink was strictly -enjoined, and the most rigid antiphlogistic regimen followed. The same -practice was pursued during the 12th, 13th, and 14th, venesection being -performed either two or three times every day, as the augmented state -of the local and general inflammatory symptoms seemed to require. -The bowels during the above period had continued perfectly free, and -the dejections were tolerably natural in color, but rather dark, and -extremely fetid. He had been frequently troubled with nausea and -vomiting of bilious matter. Two small doses of castor-oil had been -exhibited. - -Toast and water, tea, boiled milk-and-water, with a little soft bread -soaked in it, and mutton and chicken-broth in small quantities at a -time, were all that was allowed him for food and drink. - -April 15th.--Pulse above 100, weak and small; temperature natural; the -tongue clean. Continued affected with a degree of nausea and vomiting, -after drinks especially; and some diarrhœa was present. - -17th.--Was bled last night to twelve ounces, in consequence of -increased pain of abdomen and augmented pyrexia; to-day quiet and easy, -and has had several stools. - -18th.--Diarrhœa and tenesmus troublesome during the night; _ball voided -with the feces at six_ A.M.; it is somewhat flattened, as if from -impinging on a stone; has felt easy since. Continue antiphlogistic -regimen. - -19th.--Diarrhœa abated; but the abdomen is tense and painful on -pressure. He is distressed with nausea and vomiting; pulse 100, and -sharp; great thirst; tongue dry. Bleeding to sixteen ounces; abdomen -fomented. - -20th.--Bleeding was repeated last night from persistence of the -symptoms of peritonitis. Blood drawn very buffy; has had several loose -stools during the night. He is to-day easy; abdomen now scarcely -painful. Fomentations continued. - -29th.--This morning the abdomen was tense and painful on pressure; he -was affected with nausea, and had had vomiting repeatedly during the -night; thirst and pyrexia. Fomentations were applied from time to time, -and yielded relief. Suspect that he has not observed the prescribed -regimen. - -May 1st.--Pain of abdomen and bilious vomitings during the night; has -had three loose stools. Pulse 110, hard and small; thirst urgent. Blood -let to fainting; fomentations continued. - -2d.--Last night he was again bled to two ounces, when fainting -supervened. He passed a quiet night; had two liquid stools; abdomen not -painful, nor is he sick at stomach, nor thirsty. To keep himself warm, -particularly the belly. - -11th.--Suspect he has been rather irregular in diet. Passed a bad -night, partly in delirium; has vomited much; has obviously pain on -pressure of the abdomen, but appears studious to conceal it; pulse 112, -small and not soft; temperature increased; tongue red; thirsty; three -liquid stools. The stomach to be kept warm; ten drops of tincture of -digitalis in half an ounce of mist. acaciæ, to be taken three times a -day; diet of milk and farinaceous food; for drink, infusion of tea in -small quantities. Eight o’clock.--Pulse 120, soft; feels easier, and -has not vomited. Ordered a foot-bath. - -13th.--Molested by pains, nausea, and vomiting during the night; -pulse 110, not soft; skin cool, but is thirsty, and his tongue is of -a vermilion color, and arid; confesses that he has hitherto disguised -his feelings, as well as other circumstances connected with his case, -particularly his manner of living. Digitalis continued; blister to be -applied to the epigastric region, and the foot-bath repeated in the -evening. - -14th.--Bad night; pulse 112; skin hot; pain of abdomen not urgent; -no vomiting, but is affected with nausea. Digitalis continued. Four -o’clock.--Pulse 100; feels nauseated; no pain of abdomen. Digitalis -occasionally. - -16th. Eight A.M.--The tendency to vomit continues. One grain and a half -of chloride of mercury with a grain and a half of opium, made into -a pill, to be taken in the morning; to be bled. Seven P.M.--Vomits -whatever he swallows in any quantity; skin hot; thirst great; tongue -red; two motions; says abdomen is not painful; pulse 112. A blister to -be again applied to the epigastrium; foot-bath in the evening; repeat -the mucilaginous mixture for cough. - -17th.--Rested ill; blister has not risen; cough has been severe and -continues so; two motions; pulse 120, and not soft; cough augmented by -deep inspiration, and pain produced. Take blood from the arm to eight -ounces; foot-bath in the evening; continue pill. - -18th.--Bad night; cough gone; respiration easy; pulse 100; skin cool -and moist; no thirst; one motion of a natural kind. Repeat mucilage and -the calomel and opium pill. - -24th.--Has this morning experienced a severe attack of dyspnœa, -attended by cough and pain of chest, both increased by full -inspiration. Pulse 120; face flushed; says he caught cold from exposure -to the night air. Bled immediately, and as much blood taken as his -strength would permit; foot-bath repeated in the evening. - -25th.--Six ounces of blood drawn; surface buffy; bad night; cough, -pain, and pyrexia abated this morning; in the evening severe dyspnœa; -cough and pain of chest have recurred; pulse 120. Six ounces of blood -to be drawn, should strength permit; mucilaginous mixture to be -continued; another blister to be applied to the chest. - -28th.--In a fair way of recovery; was discharged for England in June, -with little or no complaint. - - John Murray, Surgeon to the Forces. - -Sergeant Matthews, of the 28th Regiment, was wounded at Waterloo by -a musket-ball, about an inch below the umbilicus, a little to the -right side, which lodged. He walked to a village in the rear, where -he remained for three days, having been bled each day to fainting, -before he was removed to Brussels, where my attention was particularly -attracted to him, in consequence of his having passed the ball (a small -rifle one) per anum, three days after his arrival, or the sixth from -the receipt of the wound. The wound was healed by the end of August; -and he felt so well that he marched to Paris with other convalescents, -to joint his regiment. After some weeks he got drunk, and suffered -from an attack of pain in the bowels, in the situation of the wound, -requiring active treatment. On attempting one day to have a motion, he -found, after many efforts, that something blocked up the anus, and on -taking hold of and drawing it out, he found it was a portion of the -waistband of his breeches, including a part of the button-hole--a fact -verified by Staff-Surgeon Dease, who wrote to me an account of this -peculiar case. After this the man recovered without further difficulty, -although, as in all such cases, there was a herniary projection. He was -afterward subject to costiveness, to pain in the part after a copious -meal, probably from the stretching of the adhesions formed between the -intestine and the abdominal peritoneum, which inclined him to bend his -body forward to obtain relief. - -In all such cases, the extraneous substance having lodged, and mainly -injured in all probability the vitality of the part which assists in -the lodgment, the ball becomes covered with a layer of coagulable -lymph or fiber, capable of retaining it in its new situation, whence -it is gradually removed by ulceration, or by the sloughing of -the injured parts into the cavity of the bowel; much in the same -manner as an abscess in the liver is evacuated into the duodenum or -neighboring intestine, to which it may become attached. It is always -fortunate when the canal from the external wound is cut off by the -deposition of lymph, as it expedites the cure, and renders the injury -less formidable; but if this should not take place, the contents of -the bowel are discharged through it for a greater or shorter length -of time, until the canal between the parts gradually closes, and -cicatrization takes place, in default of which an artificial anus may -remain in addition to the natural one, the functions of the bowels -generally being performed with more or less difficulty. - -The two following very interesting cases of abdominal injury having -been received while these pages were passing through the press, are -here inserted:-- - -A man in the 19th Regiment was wounded through the abdomen, and -survived nineteen hours, the ball entering near to the umbilicus, and -passing out close to the sacrum. On the post-mortem examination, the -small intestines were found to have been wounded no less than sixteen -times by the ball in its passage. When wounded, he was stooping in the -act of defecation. - - T. Alexander, Deputy Inspector-General. - - _5th August, 1855._ - -On the evening after the battle of Alma, as my regiment was halting on -the brow of a hill, previous to bivouacking, a wounded Russian officer, -apparently in great pain, was perceived on the other side of the -ravine. Passing over to where he lay, I found that he had been wounded -by a musket-ball, that had entered the lumbar region directly over -the spine. As he was enabled in his agony to crawl on his hands and -knees, it was evident there was no paralysis, and on passing a probe -I found the ball had avoided the spine, but as I could not pass in -the instrument more than an inch, I was left in uncertainty as to its -further course. - -He was removed to my hospital tent, when I tried, but with little -success, to remove the excessive pain from which he was suffering. -In about two hours after he took my finger and placed it on a hard -substance imbedded in the walls of the abdomen, and on cutting down on -this I perceived a musket-ball. Previous to extracting it, however, I -observed a white, glistening substance oozing from the wound, which, on -carefully removing with the probe, proved to be a portion of tape-worm, -about a yard and a half in length. I then extracted the ball, and again -another portion of the worm presented, which measured about two yards -and a half in length. It was now complete, though cut in two evidently -by the ball, and the two portions, one containing the head and the -other the tail, were soon writhing on the table. - -The patient experienced immediate relief; the pain had ceased; he -slept well, and on the following morning he was free from thirst, -with a tolerably quiet pulse. Unfortunately the order arrived for all -prisoners and wounded to be sent to the rear, and I lost sight of the -case. - -What was the cause of this agony of pain? Evidently the writhing of -the worm, or why should it so suddenly cease on the worm’s liberation? -The abdomen must have been entered by the ball, or how could the -worm’s exit have been effected? Nevertheless, but for its presence, -the patient was so free from constitutional symptoms on the following -morning that a surmise might really have arisen that the ball had -passed round the abdomen without injury to the peritoneum. - - Rt. De Lisle, Surgeon, - 4th K. O. Regiment. - - _Camp before Sebastopol, August 8th, 1855._ - - - - -LECTURE XXIX. - -ABNORMAL OR ARTIFICIAL ANUS, ETC. - - -401. In some cases of wounds of the intestine the continuity of the -bowel is not sufficiently re-established; the external wound remains -open, and becomes indurated and fistulous, giving passage to the fecal -matters, and rendering the sufferers very miserable. These cases are of -rare occurrence among the hardy natives of Great Britain and Ireland, -and comparatively little has been done or even recommended in this -country for the relief of this misfortune. - -When an intestine has lost a more or less considerable part of its -substance at a particular spot, and an artificial anus is about to -be formed, it adheres to the peritoneum around the inside of the -external wound, although the adhesion is of little extent or width, -and forms but a narrow barrier for the protection of the cavity of -the abdomen. The upper end of the bowel is more open than the lower, -the caliber of which is contracted in size, and is sometimes even -difficult to find; while its opening is partially closed by a sort of -septum extending across, or from where the two portions of a divided -gut have come irregularly in contact with each other by their sides, -without uniting in the first instance in their length; or from the -falling in especially of the posterior part of the lower end, to which -the upper has become united. The projection thus formed in the tube is -called by the French _eperon_ or _promontoire_, valve or spur, ridge or -septum; it directs the fecal matter through the external wound, while -it obstructs its passage into the lower part of the bowel. There is -generally great difficulty in ascertaining the fact of the existence -and exact situation of this valve during life; in distinguishing the -upper from the lower end of the intestine, as well as the nature and -extent of the adhesions by which the injured intestine is retained in -its situation. If the absence of such a valve can be satisfactorily -made out--and it is sometimes wanting--the external opening may be -successfully closed by compression, or by operation. If the valve -should exist, its removal by a preliminary operation is necessary; it -has been attempted in France with various but somewhat doubtful success. - -402. When a portion of small intestine has been lost by mortification -or otherwise, and the patient has recovered with an unnaturally -situated or artificial anus, the intestine, although at first in -contact with the wall of the abdomen, is gradually, in many cases -though not in all, retracted into the cavity--it has been supposed by -the dragging of the mesentery upon it at the point of union of the -divided extremities outside where the _eperon_ or valve is formed; and -it is said that this dragging has even led to the gradual disappearance -of the valve, admitting thereby of the contents passing more readily -from the upper part of the intestine into the lower, and consequently -laying the foundation for a cure. This dragging of the intestine, -or its movements under the different motions of the body, in some -cases cause an elongation of the membrane formed under the adhesive -process, by which the intestine is attached to the inside of the wall -of the abdomen in the same manner as adhesions are elongated between -the pleuræ, and a sac or pouch is thus formed between the cut ends -of the intestine and the fistulous external opening which Scarpa was -the first fully to demonstrate and explain, and which he called an -_entonnoir_, _infundibulum_, or funnel. If, then, in an old case, a -small portion of the wall of the abdomen be removed in the form of a -V, the internal opening at the apex of the V, if small, would be made -into a sort of funnel, while the outer incision would remove all the -hardened fistulous parts--an operation which is sometimes required to -be done when the external opening is not free, and fecal matters have -insinuated themselves between the aponeurotic parts, giving rise to -abscesses and other small fistulous openings in different directions. -It is necessary to bear the formation of this pouch in mind as well as -that of the valve, in order to understand the operations proposed for -the relief or cure of this complaint. - -If simple compression fail in the first instance to prevent the passage -of the feces, which never can be thoroughly controlled from the want -of a sphincter and the uncertainty of pressure, the method of Desault -may be adopted. This consists in gradually dilating the external wound -so as to enable the operator to discover the open ends of the bowel, -when a tent is to be introduced into the lower end, and afterward -into the upper, being fastened by a thread passed around its middle. -A pyramidal-shaped pad is then to be placed over the opening, and -compression made by bandage upon it so as to press the whole inward. -The size of the tent is to be gradually enlarged until the contents of -the gut begin to pass downward with ease, when a well adjusted pressure -is to be made on the fistulous opening only, to prevent all oozing from -it until the internal parts have had time to close. - -403. Dupuytren invented a pair of forceps, consisting of a male and -female branch, to be applied separately, one on each side of the valve -or _eperon_, to the extent of an inch or an inch and a half at most, -when they were to be closed by a screw until they had compressed the -part between them sufficiently to destroy its life. The separation of -the valve included within the forceps would take place by the usual -processes of ulceration in its immediate proximity, and by adhesion -of the parts external to the bowels to those surrounding them. The -inflammation, however, did not always stop at the adhesive stage, and -death has been the result as well as a successful cure. - -404. Mr. Trant has invented an instrument he calls a propeller, for -pressing back the eperon, an account of which is given in the _Dublin -Medical Press_, May 14th, 1845. He used this in one case with complete -success. The instrument by its formation admits of being passed -through the artificial anus, and of being placed on the _eperon_ at -the bottom of the wound, where it can be retained for a considerable -time without producing the slightest inconvenience. It does not, while -in the intestines, offer any obstruction to the passage of the fecal -matters flowing along the cavity of the tube. It acts as a forceps in -retaining the anterior wall of the intestine in close contact with the -posterior surface of the abdominal parietes, while the propeller is -pressing back the _eperon_ toward the spine; consequently the danger -of separating the delicate adhesions in this situation is prevented, -otherwise a fatal extravasation into the cavity of the abdomen might -ensue. The instrument was made by Mr. Reed, of Dublin, and merits -further trial, being apparently less dangerous than the other methods -recommended in similar cases. Whatever may be the method employed for -the cure of an artificial anus by operation, it cannot be doubted -that the patient must be exposed to all the dangers which may result -from inflammation, for which he must be prepared beforehand, and the -symptoms of which must be met and subdued as they arise; or, if this -cannot be accomplished, the mechanical means, if any be used that can -be taken away, must be removed, and quiet, if possible, restored by -their abstraction and by the treatment adopted. In successful cases, -a small aperture will frequently remain, constituting a fecal fistula -instead of an artificial anus. This will sometimes become irritable, -inflame, ulcerate, or burst, discharging the solid contents of the -bowel, although, on the subsidence of the irritation, the part under -pressure usually returns to its former state. - -405. _Wounds and injuries of the liver_, whether incised or -penetrating, occurring from blows or from musket-balls, are very -serious, although not _necessarily_ fatal. Some few persons recover -altogether, some few with more or less of permanent disability. The -remainder die during the first or inflammatory stage, or in the -secondary one, which follows from the twelfth or fourteenth day after -the primary symptoms have in some measure subsided. - -The symptoms which ensue after a wound of the liver are those common to -inflammation of the cavity of the abdomen, with the addition of those -peculiar to the organ--pulse often smaller and less perceptible than -in peritonitis; discoloration of the skin, eyes, and urine, amounting -even to jaundice, although this is not an immediate symptom, neither is -it always present. The pain is not confined to the part, but extends -to the umbilicus, while the pain symptomatic of inflammation of the -liver--viz., pain in the top of the right shoulder--is felt early, and -is often accompanied by cramps of the muscles of the arms and numbness -of the fingers. The usual symptoms of anxiety and depression are -present, and the stomach shows by its irritability that it has partaken -of the shock given to the system. The bowels are usually confined, but -I have known blood passed from them when it was not supposed that the -stomach or intestines had been wounded; the discharge from the wound is -either of blood or bile, or both, mixed with a serous effusion which -afterward becomes purulent. Wounds of the gall-bladder are, as far as -is known, fatal--the effusion of bile which immediately takes place -giving rise to inflammation which, with other causes, destroys the -sufferer at the end of a few days. If the gall-bladder be adherent to -the peritoneum from any previous inflammation, a wound in it need not -prove mortal, as the effusion would be avoided, and there is no reason -to believe that an injury to this part would be otherwise more vital -than that of any other of the viscera of the abdomen. - -The late Lieut.-General Sir S. Barns, when Lieut.-Colonel of the -Royals, was wounded at the battle of Salamanca by a musket-ball, -which injured the cartilages of the false ribs, a portion of the rib -being removed and passed out through the liver. A bilious discharge -continued several weeks from the wound, and his life was saved with -great difficulty. He returned to his duties, although suffering from -a dragging pain and weight in the side, which any exertion increased. -In the autumn of 1819 he was attacked by acute inflammation; the pain -in the right side, extending over the stomach and umbilicus, was -constant and acute, and increased on pressure; the pulse small, indeed -scarcely perceptible; the extremities cold; the countenance depressed -and anxious; bowels confined; stomach rather irritable. A number of -leeches were applied, and other remedies administered. The constant -pain, which was increased by pressure, could only be relieved by loss -of blood, although every other symptom seemed to forbid depletion. -Twenty ounces of blood were taken from the arm, which caused a -diminution of the pain, and gave relief for an hour; the pain then -returned, and twelve ounces more blood were taken away, with the most -beneficial effect; a blister was applied over the part, and a dose of -calomel and opium was repeated. Shortly afterward he became tranquil; -the extremities lost their coldness; and, although the pain continued -in a slight degree for several hours, and much soreness remained for -many days, he quickly recovered. Two months afterward he had another -and equally severe attack, in consequence of walking about two miles -rather hastily; from that he was relieved in a similar manner. Whenever -he bent his body, a portion of the rib appeared to press in upon the -liver, and often gave him acute, darting pain; and one day, on pulling -on his boot in haste with some bodily exertion, a third attack ensued. -In order to prevent the bending of the body forward, and to confine the -motion of the liver, which seemed liable to injury from the irregular -points of bone which could be readily distinguished above it, stays, -made with iron plates instead of whalebone, were adapted to his body, -and from these he derived great comfort. - -Corporal Macdonald, first battalion, 79th Regiment, was wounded on -the 16th of June at Quatre Bras, by a musket-ball, which entered the -abdomen, splintered the eighth rib on the right side, passed through -the liver, and was supposed to have lodged on the opposite side, as he -says he felt the ball strike the left side, on which he was not able -to lie for a long time. Lost but little blood at the time; was dressed -superficially, and arrived in Brussels on the 19th, laboring under -considerable fever. Bleeding to thirty-six ounces. For seven successive -days the bleeding was repeated, to from twelve to sixteen ounces each -day, when a large, bilious, and purulent discharge took place from the -wound, on which the inflammatory symptoms appeared to subside, until -the 30th of June, when bleeding took place from the wound during the -night to the extent of twenty ounces, and then ceased spontaneously. -On the 15th of July the hemorrhage recurred with so much fever as to -warrant twenty ounces of blood being taken from the arm, and this was -repeated the next day. The bilious discharge ceased in the middle of -August, and on the 2d of September he was discharged convalescent. - -Lieutenant Edward Hooper, first battalion, 38th Regiment, was wounded -by a musket-ball on the 9th of December, 1812. It passed through the -anterior edge of the liver, and, glancing round the ribs, was cut out -about two inches from the spine. - -On his being wounded, he could scarcely believe his shoulder was -not the part affected. His pulse was intermitting; the breathing -hurried and laborious, and in a short time the tunicæ conjunctivæ -became yellow. He was _very largely_ bled, and warm fomentations were -applied to the abdomen, from which, and the bleeding, he received some -temporary relief; but, in consequence of his removal that night to the -rear, the symptoms were much aggravated on the morning of the 10th. He -complained of acute pain over the whole abdomen, increased on pressure; -vomiting; quick, hard, and wiry pulse, (no pain referred to the wound.) -The bleeding was repeated ad deliquium, warm fomentations and an -enema also repeated, and a saline mixture, with a _very few_ drops of -tincture of opium, to allay the irritability of the stomach. On the -following evening the vomiting had ceased; his pulse was less frequent -and hard; pain less. On the 11th, after passing a very restless night, -the pulse again rose; the abdomen became tense but not very painful, -and he made ineffectual efforts to stool. He was again bled, a large -blister was applied over the abdomen, and an ounce of castor-oil was -given immediately. The blister acted well, and the purgative gave him -three copious stools of dark and fetid feces. On the 12th he complained -of twitching pains, referred to the right shoulder, and was ordered one -grain of calomel, with two of antimonial powder, three times a day. - -Jan. 13th.--Was free from pain; pulse fuller and less frequent; urine -clear; tension of abdomen subsided. The calomel and antimony were -continued, and some light nourishment was allowed. From this day a -gradual amendment took place. The calomel was continued until his mouth -became slightly affected; and, as his bowels were in general torpid, -from the deficient secretion of bile, a mild purgative was given every -two or three days, as occasion required, and an ounce of the infusion -of calumba, with quassia, three or four times daily. - -A soldier of the 48th Regiment was struck by a musket-ball at Albuhera, -on the upper part of the right hypochondrium, over the liver; it -came out behind, at a point immediately corresponding to that in -front. Blood and bile were discharged from the wounds in considerable -quantity, and his case was considered to be hopeless. Brought to me at -Valverde, the next day, he was bled largely several times; the wounds -were dressed simply, and he was kept perfectly quiet, and his bowels -gently open. The skin became of a yellow color, his strength failed -under the treatment, and he became thin, and looked ill. At the end of -three weeks he was sent to Elvas, where he gradually improved, and was -forwarded thence to Lisbon and to England, with his wounds healed. - -An officer was wounded in one of the battles in the Pyrenees, -by a musket-ball, which penetrated the outer part of the right -hypochondrium, at the edge of the false ribs, and lodged. Blood and -bile flowed in considerable quantity; the skin became yellow, the pain -and swelling of the abdomen were considerable, and he was given over as -lost. Under a vigorous and careful treatment he gradually recovered, -so as to be sent to England, with a fistulous opening at the orifice -of entrance. I examined the wound in 1817, three years afterward, and -found that a large blunt probe passed inward toward the stomach and -liver for the distance of five inches, where it ended apparently in a -sort of sac. Purulent and bilious matters were constantly discharged -from the wound; his countenance was sallow; his digestion bad; he -suffered from constant uneasiness, if not pain, and was altogether out -of health. I saw him once annually for several years, and found that -I could sometimes strike the ball with the probe; that he frequently, -after an attack of pain and derangement, passed matter by stool, -after which the pain and uneasiness about the wound ceased. I had -hopes the ball would some day pass through the opening thus made, and -had thoughts of enlarging the external wound, and of endeavoring to -extract the ball with a long pair of forceps. He ceased at last to pay -his annual visit, and I suspect he died in one of the attacks I have -alluded to. This ball must have passed very close to, if it did not -penetrate, the gall-bladder. - -I have never had an opportunity of extracting a ball from the liver -during life, although I have seen persons live many weeks into whose -livers balls had penetrated; and I have been acquainted with three -persons who had been wounded through the liver, to whom little -subsequent inconvenience was occasioned. - -406. Portions of the liver have been removed in some instances; in -one case, related by Blanchard, a small piece of liver was removed -with the forceps. The patient dying of fever three years afterward, a -small piece of the liver near the external wound was found wanting. -Dieffenbach gives a case in which a small protruded portion was cut -off with scissors, without any bad consequence. Dr. Macpherson, in the -‘_London Medical Gazette_’ for January, 1846, has related the case of -a Hindoo, a large piece of whose liver protruded through a wound an -inch in length, made by a spear in the right hypochondriac region. A -ligature was applied tightly around its base, and the piece cut off, -rather than make such an enlargement of the wound as might allow the -restoration of the protruded liver. The arteries bled from the cut -surface, and required to be tied, and a double ligature was put through -the stump of liver and tied on each side. The part was not pushed back -into the abdomen, but allowed to remain in the wound. The symptoms were -mild, the ligatures came away on the ninth day, and the man returned to -his home in three weeks. - -These cases may be considered exceptions to the general rule, which -directs the return of all protruded parts. The retention of the part -from which the piece was cut off within the divided parts of the wound -was agreeable to the principles I have inculcated with respect to -wounds of all the cavities. - -407. _Wounds of the stomach_ are usually fatal, although some persons -escape when these injuries are confined to its anterior and upper -surface, and do not penetrate both sides, in which case effusion into -the cavity of the abdomen, and consequent inflammation, can scarcely -fail to ensue. It is fortunate for the patient, when they occur, that -the stomach should be empty. If it should not be so, the contents may -possibly be ejected shortly after the receipt of the wound, but it is -not advisable to excite vomiting by remedies, or by means adapted for -that purpose. In a perfectly quiescent state, the general compression -of the contents of the abdomen by its walls may prevent effusion under -ordinary circumstances, and this state should be maintained as rigidly -as possible. The apparent course of the wound indicates the probable -mischief, which is especially confirmed by vomiting of blood, great -anxiety, depression of countenance, a cold, clammy skin, pain in the -part, hiccough, and by the discharge of the contents of the stomach, -if the wound be sufficiently open to allow it; pulse low and sometimes -intermittent. If effusion of the contents of the stomach should not -occur, the external wound, if an incised one, should be closed by -suture, and the patient kept in the utmost state of quietude, in a -somewhat elevated position, the abdominal muscles being relaxed. -Neither food nor drink should enter the stomach, although thirst should -be allayed by wetting the tongue and mouth. The bowels should be -relieved by enemata, and the belly fomented. Bleeding and leeching, as -frequently repeated as the symptoms appear to require, must be carried -to the greatest extent that can be permitted with safety. - -When the external wound is so large as to enable the wounded stomach to -be seen, the cut edges of the wound in it should be brought together -by the continuous suture, as in the intestines; and the external -wound should be closed in a similar manner, the end of the ligature -on the wound of the stomach being cut off close to the viscus, that -organ being left perfectly free, with the hope that the thread will be -carried into its cavity, while the outside adheres to the peritoneum -opposed to it. - -When the stomach pours its contents through an external opening, too -small to allow its being examined, it is desirable that the wound -should be enlarged, if a doubt be entertained of the passage being -free. It is a sufficient reason for such an operation to allow the -opening in the stomach to be seen. It is very probable that effusion -will take place into the cavity of the abdomen if it be not done, and -the death of the patient will follow. It is very probable he will -die if it be done, and therefore in such cases little has hitherto -been attempted. I am of opinion, however, that in the case I have -last alluded to, a blunt hook may be sometimes introduced through the -wound into the stomach, so as to keep it stationary while the external -opening is carefully enlarged, and that it ought to be done in such -cases, and the wound in the stomach closed in the manner recommended. -I have never had a case under my care in which I could have done this; -but I have seen some die in whom it might have been done; and it -deserves to be considered when surgeons shall be in sufficient numbers -on the field of battle to attend to such recommendations, and to the -after-treatment these cases require. - -When the stomach is injured by a musket-ball, and its contents are -discharged externally, the edges of the wound, not being in a condition -to unite, must remain open for several days. The person should be -placed in the mean time in the most easy and comfortable position -which may enable the contents of the stomach to be readily passed -out externally, if they show any disposition to be thus evacuated. -The external wound should be dilated as far as the peritoneum, if it -should be required, so as to admit of the passage being direct, and -symptoms must be awaited and treated as they arise. If the patient -should survive the first or inflammatory stage, he should be supported -by clysters composed of strong beef-tea or veal broth, given five -or six times during the twenty-four hours. When it may be expected -that the wound in the stomach has closed, or that the injured portion -has adhered to the neighboring parts, warm jellies and light broths -may be frequently given in small quantities, but solid food should -be forbidden until complete recovery has taken place. I have seen -inattention to this precaution in more than one instance prove fatal. - -408. Fistulous openings have been known to follow wounds of the -stomach, and to continue for years. The case related by Dr. Beaumont of -the American army, of St. Martin, who, in 1822, received an extensive -wound in the stomach, which became fistulous, admitting of a variety of -most interesting inquiries being made into the process of digestion, is -remarkable. - -Hevin has related some of the most interesting cases of those who had -swallowed knives, etc., by design or by accident, and whose stomachs -were opened for their removal. The most ridiculous story of the whole -is an instructive one, however. Some young students, desirous of -punishing a young woman who had offended them, cut short the hair of -the tail of a large pig, and when frozen hard, forcibly pushed it up -her anus, leaving a couple of inches only hanging out of the small -end or tip. The hairs having been cut short caught in the gut when -attempts were made to draw out the tail, and gave her inexpressible -pain. The most serious symptoms followed during six days, and every -attempt having failed, Marchetti was applied to. He prepared a hollow -tube two feet long, large enough to receive the thickest part of the -pig’s tail, to the end of which he fastened a strong waxed cord, which -he drew through the tube. This he carefully introduced into the anus, -pushing it over the pig’s tail, until he drew the whole of it into the -tube, which he then brought away, including the tail, to the great -relief of the sufferer. - -409. The necessity for an operation so grave as that of opening the -stomach must be shown by the presumed impossibility of the foreign -substances being dissolved, or of their passing out of it by any other -means, while the continued distress they occasion more than equals the -risk which is likely to be incurred. The offending substance ought -to be felt through the wall of the abdomen, and the incision for its -removal should be made between the recti muscles in the linea alba, -unless the foreign body have actually pierced the stomach, and can be -felt to the outside of the rectus muscle, at which part the incision -ought to be made obliquely in the direction of the fibers of the -external oblique muscle, all bleeding vessels being secured before the -peritoneum is opened. This having been accomplished, the protruding -body should be extracted by such an enlargement of the opening in the -stomach as may be actually necessary. When the substance does not -protrude, although it can be felt through the wall of the stomach, -it will be advisable, if possible, to draw it toward the upper or -smaller curvature of the stomach rather than to the lower, avoiding -the coronary vessels, and taking a medium distance for the opening -from the cardiac orifice, and thereby such advantage as may be derived -from gravitation. The wound in the stomach should be united by the -continuous suture, and the external wound should be closed in a similar -manner. The patient ought to be kept in bed in an easy erect position. - -410. _Injuries of the spleen_ have been usually fatal, from hemorrhage -filling the general cavity of the abdomen, especially when they have -arisen from rupture of that organ, which I have several times seen -occur in consequence of falls, or from blows from cannon-shot, which -have not opened into the cavity or exposed the viscus. Wounds from -musket-balls have for the most part destroyed the sufferers, either -from hemorrhage or from inflammation. I have not seen nor heard, during -the Peninsular war, of a wound in the abdomen through which the spleen -protruded, the patient recovering. Instances have occurred in which -this part has been removed in man after its exposure by injury. A case -is said to have taken place after the battle of Dettingen, in which -the spleen, covered with dirt, was cut off, and the patient recovered. -In another case the spleen, found without the wound at the end of -twenty-four hours, was cold, black, and mortified. The surgeon placed -a ligature above this part, and cut off three inches and a half of -the spleen; a large artery was tied, and the remaining portion of the -viscus was returned into the cavity of the belly, the ligature hanging -to it, and the patient got well. - -Wounds from stabs with a bayonet, or a sabre, or long-pointed sword -are frequently fatal, either from hemorrhage or from inflammation; -but I have seen accidentally, after death, cicatrixes in the spleen -corresponding to external marks, indicative of a former wound. The -treatment, in all such cases, should be to encourage the discharge of -blood from the part, in the first instance; then to close the external -wound if an incised one, to place the patient on the injured side, and -to subdue all unnecessary inflammation by bleeding, leeching, absolute -rest, and starvation. The application of warm fomentations where an -oozing of blood may be expected to take place cannot be recommended, -and cold should be substituted if agreeable to the feelings of the -patient. When the blow or wound does not cause the death of the -individual by hemorrhage or acute inflammation, a chronic state of -disease may supervene, which, if not duly combated, will ultimately -destroy him. The early administration of calomel and opium, and the -repeated application of blisters, will, in these cases, as well as in -those of wounds of the liver, be of the greatest service. Effusion or -suppuration may take place as well as in those cases which have been -noticed, when other viscera have been injured; although instances of -such terminations are not recorded, it does not follow that they have -not taken place. - -411. _Wounds affecting the kidney_ have been less fatal than those -of the spleen, although they are scarcely less dangerous, from the -complications by which they are attended; the successful cases on -record are not numerous, and the practice to be pursued can only be -general. The results, when not fatal, have been for the most part -unknown, from the patients either lingering on or recovering after they -have been discharged from the service. I saw two cases of this nature -after the battle of Waterloo. In one, the ball had passed through the -abdomen, entering a little below and to the left of the umbilicus, and -coming out behind nearly opposite and close to the spine. No fecal -matter was discharged from the front wound, but some came through the -posterior one, accompanied by a small quantity of urine, indicating a -lesion of the kidney or of the ureter at its upper part. The symptoms, -at first severe, had subsided under proper treatment, and there was -every probability that the sufferer would eventually recover, although -I was unable to trace the case after the man left Brussels. In the -other, pain was principally felt in the testis and the spermatic cord -of the side injured. - -An officer was wounded on the right side, on the 9th December, 1813, -the ball being cut out behind; his case was considered hopeless. An -hour afterward, on being moved to the fire, he desired to make water, -and then passed what appeared to him to be a quantity of blood. -Carried to the rear on a wagon for three leagues, he suffered beyond -description, passed bloody water again, and on his arrival in quarters -was bled and had an enema administered. He then became delirious, was -bled several times, had blisters applied to the abdomen, suffered from -pain at the top of the right shoulder, and took no other nourishment -but tea for fourteen days. He gradually recovered, and at the end of -seven weeks was sent to England. After remaining some time in London, -he joined the depot of his regiment. In consequence of this exertion, -he suffered an attack of fever and peritoneal inflammation; and a -tumor formed in the site of the posterior wound, which was opened, and -discharged several ounces of matter of a urinous odor. Another abscess -formed, and was opened. During this time he suffered great pain and -became greatly emaciated; the urine diminished in quantity with the -frequent calls to pass it. He lingered in this state until the end of -July. The flow of matter from the wound was great, and had a urinous -smell. The desire to make water was incessant; but it passed only by -drops, and brought him to a state of frenzy; the discharge from the -wounds, which had been lessening for two days before, suddenly stopped; -the pain and pressure of urine became intolerable; he remained at last -in a state of the greatest torture for about three minutes, when, -during an effort, a burst of urine took place, colored with blood, -forcing out with it a hard lump, shaped like a short, thick shrimp, -three-quarters of an inch long, which proved, when examined next day, -to be the cloth which had been driven in by the ball. It must have -passed from the pelvis of the kidney or the ureter into the bladder. It -was hard, was covered by a black crust, and was thought to be a stone -when passed. It could not, however, have been long in the bladder, or -it would have been covered by the triple phosphates, and have formed -the nucleus of a calculus requiring to be removed by operation. - -Le Capitaine Negre, of the French Infantry of the Line, was struck -on the left side above the hip, at the battle of Albuhera, by a -musket-ball, which went through the upper part of the sigmoid flexure -of the colon, and came out behind, injuring apparently the fourth and -fifth lumbar vertebræ. As urine came through this opening, the ureter -or lower part of the kidney must have been wounded; and, as he had -lost the use of one leg and much of that of the other, the spinal -marrow must also have been injured. He was left on the field of battle, -supposed to be about to die, and was brought to me to the village -of Valverde, three days afterward, in a most distressing state. The -inflammatory symptoms had been and were severe; the pain he suffered on -any attempt to move him was excessive; the discharge of feces from the -anterior wound, and of urine from the posterior one and by the usual -ways, rendered him miserable, and he at last implored me to allow the -box of opium pills, of which one was given at night to each man who -stood most in need of them, to be left within his reach, if I would not -kindly do the act of a friend and give them to him myself. He died at -the end of ten days, after great suffering, constantly regretting that -our feelings as Christians caused their prolongation. - -412. _Wounds of the spermatic cord_ are of infrequent occurrence, and -rarely lead to fatal, although often to inconvenient consequences. - -I have removed the bruised and shattered remains of a testis and -epididymis to expedite the cure, and I have been obliged to do so -at a later period in consequence of the wounded portion becoming -enlarged and diseased. These occurrences are rare; the wound in the -testis usually heals kindly; but the portion which remains, however, -is probably of little use, although the patient does not like to lose -it. A gentleman in perfect health was struck accidentally in the right -testis by two shot, while out shooting partridges. The shot lodged, -and gave rise to uneasiness, and after a time to an enlargement, which -could not be distinguished from medullary sarcoma. I removed the -testis, and the wound healed kindly. The lumbar glands had, however, -taken on the disease, and he died of their great enlargement and the -general mischief which ensued within the year. The preparation is in -the museum of the College of Surgeons. - -I have not had occasion to tie an artery, even when the penis has been -as good as amputated. If bleeding should take place in the progress of -the cure, a large catheter should be introduced into the urethra, as -a point on which pressure may be made laterally; for I am not aware -of any other use it can be, unless the urethra be also torn, when a -moderate-sized catheter should be kept in it permanently, if it can be -borne, to aid in the healing of the surrounding parts with as little -contraction as possible of the canal. When the corpus spongiosum has -been carried away or sloughs with the urethra, there is usually some -injury done at the same time to the corpora cavernosa, and the part -becomes contracted and curved when distended. I have not seen any of -these cases since the introduction into practice of the methods which -have been recommended by Dieffenbach and others for the formation of a -new urethra by borrowing from the neighboring parts; but several might -certainly have been benefited by such treatment. - -A married soldier, of the 29th Regiment, was wounded on the heights of -Roliça, in August, 1808, by a small musket-ball, which went through -both corpora cavernosa from side to side. The man suffered very little -inconvenience, and the wounds healed very well. He seemed to consider -the injury as of no importance to himself, but had some idea there -might be a difference of opinion in another party. There is usually a -deficiency of substance at the part after such wounds, and sometimes on -inconvenient curve or twist, such as often takes place when the corpora -cavernosa and the corpus spongiosum are injured or ruptured from other -causes. - - - - -LECTURE XXX. - -WOUNDS OF THE PELVIS, ETC. - - -413. _Wounds of the pelvis_ from musket-balls injuring its contents are -of common occurrence, and, although frequently fatal, often permit a -considerable length of treatment before they destroy the sufferers or -admit of their recovery. In many instances fistulous openings remain -for years. The orifices of entrance and of exit of the ball lead to -little information. It is only from the absence of paralysis or of -hemorrhage, or of those signs which indicate the lesion of any of -the organs contained within the pelvis, that the surgeon can form an -estimate of the evil which has been committed; even when parts of the -greatest importance are injured, such as the bladder or the rectum, the -general symptoms are occasionally of little moment. - -When paralysis occurs, which it rarely does unless the spinal marrow -be injured, the functions of the bladder and of the rectum are -implicated, and there is but little pain. When the nerves only are -injured, the paralysis is not complete; it usually affects one side -more than the other, is a numbness rather than a paralysis, and is -accompanied by severe pain, sometimes at the seat of injury, but more -usually extending to the thigh and to the extremities of the nerves in -the foot. I was consulted in a case of wound from a pistol-shot, in -the last dorsal or upper lumbar vertebra, of several years’ standing, -in which the paralysis of both limbs was complete. The patient had a -great desire to have the cicatrix opened, and the ball followed and -extracted, and would willingly have submitted to such an operation, but -he could not find any one in London or Paris willing to attempt it. - -When a ball appears to cross or pass even from side to side of the -pelvis, it is not always easy to say whether it has penetrated the -cavity or not, until symptoms indicative of such injury appear; the -less done to such wounds the better. When a ball enters, strikes a -bone, and lodges, it is very desirable to ascertain its situation, in -order that it may be at once removed, if it can possibly be done with -but little comparative danger; for balls which lodge in these flat -bones may often be removed, and the comfort of the patient assured by -a timely operation, instead of proving the source of much torment and -misery for many years by their being allowed to remain. - -The late Colonel Wade, one of the most distinguished officers of his -rank in Spain, was wounded at the battle of Albuhera, in 1811, by a -musket-ball on the left side; it passed through the ilium, and was -supposed to have narrowly avoided opening into the cavity of the -abdomen. It could not be followed beyond the bone. The inflammatory -symptoms were subdued in the usual time, and he gradually recovered -his health, some pieces of bone coming away from time to time. A small -fungous protrusion and discharge continued from the wound for several -years, with a certain degree of pain, and of occasional lameness in -the leg and thigh. The wound closed sometimes for a few months, and -reopened after an attack of pain, with great lameness and swelling -of the hip, and a discharge of matter from the original site. An -abscess at last formed under the gluteus maximus, and was opened at -its anterior and lower edge. This gave great relief and prevented the -irritation of the upper and anterior original wound, the matter finding -a more ready passage. I often assured him I could distinguish the ball -very deeply seated; and in the summer of 1846, thirty-five years after -the receipt of the injury, it had descended so far that I passed a -probe under it at the distance of two inches and a half from the lower -opening. He was to have come to London as early as his duties would -possibly permit, in the spring of 1847, to have had it removed, when he -was suddenly cut off by apoplexy, to the great regret of all who knew -him. - -The late General Sir Hercules Packenham, G.C.B., was wounded at the -assault of Badajos by a musket-ball, April 6th, 1812, which deprived -him of the use of the thumb and little finger, and partially of the -hand; and by another which struck him on the right iliac region, -passing in just below Poupart’s ligament and outwardly through the -ilium. Eight pieces of bone came away at Elvas, and eleven more, -in 1813, in London. He went to Baréges in 1814-15-16-17, with the -hope that the ball might be loosened and removed, but in vain; it -never could be found. A small quantity of inoffensive glutinous -matter, sometimes streaked with blood, was discharged occasionally -from the seat of the injury. At times the wound became painful and -very troublesome for a week or ten days together, after which little -inconvenience was felt in the limb. - -Colonel Sir J. M. Wilson, now of Chelsea Hospital, was wounded in -seven different places by three musket-balls on the left hip, at the -Chippewa, near the Falls of Niagara, on the 5th of July, 1814. One, -which struck him a little before the trochanter, passed upward through -the ilium, (from which several pieces of bone came away on four or -five different occasions,) and lodged against or in the spinal column, -rendering the left leg quite powerless, and impairing the power of the -right. He fell. Shortly after an Indian warrior came up, placed his -foot on his neck, drew out his scalping-knife, seized his hair, and was -in the act of beginning to scalp him, when a shot passed through his -chest and laid him prostrate by the side of his intended victim, who -thus happily escaped. The numbness and inability to put the limb to the -ground continued from eighteen months to two years, during which time -he was on crutches. After this he gradually recovered, always suffering -more or less. The pain in the back is often most excruciating, coming -on without any apparent cause, except perhaps from change of weather. -He limps after walking a couple of miles, and if exercise be continued, -pain ensues. He married in 1824, has several children, and is obliged -to lead a very regular, quiet life, without which he breaks down. The -great suffering he experiences, at the end of near forty years, is, -however, from the pain in the back, sense of coldness in the left leg, -and numbness accompanied by pain in the course of the nerves. He is -equally sensible to heat in a close atmosphere, which he is obliged -to avoid. The alvine and urinary secretions, etc. have always been -impaired or deranged since the wound was received. He is troubled with -painful affections and a train of nervous feelings of the whole system, -attributable to the injury. The ball can of late be felt at the bottom -of a soft swelling in the loins; but the colonel, since the affair of -the Indian, has no predilection for cold steel, and protests as loudly -against the scalpel of the surgeon as the scalping-knife of the Indian. - -A soldier, of the Fourth Division of Infantry, was wounded at the -battle of Salamanca by a musket-ball, which entered immediately above -the right ilium, passed across, and made its exit nearly opposite -on the left side, going nearer to the back than to the wall of the -abdomen. He was supposed to be killed, but had recovered a little -life when brought to me at the field hospital some hours afterward. -The belly was swollen, generally tympanitic, and some hemorrhage had -taken place from the wound of entrance, and he was unable to move the -leg of that side. On reaction taking place, he was bled repeatedly, -and treated antiphlogistically with the aid of calomel, opium, and -antimony. He was removed to the San Domingo Hospital, and on the sixth -day the bowels were relieved naturally. A small quantity of fecal -matter was passed for several days with the discharge from the wound, -but this gradually ceased, and the man ultimately recovered without any -particular defect, except weakness and occasional pain and derangement -of bowels, on any irregularity. - -John Bryan, 1st Light Battalion of the King’s German Legion, was -wounded on the 17th of June near Quatre Bras by a musket-ball, which -entered at the groin, and made its exit behind. He was transported -to Brussels, with his foot and leg in a state of mortification. Wine -and other stimulants were freely given, and he rallied a little -on the 23d and 24th. On the 25th, the stomach rejected everything -except brandy and opium. On the 26th, a line of separation seemed -to be about to form between the dead and the living parts, although -he was evidently failing. He died on the 28th, eleven days after -the receipt of the injury. On examination after death the ball was -found to have completely divided the external iliac artery; about a -pint of coagulated blood, mixed with some excessively fetid pus, was -collected in the pelvis; the ends of the wounded artery had receded -considerably from each other, and a coagulum had formed in each, which -was easily squeezed out, the orifice of the upper end only being a -little contracted. There were signs of some peritoneal inflammation -having taken place; the intestines had not been wounded, and the ball, -in passing out, had splintered the upper edge of the back part of the -ilium. - -General Sir Edward Packenham was killed instantaneously at New Orleans, -by hemorrhage from a nearly similar wound, in which the common iliac -artery was divided. - -414. I have removed balls on different occasions which have lodged -in the bones of the pelvis, and always with the greatest advantage, -when done early. I have seen much evil result from their being allowed -to remain, as they caused not only frequent distress, but at last -gave rise to disease in the bone, derangement of the general health, -and death. When the ball can be felt impacted in the bone, incisions -through muscular parts of little consequence should not be spared to -expose it. If an error exists at this moment, it is that too little -is done, rather than too much. Too great reliance is placed on the -efforts of nature, and not enough on the resources of art. The constant -meddling with a wound is not recommended; nevertheless, much may be -done by careful investigation from time to time, of which La Motte -gives a good example in his fifty-first observation. - -A grenadier was wounded at the battle of Dettingen, in 1743, by a -musket-ball, which entered above Poupart’s ligament, near the opening -of the external oblique muscle on the left side, and lodged. Thirteen -days after his reception into the hospital at Landau, La Motte felt -with the probe what he thought was the ball lying on the outside -of the psoas muscle against the bone. He made the patient lie on -his face, and touched the foreign body every day in order to loosen -it. On the thirty-fifth day he was satisfied it was the ball, and -on the forty-fifth, after many attempts, it was at last extracted. -His fifty-second observation relates to a case as nearly similar as -possible to those of Sir H. Packenham and Colonel Wade. He made several -deep and long incisions in search of the ball, which he could not find; -the wound became fistulous, and at the end of a year closed, in all -probability to reopen from time to time. - -The difference in practice between 1743 and 1855 ought to be, that in -1855 the ball should be found first, and the deep and long incisions -made afterward for its extraction; which do not preclude any previous -external openings that may be necessary to facilitate the first -examination. - -Captain Campbell was wounded by a pistol-ball, on the 5th of September, -1805; it penetrated the abdomen on the middle of the right side, -and was extracted from nearly the same situation on the left; from -its irregular denticulated shape, it would appear to have impinged -against a vertebra. He complained of violent pain in the loins and -belly, with numbness and pain of the left leg and thigh, and suffered -also from the greatest oppression, anxiety, and sickness. An enema -was administered, and twenty-four ounces of blood were taken from -the arm; lower extremities nearly paralyzed; anxiety and oppression -great at night. Blood-letting to ten ounces. Cannot pass his urine; -hot fomentations; and at twelve at night sixteen more ounces of blood -were drawn. At three P.M., had three motions, the two last containing -apparently a pint of pure blood. Pain and other symptoms being urgent, -eight ounces more blood were taken away. At six P.M., passed urine for -the first time, highly tinged with blood; has had two motions, also -mixed with blood. Pain continuing, ten ounces of blood were abstracted, -although occasionally almost fainting on any movement; belly fomented. -At eight at night, sixty drops of laudanum. At ten, being very -restless, twenty drops more, which procured some sleep, although he -vomited frequently; belly relieved by the fomentation; three stools -mixed with blood. - -Sept. 6th.--All the symptoms relieved; passes blood with his urine; -sickness and vomiting troublesome; pulse 90, rather firm than feeble. -One o’clock.--Complains of violent pain in the left leg and thigh, -belly, and loins; pulse 116, full and strong. Blood-letting to sixteen -ounces. Barley-water with niter for common drink. Six P.M.--Pulse 96; -bowels open, with discharge of blood; symptoms generally relieved. -Tincture of opium, twelve drops at night. - -8th.--Slept better; less pain; paralysis continues. In the evening -symptoms aggravated; lost twelve ounces of blood; enema, etc. repeated; -pulse 120. - -9th, 10th, 11th, 12th.--Pulse 96; bowels open; urine bloody; is -generally better. - -15th.--Wound of exit healed; urine bloody; bowels open. Chicken-broth -for the first time. - -20th.--The opening of entrance having nearly closed was enlarged, and a -free exit allowed for the matter. - -Oct. 20th.--Wounds quite closed; is free from pain, is able to move -about the house on crutches; warm, stimulating applications to the -limbs seem to have given most relief. - -Nov. 20th.--Paralytic affection gone; he can now mount his horse, and -has only a feeling of numbness and torpor in the left leg and thigh. - -415. The general opinion which formerly prevailed, that _wounds of -the bladder_, by musket-balls, were for the most part mortal, is now -known to be erroneous. When the bladder is wounded below, where it is -not covered by the peritoneum, persons do sometimes recover by what -may be considered the almost unaided efforts of nature. A large number -of cases came under my observation at Brussels and at Antwerp, and -many had already died. Persons rarely recover in whom urine has found -its way into the general cavity of the abdomen. They generally die of -inflammation in from three to six days. - -When the bladder is wounded where it is covered by the peritoneum, -and the opening or openings do not by some accident permit the urine -to flow into the cavity of the abdomen, the patient may be free from -immediate danger for a short time, although very anxious and greatly -depressed in countenance and manner, and even sick to vomiting. The -pain is not commonly severe at first, and if he can make water, which -in all such cases it is desirable to prevent by having recourse to -the catheter, it is more or less colored or mixed with blood. If the -urine should not escape into the cavity of the abdomen, the ordinary -inflammation which must necessarily ensue takes place and affects the -internal surface of the bladder. The desire to pass urine becomes -greater, and is frequently insupportable, while it can in some cases -be only passed by drops. In others these symptoms are less urgent. -Nevertheless, the natural action of the bladder, or, in those severe -cases, the additional efforts which are made for its expulsion by the -abdominal muscles, may cause the urine to be forced through the wound -into the cavity of the abdomen, whence the advantage to be obtained -from the early use of the elastic catheter. When the orifices of -entrance and of exit are free, and low down in the pelvis, the urine -may run out without much immediate mischief ensuing. But as this cannot -always be known, an elastic gum catheter should be introduced from -the first and fixed in the bladder, in every case where the nature of -the injury is doubtful, until the urine ceases to flow through the -wounds. It must, however, be recollected that in some cases in which -it has caused great irritation, by being introduced too early, while -the bladder was very sensitive, the patients have been much relieved -by its removal. The principle is nevertheless incontrovertible in all -doubtful cases; the urine should be allowed to drop out of the catheter -nearly as fast as it passes into the bladder, when this organ is -very irritable; great pains should also be taken that the end of the -instrument should be within, but not too far within the bladder, so as -to excite irritation by rubbing against its sides, or to allow its end -rising above the urine which might in this way collect below it, and at -last escape through the wounds. - -416. The inflammatory actions are to be subdued by general bleeding, -the application of leeches, the administration of diluent drinks -in moderate quantity, the exhibition of gentle aperients, such as -castor-oil, and by enemata. Opium in all these cases is an important -remedy, principally in the shape of morphia. Opium in substance, when -introduced into the rectum in the shape of a suppository, or dissolved -in half an ounce or an ounce of water as an enema, should be repeated -in such quantities, beginning with two grains, as will procure ease. - -417. The urine, in most cases of injury below the peritoneum, flows -readily through the wound of entrance, if not of exit, in the first -instance, and care should be taken, by enlarging the posterior wound, -that no obstacle within reach shall prevent it; but after inflammation -has been established, the parts swell, and as the sloughs begin to -separate, its passage is often obstructed; the elastic catheter, if not -used before, will then render important service by allowing the sloughs -to be separated without the healthy parts being irritated by the urine -being retained. After a time the urine may be only drawn off in small -quantities through the catheter, as frequently as circumstances may -render advisable. The permanent use of the catheter in these cases will -often prevent the urine from forming any devious paths as it proceeds -outward, ending in abscesses and fistulous openings, causing much -discomfort and even misery. It is not common for blood to be poured -into the bladder in such a quantity as to cause much inconvenience; -it coagulates with equal proportions of urine, and a silver catheter -should be used, by which it may be broken up and rendered more easy of -solution by injections of warm water. When the neck of the bladder or -the prostatic part of the urethra has been divided so that a catheter -cannot be efficiently used, surgery must come with more immediate aid -to the assistance of the sufferer, by making a clear and free opening -from the perineum for the evacuation of the urine and of the discharge -from the wound. If a ball lodge in or near the bladder, or in the -prostate, it must be removed by an operation in the perineum. - -A soldier of the Light Division was wounded on the heights of Vera, -in the Pyrenees. A musket-ball had entered behind near the sacrum -and lodged. He was bled twice, in consequence of suffering pain in -the part, but was not otherwise much disturbed. There was at first a -difficulty in passing urine, but this gradually subsided, although -he always suffered pain in micturition, which was frequent and -distressing. He remained in this state until December, when he passed, -with considerable effort and after much difficulty, a hard piece of -his jacket about half an inch in length, larger than the orifice of -the urethra, through which it was forced. As it was not incased by -calcareous matter, it could not have been long in the bladder, but must -have been lodged near it before it ulcerated its way in, giving rise to -the constant desire and irritation which he had so long experienced. -His symptoms then subsided, although they had not entirely disappeared -when he left for England. - -A French soldier was wounded by a musket-ball on the back part of the -right hip, at Almaraz, on the Tagus, was taken prisoner, and sent -to Lisbon in the autumn of 1813. The ball had lodged, but gave him -little inconvenience at the time beyond some pain in the course of the -sciatic nerve, subsequently followed by defect of motion on the right -side. Four months after the injury pain came on about the region of -the bladder, with great desire to pass urine, which he could not do -when standing, but which dribbled away when lying down. When quiet -he suffered little, but great pain followed any attempt at continued -motion. A catheter could be introduced, but with great difficulty when -it reached the prostate gland, which was exceedingly tender to the -touch. After a time the instrument could not be passed, and the man was -in great agony until something appeared to give way, and a discharge -of matter took place, when the urine followed, and he was relieved. An -abscess had formed, in all probability from the proximity of the ball, -which still could not be felt. The man recovered, retaining, however, -his former state of lameness and defect of power, although relieved -from the vexatious irritation of the bladder. - -A soldier of the Fourth Division of Infantry was wounded at the battle -of Toulouse, while entering a redoubt, by a musket-ball, which entered -at the left groin, and, crossing the pelvis, came out on the upper -part of the opposite hip behind. The urine flowed from both wounds and -from the rectum, indicating that the ball had passed between these -parts, and a little feces came from the posterior wound for three -weeks. The pain and suffering were not great, and principally arose -from retention of urine, requiring the use of the catheter, which was -left in, and changed from time to time, until the urine flowed by the -side of it, instead of through the wounds, which it did occasionally -for some weeks in drops, but not in any quantity; after which the -wounds gradually closed, and the man was sent to England cured. - -A soldier of the Cavalry of the King’s German Legion was struck, at the -battle of Salamanca, by a musket-ball, which entered just above the -pubes a little to the right side, and came out below on the opposite -nates. The urine flowed readily through both wounds for the first three -days, and he suffered afterward from great pain and distress about the -region of the bladder, from which he could not expel any urine, neither -would it pass by either wound. I immediately introduced a catheter, -drew off a moderate quantity of urine, and then fixed it in the -bladder, desiring him to draw off his urine every hour when awake. This -he did, often leaving the stopper out at night. The urine flowed after -a few days through the posterior wound, and then ceased. The catheter -was washed from time to time, and was at last withdrawn, as the urine -began to flow by the side of it, and the wound had finally closed when -he left the San Domingo Hospital. - -Captain Martin received a wound from a musket-ball at the siege of -Ciudad Rodrigo; it entered just above the pubes, passed through the -bladder and rectum, and came out behind, splintering the sacrum, the -contents of both viscera being freely discharged through this opening. -As he suffered but little inconvenience from the urine, very little -of which passed by the urethra, that passage was not interfered with -in the first instance. Inflammatory symptoms were kept within due -bounds, the rectum was carefully washed out by emollient enemata, -and his food rendered as light as possible. Under this treatment he -gradually improved; the anterior wound first healed, and subsequently -the posterior one, leaving him comparatively well when he left me for -Lisbon on his way to England. - -418. These cases give, however, a brighter view of the nature of -these wounds than they frequently justify; extravasation of urine, -inflammation, and death are not of infrequent occurrence in cases to -which strict attention is not paid; and great misery is often caused -from the irritation of the bladder and the discharge which follows, -until the constitution is undermined and death ensues. - -Captain Sleigh, of the 100th Regiment, was wounded at the battle of -Chippewa, on the 5th of July, 1814, by a musket-ball, which entered -the left groin immediately over Poupart’s ligament, by the side of -the spermatic vessels, injuring in its course the anterior brim of -the pelvis. It thence passed through the bladder obliquely across -the pelvis, and terminated its course beneath the integuments in the -right buttock, whence it was immediately extracted. Blood and urine -flowed incessantly from the groin; the quantity of blood lost was -considerable. He complained much of pain in the hypogastric region; -the abdomen was tense and painful to the touch, and he had an almost -continued inclination to micturate; but his attempts, after the most -painful efforts, were entirely frustrated. The anxiety was great, -the respiration hurried, and the pulse quick and fluttering. He was -bled to the extent of thirty ounces; an enema was given; fomentations -applied to the belly; and the catheter introduced--all which afforded -him some relief. The next day he was removed to the rear, a distance -of seventeen miles, in an open wagon, partly during the inclemency of -the night, and was quite worn out by so long a journey. He was carried -thence on board ship, and landed at York on the morning of the 9th of -July, the fourth day after he received his wound. - -July 9th.--Abdomen tense and painful to the touch; severe pain in the -perineum; great inclination to void urine, but fruitlessly; wound -in the groin sloughy, discharges urine and blood mixed with a small -quantity of pus; posterior wound healthy, no discharge of urine from -it; catheter attempted to be passed without success. Ordered an ounce -and a half of castor-oil immediately. - -10th.--Passed a restless night; had two copious stools; voided a few -drops of urine by the urethra; still great inclination to pass urine. -Ordered two grains of extract of opium made into a pill. - -11th.--All the painful sensations much relieved; abdomen less tense; a -small piece of bone extracted from the urethra about an inch in length, -of the thickness of a crow-quill; a little urine followed more freely. - -15th.--Complains of severe pain in the spermatic cord; discharge from -groin more offensive; wound filled with large maggots; bowels open. - -19th.--Wound of groin looks clean; a small piece of bone discharged by -the urethra, and a piece of cloth extracted from the groin. - -24th.--A small piece of bone extracted from the groin. - -August 5th.--Passes a good deal of pus and urine by the urethra. - -29th.--Posterior wound much inflamed and very painful upon pressure. A -poultice to be frequently applied. - -Sept. 1st.--An abscess has burst; a piece of cloth has been extracted; -urine and pus are discharged by both wounds. - -12th.--Doing well; wounds closing. - -16th.--Bladder resuming its power; discharge of matter from groin very -trivial. - -Oct. 4th.--Posterior wound closed. - -30th.--Wound of groin closed; urine, passed by the natural passage, -mixed with pus. - -At first it was supposed that only the fundus of the bladder was -wounded; but when the collection of matter took place in the right -buttock, and a piece of cloth was extracted from it, the urine -following, it was evident that both sides of the bladder had been -transfixed by the ball; and that, probably, the urine from the -commencement had been prevented flowing posteriorly by the intervention -of this foreign body. An elastic gum catheter could not be passed into -the bladder on account of the piece of bone which had forced its way -into the urethra, and from its being obstructed afterward by smaller -pieces of bone. - -When I saw this gentleman some time afterward, it appeared to me that -the purulent discharge from the urethra was not from the inner membrane -of the bladder, but was probably caused by some dead bone of the pelvis -having a communication with the bladder by a fistulous opening. - -A soldier, of the King’s German Legion, was struck, at Waterloo, by a -musket-ball, which entered a little way above the pubes, and lodged. -The symptoms which immediately followed were by no means severe, -although he passed a little bloody urine at first; the external wound -closed without difficulty. He complained of pain at the neck of the -bladder, and had a great desire to pass urine, with other signs of -stone in the bladder, which induced me to pass a sound, when I found -that the ball was lying loose in that viscus. On his arrival at the -York Hospital, at Chelsea, from Brussels, he became, with the French -soldier, whose thigh had been amputated at the hip-joint, an object of -great attention. I performed the operation for the removal of the ball -in the presence of a large concourse of military and medical persons. -It was done in less than two minutes; but the calculus, composed of -the triple phosphates, which had formed around the ball, yielded, and -broke under the forceps. The pieces were removed separately. The ball, -being heavy, fell below the neck of the bladder, which, being healthy, -yielded to the pressure, and allowed it to sink on the rectum, where -it could not be caught by the forceps, until it had been raised by a -finger in the bowel. The bladder was then well washed out, so as to -remove all the pieces that might remain, and the man was placed in bed. -He was bled once in consequence of some apprehension of pain; but he -had not a bad symptom, and rapidly recovered. - -The symptoms of irritation did not, however, entirely pass away, as -could have been wished, and I began to fear that some small pieces of -calculus had been overlooked; when, one morning, after considerable -effort, he passed a ring of sandy calcareous matter, which had formed -around the orifice of the bladder, and which, being dislodged, had -fortunately entered the urethra, along which it was forced by the -urine. It was evidently formed of the phosphates in minute portions, -which had become agglutinated together, around the meatus of the -bladder. This he took with him to Hanover, where it, himself, and -the cicatrixes of his wound, and of his operation, attracted great -notice. The ball, which was flattened on one side, I kept in a small -box, together with the pieces of calculus which were extracted, and -showed them annually at my lecture on this subject for many years. One -evening, however, I unfortunately left my little box on the table after -lecture; and when I recollected, and returned for it, I found that some -gentleman had borrowed it, and has not yet returned it. At the battle -of Chillianwallah a similar wound took place; the ball formed the -nucleus of a calculus, and was removed successfully by a gentleman in -the service of the East India Company, whose name I have not been able -to learn. - -The following case, from Baron Percy, is in point: A young man was -wounded by a pistol-shot, which entered just above the os pubis, -through the linea alba, wounded the bladder, and lodged. The belly -swelled; a tumor formed in the perineum; no urine passed; the bowels -were confined, and fever ran high, with a tendency to delirium. -Believing that the tumor in the perineum, and the fluctuation he -thought he perceived, might be caused by extravasated urine, he -punctured it with a trocar, and evacuated a large quantity of bloody -urine. This induced him to enlarge the opening, and carry it on to the -bladder, through which he brought out the ball, some shirt, and several -clots of blood. The man was bled nine times in all; the urine after a -time passed in the ordinary way, and the patient slowly recovered. - -An officer was wounded near Bayonne, by a musket-ball, on the left -side; it passed through the ilium across the pubes, and made its exit -through the gluteus maximus of the opposite side, but lower down. Urine -flowed through both wounds at first very readily, but none of any -moment came by the urethra, from which some blood occasionally oozed. -The attempt to pass a catheter failed, although the desire to make -water was urgent and painful. After a few days the passage of urine -by the external wounds became obstructed, apparently by the sloughs; -great pain and misery were experienced; fever ran high; rigors and -delirium followed extravasation of urine, and death closed the scene. -The mischief here arose from the catheter not having been passed into -the bladder, which could not be effected, from the prostatic part of -the urethra or the neck of the bladder having been injured. - -419. Surgery in such, or in nearly similar cases, requires a catheter -or staff to be passed down the urethra as far as it will go; an -incision should then be made upon it, from the center or across the -perineum, and the urethra divided on the staff until the finger rests -upon the wounded parts, when, in all probability, a straight catheter, -with the aid of the forefinger in the rectum, can be carried through -them into the bladder. The urine will then have a direct passage -outward, instead of coming indirectly from the bladder by the wounds. -If the straight catheter cannot be passed, which can scarcely occur, -the central incision is to be continued from the point of obstruction -into the bladder, guided by the finger in the rectum. A free opening -from the bladder offers the only hope of safety. - -420. The _rectum_ may be wounded without any other organ being injured -within the pelvis; of this I have seen several instances. Captain -Gordon, of the navy, was struck by a rifle-ball toward the lower part -of one side of the sacrum, after being knocked down by one he had -received on the head, and by another in the neck and back. The ball, -which passed into the rectum, made its exit on the opposite side of -the sacrum, and stercoraceous matters were evacuated by both wounds. -The pain was severe; the limbs were deprived of much of their power -of motion, and the next day the bladder was incapable of expelling -its contents. This was relieved by the catheter, and the rectum was -kept clear by warm, mild enemata, while the inflammatory symptoms were -subdued by bleeding, opium, starvation, and rest. At the end of three -months he was able to walk, but with some difficulty, on account of -defective power in one leg. Some small pieces of bone came away and -the wounds closed, although he was subject to an occasional slight -opening of the orifice of entrance, from which a little matter was -discharged, when it again closed. He remained more or less lame until -his death, which took place with the loss of the ship he commanded, in -a hurricane, on the coast of North America. - -A French soldier was wounded at the battle of Salamanca by a ball, -which entered by the side of the sacrum, and lodged. Having been rode -over and bruised, he was taken prisoner, and brought to me on the field -of battle. From this wound he suffered comparatively little, except -from a difficulty of passing urine. On the third day after his arrival -at the San Carlos Hospital, or the sixth from the receipt of the -injury, he passed the ball per anum. The wound quickly closed, and he -aided his comrades as an orderly in the hospital afterward. - - -CONCLUSIONS. - -421.--1. Severe blows on the abdomen give rise to the absorption of -the muscular structures, and the formation of ventral hernia, in -many instances; this may, in some measure, be prevented during the -treatment, by quietude, by the local abstraction of blood, and by the -early use of retaining bandages. - -2. Abscesses in the muscular wall of the abdomen, from whatever cause -they arise, should be opened early; for although the peritoneum is -essentially strong by its outer surface, it is but a thin membrane, and -should be aided surgically as much as possible. - -3. Severe blows, attended by general concussion, frequently give rise -to rupture of the solid viscera, such as the liver and the spleen, -causing death by hemorrhage. When the hollow viscera are ruptured, such -as the intestines or the bladder, death ensues from inflammation. - -4. Incised wounds of the wall of the abdomen to any extent rarely unite -so perfectly (except, perhaps, in the linea alba) as not to give rise -to ventral protrusions of a greater or less extent. - -5. As the muscular parts rarely unite in the first instance after being -divided, sutures should never be introduced into these structures. - -6. Muscular parts are to be brought into apposition, and so retained -principally by position, aided by a continuous suture through the -integuments only, together with long strips of adhesive plaster, -moderate compression, and sometimes a retaining bandage. - -7. Sutures should never be inserted through the whole wall of the -abdomen, and their use in muscular parts under any circumstances is -forbidden; unless the wound, from its very great extent, cannot be -otherwise sufficiently approximated to restrain the protrusion of the -contents of the cavity. The occurrence of such a case is very rare. - -8. Purgatives should be eschewed in the early part of the treatment of -penetrating wounds of the abdomen. Enemata are to be preferred. - -9. The omentum, when protruded, is to be returned by enlarging the -wound through its aponeurotic parts if necessary, but not through the -peritoneum, in preference to allowing it to remain protruded, or to be -cut off. - -10. A punctured intestine requires no immediate treatment. An -intestine, when incised to an extent exceeding the third part of -an inch, should be sewn up by the continuous suture in the manner -recommended, _Aph._ 391. - -11. The position of the patient should be inclined toward the wounded -side, to allow the omentum or intestine being closely applied to the -cut edges of the peritoneum. Absolute rest, without the slightest -motion, should be observed. Food and drink should be restricted, when -not entirely forbidden. - -12. If the belly swell, and the propriety of allowing extravasated or -effused matters to be evacuated seem to be manifest, the continuous -suture or stitches should be cut across to a certain extent, for the -purpose of giving this relief. - -13. If the punctured or incised wound be small, and the extravasation -or effusion within the cavity seem to be great, the wound should be -carefully enlarged, and the offending matter evacuated. - -14. A wound should not be closed until it has ceased to bleed, or until -the bleeding vessel has been secured, if it be possible to do so. When -it is not possible so to do, the wound should be closed, and the result -awaited. - -15. A gunshot wound penetrating the cavity can never unite, and must -suppurate. If a wounded intestine can be seen or felt, its torn edges -may be cut off, and the clean surfaces united by suture. If the wound -can neither be seen nor felt, it will be sufficient for the moment to -provide for the free discharge of any extravasated or effused matters -which may require removal. - -16. A dilatation or enlargement of a wound in the abdomen should never -take place, unless in connection with something within the cavity -rendering it necessary. - -17. If the epigastric, circumflexa ilii, or other artery in the wall -of the abdomen, be injured and bleed, the wound should be enlarged, -and the bleeding vessel secured by ligature. If the main trunk or the -external iliac artery be sought for and tied, the patient will in all -probability die. - -18. When balls lodge in the bones of the pelvis, they should be -carefully sought for and removed, if it can be done with propriety and -safety. - -19. In a wound of the bladder, an elastic gum catheter should be kept -in the urethra, frequently without a stopper, until the wound is -presumed to be healed--unless its presence should prove injurious, from -excess of irritation, not removed by allowing the urine to pass through -it by drops as it is brought into the bladder. - -20. In all cases in which a catheter cannot be introduced, in -consequence of the back part of the urethra or the neck of the bladder -being injured, an opening for the discharge of the urine should be made -from the perineum into the bladder. It is essential to the preservation -of life. - -21. The treatment of all these injuries must be eminently -antiphlogistic, principally depending on general and local -blood-letting, absolute rest, abstinence from food, and in some cases -almost even from drink, the frequent administration of enemata, and the -early exhibition of mercury, and especially of opium, in the different -ways usually recommended, with reference to the part injured. - -422. As the operation for opening into the colon may be necessary, -after an injury of that part, as well as from disease below it, the -following method, recommended by Mr. Hilton, is briefly transcribed -from the Reports of Guy’s Hospital. A line drawn parallel to the -spinous processes directly downward from the angle of the seventh, -eighth, or ninth rib across the costo-iliac space to the crest of -the ilium, will correspond with the outer edge of the erector spinæ -muscle and the apices of the transverse processes. A measured inch -outwardly corresponds with the outer edge of the quadratus lumborum -muscle. A vertical incision, two inches long, made at the extremity -of the measured inch, should divide the skin, cellular tissue, and -the tendon of the internal oblique muscle, and expose the outer edge -of the quadratus lumborum muscle. Any bleeding vessels to be secured. -The last dorsal nerve, if seen lying across the upper part of the -incision, should be divided, to prevent the occurrence of pain from -its being engaged in the cicatrix. The transversalis abdominis muscle -is then to be divided vertically to nearly the same extent of two -inches, parallel to the edge of the quadratus, when a quantity of loose -lobulated fat will be seen, which should be partly removed and partly -displaced by the blunt end of a director, in the vertical direction -of the original incision, when the intestine will be brought into -view. Any bleeding vessels should be secured, and pressure made on -the abdomen, which will cause the intestine to become more prominent -at the bottom of the incision. A silk ligature is now to be passed -into the bowel and through the integuments at the upper part, so as to -fix the intestine above, when a second ligature is to be applied in a -similar manner below. The intestine is then to be opened between them, -care being taken to apply another ligature above and below it, if -the intestine should not appear to be firmly held in its place. If a -vessel in its wall should bleed, it must be tied. Inflammation, pain, -and restlessness should be obviated as far as possible by fomentations, -opiates, and diaphoretics, and strict attention paid to cleanliness and -the comfort of the patient, until the first symptoms have passed away, -and he is able to assume the erect position. - -423. These commentaries are restricted to those points which -constitute, in a great degree, what the French call _la haute -chirurgie_. They are published that every soldier should have the -opportunity of knowing how he ought to be treated, when suffering for -a country not too grateful for the services rendered by her bravest -sons; and I have labored with the hope that some few of them, when -they find that their limbs, perhaps their lives, have been saved under -the precepts I have laid down, may acknowledge, when I am beyond that -bourn whence no traveler returns, that they owe them, under the will -of God, to those efforts I, more than any one else, have made, and -continue to make, for the adoption of that practice which led to their -preservation. - - - -ADDENDA. - - -Several reports and cases having reached me from various medical -officers in the Crimea, too late for publication in their proper -places, I have thought it best to notice some generally as to results, -others particularly. Chloroform has been freely administered in all the -Divisions of the army save the Second, and has been generally approved; -one death only, as far as is known, having occurred directly from its -administration, of which Staff-Surgeon Gordon, P.M.O. of the Second -Division, has favored me with the following report:-- - -Martin Kennedy, 62d Regiment, aged 32 years, a healthy soldier, having -accidentally wounded one of his fingers by his musket going off, and -the medical officer in charge considering it necessary to remove it, -was brought under the influence of chloroform, but, according to his -(the surgeon’s) statement, only about ʒij could have been inhaled. He -had commenced the operation, when the patient suddenly expired. On the -post-mortem examination, beyond a little fatty deposit on the external -surface of the left ventricle, together with a degree of hypertrophy -of the same, no morbid appearance existed. The usual restoratives were -resorted to, but ineffectually. - -The following case, furnished by Assistant-Surgeon Hannan, 49th -Regiment, is given as an illustration of the success of amputation -without chloroform in the Second Division:-- - -Patrick Kenny, 49th Regiment, aged 22. This soldier, while on duty -in the trenches on the 21st of July, received a compound comminuted -fracture of the right humerus, extending from its middle third to the -head of the bone. The integuments of the outer and upper part of the -shoulder were carried away. There was also a contused and lacerated -wound of the left knee, opening into the joint, with comminuted -fracture of the patella, these injuries being caused by pieces of -shell. He was seen a quarter of an hour after admission by Dr. Gordon, -P.M.O., who removed the arm at the shoulder-joint, making a sufficient -flap from the integuments of the axilla. The thigh was then amputated -in its lower third. These operations were performed in immediate -succession without the administration of chloroform. The thigh healed -nearly by the first intention--all the ligatures having come away by -the fourteenth day. The shoulder healed by granulation--the ligature -of the axillary artery coming away on the twenty-first day. During the -progress of treatment he had not any constitutional disturbance further -than three slight attacks of diarrhœa. He is now up and about, and goes -to England by the next opportunity. - -In the worst cases of amputation at the hip-joint, or at the upper -third of the thigh, chloroform has appeared to cause insensibility -to pain without diminishing the powers of the sufferer, when given -with due caution or not carried so far as to affect the pulse or -respiration. (See _Aphor._ 51.) The evidence on this point is -sufficient to authorize surgeons to administer it in all such cases, -with the expectation that it will always prove advantageous, an -accidental death, such as has been observed from its use, being -independent of the nature of the injury. The amputations performed -at the hip-joint, at least six in number, have not been successful -as to the result, although the sufferers bore them well in the first -instance, offering every prospect of recovery for days and even for -weeks. - -Deputy Inspector-General Taylor informs me, and his opinion is -corroborated by all the medical officers, that the labors the -troops had to perform, the privations they suffered, the frequent -insufficiency of their food, the want of proper clothing, with other -depressing causes, had so deprived them of that power British soldiers -generally possess, that all the operations of importance performed on -the lower extremities were more or less unsuccessful, while those on -the upper were as remarkable for their success. This deprivation of -power, it is said, was even more observable in the French army; and -he informs me that most of their surgeons had declined performing any -of the great operations usually done on the upper third of the thigh, -in consequence of their almost certain failure, preferring to let -the injuries take their course, even unto the death of the sufferers, -rather than hasten their dissolution by any operation usually -considered and often found to be conservative; a lamentable state of -things from which governments may draw an inference of the utmost -importance, viz., that to guard against the effects of disease as well -as of injuries, the utmost pains should be taken to preserve the health -and maintain the vigor of their soldiers. A matter of expense as well -as of arrangement. - -This statement is corroborated by Deputy Inspector-General Alexander, -who informed me, on the 3d of August, 1855, that “during the whole of -this campaign, where we have had ample opportunities of testing the -use of chloroform, both after the battles of the Alma and Inkerman, as -well as throughout the whole siege operations before Sebastopol, up to -the present period, no operations whatever of any consequence (save -with one or two exceptions, and then at the patients’ own request,) -have been performed in the Light Division, without first placing the -patient under the influence of chloroform, and in no single instance -have either the medical officers of the Division, or myself, seen any -bad results follow, or had to reject its use, but quite the contrary. -Of course, in such a campaign, many operations of the most serious -character, both on the upper and lower extremities, have been performed -in the Division by the different medical officers as well as by myself. -At the Alma, I operated upon three patients at the hip-joint, two -being our own men and the third a Russian. All the three patients were -first placed under chloroform, with the results above stated. In the -case of a soldier of the 90th Regiment, whose right arm I removed at -the shoulder-joint on the 10th of July, for great destruction of the -soft parts and extensive injury to the humerus, the patient was so -low when placed on the table that brandy and water was given to him, -and he was then immediately afterward placed under chloroform. When -I had finished, it was found that his pulse was stronger than before -commencing the operation. In Sir T. Trowbridge’s case, in which I had -to remove both feet, one at the ankle-joint and the other above it, he -was placed under chloroform for both operations, a few minutes having -been allowed to elapse before giving it to him again for the second -operation, and with the best results. Both feet were much injured -by round shot, the bones of both being completely smashed with great -destruction of the soft parts, so much so, that in the case at the -ankle-joint I had to form the flap from the cushion of the heel. I, -however, did not remove the articular surface of the lower end of the -tibia, as recommended by Mr. Syme, and the wound healed well. Of the -three cases mentioned at the hip-joint, two were performed on the 21st, -and the Russian on the 22d of September. At one of the former I was -assisted by the late Dr. Mackenzie, from Edinburgh. All three were -carried down on the 22d, to be placed on board ships for conveyance -to Scutari. It has been reported to me that one of the two operated -on, on the 21st, Peter Sullivan, 33d Regiment, died at Scutari General -Hospital on the 11th of October, three weeks from the date of the -operation, ‘from excessive debility.’ Nothing could be ascertained -about Peter Cleary, 23d Fusiliers; it is therefore most likely that he -died on the passage. - -“The Russian died on the 22d of October, ‘from great debility and -extensive sloughing.’ - -“A shoulder-joint case in the 90th Regiment never had a bad symptom, -and the wound is all but healed. The flap in this case was made from -the axillary portion of the arm, the deltoid having been all but -destroyed. - -“The flap operation has been invariably performed in the Light -Division, with but two exceptions, viz., one of the arm and the other -of the thigh.” - -Excision of the head, neck, and trochanter of the femur, with portions -of the shaft, has been performed at least six times before Sebastopol. -The result has been unfavorable in five, although in all there were -well-grounded expectations of success for weeks. In one case by Mr. -Blenkins, of the Grenadier Guards, he informs me, it was for the first -three or four weeks very favorable. The man, however, sank at the end -of the fifth week from deposition of matter in the knee-joint. (See p. -42 et seq.) Of the second case, which occurred in the general hospital -in the camp and ended fatally, I have no further notice. The third, in -the 68th Regiment, in charge of Mr. O’Leary, the operation performed on -the 19th of August, was going on most favorably on the 5th of October. - -Private Thomas M’Kenena, aged twenty-five, was struck by a fragment of -shell, on the 19th of August, over the great trochanter of the left -femur. The wound, nearly an inch in length, extended down to the bone, -which was distinctly fractured. Some loose scales could be felt at -the bottom of the wound. On examination, the injury appeared to be a -transverse fracture of the neck of the thigh-bone, apparently involving -the joint. - -After a consultation with superior medical officers, it was decided -that excision should be performed, which was done without difficulty. -No vessels required ligature, although the man lost a considerable -quantity of blood. - -The excised parts, which are herewith forwarded, show that the nature -of the injury was different from what it was supposed to be, and that -the head of the bone was intact. - -After the wound, about five inches long, had been sewn up, the limb was -placed in a sling made of strong canvas, and was swung from a beam over -the man’s cot, the bed being raised. - -This method of treatment was adopted with a view to encourage -approximation of the upper end of the bone to the pelvis, and by -pressure on the sides of the limb to prevent the accumulation of matter -among the tissues. The man progresses favorably. - -Diet was very generous. - - J. C. O’LEARY, - - _Surgeon, 68th Light Infantry_. - - Camp, 4th Division, Crimea, Sept. 14, 1855. - -The bones removed are in the museum of the Royal College of Surgeons. - -The fourth case is given at length by Staff-Surgeon Crerar, as -follows:-- - -Private William Smith, First Battalion First Royals, was brought to -hospital from the Greenhill trenches, in front of Sebastopol, about -twelve P.M., on the 6th of August. On questioning him, I ascertained -that an hour or so before he was struck by a fragment of an exploded -grenade, which first broke into small pieces a water canteen which -was suspended over the left hip, and then made an opening or wound -about the size of a shilling nearly a quarter of an inch posterior -to the great trochanter. Crepitus was quite distinct on moving the -limb; and I easily ascertained, on exploring the wound with my -finger, that a fracture through the trochanter had taken place, but -was quite unable to ascertain to what extent upward and downward the -fracture extended. I accordingly solicited a consultation with Deputy -Inspector-General Taylor and Staff-Surgeon Paynter. After a careful -examination, (the patient being under the influence of chloroform,) -the femur was discovered to be comminuted. Excision at the hip-joint -being recommended by these officers, in which opinion I concurred, I -proceeded to perform the operation by commencing an incision, nine -inches in length, in a line with and two inches posterior to the -anterior superior spinous process of the ilium, and carrying it down in -a straight line directly over the trochanter major; a second incision -about two and a half inches in length was made, commencing immediately -below the trochanter backward through the gluteus maximus; by a little -easy dissection the seat of fracture was exposed, the trochanter was -found broken into several portions, detached and imbedded in the -contused muscles around, from which they were at once removed. The -fracture was found to extend obliquely inward about an inch and a -half along the shaft of the bone. The femur was now protruded through -the wound, and I sawed off the whole of the fractured bone, leaving a -smooth, clean surface; I then proceeded to disarticulate the head of -the femur, which was effected without difficulty. Scarcely three ounces -of blood were lost, and little or no shock was induced; only one small -bleeding point was secured near the tail of the wound, and the divided -parts were brought together by two sutures and bands of adhesive -plaster. - -At twelve A.M., two hours after the operation on the 7th instant, his -pulse being rather feeble, he was ordered some wine and water. - -7th, vespere.--Countenance cheerful, voice strong; says he intends -keeping up his pluck, and is sure he will get well; has no inclination -to take the beef-tea ordered for him, but has had some arrow-root and -wine. To have a morphia draught at bedtime. - -8th.--Passed a good night; limb in a good position; retracted about two -inches; wound looks healthy; pulse 100, soft; has made urine freely; -skin moist; bowels were opened freely in the night. - -9th.--Slept well at night; says that he feels very comfortable; skin -moist; pulse 120; sutures were removed, and the wound allowed to gape; -it has a remarkably healthy appearance. To go on with the simple water -dressing, chicken-broth, arrow-root, and wine. - -Vespere.--Has been very cheerful all day; limb has retracted about -another half inch; pulse 112. - -10th.--Passed a more restless night, in consequence of not having the -morphia draught as early as the previous night; has had several hours’ -sleep this morning, and is more refreshed; pulse, on waking, from 114 -to 120, skin comfortable; no sign of distress in his aspect; wound -suppurating healthily; bowels were opened again once last night. - -10th, vespere.--Has been very easy all day; skin cool; tongue normal; -pulse 120, soft and regular; has had to-day two eggs, one ounce of -arrow-root, two gills of wine, and two pints of chicken-broth, all -of which he relished much. To have a grain of acetate of morphia in -solution at bedtime. - -11th.--Slept soundly all night; when I visited him, at six A.M., he had -just awoke; pulse 115, soft; appears contented and comfortable. - -Vespere.--Doing well; wound continues to look healthy; position of -limb good; has consumed a fair quantity of chicken-broth, beef-tea, -arrow-root, and three gills of sherry to-day; pulse 113 at eight P.M. - -12th.--Bowels were opened in the night; the introduction of the bed-pan -gave him a good deal of annoyance; the air of the hut was rather -stagnant last night, and he did not sleep as well as usual; pulse 120, -soft; tongue continues clean and moist; there is more discharge from -the wound to-day. - -Vespere.--The progress of the case is most satisfactory; had a fresh -egg, tea, and toast for breakfast, his own selection, which he appeared -to relish greatly; at twelve he had two mutton-chops and a glass of -wine, and at five P.M., a pint of chicken-broth, with bread, and a -second glass of wine. The morphia draught as usual. - -13th.--Continues to look happy and contented. Healthy-looking -granulations are evident over two-thirds of the wound; swelling of limb -subsiding; discharge from wound healthy; pulse 114, regular and soft; -all the symptoms are so very favorable that I have every reason to -expect a successful issue. - -14th.--A small slough at the lower part of the wound, remainder healthy -and clean; tongue a little too dry this morning, and he has more thirst -than usual; pulse 118. To have effervescing draughts of bicarbonate -of potassa and citric acid three times a day; to continue simple water -dressing. - -Vespere.--Thirst not so urgent; tongue cleaner and moister; has a -feeling of fullness in the abdomen. To have his usual morphia draught -and an ounce of castor-oil at bedtime. - -15th.--Passed three large stools in the night, with great relief; -aspect resigned, and his spirits continue good; slough has come away; -pulse 118, soft and regular; skin tolerably cool. - -Vespere.--Felt a good deal exhausted to-day from the heat, which was -very great--ninety-two degrees. - -16th.--Looks heavy and out of spirits this morning; discharge has -increased, but is of a better quality since the slough separated; -tongue dry, inclined to brown; pulse the same, skin rather hot; -continue effervescing draughts every third hour. - -Vespere.--Tongue more moist, less thirst. When asked how he felt, he -replied, with a great deal of life in his countenance, “I am very well, -and I feel very comfortable;” asked for a mutton-chop early in the day, -which he got, and appeared to like; he had at different times in the -day arrow-root, chicken-broth, and wine. - -17th.--Wound looks very healthy, and the general symptoms very -favorable to-day; tongue clean and moist; less thirst; skin cooler; had -him removed to a fresh bed without a great deal of pain or trouble; -limb retracted less than three inches; position now good since he was -shifted. - -18th.--Very much worse this morning; had a rigor about ten A.M. -yesterday; features now sharpened and pinched; tongue dry and brown; -pulse thready, about 125. - -Vespere.--Continues in a very low state; wound has a very healthy -appearance; discharge healthy, but not as abundant as it was; has had -besides wine, a pint and a half of porter, mutton-broth, and a chop -to-day; zinc lotion to the wound. - -19th.--When I visited him at six A.M. to-day, I was much pleased -to find him looking quite cheerful; pulse soft, 112; skin cool and -moist, paler than usual; wound doing well. Continue zinc lotion to -the sore, and to have his choice to-day of mutton-broth, beef-tea, or -chicken-broth; arrow-root to be given twice, four gills of sherry or -port as usual. - -Vespere.--No change to report. - -20th.--Looking rather pale, and features pinched; pulse better, about -100, soft; skin cool; tongue more coated than usual, inclined to be -dry. I fear this case is a bad one, not likely to terminate as we so -much desire. - -Vespere.--Has been very uneasy all day; skin hot; tongue dry. - -21st, six A.M.--Has just awoke, having been asleep since nine last -night; says that he feels stronger; aspect certainly improved since the -last visit; coating on the tongue thicker, brown; the pulse has more -strength than it had yesterday; no feeling of uneasiness; wound looking -remarkably well, and discharging laudable pus; asks for cold drinks; -to have his choice of iced soda, tamarind, toast or rice water; diet -the same as yesterday.--Eleven A.M.: has fallen off very much since -the morning, features pinched and blue; pulse irregular, small, and -wiry.--Twelve nocte: continues to sink; died at half-past twelve P.M. - -Examination of the limb six hours after death.--Cut surfaces of femur -perfectly smooth; bone easily denuded of its periosteum; acetabulum -smooth; muscles infiltrated with pus; nature had not made the slightest -attempt to repair the loss. - -What would the result have been if amputation at the hip-joint had -been performed? The same. The vis medicatrix naturæ is not sufficient -to carry our sick through such formidable operations; it is no fault -of the surgeons. A better and a more liberal allowance of animal and -vegetable food during health is required, if England expects her -soldiers to survive severe operations, disease and wounds. An attempt -to save the limb, for the very same reason, would, most undoubtedly, -have been a failure. Our Minié rifle-ball fractures of the femur all -sink under conservative surgery. Our amputations above the middle of -the thigh have a like issue; it is truly disheartening. - - J. CRERAR, _Surgeon_, _68th Regiment_. - - Camp before Sebastopol, 24th August. - - Dr. Crerar was greatly distressed by the loss of this man, and the - manner in which he expresses his grief is declaratory of his feelings. - The excised bones are in the museum of the Royal College of Surgeons. - -The fifth, by Dr. Hyde, ended fatally on the sixth day. - -Corporal Benjamin Shehan, 41st Regiment, advanced with his corps, about -twelve o’clock, on the 8th of September, to storm the Redan. Having -succeeded in getting into the work, the regiment was afterward obliged -to retire; in the retreat to our trenches he was wounded, and lay on -the field till the following day, when he was brought to the hospital -of the Royal Sappers and Miners. On examining the wound, it was found -that a grape-shot had entered at the great trochanter, and, passing -inward and a little forward, had passed out at the groin of the same -side, about an inch below Poupart’s ligament, externally to, and a -little in front of, the femoral vessels. The lower fragment of the -fracture protruded through the external wound, and the introduction of -the finger discovered a comminuted state of the neck of the bone. - -Excision of the joint having been decided on, the operation was -performed in the presence of Deputy Inspector-General Taylor, -Staff-Surgeon Dr. Paynter, and Surgeon Elliot, Ordnance Department. - -Operation performed about one P.M. 9th of September.--An incision, -about four inches in length, commencing a little above the trochanter, -was carried downward along the outer side of the femur. The lower -fragment, for about an inch of its extent, was cleared of its -attachments. An assistant holding the thigh below, and pushing the bone -upward and outward, so as to bring the fragment through the incision, -about an inch of the bone was then sawed off. The head of the bone -was next dissected from the socket; this part of the operation was -considerably facilitated by an assistant catching a firm hold of the -neck by means of a pair of tooth forceps, then rotating the head, -and using slight force to dislodge it from the cavity, the operator -dividing the capsular and round ligaments, the latter of which is -more easily and safely divided at the lower and outer side of the -articulation. The upper part of the trochanter was next dissected out, -and several small spiculæ of bone removed. The edges of the incision -were then brought together by sutures, and a bandage applied. It was -not found necessary to tie any vessel, and there was very little -hemorrhage. The man bore the operation well, and was returned to his -bed in good spirits, and with a good pulse. - -10th.--Passed a good night; slept pretty well; pulse 106, soft; skin -cool; in good spirits. - -11th.--Slept some hours; pulse 106, soft; bowels open; tongue furred, -but moist. Wound dressed and looking well; some healthy discharge. - -13th.--Going on apparently very well; pulse still 106; countenance -good. Vespere: Complains of an increase of pain in the hip, but -otherwise says he feels much as usual; pulse small and rapid. Ordered -wine and arrow-root. - -14th.--Died at six this morning. - -The autopsy showed a considerable cavity filled with sanies in the -situation of the operation, but no other fractured bone was discovered. -The articulating surface of the acetabulum was coated by a fetid, pasty -substance. - - GEO. HYDE, M.D., _Staff-Surgeon_. - - The sixth, by Staff-Surgeon Coombe, also ended fatally. - -Private James Nadauld, aged twenty-one, First Battalion Rifle Brigade, -was admitted into the Castle Hospital, Balaklava, upon the 16th of -July, 1855, five days after the receipt of a gunshot injury of the -right shoulder. Upon the 19th of July the head of the humerus was -excised, and the ball was found impacted in it. The healing process -went on most favorably, and the man was discharged upon the 26th of -August, quite well, for the purpose of proceeding to England. The -excised bone is in the museum of the Royal College of Surgeons. - - W. H. McANDREW, M.D., - _Surgeon, 57th Regiment_. - - Camp, Sebastopol, Sept. 14th, 1855. - -Private John Purcell, 57th Regiment, aged twenty-one, was wounded -upon the 18th of June, in the unsuccessful assault upon the Redan, -by a Minié rifle-ball, which passed directly through the head of the -humerus, but did not touch the glenoid cavity. Upon the 22d of June, -the head of the bone was excised; and upon the 26th of August, the man -was discharged from hospital, quite well, for the purpose of proceeding -to England. The excised bone is in the museum of the Royal College of -Surgeons. - - W. H. McANDREW, M. D., - Surgeon, 57th Regiment. - - Camp, Sebastopol, Sept. 14th, 1855. - -The following case of wound of the larynx is instructive:-- - -Lieutenant Charles H. Evans, 55th Regiment, aged nineteen years, was -wounded on the evening of the 5th of August, 1855, about eleven o’clock -P.M., while on duty in the trenches. The ball entered the right side of -the neck, close to the angle of the jaw, and passed apparently between -the hyoid bone and the arytenoid cartilages, and then downward, having -its exit below the cricoid cartilage on the left side. The pharynx -and larynx were wounded, and the trachea was contused and displaced. -Respiration somewhat hurried; a quantity of mucus collects in the -trachea, and is expectorated in fits. - -About seven o’clock P.M. of the 6th, the respiration becoming more -difficult, with a degree of lividity of the lips, indicative of the -non-oxygenation of the blood, it was deemed advisable to have recourse -to tracheotomy, which, in consequence of the displacement of the parts -and the swelling, was effected with considerable difficulty. The -usual tubes were found too short for the purpose, and a large silver -catheter was inserted, through which the air passed freely. Whenever -he attempted to drink, the liquid passed into the trachea through the -openings caused by the ball. From the operation no benefit arose, and -he continued very restless until within an hour of his decease, which -took place about twenty-six hours after the receipt of the wound. The -voice was never heard above a whisper. - -Post-mortem examination, twelve hours after death. The ball would -appear to have passed through the hyo-thyroid membrane, fracturing and -shattering the thyroid cartilage. The membrane lining the glottis was -torn and destroyed. The vessels escaped without injury, the ball having -passed anteriorly. - - ARCHD. GORDON. M.D., - _Staff-Surgeon, 1st Class, in Med. Charge, 2d Division_. - - Camp before Sebastopol, September 3, 1855. - -Deputy Inspector-General Taylor, who was present during the operation, -adds: “The want of a longer tracheal tube than is commonly supplied -for such operations was obvious, and is a good practical hint. For -the first time in my life I found my two forefingers transfixing a -man’s neck from side to side. The fingers did not cause any cough or -irritation, but those symptoms were occasioned by the least attempt to -swallow water. The thyroid cartilage was separated into two pieces.” - -The following cases, one of wound of the profunda femoris, the other of -the popliteal, deserve attention:-- - -Late in the afternoon of the 14th of August, Private George Irvine, -aged twenty-five, was brought from the trenches, having been struck by -a Minié-ball of the largest size, which had penetrated the left thigh, -about two inches below Poupart’s ligament, just in the course of the -femoral artery. The ball passed slightly outward, fracturing the femur, -and was cut out at the back of the limb, completely flattened. As there -was considerable hemorrhage, both venous and arterial, no examination -with the finger was permitted. Dr. Taylor, superintending the Division, -having been informed of the case, a consultation was held. - -Amputation at the hip-joint was forbidden by the prostration of the -man, who had lost much blood before he was brought to camp. Excision -of the head of the femur was also inadmissible, from the evident wound -of a large artery, with probably that of a large vein. Search for -the wounded artery, for the purpose of applying a ligature, was then -determined upon, but before the operation had well proceeded, the -hemorrhage was so great that it was found impossible to continue it, -and pressure by means of graduated compresses was resorted to, with -complete success. - -On the following morning an operation was still out of the question. -Prostration continued, with great irritability of stomach, and a small, -quick pulse. No return of hemorrhage, though the pressure of the -tourniquet was but very slight. - -On the 16th, the pulse was more quick and irritable, with the same -irritability of stomach, and urgent thirst. He had passed a better -night, however. At the consultation this morning, the circulation -through the posterior tibial artery was so evident that the question of -the femoral artery being wounded was set at rest. It was decided, as -no return of hemorrhage had occurred, that the case should be left to -nature. - -On the 17th, he suffered from starting pains in the thigh. There -was less irritability of stomach, but the pulse was very small and -weak. During the night there was slight hemorrhage, owing to his -restlessness, but it was easily arrested by a turn or two of the -tourniquet. - -On the evening of the 20th, this restlessness increased; delirium set -in, and early in the morning of the 22d he died. - -The limb was examined after death, when the following appearances -presented:-- - -Femoral artery intact. Femoral vein wounded, with more than half its -caliber shot away. At about two inches from its origin there was a -wound of the profunda artery, on which an aneurism, nearly the size of -a pigeon’s egg, had formed, and passed upward through the wound made -by the ball. The profunda vein was intact. The injured vessels having -been removed for preservation, the bone was then cut down upon, when a -fracture, nearly transverse, and not at all comminuted, was observed -below the trochanters. No splitting of bone upward; downward its outer -plate was slightly cracked, but nothing more. The preparation is in the -museum of the Royal College of Surgeons. - -Private James Ross, a lad of eighteen, was brought up from the -trenches, on the morning of the 3d inst., having had his right -leg blown off below the knee by a round shot. He had lost a very -large quantity of blood before the tourniquet was applied, and was -consequently so much collapsed that an operation was out of the -question. He was therefore dressed and the tourniquets (two had been -put on) removed. He never rallied, and died on the 12th, nine days -after the receipt of the injury. No hemorrhage ever occurred, though -all pressure had been removed from the artery. - - R. V. DE LISLE, - _Surgeon, 4th King’s Own Regiment_. - - Camp before Sebastopol, Sept. 14, 1855. - -The following is worthy of publication, as showing the successful -effects of strychnia, when carried to the extreme verge of propriety, -in injuries of the spinal cord. - -Sergeant William Aldridge, 46th Regiment, aged 39 years, during a -sortie from Sebastopol, was knocked down in the trenches, and his back -formed a bridge over which Russians and English passed. The result was -serious injury to the spine, causing paralysis of the lower extremities -and bladder. The pain was excruciating, and the patient could not be -moved in bed for several weeks. - -On the 4th of March, 1855, he was placed under my charge in the -military hospital at Portsmouth, when he complained of great pain -and tenderness along the spine, and incontinence of urine, together -with wandering day dreams and insomnolency at night. Solution of the -muriate of morphia ʒj was prescribed without any effect. (ʒj contains -1 gr.) The dose was gradually increased to ʒij of the solution. - -15th March.--Fell out of bed during the night, trying to hide himself. -Is wandering, and fancies that he has deserted from the Crimea, and -will be shot. The narcotic has been omitted for several days. Strychnia -was now ordered, one-sixth of a grain three times a day. - -20th.--Continues much the same, with slight twitchings of the face. - -25th.--Has been unconscious for three days. Now complains of intense -pain in the back and violent cold perspiration. - -28th.--Returning consciousness; feels easier, having slept -uninterruptedly for forty-eight hours. Expressed a desire to make his -will, and send to Dublin for his wife; both wishes were complied with. - -30th.--Sensation and motion are gone from the lower extremities, and -the urine is still passed involuntarily. One-eighth of a grain of -strychnia was ordered twice a day. - -31st.--Is powerfully under the influence of the remedy, with -convulsive movements of the upper and lower extremities; wild stare -and fixed jaws. The lower extremities had not moved for several months -previously. This paroxysm lasted for one hour under my own observation, -after which the muscles became relaxed, the face bedewed with a gentle -perspiration, and resumed its ordinary tranquil appearance. - -April 2d.--Feels greatly relieved from pain, and is comparatively -comfortable; sleeps calmly. His appearance is entirely changed; looks -natural; features calm; is cheerful, and reads the papers. Strychnia -was omitted for some days after the last paroxysm, and replaced by the -tincture of the sesquichloride of iron with quassia, and a generous -diet. - -6th.--Continues to improve. Has now and then slight twitchings in the -legs and arms. The strychnia was resumed and omitted, as the symptoms -indicated, to the end of the month. - -May 1.--Is greatly improved; goes about the balcony in a chair. -Returning sensation in the right leg. Bladder still not under the -control of the will. - -20th.--Sensation much improved in both legs, and motion increasing in -the right leg. - -25th.--Convulsive movements all over the body, resulting from the use -of the strychnine. Lower extremities decidedly improved both in motion -and sensation. - -June 1st.--Maintains his improved condition. Recommenced the strychnine -to-day, without any marked effect at the moment. - -10th.--Violent tetanic spasms followed the employment of the remedy, -producing considerable increase of motion in both extremities. The -paroxysms _usually_ continue about fifteen minutes, when the muscular -system resumes its ordinary appearance. - -20th.--Continues the same. Strychnia not resumed since last entry, as -occasional twitchings occur about the head and face, and he is now -affected by the smallest dose. - -July 1st.--General health excellent. - -10th.--Continues to improve daily in regaining the use of his limbs. -Is now able to walk on the ramparts with crutches, but is exceedingly -sensitive to every change of weather--damp always causing pain in the -spine. Continued to improve to the end of the month. - -August 1st.--No change worthy of note. - -14th.--Discharged to Chatham. - - T. H. BURGESS, M.D., - _Military Hospital, Portsmouth_. - -The following case of injury of the abdomen, sent to me by Dr. Rooke, -civil surgeon with the army in the field, is very remarkable:-- - -Robert Cousins, aged 20, 77th Regiment, was admitted into the general -hospital, camp, June 8th, with severe injuries caused by a round shot, -which struck him when he was on duty in the advanced trenches. When -the shot struck him he was standing up, half-face toward the enemy, -his right arm extended in front of the right hip; he was in the act of -reaching his water-can, which rested against the parapet of the trench. - -On admission he was in a state of semi-collapse, the integuments of -the right hand and forearm greatly lacerated, the wrist-joint laid -open, the bones of the carpus comminuted; the radius and ulna were also -fractured at the middle third. There was a lacerated wound in the right -iliac region, the size of the palm of the hand; over this space the -skin and muscles of the abdominal wall were torn away, the peritoneum -lining it was also lacerated, and at the bottom of the wound was seen -a coil of intestine in situ; there was no tendency to protrusion, nor -were its coats at all injured. The crest and body of the ilium were -much comminuted, the fracture extending downward between the anterior -superior and anterior inferior spinous processes. The anterior superior -spinous process was broken off. There was another wound just below the -great trochanter; this apophysis was also shattered. The right limb -was two inches shorter than its fellow, the foot everted, but, from -the great comminution of the pelvis and the extreme pain produced by -examination, it was not satisfactorily made out that the neck of the -femur was fractured, but the shortening of the limb and eversion of the -foot were in favor of that diagnosis. The injuries which the patient -had received were considered mortal; it was thought unnecessary cruelty -to amputate the forearm. Such pieces of the ilium as were loose were -removed; wet lint applied to the wounds; and brandy and water with -opiates were ordered. One of his comrades volunteered to watch over -him, and he was left, as all thought, to die. The next day (June 9th) -he had partially rallied from the state of collapse; had taken liquid -nourishment--beef-tea, arrow-root, etc. There was no pain or tenderness -of the abdomen; had passed his water without difficulty. The surface -of the abdominal wound was sloughy; intestine still visible; complains -of pain in the arm. It was not yet considered advisable to perform any -operation. He was ordered opium gr. j every four hours; also a dose of -morphia at night, arrow-root, beef-tea, and port wine, which he prefers -to brandy. - -10th.--Has rallied completely; no pain or tenderness of the abdomen; -complains greatly of his arm, and is anxious that something should -be done. He slept well after taking the morphia; his face is -tranquil, breathing natural, pulse weak; no irritability. Deputy -Inspector-General Taylor saw the case in consultation with Dr. Mouat, -P. M. O. of the hospital. It was decided to amputate the forearm. This -was done at the upper third; chloroform was administered, and produced -no ill effects. He was ordered any fluid nourishment he might fancy, -with port wine, and an opiate at night. - -11th.--No symptoms of peritonitis; suffers no pain; tongue clean -and moist; pulse quiet; passes his water regularly; the bowels have -not acted. The abdomen is quite soft and fallen, not the slightest -tenderness on pressure. To continue on the same plan. He could now give -some account of the way in which he was wounded. He stated that he -thought it must have been a round shot that struck him. It first struck -his arm, then entered the right iliac region, emerging at the lower -wound. The surface of the wound in the iliac region is in a sloughy -state from the severe bruising of the parts. The coil of intestine is -still visible at the bottom of the wound. - -12th.--No symptoms of peritonitis; bowels have not acted; tenderness -down the outside of the thigh, with redness of the skin, and pitting -upon pressure. Stump dressed to-day and looking well. - -13th.--No unfavorable constitutional symptoms. The outer part of the -thigh is tender and the skin red; free incisions were made; the fascia -was sloughy. He takes nourishment; has eight ounces of port wine daily, -eggs, arrow-root, and essence of beef. Bowels not acted. - -21st.--He had no symptoms worthy of remark since the 13th. The bowels -have not been moved; he complained to-day of not being able to pass -his motions. Two injections of warm water were administered in the -course of the day. He passed a large quantity of hardened feces, which -relieved him greatly. The sloughs are separating from the incisions -in the thigh; the crest and ala of the ilium are exposed; healthy -granulations are springing up from the bottom of the wound. Stump -healing favorably. - -July 26.--The case has progressed without a bad symptom. At first -it was thought that the greater part of the ala of the ilium would -exfoliate, but some red points appeared on the surface, and the -concavity of the bone became covered with granulations. The exfoliation -was limited to the anterior part of the crest of the ilium, which -separated on the 17th instant. At various times pieces of bone have -been removed as they became detached; there are others still left -to come away. The granulations on the upper wound are on a level -with the skin of the abdomen. The crest of the ilium is covered with -granulations; the wound is contracting, but there is a deficiency of -skin to cover the projecting portion of the ilium. The lower wound -is also open, and has been enlarged to remove pieces of bone; the -incisions in the thigh have healed. The bowels have acted regularly -without medicines until to-day, when he required a castor-oil -injection. The right thigh is more than two inches shorter than the -left; union appears to have taken place; he has no pain on motion. The -dead bone that still remains alone prevents the wounds from closing, -their surfaces being covered with healthy granulations. His general -health is good. He has taken at intervals some oleum jecoris aselli, -and, for a mild attack of bronchitis under which he suffered at the end -of June, expectorants and diaphoretics. There has not been a single -symptom of any abdominal complication. He has an opiate at night. The -stump has been healed nearly three weeks. - -September 14th.--Since the last report no unfavorable symptoms have -occurred. The stump of the forearm has been healed some weeks; his -health is good; indeed, from first to last, he has not had a single -symptom denoting constitutional disturbance. All the dead bone from the -crest of the ilium has separated; the wound of the abdomen is skinned -over, with the exception of a small spot about the size of a sixpence. -This is healthy, and is gradually healing. The bowels act regularly. -There are still two sinuses on the outer side of the thigh--one above, -the other below, the great trochanter. On probing these, dead bone is -felt, which has not yet separated. The right limb is about three inches -shorter than the left, is freely movable in any direction without -pain. He can raise the knee from the pillow, but cannot lift the -heel from the bed; he can, however, turn himself over on to the left -side without assistance. The prominence of the crest of the ilium is -greatly diminished from loss of bone. The trochanter major is unusually -projecting; the natural appearance of the hip-joint is entirely -gone. The injuries to the bones have been so severe, it is difficult -to say what changes have occurred. The ilium and pubis have been -greatly comminuted, the fracture most probably extending through the -acetabulum. Immediately below Poupart’s ligament, to the outside of the -femoral artery, a hard substance is felt beneath the skin. This, when -he was admitted, was at first supposed to have been a piece of a shell, -but it is now thought to be a portion of the pubis driven downward upon -the thigh. - -He may now be said to be convalescent. - - * * * * * - -John Shehan, aged nineteen, 57th Regiment, was wounded in the left -thigh before the Redan, on the 18th of June. He was brought to the -general hospital, and placed under the charge of a gentleman of -considerable skill and experience. The wound presented two openings, -an anterior and a posterior; the latter offered greater facilities for -examination than the former; the finger, passed from behind, detected -several fragments, which were removed, and as a tolerably uniform -surface of bone (_vide_ specimen) was then felt, it was determined, -after consultation, to make an attempt to save the limb. The injured -extremity was accordingly bound up with a long splint in the most -careful manner, and matters promised favorably for a time. He, however, -complained of a good deal of suffering in the limb from time to time, -gradually wasted, suffered from diarrhœa, and finally sank on the 6th -of August. On examination post-mortem, I found the chief organs in a -normal condition. There was some congestion of the ilium, and the colon -presented a few points of ulceration. The condition of the parts in the -left lower extremity was very remarkable. Beneath the integuments, all -the muscular and other textures, from the seat of injury to the groin, -were converted into a soft, broken-down, black, rotten mass; and I may -here observe that this low but intense disorganizing process, extending -through the greater part of the limb, has presented itself in several -of my examinations of somewhat similar injuries, and appears to me -to be connected with _a peculiar pathological state in which all the -vital organs remain sound, but the vis vitæ is remarkably reduced below -par_. The fractured bone it is unnecessary to describe. The vertical -and cross infraction of the fragments and its almost “arborescent” -appearance are most remarkable. I look upon it as a specimen of no -ordinary value, conveying more than one most useful lesson. The bones -are in the museum of the Royal College of Surgeons. - - R. D. LYONS, - _Pathologist to the Army in the East_. - - Camp before Sebastopol, August 30, 1855. - -Private William Leah, 30th Regiment, aged twenty-one, was brought to me -on the 27th of June, while I was on duty in the trenches, with fracture -of the external condyle of the humerus of left arm, by a musket-ball, -which had entered the joint between it and head of radius, and had -made its exit over olecranon process of ulna. Artery uninjured. On -being sent to camp, the joint was excised by Mr. Dowse, surgeon of the -regiment. The patient progressed favorably, and the wound has been -healed for nearly a month. He can use all the muscles of the forearm, -except the flexor of the little finger, and is regaining the motion -possessed by the elbow-joint. - - DAVID MILROY, M.D., - _Assistant-Surgeon, 30th Regiment_. - - Camp, Second Division, Heights of Sebastopol, Sept. 5, 1855. - -J. Maguire, 31st Regiment, aged twenty, wounded in the advanced -trenches. - -July 12, five A.M.--Carried into hospital, wounded by a splinter of -shell in left elbow and on left hip. The splinter struck him in an -oblique direction, from behind, fracturing olecranon process and -internal condyle of humerus, lacerating and otherwise injuring the -joint, the ulnar nerve being also injured. The splinter continuing its -onward course, inflicted a lacerated wound on the hip, with comminuted -fracture of about the anterior fifth of the crest of the ilium, several -small pieces of bone being driven in on the peritoneum, causing pain on -the slightest motion. All the loose portions of bone were removed, and -several others separated from the muscles. Abdomen painful, and swollen -at that side. Abdomen continued painful during the day; bowels acted; -he also passed water freely. - -13th.--Pain in abdomen much less; little, if any, constitutional -disturbance; elbow extremely painful; the pain accompanied with partial -paralysis of the little and ring fingers. Staff-Surgeon Dr. Gordon -having seen him, and not apprehending any danger from the wound in the -side, the operation for excision of the elbow-joint was determined -on, and performed under chloroform, by a single straight incision -passing through the original wound, including the upper and lower -fourths of the forearm and arm. There was very little hemorrhage. The -arm was then put up in an angular splint. It continued to progress -favorably, the greater part healing by the first intention. There was -some suppuration, but a free exit being given to the matter, it did not -retard recovery. - -August 19th.--This patient was discharged from the regimental hospital, -to general hospital, Balaklava. The wound nearly healed; sensation -partially restored to the fingers; slight motion at the bend of the -elbow; but he has not power to raise the hand. - - THOMAS J. ATKINSON, - _Assistant-Surgeon, 31st Reg. in Med. Charge_. - - Camp before Sebastopol, Sept. 1, 1855. - -Private Anthony Murray, aged twenty-eight, 41st Regiment, a healthy -man, was struck, while on duty in the trenches before Sebastopol, on -the night of the 23d of July, 1855, by a portion of a shell, which -penetrated the left elbow-joint; the head of the radius and the outer -half of the articulating surface of the humerus were comminuted, -fragments being impacted in the cancelous structure of the humerus, -and driven in between that bone and the ulna. Excision of the joint -having been determined on, it was performed in the following manner: a -straight incision was made along the posterior surface of the joint, -the olecranon cut through, and the extremities of the several bones -removed in succession; the parts were then brought together by suture, -and the limb placed in a flexed position; about a third of the wound -healed by the first intention; no inflammation supervened. On the -3d of August the wound was granulating in a healthy manner; on the -22d, it had almost healed, and the limb was put up permanently, the -forearm at right angles to the arm; on the 31st, some union had taken -place between the bones; the man can move the thumb and three fingers; -he is free from pain; his health is very good, and he appears to be -progressing favorably in every respect. - - J. E. SCOTT, M.D., _Surgeon, 41st Regiment_. - - August 31st, 1855. - -Private Jesse Lockhurst, 31st Regiment, aged twenty-six, was wounded in -the advanced trenches, 17th of August, 1855. - -August 17th.--Six o’clock A.M., carried into regimental hospital, -having received an extensive lacerated wound of right cheek: very -little apparent hemorrhage, but the power of deglutition was -completely lost, and respiration impeded. On making an examination -of the wound, it was ascertained that the right superior maxillary -bone was fractured, and a portion of the hard palate with the molar -teeth driven in on the tongue; there was a large piece of shell or -shot lodged at the bottom of the wound, lying on left palate, and, -as far as could be ascertained, on the back of pharynx. Staff-Surgeon -Dr. Gordon being present, the ball, after much labor, was extracted, -and found to be a grape-shot of seventeen and a half ounces weight. -During the operation it was found necessary to dilate the wound by -dividing the lip near its external angle--the portions of bone that -were removed were the alveolar process, with all the molar teeth, -including part of the palate and a portion of the orbital plate and -nasal process of the superior maxillary bone, and all the malar bone. -There was no serious hemorrhage during the operation, nor immediately -after the extraction of the shot. The cheek was then plugged with lint -and the wound brought into apposition by sutures. The man experienced -immediate relief after the operation, sat up in bed, washed out his -mouth, and drank some water; he seemed extremely thankful, and blessed -the doctors. During the night and part of the next day there was some -oozing from the mouth. No bad symptom occurred until the 20th, when an -active hemorrhage came on from the back of the palate. The exact source -could not be ascertained. He became very weak and almost pulseless; but -the hemorrhage was eventually restrained by means of ice and plugging -the wound with lint moistened in tincture of matico. Iced drinks -occasionally. - -31st.--The man is now doing extremely well, can talk, and takes a -pint of jelly daily; the external wound is not yet quite healed, -in consequence of the saliva flowing through it. The right eye is -uninjured, and sight unaffected. - -September 1st.--He has just been discharged to general hospital, -Balaklava, from the regimental hospital. - - THOS. J. ATKINSON, _Assistant-Surgeon_, - _31st Regiment, in Med. Charge_. - - Camp before Sebastopol, September 1, 1855. - -On the morning of July 24th, Private Francis O’Brien, a lad of -eighteen, was brought from the trenches, with a wound from a -musket-ball in the right temple. It entered about two inches above -the orbit, passed downward, and drove out a large portion of the -supra-orbital ridge, which appeared to be imbedded in the upper eyelid, -and was cut down upon by the medical officer in the trenches, in -mistake for the ball, which it certainly very much resembled. As no -ball could be found, it was supposed to have passed out at the opening -of entrance. - -The finger when passed into the wound could feel the pulsation of -the brain, yet from that day to the present no symptom of cerebral -disturbance has appeared, unless it be that since his convalescence the -muscles of the face work convulsively when he feels faint and weak from -remaining too long in the erect posture. About a month after admission, -the detached portion of the bone above the orbit was removed from the -eyelid, though with considerable difficulty, and on the following -morning the ball fell from the wound, much to the poor lad’s horror, -who thought his eye had dropped out. - -Both wounds have now healed, but he is unable to raise the right -eyelid; the eye is perfect, but apparently without power of vision, -though sensible to the stimulus of light, for on turning the wounded -side to the light, the left pupil contracts. His general health is good. - - R. V. DE LISLE, - _Surgeon, 14th King’s Own Regiment_. - - Camp, Sept. 10. - -Private Joseph Bourke, 17th Regiment, admitted on 9th of September, -1855, with fracture of anterior superior angle of right parietal bone, -with depression of about one-third of an inch, for the size of a -florin. No attempt was made to elevate the depressed portion. Has not -had a bad symptom. Wound of scalp nearly healed. - - W. P. WARD, - _Surgeon, 17th Regiment_. - -Private Michael Caffrey, 88th Regiment, wounded at the attack upon the -Redan on the 8th of September, was brought to the hospital of the 38th -Regiment on the morning of the 9th. A round rifle-ball struck him at -the anterior part of the left parietal bone, and passed through the -brain in a line which brought it out at the vertex, fracturing the -parietal bone of the opposite side; the ball at its entrance split, -and one-half pushing before it a small piece of bone, both lodged at -the entrance; the other half of the ball was found lodged in the brain -at the upper and back part, having detached a circular portion of the -skull. - -A director was passed along the track of the wound, and the scalp -laid open; the brain was found to protrude through the fracture. In -this condition the patient lived for eleven days, utterly unconscious -of everything passing around him, the urine and feces coming away -involuntarily. There was paralysis of the opposite side. - -A post-mortem examination showed the brain to have been reduced to a -pultaceous mass only in the direction of the passage of the missile; -the remaining portion of the wounded hemisphere and that of the -opposite side were healthy. - -The absence of the usual train of head symptoms, and the length of time -which so extensive an injury permitted life to remain, render this case -worthy of some remark. - - FREDERIC WALL, - _Surgeon, 38th Regiment_. - - Camp before Sebastopol, Sept. 20, 1855. - -Private William Doyle, 19th Regiment, aged nineteen years, was wounded -in the head by a rifle-ball, in the advanced trench of the right -attack, on August the 30th. The scalp and pericranium were cut about -two inches, and a portion of the cranium, a little in advance of -the posterior and superior angle of the right parietal bone, close -to the sagittal suture, about an inch in length and half an inch in -breadth, was depressed. According to statement the man was rendered -perfectly senseless and motionless, from the instant of being struck -by the bullet. On reaching camp he presented all the usual symptoms -indicating compression; pupils dilated and fixed, warm surface, total -unconsciousness, complete paralysis, etc. On examination of the -depressed portion of bone, no opening whatever could be felt; the edges -of the sunk bone and the bone adjoining were in contact, and it was -presumed to be an ordinary case of fracture with depression simply. -Some very minute portions of cerebral substance were observed to be -mixed with the clot of blood about the wound, such as might be squeezed -through a fissure. Trephining being determined on, it was performed -at once, and the depressed bone raised without difficulty. No relief -of symptoms followed. The dura mater bulged slightly upward into the -opening. On passing the finger over its surface, a little beyond the -space exposed by the trephine, a defined cut edge was felt about an -inch in advance of the depressed piece of bone, being the boundary of -an opening into the cerebral substance. - -Three hours after arrival in camp the patient died. On examination -post-mortem, a wedge-like section of the ball was found to have -entered and penetrated the cerebral substance; it was discovered in -the anterior lobe on the right side, just above the orbitar plate. -It had not completely penetrated, but was lying just above the -membrane covering the lobe. The ball--a conical rifle-ball with three -cannelures--was cut smoothly from apex to base, as if by a sharp knife. -This must have been done by the edge of broken bone above the opening -made in the parietal bone, one-half of the ball flying off, the other -entering the skull. On close examination, several very small points of -lead were found to be imbedded along the margin of the bone alluded -to. The depressed portion of bone, directly after the piece of ball -entered, must have sprung up again by its own resiliency, or been -forced up by sudden pressure from within, so that no evidence of an -aperture, but merely a fissure and depression remained. The inner table -was separated, and nearly detached, for a space rather more extensive -than that of the depressed part of the outer table. The superior -longitudinal sinus was wounded by the sharp edge of the broken inner -table, and a very considerable quantity of blood extravasated upon the -surface of the brain. - -The portion of bone implicated in this injury has been preserved. - - THOMAS LONGMORE, - _Surgeon, 19th Regiment_. - - Camp before Sebastopol. - - -REMARKS. - -Six amputations at the hip-joint (if not more) have been performed in -the Crimea, and all the sufferers have died, a loss which has not been -experienced in civil life under any circumstances, many persons having -survived the operation for years. It has been fairly attributed to -the depressing causes from which the army suffered, and for which the -government has been blamed; although the great functionaries appear -to me to have less to account for than their subordinates, as far as -regards deficiencies in the treatment of the sick and wounded. - -The operation for removing the head of the femur from its connection -with the hip, leaving the limb for future use, was first recommended by -me as a substitute for amputation at the hip-joint, and has been done -in at least six instances, one only surviving. I limited the operation -to injuries of the head and neck of the bone, or with little extension -beyond these two parts, being cases which hitherto invariably died -unless amputation at the hip-joint were performed, and which it was -and is hoped the operation of excision might render unnecessary; but -it must be done under happier circumstances, and perhaps with greater -restriction. The success which has followed the removal of the head of -the humerus from the shoulder-joint even with as much as one-third of -the shaft, as low as the insertion of the deltoid muscle, has led to -the belief that as much may be done in the thigh; and in the hope that -it might be so, a considerable portion of the shaft of the femur has -been removed with the head and neck in the cases alluded to, so that an -approximation of the remainder of the shaft to the cavity of the joint -has not been possible. If the operation performed by Surgeon O’Leary, -68th Regiment, (page 564,) which at the end of seven weeks is reported -as doing well, although the pulse remained between 80 and 100, should -succeed, it is doubtful whether the limb will be of any use or better -than an artificial leg, from the extent of the bone removed, which will -prevent the formation of a firm joint or union. The sling used in this -case has been considered very advantageous by all who have seen the -man, and proves how much may be done in all cases of compound fractures -by similar appliances, but which has not yet been done. A correct -judgment cannot, however, be formed as to the value of this operation -until it has been performed on one of those cases in which a ball shall -simply lodge in the head or neck of the femur without injuring the -shaft of the bone--an accident which has been so frequently observed in -the head of the humerus, and of which I have sent two preparations to -the museum of the College of Surgeons. (See page 127.) - -It has been already stated that the loss of life after amputations -performed for gunshot fractures of the upper part of the thigh has been -so great, both in the French and English armies, that such operations -have been nearly abandoned. - -The Russians, at the commencement of the siege of Sebastopol, made use -of a conical rifle bullet, flat at the base, weighing nearly one ounce -and three-quarters. Latterly they have used a larger conical one, with -three grooves around the circumference of the base of the cone, which -is hollowed out to receive a cup, and shows a projection on the inside -of the hollow. This ball is near two inches long, and weighs somewhat -more than one ounce and three-quarters. - -The balls formerly used by the French army were twenty to the pound, -and by the English, sixteen. The balls alluded to are nine to the -pound. When this Russian ball strikes soft parts only, such as the -thigh, it merely makes a larger hole than the common bullet, into which -the finger passes easily, and the wound heals as readily. Whenever it -strikes a bone, it would appear to break it more extensively, and to -require more certainly the amputation of the limb; although the smaller -French ball used in former days, when it struck a bone, disabled the -sufferer as effectually for all future service, yet it might not as -certainly lead to his death. - -Dr. Lyons not only transmitted to me the case, related page 579, of -John Shehan, but has since sent me the broken bones, which confirm -everything I have said on this subject, page 321. The sound bone above -the fracture has become more solid; the splinters not having been -removed are lying across, and prevent the approximation or union of -the ends of the old bone, while the effort made by nature to effect -this object by the deposition of new ossific matter, adds to the evil -by fixing these splinters in so solid a manner that they cannot escape -or be removed by any other means than that of forcible abstraction, -after painful and perhaps dangerous operations, each splinter possibly -requiring a separate one. Shehan’s case was one for amputation from -the first, if he had been in a state to undergo it with a prospect of -success. - -The treatment of gunshot fractures of the leg ought to have been more -successful than it has been, even when both bones were broken; the -want of success may be in part attributed to the remissness which has -taken place in supplying the necessary, nay, the essential appliances, -by means of which much suffering might have been alleviated, perhaps -prevented, even if cures could not have been effected. - -In performing the operation for the excision of portions of the -extremities of bones, a chain saw is a most desirable aid on many -occasions. There was not one with the British army in the Crimea, and -when wanted, they were borrowed from the French ambulances. It was only -on the 30th of September last some were ordered to be sent out, and -they cannot yet have arrived. In a lecture I delivered on the 14th of -April last in the Theater of the College of Surgeons, as its President, -by permission of the Council, the proceeding being unusual, I drew -attention, for the express purpose, to the necessity which existed -for the Crimean army being supplied with a machine capable of being -moved from bed to bed, by means of which the unfortunate soldier could -be raised in the extended state, and after being washed, his wounds -dressed, and his bedclothes changed, he might be again laid down with -comparatively little uneasiness. Fifty of them would not cost £300, but -there are none in the Crimea, except two, one sent to the Coldstream -Guards, by Lord Strafford at his own expense, and one which the makers -placed at my disposal. I hear that _three_ have been ordered lately, -like the chain saw, when too late, for many are now no more who stood -in the greatest need of them, and without which machine they had little -chance of being saved. - -On the 14th of April, 1855, I published a lecture, in which I gave a -sketch of an apparatus for slinging a broken leg, which instrument -I declared to be a _sine qua non_ in the successful treatment of a -gunshot fracture of the leg. By permission of the Duke of Newcastle, -I sent out forty-six sets complete for every part of the body, the -year preceding. They were, I am told, left at Varna; and four medical -officers, of character and knowledge, who have lately returned -from the East, assure me within the last week that no such, or any -similarly useful, apparatus was ever seen in the hospitals in front of -Sebastopol. Other instances of remissness of equal importance might -be adduced, if it were not useless to advert to them; for we delight, -I believe, in being admitted by foreigners to be a wonderful people -in the mismanagement of our affairs in the first instance, however -important or trivial. It is, I believe, an admitted maxim, that the -right men should be in the right place--the square ones in the square -holes, the round ones in the round holes; but there is another one of -equal importance, viz., that the right thing should be in the right -place at the right time, without which teaching or practicing surgery -becomes of little value. - -Amputation at the knee-joint has been done, I hear, in six cases since -the taking of Sebastopol; four are dead; one is doing well under Mr. -Blenkins, of the Guards, and the other yet survives. Excision of the -knee-joint has been performed since the taking of Sebastopol in one -case by Staff-Surgeon Lakin, and is doing well. - -The excisions performed on the head of the humerus, and on the bones -composing the elbow-joint, have been very successful. There is, -however, a circumstance to which I am desirous of drawing attention, -viz., that the head of the humerus should never be removed in -amputations, when it is uninjured, however close the destruction below -may have approached it. The round head of bone left in the socket -preserves the squareness of the shoulder, and renders the loss of -the arm less unseemly. It tends to prevent the inclination the body -generally has to the opposite side, and its being left adds nothing to -the difficulties of the operation. The excisions of the ankle-joint -have been numerous and more successful than might have been expected -under the depressing causes alluded to. - -For the preparations of the head of the humerus and of the astragalus, -referred to at pages 110 and 128, I have since learned I am indebted -to Deputy Inspector-General Macgregor; and I am particularly so to -Assistant-Surgeon Gregg, of the 17th Regiment, for the great care he -has bestowed on several of the specimens of injury sent to me. - -Wounds penetrating the cavities of the chest and abdomen have been no -less fatal than those of the lower extremities. The same want of power -has been exhibited in them; the same inability to bear the means of -cure which, under happier circumstances, have proved successful. - -I hope to receive reports on wounds of arteries, on secondary -hemorrhage, and on injuries of the head, so as to enable me to remove -any doubts which may exist on these points; and I beg to assure those -officers who will favor me with their opinions and facts, that they -shall be duly reported in another “Addenda.” - -I cannot conclude these remarks without expressing my sense of the -great practical ability displayed by very many of the medical officers -in the Crimea, of their devotion, of their self-denial--qualities which -ought to obtain for them the special approbation of the nation. - -_October 18, 1855._ - - - - -INDEX. - - - Abdomen, wounds of, 488, 649. - causing abscesses in parietes of, 489. - penetrating wounds of, 497. - protrusion of viscera in, 498. - of omentum, 498. - of intestine, 501, 509. - effusion of blood into, 505, 510. - treatment of hemorrhage in penetrating wounds of, 510. - suppuration in cavity of, 511. - and pelvis, conclusions respecting wounds of, 555. - right arm and thigh, extensive injury to, by a round shot, 576. - - Abdominal parietes, gunshot wounds of, 489. - lodgment of balls in, 489. - incised wounds of, 490. - followed by ventral rupture, 493. - on continuous suture of, 493. - severe contusions of, followed by rupture of the hollow or solid - viscera, 491. - - Abernathy’s mode of tying the external iliac, 257. - - Abscess of liver, consequent to injuries of the head, 356. - in abdominal parietes, caused by neglected injuries, 489. - - Acids, mineral, use of, in sloughing wounds, 70, 168. - in hospital gangrene, 70, 168. - - _Addenda_, commentaries on the cases in, 586. - - Alexander, Deputy Inspector-General, on amputations, while under the - influence of chloroform, 563. - - Amaurosis from balls passing behind the eyes, 478. - - Amputation, primary, not required in gunshot wounds of the upper - extremity, 120. - aphorisms on, 73. - at the ankle-joint, Mr. Syme’s operation for, 105. - of the arm below the tuberosities, 126. - by the circular incision, 134. - by Mr. Luke’s operation by two flaps, 135. - primary, of the arm, 120. - at the elbow-joint, 137. - place of election for, in local mortification of a limb, 46. - of the fingers, 139. - of the foot, 114. - by Roux’s plan, 108. - of the forearm, 137. - by the flap operation, 137. - by the circular incision, 138. - for gunshot wounds of the femur, 145. - at the hip-joint, 77, 92, 562, 563, 586. - Mr. Guthrie’s mode of operating in, 79, 83. - Professor Langenbeck’s, 80. - Mr. Brownrigg’s, 82. - under chloroform, 564. - immediate, question as to, 51. - cases for, 150. - of the leg, 99. - by the circular incision, 99. - by Mr. Luke’s flap operation, 101. - immediately below the tuberosity of the tibia, 102. - of the metacarpal bones, 139. - of a metatarsal bone, 118. - in cases of mortification from wounded arteries, 228. - necessity for, 51. - of the phalanges, 140. - primary and secondary, 59. - secondary, 59, 141. - at the shoulder-joint, 122. - by two flaps, 124. - by one flap, 125. - by Lisfranc’s operation, 125. - at the tarsus, 112. - of the thigh, by the circular incision, 83. - by Mr. Luke’s flap operation, 86. - at the wrist, 138. - under the influence of chloroform, in the Crimea, 561. - case of death from, 561. - Deputy Inspector-General Taylor on, 562. - Deputy Inspector-General Alexander on, 563. - - Ankle-joint, excision of, 103. - Mr. Syme’s amputation at, 105. - - Aneurism of the arch of the aorta, 276. - formation of, after wound of artery, 212. - Hunterian theory respecting, 188. - popliteal, operation for, 263. - traumatic, formation of, 214. - - Aneurismal swelling after deep wound of an artery, 212. - - Anus, artificial, 525. - operation for the formation of, in the loins, 558. - Desault’s operation for, 527. - Dupuytren’s forceps for, 527. - Mr. Trant’s forceps for, 528. - - Aorta, ligature of, 250, 252, 256. - aneurism of the arch of, 276. - - Arachnoid and dura mater, wounds of, 345. - - Arm, amputation of, below the tuberosities, 126. - primary, 120. - by the circular incision, 134. - by Mr. Luke’s double flap operation, 135. - gunshot fracture of, 121, 156. - wounds of the arteries of, 238. - thigh and abdomen, extensive injury to, 576. - - Arsenic, local use of, in hospital gangrene, 169. - - Arteries, wounded, the Hunterian theory inapplicable in the treatment - of, 189. - Mr. Guthrie’s theory respecting, 189. - principles of surgery relative to, 191. - punctured wounds of, 210. - formation of aneurism after, 211. - transverse wound of, 212. - complete division of, 212. - large, mode of arresting hemorrhage from, 234. - of arm and forearm, wounds of, 238. - - Artery, structure of, 176. - deep wound of, forming aneurismal swelling, 213. - effects of a ligature on, 203. - wounded, not to be operated on, unless it bleed, 215, 241. - to be tied at the seat of injury, 191, 219. - main, of the lower extremity, mortification caused by a wound of, - 45, 226. - - Artificial anus, 525. - formation of, in the loins, 558. - Desault’s operation for, 527. - Dupuytren’s forceps for, 527. - Mr. Trant’s forceps for, 528. - foot, M. de Beaufoy’s, 119. - - Astragalus and calcis, Mr. T. Wakley’s operation for the removal of, - 115. - ball lodged in the, 109, 590. - removal of, 109. - - Auscultation, value of, in injuries of the chest, 367. - - Axillary artery, gunshot wounds of, rarely cause mortification of the - hand or fingers, 46, 235. - ligature of, 278. - wounds of, 235. - - - Ball, lodging in the abdominal parietes, 489. - in the astragalus, 109, 590. - in the bladder, 553. - calculus formed on, 553. - operation for removal of, 554. - in bone, 36, 149. - in the brain, 283. - behind the eye, 478. - or other foreign bodies loose in the cavity of the pleura, 448. - inclosed in a cyst, 451. - lodged in the head of the humerus, 128. - in the liver, 532. - orifices of entrance and exit, 27, 489. - passing behind the eyes, causing amaurosis, 478. - lodging in the pelvis, 545. - penetrating the brain, 347. - rolling on the diaphragm, 451. - operation for extraction of, 455. - separating the sutures of the skull, 349. - - Balls, relative size of those used by the Allies and by the Russians, - 588. - on cysts inclosing foreign bodies, in gunshot wounds of the chest, 451. - operation for empyema, 452. - operation for gunshot fracture of the lower jaw, 480. - - Baudens, M., on excision of the head of the humerus, 133. - - Bayonet, wounds by, 37. - wounds, delusion as to, 38. - - Bearers for the wounded, 156. - - Beaufoy’s, M. de, artificial foot, 119. - - Bedsteads for gunshot fractures of the femur, 152. - - Bell, Mr. J., on emphysema in gunshot wounds of the chest, 412. - - Bennet, Dr. Hughes, on phlebitis, 71. - - Blackadder, Mr., on hospital gangrene, 164, 169. - - Bladder, wounds of, 546. - ball in the, 553. - calculus formed on, 553. - operation for extraction of, 554. - - Blood, effusion of, into the abdomen, 505, 510. - - Boggie, Dr., on hospital gangrene, 168, 169. - - Bone, lodgment of a ball in, 36, 149. - protrusion of, after amputation, 89. - exfoliation of, after amputation, 89. - - Bones of the face, penetrating wounds of, 479. - - Brachial artery, ligature of, 279. - - Brain, balls lodging in, 283. - balls penetrating into, 347. - M. Burdach’s statistics of lesions of, 306. - compression of, 302. - paralysis caused by, 305. - injuries of the head affecting the, 283. - concussion of, 287. - causing mania, 299. - laceration of, by contre-coup, 340. - motions of, 303. - suppuration of the surface of, 342. - wounds of, 347. - causing abscess of the liver, 356. - - Bronchophony, 372, 376. - - Brow and eyelids, wounds of, 477. - - Brownrigg’s mode of amputating at the hip-joint, 82. - - Brunner, glands of, 486. - - Buck, Dr. Gurdon, operation for excision of the knee-joint, 97. - - Burdach’s statistics of lesion of the brain, 306. - - - Calcis and astragalus, operation for the removal of, 115. - removal of, 104. - - Calculus formed on a ball in the bladder, 553. - operation for extraction of, 554. - - Cannon-shot, hemorrhage after the carrying away a limb by, 25. - wind of, 43. - causes mortification of a limb, by destroying its internal textures, - 43. - - Carotid, common, ligature of, 270. - statistics of ligature of, 241. - external, ligature of, 272. - the common carotid not to be tied for wounds of, 242. - internal, ligature of, 272. - wounds of, through the mouth, 245. - operation for securing, 245, 248, 272. - the primitive carotid not to be tied for wounds of, 246. - primitive, not to be tied for wounds of external carotid, 541. - nor for wounds of the internal carotid, 246. - - Cartilages, costal, fracture of, in gunshot wounds of the chest, 429. - - Cerebrum, fungus of, (hernia cerebri,) 352. - - Chain saw, utility of, 588. - - Chelius on suture of incised wounds of abdominal parietes, 493. - - Chest, wounds of, 364, 590. - effusion into, 371, 378, 420. - purulent effusion, etc. into, 378, 390, 420, 435. - operation for, 394. - non-penetrating wounds of, 364. - value of auscultation in wounds of, 367. - incised wounds of, 364, 414. - wounds of both sides of, 417. - large penetrating wounds of, the lung injured, 418. - with hemorrhage into the cavity, 421. - ecchymosis a sign of internal hemorrhage in penetrating wounds of, 424. - conclusions respecting wounds of, 424. - gunshot wounds of, 426. - statistics of, 426. - enlargement of, 427. - fracture of the ribs in, 428. - of the costal cartilages in, 429. - involving the lungs, 429. - removal of splinters, etc., 445. - the ball loose in the cavity of the pleura, 448. - rolling on the diaphragm, 451. - inclosed in a cyst, 451. - involving the lungs, effusion caused by, 435. - formation of a dependent opening, 452. - operation for the evacuation of the fluid, 455. - anatomy of the parts concerned, 453. - - Chloroform, use of, 55. - Dr. Snow on, 55. - Mr. Syme on the treatment of approaching death from, 58. - amputation under the influence of, in the Crimea, 561. - case of death from, 561. - Deputy Inspector-General Taylor on, 54, 562. - Deputy Inspector-General Alexander on, 563. - - Circulation, collateral, 184. - - Colon, Hilton’s operation for opening into, 558. - - Commentaries on the cases in the _Addenda_, 586. - - Compound fractures, 145. - splints for, 153. - - Compression of the brain, 302. - convulsions caused by, 307. - paralysis caused by, 305. - in hemorrhage from wounds of the hand, 238. - - Conclusions respecting wounds of the chest, 424. - abdomen and pelvis, 555. - hospital gangrene, 173. - - Concussion of the brain, 287. - causing mania, 299. - - Contre-coup, fracture of the skull by, 316. - laceration of the brain by, 340. - - Contusions, severe, of abdomen, followed by rupture of the hollow or - solid viscera, 490. - - Convulsions caused by compression of the brain, 307. - - Cooper, Sir A., mode of tying the external iliac, 258. - - Cranium, fracture of the base of, 317. - - Crepitating râle, or rhonchus, 375. - - - Delpech on hospital gangrene, 165, 166, 167. - - Deposits, purulent, 61, 68. - - Depression of the skull, 329. - of the back of the skull, with fracture, 338. - - Desault’s operation for artificial anus, 527. - - Diaphragm, ball rolling on the, 451. - operation for the extraction of, 455. - wounds of, 458. - may cause internal hernia, 463. - - Dupuytren’s forceps for artificial anus, 527. - - Dura mater, incision of, 343. - removal of blood from the surface of, 360. - suppuration on the surface of, 342. - wounds of, 345. - - - Ecchymosis, a sign of hemorrhage into the chest, 424. - - Effusion, purulent, in penetrating wounds of the chest, 420, 435. - - Elbow-joint, amputation at, 137. - excision of, 135, 580. - - Emphysema, 410. - Mr. J. Bell on, in gunshot wounds of the chest, 412. - - Empyema, 390, 436. - operation for, 394, 455. - M. Baudens on, 452. - necessity for depending opening in, 452. - Mr. Quekett’s experiments on the anatomy of the parts engaged in, - 452. - operation for, by incision, 455. - - Endocardial sound of the heart, 466. - - Epigastric artery, ligature of, 510. - - Erysipelas phlegmonodes, 40. - improvement in the treatment of, 41. - of the scrotum, 42. - of the scalp, 359, 363. - - Excision of the ankle-joint, 103. - calcis, 104. - calcis and astragalus, 115. - elbow-joint, 135, 580. - with injury to left hip, 581. - head of the femur, 90, 150, 564, 587. - in gunshot wounds of, 150. - of the head, neck, and great trochanter of the femur, 564. - of the head of the humerus, 126, 571, 590. - Langenbeck’s operation for, 130. - M. Baudens on, 133. - of the knee-joint, 97. - Mr. Jones’s mode of operating, 97, 98. - Dr. Gurdon Buck’s operation for, 97. - metacarpal bone of thumb, 140. - phalangeal joints, Langenbeck’s operation for, 140. - - Excito-motory system of Dr. Marshall Hall, 286. - - Exfoliation of bone after amputation, 89. - - Exocardial sound of the heart, 466. - - Expiration, 369. - - Extraction of the ball in gunshot wounds, 32. - - Extremities, upper, gunshot wounds of, 20. - - Eye, ball lodged behind, 478. - wounds of, 477. - - Eyelids and brow, wounds of, 477. - - - Face, wounds of, 476. - penetrating wounds of the bones of, 479. - - Femoral artery, gunshot wound of, a cause of local mortification, - 45, 226. - laceration of, 208. - ligature of, 260. - superficial ligature of, 262. - and vein, injuries of, may cause gangrene, 45. - - Femur, removal of the head of, 90, 150, 564, 587. - gunshot wounds of, 145, 579, 587. - secondary amputation in, 145. - of the head and neck of, 150. - bedsteads for, 152. - - Fingers, amputation of, 139. - mortification of, rarely caused by wound of axillary artery, 46. - - Fissure of the skull, 311. - - Foot, gunshot wounds of, 107, 112. - amputation of, 114. - amputation of, by Roux’s plan, 108. - at the ankle-joint, Mr. Syme’s operation for, 105. - artificial, M. de Beaufoy’s, 119. - - Forearm, gunshot wounds of, 137. - amputation of, 137. - by flap operation, 137. - by circular incision, 138. - wounds of arteries of, 238. - - Forehead, gunshot wounds of, causing loss of sight, 350. - - Foreign body, lodgment of in a nerve, 47. - - Fowler’s solution of arsenic, in hospital gangrene, 169. - - Fractures, compound, 145. - splints for, 153. - - Fracture, gunshot, of the leg, 154, 588. - Mr. Luke’s apparatus for, 154. - of the head of the femur, 150. - of the upper extremities, 120. - of the shoulder-joint, 120. - of the elbow-joint, 136. - of the arm, 121, 156. - of the skull, 311. - of the skull by contre-coup, 316. - of the base of the cranium, 317. - of the inner table of the skull, 321, 324, 328. - with depression at the back part of the skull, 338. - of the superior maxillary bone, 582. - of the ribs in gunshot wounds of the chest, 429. - of costal cartilages, ditto, 429. - - Frontal sinuses, gunshot wound of, 350. - - Fungus, or hernia cerebri, 352. - - - Gall-bladder, gunshot wounds of, 530. - - Gangrene, hospital, 163. - Fowler’s solution of arsenic in, 169. - mineral acids in the treatment of, 70, 168. - sloughing or pulpous form of, 166. - conclusions respecting, 173. - local and dry, from wound of the main artery of the lower extremity, - 44, 226. - traumatic, 42. - - Glands of Brunner, Grew, and Peyer, 486. - solitary, 487. - - Gluteal artery, ligature of, 259. - - Goyraud’s operation for ligature of the internal mammary, 473. - - Grew, glands of, 486. - - Gross’s experiments on intestine, 506. - - Gunshot fractures of the upper extremities, 120. - lower ditto, 154. - wounds of axillary artery, rarely cause mortification of hand or - fingers, 46, 285. - extraction of the ball in, 32. - of the foot, 107, 112. - knee-joint, 94, 574. - shoulder-joint, 120. - arm, 121, 156. - elbow-joint, 136. - forearm, 137. - hand, 139. - femur, 145, 579, 587. - head and neck of, 150. - face, 479. - leg, 154, 588. - lower jaw, 480. - skull, 346, 584. - frontal sinuses, 350. - forehead, causing loss of sight, 353. - orbit, 350, 583. - superior maxillary bone, etc., 582. - chest, 426. - statistics of, 426. - fracture of the ribs in, 428. - costal cartilages in, 429. - involving the lungs, 429. - heart, 468. - abdominal parietes, 489. - intestine, 515. - liver, 528. - gall-bladder, 530. - stomach, 535. - spleen, 536. - kidney, 538. - spermatic cord and testicle, 539. - penis, 540. - pelvis, 541. - bladder, 546. - rectum, 555. - inflammation consequent on, 30. - - Guthrie, Mr., mode of amputating at the hip-joint, 79, 83. - theory respecting wounded arteries, 189. - - - Hall, Dr. Marshall, excito-motory system of, 286. - - Hand, gunshot wounds of, 139. - mortification of, rarely caused by wound of the axillary artery, - 46, 235. - compression in wounds of, 238. - - Head, injuries of, 283. - affecting the brain, 283. - causing abscess of the liver, 356. - mania, 299. - - Heart, sounds of, 465. - relative position of, 464. - wounds of, 464. - recovery after, 464, 468. - insensibility of, 471. - laceration and rupture of, 472. - - Hernia cerebri, 352. - of the lung, 456. - of the stomach or bowels into the chest, after wounds of the - diaphragm, 463. - - Hevin on the swallowing of knives, 535. - - Hilton’s operation for opening into the colon, 558. - - Hip-joint, amputation at, 77, 92, 562, 563, 586. - Mr. Guthrie’s operation for, 79, 83. - Langenbeck’s, 80. - Mr. Brownrigg’s, 82. - injury to, with excision of elbow-joint, 581. - - Hemorrhage after a gunshot wound, 25. - secondary, 208. - from the intercostal artery, 474. - after the carrying away a limb by cannon-shot, 25. - from sloughing stumps, 71. - means used by nature for the suppression of, 187, 191. - from large arteries, mode of arresting, 234. - from wounds in the hand, compression in, 288. - in penetrating wounds of the chest, 421. - in wounds of the heart, 468. - in penetrating wounds of the abdomen, 510. - - Hospital gangrene, 163. - Deputy Inspector-General Taylor on, 171. - Dr. Tice on, 165. - M. Delpech on, 165, 166, 167. - Mr. Blackadder on, 164, 169. - Dr. Boggie on, 168, 169. - Dr. Walker on, 170. - mineral acids in the treatment of, 70, 168. - use of Fowler’s solution of arsenic in, 169. - sloughing or pulpous form of, 166. - conclusions respecting, 173. - hospital returns respecting, 175. - - Hospital, statistics of operations, 158. - - Hughes, Dr., on pneumothorax, 396. - - Humerus, amputation of, below the tuberosities, 127. - excision of the head of, 126, 571. - by Langenbeck’s operation, 130. - M. Baudens on, 133. - ball lodged in the head of, 128. - amputation of, by the circular incision, 134. - Mr. Luke’s, by two flaps, 135. - gunshot fracture of, 156. - - Hunter, John, on inflammation of the veins, 70. - - Hunterian theory of aneurism, 188. - inapplicable to the treatment of wounded arteries, 189. - - - Iliac, external, ligature of, 257. - internal, ligature of, 256. - - Iliacs, common, relative situation of, 251. - ligature of, 252. - - Immediate amputation, question as to, 51. - cases for, 150. - tumors of the scalp, 340. - - Incisions, use of, in erysipelas phlegmonodes, 40. - - Inflammation consequent on gunshot wound, 30. - acute idiopathic, of the pleura, 370, 376. - of the lungs, 373, 380. - typhoid, of the lungs, 388. - of the pleura, 390. - - Innominata, ligature of, 273. - - Inspiration, 368. - - Intercostal artery, wounds of, 474. - - Internal carotid, wounds of, through the mouth, 245. - operation for, 245, 248, 272. - mammary artery, wounds of, 473. - strangulated hernia, after a wound of the diaphragm, 463. - - Intestine, structure of, 482. - rupture of, 491. - protrusion of, in penetrating wounds of abdomen, 501, 509. - wounds of, 504, 508. - punctured, 504, 509. - Travers and Gross’s experiments on, 506. - divided, treatment of, 507. - Ramdohr on, 507. - wounded, application of continuous suture to, 508. - gunshot wounds of, 515. - - - Jaw, lower, wounds of, 480. - Baudens’s operation for, 480. - upper, wounds of, 479. - - Jones’s mode of excising the knee-joint, 97, 98. - - - Knee-joint, gunshot wounds of, with fracture of the bones, 94. - excision of, 97. - Jones’s operation for, 97, 98. - Dr. Gurdon Buck’s operation for, 97. - loss of, by a round shot, 574. - - Kidney, wounds of, 537. - - Knives, etc. in the stomach, 535. - operation for their removal, 536. - - - Laceration of the femoral artery, 208. - brain by contre-coup, 340. - and rupture of the heart, 472. - - Langenbeck’s mode of amputating at the hip-joint, 80. - excision of the head of the humerus, 130. - phalangeal joints, 140. - metacarpal bone of thumb, 141. - - Larrey’s operation for opening the pericardium, 469. - ligature of the femoral artery, prior to amputation at the - hip-joint, 79. - - Lateral sinus, wounds of, 351. - - Larynx, wound of, 571. - - Lee, Mr. Henry, on phlebitis, 70. - - Leg, gunshot fractures of, 154, 588. - amputation of, 99. - by the circular incision, 99. - by Luke’s flap operation, 101. - immediately below the tuberosity of the tibia, 102. - apparatus for compound fracture of, 154. - for slinging, when broken, 589. - - Ligature on an artery, effects of, 203. - size of, etc., 207. - one, utterly insufficient to control hemorrhage from a wounded - artery, 245. - - Lisfranc’s amputation at the shoulder-joint, 125. - - Liver, abscess of, consequent to injuries of the head, 356. - wounds and injuries of, 528. - removal of portions of, 533. - lodgment of balls in, 532. - - Longitudinal sinus, wounds of, 351. - - Luke’s flap amputation of the thigh, 86. - leg, 101. - arm, 135. - apparatus for compound fracture of the leg, 154. - - Lung, hernia of, 456. - - Lungs, acute inflammation of, 373, 380. - morbid changes caused by, 380. - typhoid inflammation of, 388. - gunshot wounds of, 413. - removal of splinters from, 445. - - - Machine for raising wounded soldiers in bed, 589. - - Mammary, internal, wounds of, 473. - Goyraud’s operation for ligature of, 473. - - Mania caused by concussion of the brain, 299. - - Maxillary bone, superior, gunshot fracture of, 582. - - Membrane, mucous, of the stomach, 485. - - Meningeal artery, middle, injury of, 314. - - Metacarpal bone of thumb, excision of, 140. - bones, amputation of, 139. - - Metatarsal bone, amputation of, 118. - - Mineral acids, use of, in hospital gangrene, etc., 70, 168. - - Mortification, 42. - from wind of cannon-shot, not admitted, 43. - from extensive injuries from large shot, etc., 44. - from gunshot wound of main artery of a limb, 45, 226. - of hand and fingers, rarely caused by wound of the axillary - artery, 46, 235. - from cold, 46. - - Motions of the brain, 303. - - Mouth, wound of the internal carotid through, 245. - operation for, 245, 248, 272. - - Mucous membrane of the stomach, 485. - - Musket-ball wounds. See _gunshot wounds_. - - - Neck, wounds of, 242, 475. - Velpeau on wounded arteries of, 246. - - Nerve, consequences of the section of, 47. - lodgment of a foreign body in, 47. - enlargement, of extremity of, after amputation, 89. - consequences of incomplete section of, 47. - - Nose, wounds of, 477. - - - Occiput, depression and fracture of, 338. - - Œgophony, 373. - - Ollivier on lacerations and ruptures of the heart, 472. - - Omentum, protrusion of, in penetrating wounds of abdomen, 498. - - Operations, hospital statistics of, 158. - - Orbit, wounds of, 350, 583. - - Os calcis, removal of, 104. - - - Patella, compound gunshot fractures of, 95. - - Paracentesis thoracis, 394, 455. - - Paralysis, the result of compression of the brain, 305. - - Parotid gland, wounds of, 479. - and duct, wounds of, 479. - - Pelvis, wounds of, 541. - balls lodging in, 545. - and abdomen, conclusions respecting wounds of, 555. - - Penis, wounds of, 540. - - Pericardium, Larrey’s operation for opening, 469. - Skielderup’s ditto, 469. - - Peroneal artery, ligature of, 266. - - Peyer, glands of, 486. - - Phagedena gangrenosa, 163. - - Phalangeal joints, excision of, 140. - - Phalanges, amputation of, 140. - - Phlebitis, 60, 62, 63. - Mr. Hunter on, 70. - Mr. Henry Lee on, 70. - Dr. Hughes Bennett on, 71. - - Plantar artery, external, ligature of, 267. - - Pleura, acute idiopathic inflammation of, 370, 376. - typhoid ditto, 390. - effusion into the cavity of, 371, 378, 420. - purulent ditto, 379, 390. - operation for, 393. - balls or other foreign bodies loose in the cavity of, 418. - - Pneumonia, 373, 379. - morbid changes caused by, 380. - typhoid, 388. - - Pneumothorax, 396, 402. - Dr. Hughes on, 396. - - Popliteal aneurism, operation for, 263. - artery, not to be tied, unless wounded and bleeding, 265. - wound of, 573. - - Pourriture d’hôpital, 163. - - Primary amputation, advantages of, 59. - not required in gunshot wounds of the upper extremity, 120. - - Profunda femoris, ligature of, 261. - wound of, 573. - - Protrusion of bone after amputation, 89. - of the brain, 352. - - Pulpous form of hospital gangrene, 166. - - Purulent deposits, 61, 68. - - - Quekett, Mr., experiments on the anatomy of the parts engaged in - empyema, and the operation by incision, 452. - on the structure of the agminated glands of Grew and Peyer, 486. - - - Radial artery, wound of, 238. - ligature of, 282. - wound of, in the hand, 238. - operation for, 282. - - Ramdohr on the treatment of divided intestine, 507. - - Ravaton on protrusion of omentum in penetrating wounds of abdomen, - 501. - - Rectum, wounds of, 555. - - Removal of the head of the femur, 90. - and neck of, in gunshot wounds of, 150. - os calcis, 104. - astragalus and calcis, 115. - - Respiration, the four movements of, 285. - distinction of sounds during, 367. - - Respiratory murmur, 367. - - Rhoncus crepitans, 370, 375. - - Ribs, fracture of, in gunshot wounds of the chest, 428. - the cartilages of, 429. - - Roux’s amputation of the foot, 108. - - Rupture of the heart, 472. - ventral, 488, 493. - of intestine, by violence, 491. - of the solid viscera, by violence, 493. - - - Scalp, immediate and secondary tumors of, 341. - wounds of, 361. - erysipelas of, 359, 363. - - Sciatic artery, ligature of, 259. - - Scrotum, erysipelas phlegmonodes of, 42. - - Secondary amputations, 59, 141. - in gunshot wounds of the femur, 145. - hemorrhage, 208. - tumors of the scalp, 341. - - Shock or constitutional alarm, 26. - - Shoulder-joint, gunshot wounds of, 120. - amputation at, 122. - - Sight, loss of, from a musket-ball traversing the forehead, 350. - - Sinuses, frontal, gunshot injury to, 350. - - Sinuses, longitudinal and lateral, wounds of, 351. - - Skielderup’s operation for opening the pericardium, 469. - - Skull, simple fissure or fracture of, 311. - fracture of, by contre-coup, 316. - the inner table of, 321, 324, 328. - depression of, 329. - and fracture of back part of, 338. - gunshot wounds of, 346, 584. - balls separating the sutures of, 349. - removal of a large portion of, 359. - - Sloughing stumps, hemorrhage from, 71. - form of hospital gangrene, 166. - ulcer, 164. - wounds, use of mineral acids in, 70. - - Snow, Dr., on chloroform, 55. - - Solitary glands, 487. - - Sounds, distinction of, in respiration, 367. - of the heart, 465. - - Spermatic cord, wounds of, 539. - - Sphacelus, dry, from wound of main artery of lower extremity, 45, 226. - - Spine, effects of strychnia in injury of, 574. - - Spleen, wounds and injuries of, 536. - removal of, 538. - - Splints for fractures, 153. - - Splinters, removal of, from a wounded lung, 445. - - Statham’s operation for removal of astragalus, 110. - - Statistics, hospital, of operations, 158. - Burdach’s, of lesions of the brain, 306. - of ligature of common carotid, 241. - - Stomach, mucous membrane of, 485. - wounds of, 533. - gunshot wounds of, 535. - fistulous opening in, after gunshot wounds of, 535. - knives in, 535. - operation for the removal of, 536. - - Structure of arteries, 176. - of intestine, 482. - - Strychnia, effects of, in injury of the spine, 574. - - Subclavian, ligature of, 274. - above the clavicle, 276. - - Suppuration on the surface of the dura mater and brain, 342. - - Suture, continuous, for wounded intestine, 508. - for incised wounds in abdominal parietes, 493. - - Sutures of the skull, separated by a ball, 349. - - Syme, Mr., amputation at the ankle-joint, 105. - on the treatment of approaching death from chloroform, 58. - - - Tarsus, amputation at, 112. - - Taylor, Deputy Inspector-General, on hospital gangrene, 171. - on amputations under chloroform, 54, 562. - on wound of the larynx, 572. - on the privations endured by the British soldiery in the Crimea, - and their effects, 562. - - Testicle, removal of, after a wound, 539. - - Thigh, amputation of, by the circular incision, 83. - by Luke’s flap operation, 86. - arm and abdomen, extensive injury to, 576. - gunshot fractures of, 579, 587. - - Thumb, excision of metacarpal bone of, 140. - - Tibia, amputation of the leg below the tuberosity of, 102. - - Tibial artery, anterior, ligature of, 268. - posterior, ditto, 266. - - Tice, Dr., on hospital gangrene, 165. - - Tongue, wounds of, 481. - - Trant’s forceps for artificial anus, 528. - - Traumatic aneurism, formation of, 214. - gangrene, 42. - - Travers’s experiments on intestine, 506. - - Trephine not applicable in simple fracture of the skull, without - depression, 312. - manner of applying, 358. - use of, at different periods, 327. - frequent application of, 359. - - Trochanter, head and neck of the femur, excision of, 564. - - Tumors, immediate and secondary, of the scalp, 341. - - Typhoid pleuritis, 390. - pneumonia, 388. - - - Ulnar artery, ligature of, 281. - wound of, 238, 281. - - - Valvulæ conniventes, 483. - - Veins, inflammation of, 60, 62. - Mr. Hunter on, 70. - Mr. Henry Lee on, 70. - Dr. Hughes Bennett on, 71. - - Velpeau on wounded arteries of the neck, 246. - - Ventral rupture, 488, 493. - - Vertebral artery, wounds of, 242. - ligature of, 248. - - Vesicular, or respiratory murmur, 367. - - Viscera, rupture of, 491. - protrusion of, in penetrating wounds of the abdomen, 498. - - - Wakley, Mr. T., removal of os calcis and astragalus, 115. - - Walker, Dr., on hospital gangrene, 170. - - Wounded, bearers for the, 156. - - Wound by a musket-ball, 25. - shock or alarm after, 26. - - Wounds of entrance and exit, made by a musket-ball, 27, 489. - from flattened balls, pieces of shell, etc., 28. - gunshot, formation of sinuses in, 31. - extraction of ball and other foreign substances, 32. - gunshot, the bone struck or penetrated, not broken, the ball - lodging, 36. - of the skull, 346, 584. - of the forehead, causing loss of sight, 350. - of the frontal sinuses, 350. - by a bayonet thrust, 37. - of the neck, with hemorrhage, 242, 475. - of the larynx, 571. - Deputy Inspector-General Taylor on, 572. - of the orbit, 350, 583. - of the longitudinal or lateral sinus, 351. - of the arm, 121, 156. - of the forearm, 137. - of the profunda femoris, 573. - of the popliteal artery, 573. - of the abdomen, 488. - causing abscess in paries of, 489. - gunshot ditto, 489, 515. - incised ditto, 490. - followed by ventral rupture, 493. - penetrating, 497. - followed by protrusion of viscera, 498. - of omentum, 498. - of intestine, 504, 508. - punctured ditto, 504, 509. - of the chest, 364. - non-penetrating, 364. - incised, 364, 414. - of both sides of the chest, 417. - large, penetrating, of the chest, the lung being injured, 418. - of the chest, conclusions respecting, 424. - gunshot of the chest, 426. - statistics of, 426. - fracture of the ribs in, 428. - costal cartilages in, 429. - of the lung, 429. - diaphragm, 458. - heart, 464. - internal mammary and intercostal arteries, 473. - face, 476. - eyelids and brow, 477. - eye, 477. - nose and ear, 477. - penetrating, of the bones of the face, 479. - of the parotid gland and duct, 479. - upper jaw, 479. - lower jaw, 480. - of the head and neck of femur, 150. - of the knee-joint, gunshot, 94. - of the patella, ditto, 95. - of the leg, 154. - of the foot, 107. - of the tongue, 481. - of the liver, 528. - of the gall-bladder, 530. - of the stomach, 533. - of the stomach, gunshot, 535. - of the spleen, 536. - of the kidney, 538. - of the spermatic cord and testicle, 539. - of the penis, 540. - of the pelvis, 541. - gunshot, of the bladder, 546. - of the rectum, 555. - of the abdomen and pelvis, conclusions respecting, 555. - - Wrist, amputation at, 138. - - - - -INDEX OF CASES. - - - A soldier, wounded in the thigh, the ball passing between the femoral - artery and vein, 26. - - Generals Sir Lowry Cole, Sir E. Packenham, and Colonel Duckworth; - injuries to arteries, 26. - - Colonel Sir W. Myers and General Sir R. Crawford, illustrating the - shock of a severe wound, 26, 27. - - Colonel Ross; musket-shot wound of arm: gradual descent of the ball to - the elbow, 36. - - Erysipelas phlegmonodes of the left arm, treated by incisions, 41. - - Local mortification of a leg struck by a cannon-shot, the internal - textures being destroyed, 43. - - Section of the brachial plexus of nerves by a gunshot wound, causing - paralysis, complicated by gunshot wound of the knee-joint, requiring - secondary amputation, 47. - - Sir James Kempt; injury to a nerve, 48. - - Admiral Sir Philip Broke; wound of skull, with paralysis, 48. - - Brigade-Major Bissett; gunshot wound, injuring the left great sciatic - nerve, perineum, and rectum, 49. - - Mr. Wrottesley, of the Engineers; right thigh shattered by a - cannon-shot, etc., 53. - - An East Indian; severe wound of left thigh from the explosion of his - gun; amputation, death, 53. - - A soldier of the siege train before Sebastopol; the left thigh nearly - carried off by a cannot-shot, 54. - - Purulent deposit, after amputation, 61. - - Phlebitis, 64. - - Jane Strangemore; amputation of limb for white-swelling of the - knee-joint; fatal phlebitis, 64. - - Endemic fever, after secondary amputation, with subacute pneumonia, - 67, 68. - - Sloughing of a spear-wound of the arm, 69. - - Captain Flack; cannon-shot wound of left thigh, 77. - - Excision of the head and neck of the femur, 94. - - Colonel Donnellan; musket-shot wound of knee-joint, 96. - - Excision of knee-joint, by Dr. Gurdon Buck, 97. by Mr. Jones of - Jersey, 97, 98. - - Amputation of the foot, by Roux’s operation, 108. - - Ball lodged in the astragalus, 110. - - Excision of the astragalus and calcis, 115. head of the humerus, a - musket-ball having lodged in the bone, 128, 131. - - Gunshot wounds of the shoulder-joint, 131, 132. - - Lieutenant Timbrell; gunshot fracture of both thighs; recovery without - amputation, 149. - - Illustrative of the means used by nature for the suppression of - hemorrhage, 194. - - Illustrative of gunshot wounds of the femoral artery, 196, 208. - - Ligature of the right common iliac artery, for supposed gluteal - aneurism, 206. - - Punctured wounds of arteries, 210. - - Colonel Fane; wound of carotid by an arrow; formation of an aneurism, - 211. - - Scythe wound of the femoral artery, 213. - - Wound of femoral artery with a pen-knife; closure of wound; formation - of traumatic aneurism, 215. - - Gunshot wound of the thigh; severe hemorrhage finally arrested without - ligature of the artery, 216. - - Don Bernardino Garcia Alvarez; gunshot wound of the thigh; hemorrhage - from a deeply-seated vessel; ligature of the common femoral; fatal - mortification. The femoral artery quite sound, 218. - - Duckshot wound of thigh; closure of wound; aneurismal swelling - punctured; hemorrhage; ligature of femoral high up; death, 218. - - Captain Seton; gunshot wound of upper part of thigh; hemorrhage from - a superficial branch of the femoral; ligature of the external iliac; - fatal peritonitis; errors in the treatment, 219. - - Dry gangrene, from injury to the main artery of the lower extremity, - 227. following an injury to the popliteal space; large incision in the - calf, evacuating a quantity of coagulated blood; subsequent separation - of the limb, 228. - - Gunshot wound of the posterior tibial artery; secondary hemorrhage and - traumatic aneurism; ligature of the femoral artery, renewal of the - hemorrhage, amputation, death, 230. of the peroneal artery, hemorrhage - and formation of an aneurism; ligature of the wounded vessel; - recovery, 231. - - Axillary aneurism from a bruise; ligature of the subclavian; rupture - of the sac; death, 236. - - Shell injury; amputation of right leg and arm; secondary hemorrhage; - ligature of the subclavian near the seat of the bleeding, 237. - - Wounds of the vertebral artery, recorded by Breschet, Chiari, - Ramaglia, and Maisonneuve, 242. - - Wound of the external carotid during an operation; utter insufficiency - of one ligature, 244, 245. - - Gunshot wound of head, face, and neck; injury of external carotid and - its branches; partial slough of internal carotid; ligature of latter - vessel; compression; recovery, 247. - - Wound of internal carotid through the mouth; successful ligature of - the vessel, 249. - - Ligature of the common iliac artery, 252. - - Wound of the gluteal artery; ligature of that artery and of the - internal iliac; death, 260. - - Wound of the popliteal artery by a mortising chisel; secondary - hemorrhage; ligature of the femoral unsuccessful; cure by ligature - of the popliteal, 265. - - Balls lodging in the brain, 284. - - Concussion in a child, 289. - - Coup-de-soleil, 293. - - Concussion of the brain, passing into excitement, etc., 294. - - Gouty inflammation, transferred to the brain, 296. - - Illustrative of the treatment of concussion, 297. - - Concussion, complicated by the symptoms of compression, 298. - followed by mania, 300. - - Illustrative of the after-effects of concussion, 301. - - Fatal paralysis, caused by compression of the brain, 307. - - Illustrative of the different forms of paralysis following compression - or irritation of the brain, 309. - - Fracture of the skull without depression, 311. - - Fracture of the skull, with injury to the middle meningeal artery, - 315. - - Fracture of the base of the cranium, 317. - - Fracture of the inner table of the skull, without injury to the outer - plate of bone, 322. - - Fracture of the inner table of the skull, without injury to the outer; - subsequent hemiplegia of the right side; operation with the trephine - two years afterward, 323. - - Illustrative of a peculiar fracture of the inner table of the skull, - with a cutting instrument, 325. - - Gunshot wounds of the skull and brain, the ball lodging, - 331, 343, 348. - - Injury to the head from a fall; large abstraction of blood, 334. - - Comminuted fracture of the skull, by a piece of shell, 336. - - Injury to the head, the symptoms of concussion and compression being - combined, 338. - - Gunshot fracture of the left parietal, with suppuration on the surface - of, and in the substance of the brain, 343. - - Gunshot wound of the skull, the breech-pin of the gun lodging in the - brain, 348. - - Separation of the sagittal suture by a fall, consequent to a gunshot - wound of the body, 349. - - Gunshot injury to the frontal sinuses, 350. - - Wounds of the orbit, 351. - - Fungus cerebri, 353. - - Major D.; gunshot wound of the forehead; incomplete recovery, 357. - - Loss of a large portion of the skull; reported by Dr. Drummond, 359. - - Cannon-shot wound of the head and face, 361. - - Wound of scalp and parietal bone, 362. - - Non-penetrating wounds of the chest, 365. - - Acute pneumonia and pleurisy, 383. - - Dr. Wendelstadt; empyema, 398. - - Mr. Winter; gunshot wound of the chest, followed by empyema, 399. - - Lance and musket-shot wounds of the chest, causing empyema, 399. - - Mr. Cornish; pneumothorax and phthisis, 403. - - Pistol shot wound of the chest, with pneumothorax and empyema, 404. - - Lord Beaumont, 407. - - Sword wound of the chest, with emphysema, 412. - - Wounds of both sides of the chest, 417. - - Penetrating wounds of the chest, the lung being injured, 418. - - Sword wounds of the chest, 420. - - Penetrating wounds of the chest, with internal hemorrhage, 423. - - Fracture of rib, in gunshot wound of chest, 428, 447. - - General Sir Lowry Cole; gunshot wound of the lung, 430. - - Illustrative of gunshot wounds of the lungs, 431. - - General Sir A. Barnard, 431. - - Major-General Broke, 432. - - The Duke of Richmond, 433. - - Mrs. M., 435. - - Sir C. B.; effusion, 436. - - Gunshot wounds of the lungs, with fracture of ribs, effusion, etc., - 436. - - Lieut.-Col. Dumaresq, 440. - - A two-pound shot passing through the right side of the chest, 441. - - Post-mortem appearances in gunshot wounds of the chest, 442. - - Mr. Drummond, 443. - - Gunshot wound of the lung; extensive enlargement of the wound; removal - of splinters and of a piece of cloth, 446. - - Gunshot wound of the lung, remaining fistulous; death from pneumonia - seven months afterward, 447. - - Gunshot wounds of the chest, the ball or other foreign body being - loose in the cavity of the pleura, 448. - - Major-General Sir R. Crawford, 449. - - Gunshot wounds of the chest, the ball or other foreign body being - inclosed in a cyst, 451. - - Wounds of the diaphragm, 458. - - Captain Prevost, 458. - - The Duc de Berri, 469. - - Lance wound of the heart and diaphragm, 470. - - Latour d’Auvergne, premier grenadier de France, 472. - - General Sir G. Walker; gunshot wound of the chest; secondary - hemorrhage from the intercostal artery, 474. - - Gunshot wound of the chest, with rapidly fatal hemorrhage from a - wounded intercostal artery, 475. - - Gunshot wounds of the neck, 476. - - General Sir E. Packenham; twice shot through the neck, on different - occasions, 476. - - Lieut.-General Sir A. Leith; amaurosis from a sword wound in the - forehead, 478. - - General Sir Colin Halkett; gunshot wounds of the neck, thigh, and - face, 479. - - Gunshot fracture of the lower jaw, 480. - - Colonel Carleton; gunshot fracture of the lower jaw, 481. - - Captain Fritz; bursting of his gun; lodgment of the iron breech in the - forehead; its descent through the nares into the mouth, 482. - - Ventral rupture, the result of severe bruises or other injuries to the - abdominal parietes, 488. - - Severe and extensive wound of abdominal parietes from a musket-shot; - exposure of the peritoneum, healing by granulations, 489. - - General Sir John Elley; sabre wound of abdomen, involving the stomach, - and followed by a small hernia, 490. - - Rupture of intestine from external injury, 491. - - Rupture of kidney and injury to the spine from a cannon-shot, 492. - - Fatal inflammation of omentum, intestines, and peritoneum, with - effusion, from a severe bruise inflicted by a ricochet cannon-shot, - 492. - - Penetrating wound of abdomen by a ramrod, 497. - - Penetrating wounds of abdomen, with protrusion of omentum, 500. - with protrusion of intestine, 502. - - Penetrating wound of abdomen, with formation of abscess, 505. - - Sabre wounds of the abdomen, with extensive hemorrhage, 510. - - Sabre wound of abdomen, with suppuration in the cavity, reported by - Ravaton, 512. - - Strangulated inguinal hernia; operation; sloughing of the intestine, - etc., 512. - - Gunshot wounds of abdomen, with protrusion or injury of intestine, - 516. - - A Russian officer, with a gunshot wound of abdomen, a tape-worm cut in - two by the ball, causing intense suffering until it was extracted, - 524. - - Lieut.-General Sir S. Barns; gunshot wound of the liver, 529. - - Gunshot wounds of the liver and gall-bladder, 530. - - In which portions of the liver have been removed, 533. - - In which a pig’s tail was thrust up the rectum, 535. - - In which the spleen was removed, 537. - - Wounds of the kidney, 538. - - Medullary sarcoma of the right testicle, involving the lumbar glands, - ending fatally, caused by a gunshot wound of the testis, 540. - - Gunshot wound of the penis, 540. - - Pistol-shot wound in the last dorsal or upper lumbar vertebra, causing - complete paraplegia, 541. - - Gunshot wounds of the pelvis, 542. - - The late Colonel Wade; gunshot wound, the ball passing through the - ilium; lodgment of the ball for thirty-five years, 542. - - The late General Sir Hercules Packenham, G.C.B.; musket-shot wound of - the pelvis, lodgment of the ball, 542. - - Colonel Sir J. M. Wilson; three musket-shot wounds of the left hip, - one passing upward through the ilium, and lodging against or in the - spine, causing paralysis of the left lower extremity, etc.; lodgment - of the ball, 543. - - Gunshot wound of the external and common iliac arteries, 544. of the - pelvis, the ball lodging, extracted on the forty-fifth day after the - wound; reported by La Motte, 545. - - Captain Campbell; pistol-shot wound of abdomen; injury to spine, 545. - - Gunshot wounds of the bladder, 549. - - Captain Sleigh; gunshot wound of the pelvis, the ball entering the - left groin, over Poupart’s ligament, and traversing the bladder - obliquely; retention of urine; urethra obstructed by pieces of bone, - 551. - - Calculus formed around the ball in the bladder, 552. - - Pistol shot wound of the bladder; retention of urine; tumor in the - perineum containing bloody urine, punctured; the ball, portions of - shirt, etc., extracted from the bladder; reported by Baron Percy, - 554. - - Captain Gordon, R. N.; rifle-shot wound on one side of the sacrum, - the ball wounding the rectum, and passing out on the other side of - the sacrum; paralysis of the bladder for a time; permanent partial - paralysis of the lower limbs, 555. - - Gunshot wounds of the rectum, 555. - - -CASES IN THE ADDENDA. - - Amputation of finger; death caused by exhibition of chloroform, 561. - - Successful amputation of the arm at the shoulder-joint, and of the - thigh in the lowest third, without chloroform, 561. - - Amputations while under the influence of chloroform, reported by - Deputy Inspector-General Alexander, 563. - - Sir T. Trowbridge; amputation of both feet under chloroform, 563. - - Amputations at the hip-joint under chloroform, 564. - - Excision of the head, neck, and great trochanter of the femur, - reported by Mr. O’Leary, 564. - reported by Staff-Surgeon Crerar, 565. - reported by Dr. Hyde, 570. - - Excision of the head of the humerus, reported by Dr. M’Andrew, 571. - - Lieut. Evans; fatal case of wound of the larynx; - reported by Dr. Gordon, 571. - - Wounds of the profunda femoris, and of the popliteal artery, - reported by Mr. De Lisle, 573. - - Loss of the right leg by a round shot, 574. - - The effects of strychnia in injury of the spine, etc., reported by - Dr. Burgess, 574. - - Extensive injury by a round shot to the abdomen, right arm, and thigh, - reported by Dr. Rooke, of the Civil Service, 576. - - Gunshot fracture of the left femur, reported by Mr. Lyons, Pathologist - to the Army in the East, 579. - - Excision of the elbow-joint for a gunshot wound, reported by - Dr. Milroy, 580. - with lacerated wound of the left hip, and comminuted fracture of the - ilium, reported by Mr. Atkinson, 581. - for a comminuted fracture of the bones by a piece of shell, reported - by Dr. Scott, 582. - - Grape-shot wound of the superior maxillary and malar bones, reported - by Mr. Atkinson, 582. - - Musket-shot wound of the right temple, fracturing the supra-orbital - ridge, reported by Mr. De Lisle, 583. - - Musket-shot fractures of the skull, reported by Mr. Ward, Mr. Wall, - and Mr. Longmore, 584, 585. - - -THE END - - - - -MEDICAL WORKS - -PUBLISHED BY - -J. B. LIPPINCOTT & Co., - -PHILADELPHIA. - - -Will be sent by mail, post paid, on receipt of the price by the -Publishers. - - -Leidy’s Anatomy. - -[Illustration: View of the Heart, with the anterior portions of the -ventricles removed.] - -[Illustration: Dorsal Vertebra.] - - Human Anatomy: An Elementary Text-book for Students. By Joseph - Leidy, M.D., Professor of Anatomy in the University of Pennsylvania. - Elegantly illustrated from numerous original drawings. One vol. 8vo. - $5.00 - - -Macleod’s Surgery of the Crimean War. - - Notes on the Surgery of the War in the Crimea, with Remarks on the - Treatment of Gunshot Wounds. By George H. B. Macleod, 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. - - -SUMMARY OF CONTENTS. - - Chap. I.--The History and Physical Characters of the Crimea. The - Changes of the Seasons during the occupation by the Allies. 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Wood, 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. - - 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:-- - - “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.” - - -Wood’s Lectures and Addresses. - - Introductory Lectures and Addresses on Medical Subjects. Delivered - chiefly before the medical classes of the University of Pennsylvania. - By Geo. B. Wood, 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. - - -Eberle and Mitchell on Children. - - A Treatise on the Diseases and Physical Education of Children. By John - Eberle, M.D., late Professor of the Theory and Practice of Medicine - in Transylvania University, etc. etc. Fourth edition, with notes - and large additions by Thomas D. Mitchell, 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. - - 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. - - -Richardson’s Anatomy. - -[Illustration: Veins of the head and neck.] - - Elements of Human Anatomy: General, Descriptive, and Practical. With - over 400 illustrations. By T. G. Richardson, M.D., Demonstrator of - Anatomy in the Medical Department of the University of Louisville, and - one of the attending Surgeons to the Louisville Marine Hospital. One - vol. 8vo. $3.00. - - It is an amply sufficient text-book, and the preceptor may confidently - place it in the hands of his pupils as such. The wood-cuts are - numerous and elegant, and serve admirably to illustrate the - text.--_New Jersey Medical Reporter._ - - Our author claims for his work the improvement of having general, - descriptive, and practical anatomy in the same volume; the - arrangement of the section devoted to practical anatomy so as to - secure the greatest possible economy of material; and lastly, in the - substitution of English for Latin terms, wherever it appeared to be - practicable and judicious.--_N. Y. Medical Times._ - - -Ricord on Venereal Diseases. - - A Practical Treatise on Venereal Diseases; or, Critical and - Experimental Researches on Inoculation applied to the study of these - affections: With a therapeutical summary and special formulary. By - Ph. Ricord, M.D., Surgeon of the Venereal Hospital of Paris, Clinical - Professor of Special Pathology. Translated from the French by A. - Sidney Doane, A.M., M.D. Thirteenth edition. One vol. 8vo. $1.50. - - M. Ricord’s reputation as a lecturer and practitioner in Paris is of - the highest order. He is distinguished for his sound and philosophical - views upon a disease which carries terror wherever it appears, and - whose consequences are often felt by the innocent as well as the - guilty. The first part of the book partakes of the philosophical - spirit of its author, while in the pages devoted to the treatment of - syphilis, M. Ricord has spread out the results of thousands of cases - coming under his observation. - - -Thomson’s Domestic Medicine. - - A Dictionary of Domestic Medicine and Household Surgery. By Spencer - Thomson, M.D., L.B.C.S. Edinb. First American, from the last London - edition. Revised, with additions, by Henry H. Smith, M.D., Professor - of Surgery in the Pennsylvania University. One vol. 12mo. $1.50. - - This work has received the highest encomiums from the critical - journals of the day. “Many a useful life,” remarks a British - periodical, “might have been spared, and many an insidious disease - checked in the bud, had such works as that of Dr. Thomson been earlier - in existence. To the traveler by sea or by land, to the settler and - the emigrant, far from medical aid, it must prove invaluable.” - - The work has been carefully adapted to the American climate and habits - by Dr. Henry H. Smith, of Philadelphia, whose contributions to the - volume have greatly added to its value. It is the standard book of - domestic medicine. The arrangement of the subjects in alphabetical - order renders it extremely convenient for prompt reference and - consultation. - - -Agnew’s Practical Anatomy. - - A new arrangement of the London Dissector, with numerous modifications - and additions; containing a concise description of the Muscles, - Nerves, Blood-vessels, Viscera, and Ligaments of the Human Body as - they appear on Dissection. With Illustrations. By D. Hayes Agnew, - M.D., Lecturer on Anatomy, and Surgeon to the Philadelphia Hospital, - (Blockley.) One vol. 12mo. $1.00. - -[Illustration] - - This work has been adapted to the use of the American student by - altering the arrangement and changing the nomenclature in many cases; - by adding the ligamentous system; by illustrations; by erasing what - was unnecessary, and presenting the whole as nearly as possible in - the topographical order. The work, as now published in this American - edition, has been prepared with a single eye to the faithful economy - of the student’s time. - - -Acton on the Urinary Organs. - - A Practical Treatise on Diseases of the Urinary and Generative Organs - in both Sexes. Part I.--Non-specific Disease. Part II.--Syphilis. By - William Acton, late Surgeon to the Islington Dispensary, and formerly - Externe at the Female Venereal Hospital, Paris. From the second London - edition. With additional Illustrations and Colored Plates. One vol. - 8vo. $4.00. - - This work is intended to be used by the student as a complete - Text-book on the subjects of which it treats; and, at the same time, - to supply data for the surgeon desirous of learning the most modern - treatment of the protean forms of Syphilis, as well as materially - to assist the practitioner who, in the witness-box, is liable to be - cross-examined on many of the most intricate questions of generation, - absorption, or contagion. - - -Transcriber’s Notes: - - -A number of typographical errors have been corrected silently. - -Archaic spellings have been retained. - -Cover image is in the public domain. - -“Remarks” heading added to Table of Contents. - -Index, Index of Cases, and Medical Works added to the Table of Contents. - -Amputation of arm index to page 156 is deduced, only “ 56” was printed. - -Index references page 649 which does not exist. - -*** END OF THE PROJECT GUTENBERG EBOOK COMMENTARIES ON THE SURGERY OF -THE WAR *** - -Updated editions will replace the previous one--the old editions will -be renamed. - -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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