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COMMENTARIES 
 
 OS THE 
 
 Surgery of the AVar 
 
 IN PORTUGAL, SPAIN, PRANCE, AND 
 THE NETHERLANDS, 
 
 FROM THE BATTLE OF ROLI^A, IN 1808, TO THAT OF 
 WATERLOO, IN 1815; 
 
 WITH ADDITIONS RELATING TO THOSE IN THE CRDIEA IN 
 
 1854-1855. 
 
 THE niPROTEMEXTS MADE DURING AND SINCE THAT PERIOD IN THE 
 
 GREAT ART AND SCIENCE OE 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 P a n m u r e, 
 
 SECRETARY OF STATE FOR THE MAR DEPARTMEXT, 
 ETC ETC. ETC., 
 
 %\ltH €ti\\mn\\mts 
 
 ARE, BY PERMISSION, 
 
 INSCRIBED, 
 
 BY HIS lordship's VERY OBEDIENT 
 
 AND FAITHFUL SERVANT, 
 
 G. J. GrTHRIE. 
 
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 sep- 
 arately to complete the number of which the present work 
 is composed. Divested of the historical and argumenta- 
 tive, 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 Professor- 
 ship 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 unac- 
 quainted 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 afi'orded the desired opportunity. Sir James 
 M'Grigor, then first appointed Director-General, offered to 
 
 1* (v) 
 
 n/' 
 
VI PREFACE TO THE FIFTH EDITION. 
 
 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 want- 
 ing 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, pro- 
 vided 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 inefiSciency 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 discon- 
 nected with propriety. This equally obtains in other 
 
PREFACE TO THE FIFTH EDITION. vii 
 
 parts ; aud my second and extended Course was recog- 
 nized by the Council of the Royal College of Surgeons 
 as one of General Surgery. 
 
 When the Court of Examiners of the Koyal 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 con- 
 sider 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 op- 
 portunities 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 advanta- 
 geously granted to officers in turn for the purpose of at- 
 
Vlll PREFACE TO THE FIFTH EDITION. 
 
 tending these lectures, and the Professor should certify as 
 to their time having been well employed. For thirty 
 years I endeavored to render this service to the Army, 
 the iS'avy, and the East India Company, from the knowl- 
 edge 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 thera. 
 
 4 Berkeley Street, Berkeley Square, 
 June 21, 1853. 
 
PREFACE TO THE SIXTH EDITION. 
 
 The rapid sale of tlie 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 be- 
 yond 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. 
 
 (ix) 
 
X PREFACE TO THE SIXTH EDITION. 
 
 The precepts laid down are the result of the experience 
 acquired in the war in the Peninsula, from the first battle 
 of Rolica 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 circum- 
 stantially 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; second- 
 ary 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 IL 
 
 Peculiar phlegmonous inflammation. Erysipelatous inflammation ; 
 internal treatment. Erysipelas phlegmonodes, or diffused inflam- 
 mation of the areolar tissue; treatment, by incision; first case 
 treated in England by incision ; caution with respect to the 
 scrotum. Mortification — distinction into idiopa,thic or constitu- 
 tional and that which is local; humid and di^y ; 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 axillarj' 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 
 
 (xi) 
 
Xll CONTENTS. 
 
 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 as to immediate amputation — of the arm, or leg below 
 the knee; in the upper half of the thigh. Constitutional alarm 
 of sliock 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 pu- 
 rulent deposit in the thyroid gland ; Daniel Lynch's case. In- 
 flammation of the veins; cases; two varieties of phlebitis — the 
 adhesive and irritative, or unhealthy; symptoms and treatment of 
 the unhealthy inf}.ammation. The case of Private A. Clarke ; of 
 Jane Strangemore ; cases of endemic fever after secondary ampu- 
 tation ending in sub- acute inflammation of the lungs and effusion 
 into the chest. Employment of the sulpliui'ic acid lotion in slough- 
 ing stumps. Writers on purulent deposits ; the author's claims ; 
 opinions of Mr. Henry Lee and Dr. Hughes Bennett. Hemor- 
 rhage in sloughing stumps, and its treatment; ligature of the 
 principal artery of the limb in such cases, and its failure ; hem- 
 orrhage 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. 61-73 
 
 LECTURE IV. 
 
 Aphorisms for amputations ; necessity for the operation ; compres- 
 sion of the femoral artery as it passes over the edge of the pubes ; 
 no necessity for the tourniquet in great amputations ; the hemor- 
 rhage 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 ; subse- 
 quent treatment. Amputation at the hip-joint; injuries jus- 
 tifying the operation; case of Captain Flack; wound of the 
 principal artery, with fracture of the femur, necessitates the op- 
 eration ; 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 prac- 
 ticed in the British army ; directions for operating ; Professor 
 Langenbeck's mode; Mr. Brownrigg's; illustrative engravings; 
 amputation by the circular incision ; secondary amputation ; 
 number of vessels to be tied in primary and secondary operations ; 
 Mr. Luke's amputation of the thigh by the flap operation ; pro- 
 
CONTENTS. XIU 
 
 trusion of bone after the operation ; exfoliation from hadly sawing 
 or splitting the bone, or unduly separating the periosteum. Bul- 
 bous enlargement of the divided nerve pp. 73-89 
 
 LECTURE V. 
 
 Removal of the head of the femur, dislocated in consequence of stru- 
 mous disease, or for fracture of the head or neck of the bone, 
 caused by an external wound ; cases most favorable for the oper- 
 ation ; 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 re- 
 moval of the head of the femur; wounds of the knee-joint from 
 musket-balls, with fracture of the bones, require immediate ampu- 
 tation ; secondary amputation does not olfer 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 popli- 
 teal 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 oper- 
 ating ; 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; ampu- 
 tation 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 depend- 
 ing 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 olf : 
 cases for amputation of the arm ; site of the operation, the head 
 of the bone being uninjured; complete shattering of the arm; 
 
 2 
 
XIV CONTENTS. 
 
 complicated with more or less severe injury of the chest or abdo- 
 men ; 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 abso- 
 lutely 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 oper- 
 ation by two flaps, external and internal ; by one, or nearly one, 
 upper flap; Lisfranc's operation; modification of it by M Bau- 
 dens ; difficulties of the secondary amputation; amputation of 
 the arm immediately below the tuberosities of the humerus ; ex- 
 cision 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 o'f the head of the humerus, with much loss of 
 the soft parts; giving way of the axillary artery during the treat- 
 ment 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 attend- 
 ing 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 mid- 
 dle 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 frac- 
 tured 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 op- 
 eration for excision of the phalangeal joints ; excision of the meta- 
 carpal bone of the thumb by Langenbeck, the periosteum being 
 separated from the bone, and left behind in the wound, pp. 120-141. 
 
 LECTURE YII. 
 
 Secondary amputations not so successful after injuries as after 
 incurable disease ; circumstances under which the operation is 
 
CONTENTS XV 
 
 performed in milifai'j 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 ofi"; consequences of not doing so. Co3i- 
 POUND Fractures: definition of: comminuted; compound frac- 
 ture 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 cf 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 trans- 
 verse fracture of a bone by a ball; flattening of a ball; its lodg- 
 ment 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 prin- 
 cipal splinters to be removed ; the necessary incisions often neg- 
 lected; if the splinters cannot be got at, amputation is requisite; 
 secondary danger from the smaller splinters; a careful examina- 
 tion to be made for them when suppuration is established, and in- 
 cisions 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 com- 
 pound 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 
 
XVI CONTENTS. 
 
 employed on infected parts ; is a highly contagious and infections 
 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 oc- 
 curred in his own person, from inoculation ; M. Delpech attributed 
 its spread in the French army to the misfortunes and suflFerings 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 ques- 
 tion as to its constitutional or local origin ; character of the fever ; 
 opinion of the French surgeons that the disease was of local ori- 
 gin ; 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 treat- 
 ment of phagedoena, and of intlammatory gangrene, after disor- 
 ganization ; 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 phagedoenic 
 ulcer, and its treatment; attributes the first employment of min- 
 eral 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 treat- 
 ment; 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 Pen- 
 insula 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; 3, mus- 
 cular; 4, elastic; 5, elastic and areolar combined; 6, areolar. 
 Nature of epithelium ; divided into three kinds — tesselated, cylin- 
 drical, and spheroidal. Structure of epithelial (1) and of fene- 
 strated coat (2) ; structure of muscular (3) and elastic coat (4) ; 
 structure of elastic and areolar coats (5 and t). Chemical com- 
 position, 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 cir- 
 culation 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. 170-187 
 
CONTENTS. XVll 
 
 LECTURE X. 
 
 Proper treatment of wounded arteries due to tlie 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 dis- 
 puted ; 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 ; applica- 
 tion of a small ligature ; consequent processes ; opinions formerly 
 entertained, erroneous; internal coagulum not absolutely neces- 
 sary ; 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 XL 
 
 Appearance of the femoral artery when torn across high up ; illus- 
 trative 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 sui'face ; 
 course to be pursued; illustrative case. Xo 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 j 
 such cases; the case of Cook demonstrative on this point. Gen- 
 eral 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 ; burst- 
 ing after ligature of the subclavian ; wounds of the radial in the 
 hand pp. 226-240 
 
 LECTURE XIIL 
 
 Primitive carotid artery not to be tied for a wound of the external 
 or internal carotid; danger of doing it. Wounds of tlie vertebral 
 artery ; illustrative cases. Opinion of Velpeau. Parisian in ad- 
 vance of some London surgeons. Wound of internal carotid; 
 case by Dr. Twitchell. Operative process described ; case by Dr. 
 
 Keiih " . . . . pp. 241-250 
 
 2* 
 
XVIU CONTENTS. 
 
 LECTURE XIV. 
 
 Ligature of the common iliac artery: abdominal hernia; ligaturp of 
 the aorta; of llie internal iliac artery; of the external iliac artery 
 — two methods; in cases of aneurism of the gluteal or sciatic ar- 
 tery, 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 fem- 
 oral 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 mortis- 
 ing chisel; secondary hemorrhage; unsuccessful ligature of the 
 femoral; subsequent ligature of the popliteal, followed by cure; 
 ligature of the posterior tibial and p>eroneal arteries; of the ante- 
 rior 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 XVL 
 
 General remarks. Balls lodged in the brain. Respiration consists 
 of four movements. Excito-motor system of Dr. Marshall Hall. 
 Concussion of the braiu ; 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 mid- 
 dle 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 
 
CONTENTS. XIX 
 
 LECTURE XVIII. 
 
 Fracture of inner table without injury to the outer, of rare occur- 
 rence. Illustrative cases. Subsequent mischief relieved b}' op- 
 eration 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 pe- 
 riod. Fragments of bone injuring the brain to be removed ; pro- 
 priety 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. Injui^y 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. Con- 
 tused wounds. Auscultation of primary importance ; distinctive 
 sounds learned from it. Symptoms of inflammation. Serous ef- 
 fusion the most important evil in wounds of the chest. Respira- 
 tory murmur; pleuritic effusion. Symptoms of pneumonia. Pulse. 
 Ditiieulty of breathing ; cough ; sputum. Differences of delirium. 
 Rhoncus crepitans. Effects of iuflamraation of the pleura; thick- 
 ness of pleura in or after chronic inflammation. Changes in the 
 lung, subsequent on pneumonia, are principally three, pp. 364-381 
 
 LECTURE XXL 
 
 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. Aus- 
 cultation; 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 
 
XX CONTENTS. 
 
 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 su- 
 ture ; 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 ; secre- 
 tion 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 ; sta- 
 tistics 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 reqiiisite ; pieces of shell, of a 
 sword or lance, broken oflF, 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 ; efi'usion of 
 blood; if the lung previously adherent, the cavity of the cliest not 
 opened by the ball, its track only communicating externally; illus- 
 trative 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 efi'usion where the external wound does not commu- 
 nicate freely with the chest; necessity for its removal by opera- 
 tion ; illustrative cases. pp. 426-442 
 
 LECTURE XXIV. 
 
 Appearances after death in various instances. Cases of Mr. Drum- 
 mond, etc. Splinters of bone to be removed. M. Guerin's case, 
 extensive incision for the extraction of a splinter sticking in the 
 
CONTENTS. TSd 
 
 lung. Balls, or other foreign bodies, loose, or rolling about on 
 the diaphragm. lUush alive cases. Case of General Sir Robert 
 Crawford. Consequences of traumatic inHammaiion of the chest; 
 effusion. Presence nf 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 ; man- 
 ner in which the operation shuuld 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; anatom- 
 ical position of the heart; theory of the sounds of; endocardial, 
 exocardial sounds: symptoms when the heart is wounded; treat- 
 ment; Larrey's operation for opening the pericardium, in cases 
 of hemoi'rhage from wounds of the heart, or of hydrops pericar- 
 dii. Skielderup's operation ; case of J. Dierking, with a dia- 
 gram; 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 XXVL 
 
 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 hem- 
 orrhage 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 (he 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 nnse. Wounds of the 
 cheek; of the parotid gland and duct. Salivary fistula. Wounds 
 of the lachrymal bones and sac; lachrymal fi^lula; case of Gen- 
 eral 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. pp. 473-482 
 
XXU CONTENTS. 
 
 LECTURE XXVIL 
 
 Structure of an intestine ; eight distinct layers, Valvulae conni- 
 ventes 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; treat- 
 ment. Admission of atmospheric air a bugbear. Penetrating 
 wounds. Protrusion of omentum ; of intestine. Illustrative cases. 
 Treatment of wounded intestine. Lai"ge 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. In- 
 testine 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 abdo- 
 men 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 
 occuri-ing 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, Dief- 
 fenbach, 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. 
 
CONTENTS. XXlii 
 
 Wounds and injuries of the spleen ; removal of the organ entire or 
 in part. Treatment of inciseil, 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 sar- 
 coma 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 conse- 
 quence. Paralysis of one or of both limhs, complete or incom- 
 plete. 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. AVounds of the bladder and rectum ; oper- 
 ation 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; ampu- 
 tation 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. Dep- 
 uty 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 
 
XXIV CONTENTS. 
 
 cases of excision of the head of the humerus; attended with suc- 
 cess. 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, 
 showins the effects of strychnia in injury of the spine and spinal 
 cord. Dr. Rooke's case of severe and extensive injuj-y to the right 
 hand and forearm, and the right side of the abdomen, (the bowels 
 being exposed by the destruction of skin, muscles, and perito- 
 neum,) with comminuted fractures of the ilium and neck and tro- 
 chanter of the femur; recovery at the end of three months. Mr. 
 Lyons's fatal case of gunshot fracture of the left femur. Dr. Mil- 
 roy'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 
 
 SuKGiCAL 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 ma- 
 chines 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 
 
COMMENTARIES 
 
 ON 
 
 S XJ R a E R Y, 
 
 LECTURE L 
 
 ON GUNSHOT WOUNDS, ETC. 
 
 1. A WOUND made by a musket-ball is essentially con- 
 tused, 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 Fusi- 
 liers, 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 dan- 
 gerous. 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 hemor- 
 rhage thus spontaneously suppressed does not generally 
 return ; it is the effort of nature to save life. The applica- 
 tion of a tourniquet is rarely necessary, unless as a precau- 
 
 3 (25) 
 
26 SECO^^DARY HEMORRHAGE RARELY HAPPENS, 
 
 tionary measure, when it shoald be applied loosely, and the 
 patient, or some one else, shown how to tighten it if .neces- 
 sary. 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, fol- 
 lowed 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 Pakenham 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 bail 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 con- 
 tused 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 propor- 
 tion 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 
 
SHOCK — ENTRANCE AND EXIT OF BALLS. 27 
 
 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 sufiQciently advanced in those days to point out the situ- 
 ation, 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 impiog- 
 ing with much impetus, it may become a penetrating, with- 
 out 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 mus- 
 ket-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 wouiid a more frightful appearance, such 
 as is not usually seen in the thigh, or other equally firm 
 fleshy part. 
 
28 COURSE OP THE BALL. 
 
 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 en- 
 trance 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 re- 
 gard 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 dis- 
 tance. At the battle of Yimiera, 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 inconve- 
 nience 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 them- 
 selves. Nothing should be applied but a piece of linen or 
 
TREATMENT OF SI>IPLE GUNSHOT WOUNDS. 29 
 
 lint, wetted with cold water ; this may he retained by a strip 
 of sticking-plaster, or any other thing applicable for the pur- 
 pose 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 use- 
 less, 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, tliey were not forth- 
 coming. An advancing army cannot, and ought not to carry 
 casks full of rollers into the field ; and the apothecary-gen- 
 eral 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 emergen- 
 cies as his capital instruments, they will require from time 
 to time to be replaced. Xo 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 negli- 
 gence, and sure precursors of amputation la all serious inju- 
 ries 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 ves- 
 sels toward the formation of matter. As soon as the effect 
 intended has been obtained, the poultice should be aban- 
 doned, 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 fliesh wounds are cured in four weeks; 
 
 the greater part in six. Fresh air and cold water are essen- 
 
 3>K 
 
30 INFLAMMATION A CONSEQUENCE OF GUNSHOT WOUNDS. 
 
 tial. Purgatives may be occasionally given, and abstinence 
 is an excellent remedy. Emetics, bleeding, and something 
 approaching to starvation as to solids, are of great import- 
 ance 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 mat- 
 ter 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 fre- 
 quently 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 
 
EFFECTS OF CONSTITUTION, ETC. 31 
 
 wound ; and there is frequently a slight bleeding, if the irri- 
 table 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 dis- 
 tresses 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 symp- 
 toms, 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 glisten- 
 ing 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 co- 
 piously, not only in the track of the wound, but in the sur- 
 rounding parts ; sinuses may form in the course of the mus- 
 cles, 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 
 
32 EXAMINATION OP THE WOUND. 
 
 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 recom- 
 mended. 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 treat- 
 ment. If the limb become contracted and the cellular mem- 
 brane 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 sub- 
 stances, 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 be- 
 longing 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 uncom- 
 mon for such missiles, or a grape-shot, to lodge wholly 
 unknown to the patient, and to be discovered by the sur- 
 geon 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 neces- 
 sary 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 
 
REASONS FOR DILATING THE WOUND. 33 
 
 piece of shell was lodged, and kept up considerable irrita- 
 tion until it was removed. The man recovered. 
 
 18. In examining a wound, a finder should be gently in- 
 troduced, 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 afi'ected, and what may be called the general anatomy 
 of the whole circle of injury. A muscle, in the act of con- 
 traction, may oppose an obstacle to the passage of an in- 
 strument in the direction the ball has taken, especially if it 
 should have passed between tendons or surfaces loosely con- 
 nected 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. Tlie necessity should 
 first be seen, when the operation follows of course. 
 
 Suppose a man be brought for assistance with a wound 
 
34 REASONS FOR DILATING THE 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, Xo. The surgeon should take the pre- 
 caution of applying a tourniquet loosely on the limb, and 
 of placing the man in a situation where he can receive con- 
 stant 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 re- 
 quired. 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 in- 
 stance, 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 in- 
 ferior or opposite opening, if mischief be seriously impend- 
 ing, 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 serv- 
 iceable 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 makinor 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 ac- 
 cident 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 
 
MANNER OF MAKING INCISIONS. 35 
 
 of Saca Parte, near Alfaiates, io Portugal, I stationed my- 
 self 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 mo- 
 ment 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 direc- 
 'tions. From my hand being unsupported, no mischief en- 
 sued, 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 re- 
 moved 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 fur 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 incon- 
 venience 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 re- 
 main harmless, but frequently give rise to distressing or har- 
 assing pains in or about the part, which often oblige the 
 sufl'erer to submit to their extraction at a later period, vrhen 
 their removal is infinitely more difficult; and may be more 
 distressing than at the moment of injury. 
 
36 ATTACHMENT OP BALLS. 
 
 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 im- 
 agined ; 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 ad- 
 hering 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 term- 
 inates 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 ex- 
 tracted 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 emol- 
 lient applications.* 
 
 21. A ball will frequently strike a bone, and lodge, with- 
 out causing a fracture, although it will a fissure. It will 
 even go through the lower part of the thigh-bone, between 
 
 * Various instruments have been inreuted for the removal of 
 balls vf'hich liave been deeply lodged iu soft parts; but little assist- 
 ance has been derived from them hitherto, although many of them 
 are very ingenious. 
 
WOUNDS BY THE BAYONET. 3T 
 
 or a little above the condyles, merely splitting without sep- 
 arating it, and some balls have lodged in bones for years, 
 with little inconvenience. It should nevertheless be a gen- 
 eral rule not to allow a ball to remain in a bone, if it can be 
 removed by any reasonable operation. The rule is not en- 
 tirely 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 remain- 
 ing enveloped in bone. 
 
 22. When a bayonet is thrust into the body it is a punc- 
 tured 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 punc- 
 tured wound, extending to considerable depth, labors under 
 disadvantages in proportion to .the smallness of the instru- 
 ment, and the differences of texture through which it passes. 
 When the instrument is large, the opening made is in pro- 
 portion, 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 danger- 
 ous 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 con- 
 stitutional disturbance is, if possible, less so ; but that this 
 disturbance takes place without the occurrence of inflamma- 
 
 4 
 
38 DELUSION AS TO BAYONET WOUNDS. 
 
 tion, or the formation of matter, may be doubted ; and it 
 may be concluded that there is no peculiarity in punctured 
 wounds that may not be accounted for in a satisfactory 
 manner. Serious effects have been attributed to injuries of 
 nerves, but without sufficient reason ; nevertheless, those 
 who have seen locked-jaw follow a very simple scratch of 
 the leg from a musket-ball, more frequently than from a 
 greater injury, are not surprised at any symptoms of nervous 
 agitation that may occur after punctured wounds. As many 
 bayonet wounds through muscular parts heal with little 
 trouble, it is time enough to dilate them when assistance 
 seems to be required. Cold water should be used at first ; 
 care should be taken not to apply a roller or compress of 
 any kind over the wound ; matter, when formed, should be 
 frequently pressed out, and, if necessary, a free exit should 
 be made for it. 
 
 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; doubt- 
 less 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 
 
INFLAMMATION. 39 
 
 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 pris- 
 oners." 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 ludi- 
 crous name of the " Resurrection men," 
 
 The siege of Sebastopol has furnished many opportuni- 
 ties 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 11. 
 
 ON INFLAMMATION, MORTIFICATION, ETC. 
 
 24. In some very rare cases, an intense, deep-seated in- 
 flammation 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. 
 
40 ERYSIPELATOUS AND PHLEGMONOUS INFLAMMATIONS. 
 
 25. Erysipelatous inflammation is marked by a rose or 
 yellowish redness, tending in bad constitutions to brown or 
 6ven 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 ex- 
 tends 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 dia- 
 phoretics, 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 difl'use, 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 sur- 
 vive, 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 areolae or cells of the cellular tissue will be seen of 
 a bright leaden color, and of a gelatinous appearance, aris- 
 ing from the fluid secreted into them, being now nearly in 
 the act of being converted into pus. The septa, dividing 
 the tissue into ceils, 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. 
 
TREATMENT OF ERYSIPELAS PHLEGMOXODES. 41 
 
 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. 
 Xature 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 cel- 
 lular 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, particu- 
 larly if the deep fascia be divided on which the larger ves- 
 sels 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 followiog 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 im- 
 proper. 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 hos- 
 pital ; and, after my old Peninsular fashion, made an in- 
 cision 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 
 
 4* 
 
42 MORTIFICATION. 
 
 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 mortifi- 
 cation. 
 
 26. Mortification is the last and most fatal result of in- 
 flammation, 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 constitu- 
 tional 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 inflamma- 
 tion and a great deposition of fluid in it, followed by putre- 
 faction 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. cover- 
 ing 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 ap- 
 plied 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. 
 
GANGRENE FROM CONTUSION BY A CANNON-BALL. 43 
 
 2*7. 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 ifollowing, 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 insen- 
 sible. The bone or bones may or may not be broken, but in 
 either case the sufferer, if the injury be in the leg, is incapa- 
 ble 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 extravasa- 
 tion between the muscles and the bones than from inflamma- 
 tion, 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 fre- 
 quent 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 stupe- 
 fied at first by the blow, and the part or parts about the 
 injury feel benumbed. I made these cases an object of par- 
 ticular 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 be- 
 lieved 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 grad- 
 ually 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 gan- 
 grene ; the mortification had extended nearly as high as the 
 knee ; there was no appearance of a line of separation ; and 
 
44 LOCAL MORTIFICATION FROM 
 
 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 
 Lad 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 fibu- 
 lar 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 ascer- 
 tained, 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 mortifica- 
 tion. 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 amputa- 
 tion unavoidable in such a case. Under more favorable cir- 
 cumstances, the surgeon should be guided by the principle 
 laid down of constitutional and local mortification ; and, 
 although the line cannot perhaps be distinctly drawn be- 
 tween 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 circum- 
 stances 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 con- 
 stitution and apparent strength. 
 
INJURY or THE MAIN ARTERY. 45 
 
 28. Whenever the main artery of a limb is injured by a 
 miisket-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 com- 
 plaining 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 mot- 
 tled 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 pres- 
 ent mischief The temperature of the limb above is some- 
 what 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 
 constitutiontd causes. In a day or two more, the gangrene 
 will frequently extend, when the limb swells, becomes pain- 
 ful, and more streaked or mottled in color ; the swelling 
 passes the knee, the thigh becomes oedematous, 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, pro- 
 vided 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 
 
46 INJURIES OF NERVES. 
 
 clone. Where in suoli a case should the amputation be per- 
 formed ? 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 impli- 
 cated ; 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 fem- 
 oral 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 mast 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 morti- 
 fication of the fingers or hand. If it should do so, the prin- 
 ciple 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 sensa- 
 tion 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 oppo- 
 site or sound extremity. In other words, it will be scalded 
 by hot water and frost-bitten by iced or even cold water, 
 
ENLARGEMENT OF EXTREMITY OF NERVE. 4t 
 
 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 ]eg 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 magis- 
 trates, 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 sho'uld lodge in and con- 
 tinue 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, requir- 
 ing 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, re- 
 ferred 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 
 
48 WOUNDS AND INJURIES OP NERVES. 
 
 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 re- 
 bounded 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 
 nuQierous 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 Water- 
 loo the spasms became more frequent and troublesome, at- 
 tacking 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 throygh 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 pa- 
 ralysis 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 Ms 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 
 
ILLUSTRATIVE CASES. 49 
 
 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 af- 
 fection. 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 atten- 
 tion to any particular subject. The Admiral died unre- 
 lieved, 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 con- 
 traction 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 in- 
 jury. 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 im- 
 parted by the nerves, until after the loss of life has taken 
 
 5 
 
60 MEANS OF RELIEF. 
 
 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 in- 
 capability, 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 ordi- 
 nary circumstances, but no extra evolution of heat can take 
 place by vfhich cold is resisted, nor any absorption of it, 
 which perhaps renders the application of a high tempera- 
 ture, 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 com- 
 municated by the nerves in a state of integrity. In the 
 case of Sir P. Broke, this sometliing appeared to be de- 
 rived 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 at- 
 tempts 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, independ- 
 ently 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, fol- 
 lowed by narcotics. The tinctures of iodine and lytta, the 
 oleum terebinthinse, the oleum tiglii or cajeputi, the liquor 
 ammonige or veratria, may be used in the form of an em- 
 brocation, 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 ap- 
 plied on linen. Great advantage has been derived in many 
 neuralgic pains from the application of an ointment of aconi- 
 tine, carefully prepared, in the proportion of one grain to a 
 
"WHEN SHOULD AMPUTATION BE PEEFORMED ? 51 
 
 drachm of lard, at which strength it will sometimes irritate 
 almost to yesication, 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, ad- 
 ministered internally in small doses frequently repeated, but 
 DOt suffered to accumulate without purgation; as the accu- 
 mulated 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 scien- 
 tific 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 que^stion distinctly, it should 
 be considered with reference to distinct places of injury: — 
 
 1st. When injuries require amputation of the arm below 
 
.52 WHEN SHOULD AMPUTATION BE PERFORMED ? 
 
 the sboulder-joiat, or of the leg below the knee, these opera- 
 tions 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 saflferer with 
 regard to his recovery; although every one, under such cir- 
 cumstances, 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 
 v^hich 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, neces- 
 sary. It is this or nearly this state which alone implies a 
 doubt as to the propriety of immediate amputation, and de- 
 mands further investigation. It is the state to which atten- 
 tion 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 am- 
 putations 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 every- 
 thing 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 
 
CONSTITUTIONAL SHOCK IN SEVERE WOUNDS. 53 
 
 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 pos- 
 sible 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. ISTevertheless few have seen a man lose even a 
 piece of his skin and of his breeches by a cannon-shot, with- 
 out 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 
 
 5* 
 
54 REASONS FOR IMMEDIATE AMPUTATION. 
 
 use of stimulants, till the system had in some degree recov- 
 ered its equilibrium. Such wds the case at five p.m., and 
 the flap operation was done vi'hile the man was under the 
 full influence of chloroform, (three drachms being required 
 for that purpose.) When placed in bed, he became con- 
 scious, but never rallied, and died in half an hour. 
 
 "Yery 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 stimu- 
 lants 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, Burgeon to the Forces. 
 
 Deputy Inspector-General Taylor informs me that "a 
 youug muscular man, of the siege-train, had his left thigh 
 nearly carried off at its middle by a cannon-shot at Sebas- 
 topol. 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 in- 
 jured. The prostration was great ; pulse feeble ; the man's 
 spirits were good, and he desired amputation under chloro- 
 form. 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 sys- 
 tem 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 ampu- 
 tation 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 speech- 
 less, others are said to suffer extreme pain, and earnestly 
 entreat assistance, under which circumstances amputation 
 should be performed forthwith. In the former, the admin- 
 
DR. SNOW ON THE INFLUENCE OF CHLOROFORM. OO 
 
 istration of stimulants may render the operation less imme- 
 diately dano^erous. In the latter, they will be beneficial, and 
 may save life. 
 
 51. Chloroform, or other similar medicaments, may pro- 
 duce 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 super- 
 intended 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 follow- 
 ing 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 chloro- 
 form. This agent acts as a stimulant in the first instance, 
 increasing the strength of the pulse, and enabling the pa- 
 tient, 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 acci- 
 dents 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 con- 
 tinues to beat for a minute or two after respiration has 
 ceased. During this interval, while the heart is still beat- 
 ing, the animal can be easily restored by artificial respira- 
 
56 DR. SNOW ON THE INFLUENCE OP CHLOROFORM. 
 
 tion. This mode of death from chloroform might undoubt- 
 edly 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 contain- 
 ing eight or ten per cent, of the vapor of chloroform. It 
 is therefore evident that the cause of death is the inhala- 
 tion 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 inha- 
 lation 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 suffi- 
 ciently insensible for a surgical operation, is eighteen min- 
 ims, while twenty-four minims are as much as can be present 
 in the system at one time with safety. The absorption of 
 
DR. SNOW ON THE INFLUENCE OF CHLOROFORM. 57 
 
 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 chloro- 
 form ; 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 uncon- 
 scious 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 recti- 
 fied 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 chlo- 
 roform . 
 
 "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 regu- 
 larly. 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 ster- 
 torous. The pulse is not a very important guide in the exhi- 
 bition 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 
 
58 CASES FOR THE EMPLOYMENT OP CHLOROFORM. 
 
 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 spon- 
 taneously. The prospect of success from artificial respira- 
 tion 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 preserva- 
 tion 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 respi- 
 ration and the pulse often cease almost simultaneously, and 
 in some instances have done so irrecoverably. 
 
 I formerly said that chloroform might be used with ad- 
 vantage 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 amputa- 
 tion 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 obser- 
 vations which have been made in the Crimea have not been 
 sufficiently numerous or so decisive as to settle the point in 
 
KEASONS FOR IMMEDIATE AMPUTATION. 59 
 
 favor of the chloroform, although they confirm all the others 
 to which allusion has been made. In these cases a tourni- 
 quet cannot be applied, and the sudden loss of blood saves 
 the life of the sufferer for the time, bv suppressing the bleed- 
 ing; 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 ampu- 
 tation, unless chloroform should relieve it. This has oc- 
 curred to me so often as to induce me formerly to recom- 
 mend delay for four, six, or even eight hours, if the unfortu- 
 nate 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 per- 
 formed. 
 
 54. The advantageous results of primary amputations, 
 or those done within the first twenty-four, or at most forty- 
 eight hours, over secondary aniputations, 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. 
 
60 INFLAMMATION OP THE VEINS. 
 
 56. In the secondary period after great injuries, the areo- 
 lar and muscular textures near the part injured are often 
 unhealthy, the bones are in many instances inflamed inter- 
 nally, and their periosteal membranes deposit on the sur- 
 rounding 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. 
 
 b'l. Sloughing of the stump, accompanied by inflamma- 
 tion of the vein or veins leading to the cava, frequently 
 takes place. This state of stump is often followed by puru- 
 lent deposits in and upon the different viscera, and princi- 
 pally 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 impli- 
 cate 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 communi- 
 cated 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 partici- 
 pating in (not originating) the disease, which had existed 
 some days, and thereby more cluickly 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-let- 
 ting, but generally in vain; and the patient dies in a few 
 hours, as in the last stage of inflammation of the lungs, in 
 which effusion or suppuration has taken place." "My atten- 
 
PURULENT DEPOSITS. 61 
 
 tion was drawn to it after losing several cases in this way, 
 as a circumstance of more than common accident, from its 
 having happened to a young officer to whom I was paying 
 considerable attention, (at Salamanca.) Since that I had 
 one well-marked case at Santander, of a sudden and fatal 
 affection of the lungs after amputation of the thigh, which 
 was under the immediate care of Dr. Irwin," and of myself 
 as the principal medical officer. The late Mr. Rose, of the 
 Guards, communicated a case, after amputation of the arm, 
 to Sir James M'Grigor, who forwarded it to me ; and my 
 old friend, the late Mr. Boutflower, who served frequently 
 under me during the latter part of that war, and aided me 
 in all my labors and views, forwarded to me, at the same 
 time, two cases from Fuenterabia, which terminated fatally 
 after amputation of the arm, from the deposition of a con- 
 siderable 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 exist- 
 ence of such a morbid affection." IS'o 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 Pan, St. Sever, Tarbes, or Orthez, until after 
 the battle of Toulouse, wliere 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 thy- 
 roid 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 sub- 
 stance of the thyroid gland was destroyed, a deposit of good 
 pus occupying its place, which descended by the sides of the 
 trachea and oesophagus 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. 
 
 6 
 
62 PURULENT DEPOSITS. 
 
 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 irrita- 
 ble; 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 liga- 
 tures came out; but, on cutting through the line of adhe- 
 sion, 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 absorp- 
 tion 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 mat- 
 ter appeared to have been deposited without any. The 
 inner side of the soleus muscle seemed simply to be dis- 
 colored. 
 
 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, pub- 
 lished June 18, 1827. 
 
 59. Forty years have passed away since I stated my opin- 
 ion, that inflammation of the veins is of two kinds — the ad- 
 hesive or healthy, from which the sufferers usually recover, 
 as in the cases of women laboring under the disease called 
 
UNHEALTHY INFLAMMATION OF VEINS. 63 
 
 phlegmasia dolens, and the irritating or unhealthy, occur- 
 ring 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 demon- 
 strated in 1825, in the case of Jane Strangemore, p. 41. 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, accom- 
 panied 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 irrita- 
 ble, the emaciation is considerable, and the patient gradually 
 sinks ; or the febrile symptoms may subside, with the excep- 
 tion 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, 
 
64: CASES OF UNHEALTHY INFLAMMATION OF VEINS. 
 
 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 Pv,egiraent, 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 Hos- 
 pital, 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, suf- 
 fered severely from vomiting, general fever, greater prostra- 
 tion 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 forma- 
 tion 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 w^as 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 in- 
 flamed, and contained coagulated blood, lymph, and puru- 
 lent 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 w^as discouraged 
 from the first dressing. 
 
 The following case is so highly instructive on all points, 
 that it is transcribed from the London Medical and Physi- 
 cal 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 
 sufiered a good deal from pain after the operation. An 
 opiate was administered and repeated, and she passed a 
 good night. 
 
CASES OF UNHEALTHY INFLAMMATION OF VEINS. 65 
 
 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. — Xot so well ; pulse 120; skin hot ; feels ill ; com- 
 plains 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 oedematous limb. Mr. Guthrie pronounced 
 the disease this morning to be inflammation of the veins, 
 extending from the opposite side; but after a careful exam- 
 ination, 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 bilioas 
 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 en- 
 larged. 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 
 
 6* 
 
66 CASES OP UNHEALTHY INFLAMMATION OP VEINS. 
 
 emaciated state, seem to enjoy it. The bowels occasion- 
 ally 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, 
 w^here 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 in- 
 flammation appeared to have been of an irritative or erysi- 
 pelatous kind, had gone on to suppuration, and the vein was 
 filled with purulent matter, lymph, and blood, partly coag- 
 ulated and partly broken down. These appearances ex- 
 tended up the cava as high as the diaphragm, and traces of 
 inflammation could be distinctly observed almost in the au- 
 ricle. 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, appar- 
 ently 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 su- 
 perficial 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 con- 
 ceive. 
 
 These two cases mark the course, the symptoms, and the 
 termination of inflammation of the veins after amputation, 
 in as clear (if nijt a more clear) and distinct manner as 
 any which have since been published, and which they pre- 
 ceded ; nevertheless, most authors of more modern date 
 overlook the first, and some appear to avoid as much as 
 possible noticing the second. 
 
ENDEMIC FEVER AFTER SECONDARY AMPUTATION. 6T 
 
 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 suf- 
 fered principally from inflammatory fever after amputation ; 
 those at Antwerp, from the epidemic fever prevailing at the 
 time, beginning as an intermittent and ending often in ty- 
 phus ; facts of great' importance to recollect, as showing the 
 influence of malaria. The following are instances of en- 
 demic fever after secondary amputation, ending in sub-acute 
 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 1 8th 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 ; respi- 
 ration hurried; thirst; skin hot and yellowish; pulse 90. 
 14th: Intermittent returned ; head aifected 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 pleurae costales in 
 several places, and were hepatized ; a quantity of serum 
 and lymph was contained in the left pleura, so as to com- 
 press 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, suf- 
 fered 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 ac- 
 count of himself. He had had the ^gue, 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, 
 
68 CASES OF PURULENT DEPOSIT. 
 
 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, notwith- 
 standing 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 dis- 
 tended 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 appear- 
 ance. 
 
 0. Sweeney, 90th Regiment, aged nineteen, was wounded 
 m the hand on the 18th of June, 1815, and taken to Brus- 
 sels. On the 5th of July he left for England, and arrived 
 at Colchester on the 14th. The wound shortly after as- 
 sumed an unhealthy appearance : Tieraorrage 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 re- 
 duced 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 
 
CASES OF PURULENT DEPOSIT. 69 
 
 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 dis- 
 ease 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 Wa- 
 terloo ; 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 ten- 
 derness around the whole circumference of the sore was so 
 great that he could not sufi'er 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 favor- 
 able 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 27 th, 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 death-like pale- 
 ness ; pulse 120, intermitting every fifth pulsation; breath- 
 ing 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 
 
70 EXTERNAL USE OF ACIDS IN HOSPITAL GANGRENE. 
 
 examiniDg the stump, the sanative process was found to 
 have been entirely confined to the integuments. No ap- 
 pearance of granulation could be perceived on the muscular 
 surface. 
 
 This last case is worthy of especial observation, on ac- 
 count 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 testi- 
 mony I shall confirm in its proper place. 
 
 I have departed, in some degree, in the foregoing obser- 
 vations, from the aphorismal form I had prescribed for my- 
 self 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 dis- 
 ease, 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 IT 93, described the appearances and 
 the fatal results of inflammation of the veins, as a conse- 
 quence 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 inti- 
 mate connection with certain low inflammatory attacks, at- 
 tended 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 Ghirurgical 
 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 iu 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 
 
HEMORRHAGE FROM SLOUGHING STUMPS. 71 
 
 in cases where, from long-continned disease, there have been 
 repeated introductions of vitiated fluids into the circulation, 
 the blood loses much of its coagulating power, which pre- 
 vents 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 depend- 
 ent on the introduction of a peculiar animal poison. At- 
 tention 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 mi- 
 croscope ;* 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 any- 
 thing 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. 
 
 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 conse- 
 quence 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 pa- 
 tient dies. 
 
 Some surgeons have, in such cases, preferred cutting down 
 upon the principal artery of the limb, in preference to per- 
 forming another amputation, even when it is practicable ; 
 
 * 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. 
 
12 HEMORRHAGE FROM SLOUGHING STUMPS. 
 
 and they have sometimes succeeded in restraining the hem- 
 orrhage 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 in- 
 stance, 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, be- 
 cause 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 in- 
 flammation of the stump. In case the hemorrhage should 
 only be restrained by pressure above the origin of the pro- 
 funda, 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 pa- 
 tient 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 diffi- 
 culty anywhere below the clavicle. 
 
 If the state of the stump in any of these cases should ap- 
 pear 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 fa,ce 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 
 
APHORISMS FOR AMPUTATIONS. 73 
 
 reappears, and even becomes dangerous. This hemorrhage 
 is usually preceded by pain, heat, and throbbing in the sur- 
 face 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, fol- 
 lowed 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 infal- 
 lible could be relied upon, their application in these cases 
 would be most advantageous. The solution of the per- 
 chloride of iron is the best. 
 
 LECTURE lY. 
 
 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 murder- 
 ous. 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. 
 
 6t. 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 
 
 7 
 
14 THE TOURNIQUET AFTER AMPUTATION. 
 
 operative boldness and dexterity, much after the fashion of 
 the young lady pianisies, 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 Ghromatique 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 re- 
 course should not be had to it in the smaller or less danger- 
 ous 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 com- 
 mon 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 cir- 
 cumstances. The ancient illusion with regard to the neces- 
 sity for tourniquets in amputation must be given up, except 
 by incompetent persons, or by those who are fearful and su- 
 perstitious, 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, al- 
 though 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-hand- 
 kerchief, or a roller. The great point is to know where and 
 how to apply it. When gentlemen called surgeons by war- 
 rant 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 
 
NICKING THE PERIOSTEUM. 'J5 
 
 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 fu- 
 ture. 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 \eg 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 fol- 
 low, 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 wiiatever way, and 
 however clumsily and tediously, the muscles might be di- 
 vided, it did not prevent the successful result of the opera- 
 tion, 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 up- 
 ward 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 appar- 
 ently 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 
 
76 SECURING THE BLOOD-VESSELS. 
 
 the limb may be duly supported, aud drawn inward or out- 
 ward, 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 care- 
 fully 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 min- 
 utes, but the securing the blood-vessels should be done with- 
 out 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 pa- 
 tient, 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 with- 
 out 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 an- 
 other 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 ac- 
 cidental 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 
 
CASE OF CAPTAIN FLACK. tT 
 
 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. 
 
 Yt. 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 pres- 
 ent 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, 
 
 7* 
 
78 CASES REQUIRING AMPUTATION AT THE HIP- JOINT. 
 
 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 frac- 
 ture of the femur, requires amputation, for although many 
 would survive either injury alone, none would, it may be ap- 
 prehended, 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 lig- 
 ature 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 op- 
 eration 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 instruc- 
 
MODE OF OPERATING. 79 
 
 tions and recommendations to be found in books for the per- 
 formance 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 recommend- 
 ed that an assistant should rotate the knee outward or in- 
 ward, to show the head of the femur ; to which recommend- 
 ation 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 be- 
 hind, 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, iu 
 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 opera- 
 tions, which were secondary ones, had a choice of integu- 
 ment, 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, de- 
 pendent 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 pos- 
 terior, the artery being compressed against the pubis. 
 
 The patient is to be laid on a low table, or other conve- 
 nient 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 in- 
 cision 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 ob- 
 lique 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 in- 
 cision being rather less than one-third the length of the first. 
 The integuments, including the fascia, being retracted, the 
 
80 PROF. LANGENBZCK AND MR. BROWNRIGG'S 
 
 three gluteal muscles are to be cut through to the bone. 
 The knife being then placed close to the retracted integu- 
 ments, 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 ligainentum 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 integ- 
 uments 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 sup- 
 port 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 im- 
 mediate 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 integu- 
 ments 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 instru- 
 ments 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, 
 
MODE OF OPERATING. 81 
 
 cutting from within outward, but the posterior one by cut- 
 ting through the integuraeuts 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 thick- 
 ness. 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 liga- 
 mentous structure about the joint. The after-treatment will 
 be the same as in other formidable cases. The shock, how- 
 ever, 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, Gr. Guthrie, at the Westmin- 
 ster 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 pre- 
 viously drawn away. The knife is to cut slowly downward, 
 to make a flap, under which, and behind the knife, an assist- 
 ant 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. 
 
82 
 
 MODE OF OPERATING. 
 
 Fig. 1. 
 
 Amputaiion of the Hip-joint as performed by Mr, Broav>tiigg. 
 (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 Me. 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 liga- 
 mentum 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 amputa- 
 tions 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. 
 
MR. GUTHRlE^S OPERATION. 
 
 83 
 
 Fig. 2. 
 
 Mr. Gctheie's OPEEATioy. 
 
 Left side — a, anterior superior spine of ilium: 6, commencement of anterior incision, 
 continued by the black line; c, the posterior incision joining the anterior one. 
 
 (Second figxire.) 
 & c. line of incision marked bv 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, 
 
84 AMPUTATION BY THE CIRCULAR INCISION. 
 
 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 cer- 
 tainly 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 in- 
 cision, 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 com- 
 pleted, 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 sur- 
 geon, so as to mark the bone, in which furrow he will con- 
 tinue 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 
 
SECONDARY AMPUTATION OF THE THIGH. 85 
 
 the thigh should be held steadily above, and in such a man- 
 ner 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 ves- 
 sels 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 liga- 
 tures 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 mus- 
 cles and integuments brought forward and placed in apposi- 
 tion, 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 liga- 
 tures 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 
 
86 MR. LUKE'S FLAP AMPUTATION. 
 
 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 neces- 
 sary; the tourniquet and all tight bandages should be re- 
 moved, 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 circum- 
 stances 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 recom- 
 mended 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 narrov/, pointed, and longer by two or three 
 inches than the diameter of the thigh at the place of ampu- 
 
MR. LUKE S FLAP AMPUTATION. 87 
 
 tation. The point of the knife should be entered mid- 
 distance between the anterior and posterior surfaces of the 
 thigh, which maj be effected with accuracy, if the eve 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 traversiug 
 the thigh, the kuife should pass behind the bone, and will 
 be more or less remote from it in different individuals, ac- 
 cording 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 in- 
 cision through the integuments and muscles on the side of 
 the thigh opposite to the surgeon, at a little distance ante- 
 rior 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 recpiire a second, or perhaps a third, appli- 
 cation of the knife. In the two flaps thus made, the division 
 of almost all the soft structures is included, a few only imme- 
 diately surrounding the bune 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 suffi- 
 ciently 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 tiie 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 commence- 
 ment; 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 
 
88 MR. LUKE'S FLAP AMPUTATION. 
 
 passed through the integaments 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 com- 
 presses are to cover the flaps only, and not to extend over 
 the extremity of the bone, where their pressure would prob- 
 ably 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 treat- 
 ment of the stump, care must be taken to prevent an accu- 
 mulation 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 un- 
 easiness of the patient. The line of division of the integu- 
 ments 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 a^buts upon the anterior flap, by which alone it 
 is eventually covered, and the cicatrix is thus removed from 
 its pressure. 
 
PROTRUSION AND EXFOLIATION OF BONE. 89 
 
 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 opera- 
 tion, an incision being made on, and down to, the bone, and 
 the saw applied where it is soand. 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 un- 
 duly 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 occupy- 
 ing 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 dis- 
 ease, 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. 
 
 8* 
 
90 REMOVAL OP THE HEAD OF THE FEMUB. 
 
 LECTURE Y. 
 
 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 meas- 
 ure from its attachments bj disease of a scrofulous nature, 
 is an operation which has been several times successfully 
 peformed, 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 invari- 
 ably 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 fol- 
 lowed 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 ex- 
 ception 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 suffer- 
 ing attendant on the repeated formation of matter burrow- 
 ing 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 sur- 
 geon should make himself well acquainted with the anatomy 
 of the parts ; and as the war in the Russian Empire may 
 
REMOVAL OF THE HEAD OE THE FEMUR. 91 
 
 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 vaginaa femoris ; this should be di- 
 vided ; 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, Xow, 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 imme- 
 diately 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 'th 
 great care, when by a gentle rotation of the knee inwaro tlie 
 head of the thigh-bone will be readily dislocated outward. 
 The ligamentum teres, or the round ligament, as it is terir-u, 
 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 ilie 
 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. 
 
92 REMOVAL OF THE HEAD OF THE FEMUR. 
 
 It is not always necessary to injure them, and they will be 
 of great use afterward, if the operation should prove suc- 
 cessful. If the neck of the bone be broken through, rota- 
 ting 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 great- 
 est 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 acetab- 
 ulum which can be quickly removed with it, but no time 
 should be unnecessarily lost in trying to remove the carti- 
 laginous 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 recom- 
 mended 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 un- 
 dissected limb. The first cut through the skin, integuments, 
 and fascia lata should be a curved one, beginning just over 
 
AMPUTATION AT THE HIP- JOINT. 93 
 
 the inner edge of the tensor vaginae 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 vaginae 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 am bleed- 
 ing 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 mid- 
 dle 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 den- 
 tists' 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 acci^ilental circumstance of the outside of the orifice 
 of the branch being in contact with the ligature, the irrita- 
 tion 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 
 
94 GUNSHOT WOUNDS OP THE KNEE-JOINT. 
 
 the vessel to no greater extent than its own width, proving 
 all the facts T 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 array in the Crimea 
 after the engagement of the 18th of June. The continu- 
 ity of the head with the shaft was not altogether destroyed, 
 the fracture being principally confined to the great tro- 
 chanter and the trochanteric ridge. It was at first thought 
 the operation might be dispensed with, but as great irrita- 
 tion 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 con- 
 sideration 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 am- 
 putation ; 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 months 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 
 
COMPOUND FRACTURES OF TUE PATELLA. 95 
 
 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, un- 
 less 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 direc- 
 tion behind, the limb will not be saved. If the ball have 
 struck the patella on its edge, and gone through it trans- 
 versely, 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 abso- 
 lutely necessary, amputation or excision had better be per- 
 formed 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 imme- 
 diately 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 pre- 
 served, will not be a useful one. If the ball, on the other 
 hand, lodge without the capsular ligament, and cannot read- 
 ily be extracted, the wound should be healed as soon as pos- 
 sible ; and, although it may cause some little inconvenience 
 to the knee-joint, the limb and life of the patient may be 
 
96 GUNSHOT WOUNDS OF THE KNEE-JOINT. 
 
 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 cut- 
 ting 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 sufScient 
 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 abstrac- 
 tion 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 ulcer- 
 ation of the cartilages and caries of the bones. By local 
 and general bleeding, the application of cold, rigid absti- 
 nence, 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 Kegiment, 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 
 
EXCISION OF THE KNEE-JOINT. 97 
 
 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 probabih'ty, 
 be more favorable in cases of injury from musket-balls, iu 
 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 ab- 
 solute rest and good air, can be obtained for the sufferer, 
 excision should be attempted, in preference to the amputa- 
 tion 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. Grurdon 
 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 re- 
 moved — 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 fol- 
 lowed with the tibia: the bones were then placed in juxta- 
 position, 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 fol- 
 lowed 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 
 
 9 
 
08 GURDON BUCK AND JONES'S OPERATIONS. 
 
 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 pa- 
 tellae 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 ten- 
 dons 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, 
 W'Cre 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. Suppura- 
 tion 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 hmb could be raised 
 bodily from the bed. There is no mobility between the 
 bones; the diflferencein 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 patellae, 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 
 
AMPUTATION OP THE LEG. 99 
 
 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 patellas. 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 apposi- 
 tion, 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 admira- 
 ble 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 con- 
 venient 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 
 
100 AMPUTATION OP THE LEG. 
 
 the motion of the leg, from the preservation of the insertion 
 of the flexor tendons. The most eh'gible place for the appli- 
 cation 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 out- 
 side, 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 undi- 
 vided, whatever pains may otherwise be taken by the assist- 
 ants 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 inter-osseous 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 be- 
 tween 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 dis- 
 tance, 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 prin- 
 cipal arteries should be secured: the anterior tibial, on the 
 fore part of the inter-osseous ligament, between the tibia 
 and fibula ; the peroneal artery behind the fibula ; and the 
 
MR- Luke's flap operation. 101 
 
 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 oif the 
 artery abo7e. 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 re- 
 tracted 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, dif- 
 fers 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 dis- . 
 tance 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 proportion- 
 ately mor^ integuments and is thinner ; yet its base and 
 length are rendered equal to the base and length of the pos- 
 terior 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 neces- 
 sary variation in the proceedings, from the circumstance of 
 there being two bones united by inter-osseous membrane. 
 It may, however, be accomplished by sweeping the knife 
 
 9* 
 
102 MR. LUKE'S FLAP OPERATION. 
 
 around the more distant bone of the two, its point being 
 afterward carried between the bones through the inter- 
 osseous 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 intro- 
 duction 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 accom- 
 plished as in the thigh amputation ; but more care is re- 
 quired to avoid pressure on the acute margin of the tibia, 
 (which, when very sharp, should be removed,) and to pre- 
 vent the pendulous state of the flaps. 
 
 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 neces- 
 sary at or immediately below the tuberosity of the tibia, the 
 operation may be done with safety. Baron Larrey recom- 
 mended the removal of the head of the fibula in such cases ; 
 I have done it v^ith 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 impli- 
 cated. 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 
 
EXCISION OF THE ANKLE-JOINT. 
 
 103 
 
 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 pos- 
 terior 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. 
 
 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 inter- 
 nal 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 nip- 
 pers, cut through the fibula from one-half to three-quarters 
 of an inch above its junction with the tibia, and, after divid- 
 ing 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 
 
104 REMOVAL OF THE OS CALCIS. 
 
 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 approxima- 
 tion, 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 present 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 in- 
 flicted by a masket-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 follow- 
 ing 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 as- 
 certained, the ligamentous fibers are to be cut through and 
 the joint between them opened, when the knife is to be car- 
 ried from behind forward, in order to divide the inter-osseous 
 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 ampu- 
 tation 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 : — 
 
AMPUTATION AT THE ANKLE-JOINT. 105 
 
 " Pressure should be made on the tibial arteries by the 
 finger of an assistant or a tourniquet applied above the an- 
 kle. 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 pro- 
 jection 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 tlie point exactly 
 opposite its commencement. The extremities of the incision 
 thus formed are then joined by another passing in front of 
 the joint. 
 
 " 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 in- 
 serted the point of his thumb between the edges of tiie 
 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, to- 
 
106 AMPUTATION AT THE ANKLE-JOINT. 
 
 gether with the thin connecting slice of bone covered by 
 cartilage. The vessels being then tied, and the edges of 
 th& 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 becom- 
 ing 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 sup- 
 port 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 muti- 
 lation, 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 suc- 
 cess im 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, suf- 
 ficient 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 ex- 
 planation : — 
 
 "A transverse incision should be carried across the sole 
 of the foot, from the tip of the external malleolus, or a little 
 posterior to it, (rather nearer the posterior than the anterior 
 margin of the bone,) to the opposite point on the inner side, 
 which will be rather below the tip of the internal malleolus, 
 but can be readily determined by placing the thumb and 
 finger at opposite sides of the heel. If the incision be car- 
 
GUNSHOT WOUNDS OF THE FOOT. lOt 
 
 ried farther forward, a considerable inconvenience is experi- 
 enced from the greater length of the flap ; and I believe a 
 great deal of the diflSculty 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 en- 
 ergy 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 scor- 
 ing 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 de- 
 fects in the performance of the operation ; the flap having 
 been cut too long, difficulty has been experienced in sepa- 
 rating 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 oper- 
 ations 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 with- 
 out 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 thick- 
 ened 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 am- 
 putation of the foot necessary. Tetanus is a frequent con- 
 sequence of these injuries, and is a disease, in its acute form, 
 certainly irremediable by any operation or medicine at pres- 
 
108 M. ROUX'S AMPUTATION OF THE FOOT. 
 
 ent known. Amputation has always failed in my hands, 
 although it was strongly recommended by Baron Larrey. 
 The operative surgery of the foot should be done as soon 
 after the injury as it can be conveniently accomplished ; for 
 a large, clean, incised wound is a safe one, compared with a 
 torn surface of much less extent, and a splintered bone with 
 extraneous substances ; as a ball lodged in the foot is always 
 very dangerous, great attention should be paid in the exam- 
 ination of even slight wounds. A cannon-shot can seldom 
 strike the foot without destroying it altogether ; it may, how- 
 ever, 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 Regi- 
 ment, 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: '' Chlo- 
 roform 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, extend- 
 ing backward along the sole and upward over the attachment 
 of the tendo Achillis to the os calcis. A third incision was 
 carried from this round and below the external malleolus to 
 meet the first at its commencement. Disarticulation of the 
 ankle-joint was made from the outside, the soft parts put 
 well on the stretch by forcibly depressing the foot, when, by 
 successive sweeps of the scalpel, care being taken to keep 
 the edge close to the bone, the os calcis was separated from 
 its connection with the soft parts. The plantar arteries were 
 divided at the very extremity of the flap. The operation 
 was completed by sawing off the two malleoli and the thin 
 scale of the articulating surface of the tibia. The anterior 
 tibial and the two plantar arteries each required a ligature. 
 Sutures were inserted, and the flap supported by strips of 
 wet lint. The operation was performed on the 4th of July. 
 The stump was dressed the second day after the operation. 
 There had been no hemorrhage ; the flap was partially ad- 
 
BALL LODGED IN THE ASTRAGALUS. 109 
 
 herent ; on the outer side the skin was red, tense, and shin- 
 ing ; 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 in- 
 cision is now entirely healed at the outer part ; the inner is 
 not so far advanced, but is doing well. The flap is becom- 
 ing 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 pos- 
 terior 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 pur- 
 pose, 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 Eng- 
 land. 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. 
 
 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 
 
 10 
 
110 
 
 REMOVAL OF THE ASTRAGALUS. 
 
 proper place ; less so when the ends of the tibia and fibula 
 are also removed for disease of these parts, in which case, 
 
 3. The ball. 
 
 1. Astragalus. 2. Os calcis. 
 
 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. 
 
 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 dis- 
 ease in children, in two instances, by Mr. Statham, of Uni- 
 versity College Hospital, and has been strongly recommended 
 by Dr. Buchanan, of Glasgow, and others. The operation, 
 according to Mr. Stathara'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 
 
REMOVAL OF THE ASTRAGALUS. 
 
 Ill 
 
 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 pro- 
 ceedings, without injuring them. The un- 
 der 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 inter- 
 osseous 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 attach- 
 ments 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 af- 
 terward as little as possible. The wood-cut 
 represents the forceps for extracting a ball 
 imbedded in the astragalus. 
 
 Many years have elapsed since I stated that muscles might 
 be cut across without, or with very little, inconvenience re- 
 sulting from their division. Mr. Stanley has lately shown 
 that tendons even may be cut across with little disability 
 
112 CANNON-SHOT WOUNDS OF THE FOOT. 
 
 following, in a boy who had sufifered 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 re- 
 markably 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 op- 
 eration dividing the extensor tendons of the toes, commenc- 
 ing on the outside of the fibula, and being carried round 
 in front, but not so far as to injure the tibialis anticus ten- 
 don, 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 sur- 
 geons 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 gener- 
 ally 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 difiBcult 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 fre- 
 quently render it necessary as a secondary one. The splin- 
 ters of bone are to be removed, the ball and extraneous 
 
AMPUTATION AT THE TARSUS. 113 
 
 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 met- 
 atarsal 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 met- 
 atarsal bone of the great toe at the tarsus necessary, al- 
 though 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 ac- 
 quired 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 integ- 
 uments 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 dis- 
 sected 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 
 
 10* 
 
114 • AMPUTATION OF THE FOOT. 
 
 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 con- 
 tact 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 un- 
 common 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 trans- 
 versely 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 assist- 
 ant, 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 
 
MR. T. WAKLEl'S OPERATION. 115 
 
 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 to- 
 ward 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 cal- 
 cis 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 be- 
 tween the under surfaces of the scaphoides and cuboides, 
 and the soft parts adhering to them, and a flap cut from be- 
 hind 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, de- 
 serving of imitation in peculiar cases. It is done as fol- 
 lows : — 
 
 "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 an- 
 other on the opposite side of the foot, from the vertical inci- 
 sion 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 be- 
 tween 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 integu- 
 ment of the heel included between the two incisions. The 
 lateral ligaments connecting the astragalus with the tibia 
 and fibula w^ere 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 w^as in view. The 
 
116 
 
 MR. T. WAKLEY'S operation. 
 
 astragalus was then detached from the soft parts in front of 
 the joint and from its articulation with the scaphoid bone, 
 
 The incisions above described are here marked out on a healthy foot. 
 
 The skeleton of the foot will at the same time show the amount of bone 
 
 removed. 
 
 and the malleoli were removed with the bone-nippers. The 
 only artery requiring ligature was the posterior tibial. Dur- 
 
MR. T. WAKLEY'S operation. 
 
 lit 
 
 ing the few minutes the operation lasted, the patient did not 
 manifest the slightest symptoms of pain or uneasiness. On 
 
 These drawings exhibit the present condition of both sides of the foot — 
 the amount of deformity is less than might have been expected. 
 
 bringing the edges of the flaps together, they were found to 
 fit with acccuracy, 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. 
 
 " On the 21st of February he was discharged the hospital, 
 exactly two months after the operation, to go into the coun- 
 try, the foot being well, with the exception of a small open- 
 
118 AMPUTATION OF A METATARSAL BONE. 
 
 ing. He came again up to town on the 15tli 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, accompa- 
 nied 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 out- 
 side or inside of the foot, is to be done by an incision round 
 the root of the toe, terminating in a line on the outside of 
 the foot, which is continued down to the joint of the tarsus. 
 The integuments are turned back above and below from the 
 metatarsal bone, which is to be dissected out, with the toe 
 attached to it, and the flaps brought together so as to leave 
 but one line of incision. In military surgery, there is always 
 a wound ; and when the removal of the bone is necessary, 
 it is in general an extensive one, with loss of substance, so 
 that a covering cannot be saved in this way, especially on 
 the upper part of the foot, when struck by a ball or piece of 
 shell. The surgeon, therefore, must be prepared to look for 
 his covering on the under part, where he will occasionally 
 not be able to procure it in sufficient quantity, and it must 
 not be forgotten that the neighboring parts will often be 
 injured. The object must then be to save the integuments 
 from such parts as are uninjured, so as to cover in the wound 
 as nearly as possible when the bone has been removed. In 
 doing this, the first incision should commence at the upper 
 part and inside of the toe, and be carried round so as to 
 separate the toe from its attachment to its fellow. If the 
 injury be entirely on the upper part, the continuation of this 
 incision must be so regulated as to form the whole of the 
 flap from below, and its commencement above must be con- 
 
M. DE BEAUFOY'S ARTIFICIAL FOOT. 
 
 119 
 
 tinued 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 sur- 
 round 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. 
 
 No. 1. 
 
 No. 2. 
 
 Amputation above Knee. 
 
 a, wooden bucket for stump; h, pin to attach foot, c, the rolling foot; 
 
 d, straps of attachment to body. 
 
 ■Amputation below Knee, No. 1. 
 
 a, wooden shape to receive knee ; ft, pin ; c, rolling foot ; c?, e, straps of 
 
 attachment. 
 
 Amputation below Knee, Ko. 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 Chel- 
 sea Hospital ; one of them reports that he has not only found 
 
120 PRIMARY AMPUTATION. 
 
 his step to be steadier, but that he could walk t,wice the dis- 
 tance 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 conse- 
 quently 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 YI. 
 
 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 pri- 
 mary 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 ex- 
 amination 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 band- 
 ages, 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 op- 
 eration. 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. 
 
CASES FOR AMPUTATION. 121 
 
 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 in- 
 convenience and suffering for many years afterward — during, 
 in fact, the remainder of the life of the sufferer ; which mis- 
 ery 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. Sec- 
 ondary 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 maybe 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 can- 
 non-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 exten- 
 sive that it cannot be saved, although the head of the hu- 
 merus 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 irre- 
 coverably shattered, and the thorax partake in a less degree 
 of the injury, there being apparent only some slight contu- 
 sion 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 integ- 
 uments. 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 dis- 
 solution 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 
 
 11 
 
122 SHOT AND SHELL INJURIES OF THE ARM. 
 
 remaining the same. The danger to be apprehended in the 
 more favorable eases is from inflammation, and this will be 
 rather diminished than increased by the operation ; the dan- 
 ger 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 expec- 
 toration of blood in moderate quantities, although a danger- 
 ous 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 reboundiog from the ground, or when nearly ex- 
 hausted 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 con- 
 siderably broken or splintered, the muscles and nerves greatly 
 contused. The injury may not, perhaps, be quite so exten- 
 sive. 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 
 
AMPUTATION AT THE SHOULDER- JOINT. 123 
 
 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 uninten- 
 tionally, 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, di- 
 vest himself of all fear of hemorrhage. When gentlemen 
 are afraid, however, and cannot help it, (for Henry lY. of 
 France, ce roy si vaillant, always felt an inconvenient intes- 
 tinal motion when a fight began,) compression maybe 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 direc- 
 tions, 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 ex- 
 perience 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 round- 
 ness of the shoulder. In such cases, the removal of the ex- 
 tremity 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, 
 
124 OPERATION BY TWO FLAPS. 
 
 they may be included in or adhere to the cicatrix, and canse, 
 during a long life, much distressing pain to the sufferer. 
 
 111. Amputation at the shoulder-joint, performed imme- 
 diately after the receipt of an injury, is now a very simple 
 operation, for which simplicity English surgery is also in- 
 debted 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 neces- 
 sary 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 op- 
 erative methods are hereby condemned in which this precau- 
 tionary measure is not the first step. 
 
 112. Operation by iivo flaps, external and internal. — 
 The outer — beginning nearly an inch below the acromion 
 process, the hair in the axilla having been previously re- 
 moved — 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 in- 
 cision 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 ten- 
 don of the sub-scapularis muscle internally, where it is at- 
 tached 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 
 
THE OPERATION BY ONE FLAP. 125 
 
 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 ap- 
 proximated 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 per- 
 formance. 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 
 
 11* 
 
126 AMPUTATION BELOW TUBEROSITIES OF HUMERUS. 
 
 infra-spin atus, 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, bj cutting downward and 
 inward, including in it a very small portion of the deltoid, 
 the pectoralis major, latissimus dorsi, teres major, the tri- 
 ceps, 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 im- 
 pacted 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 tube?^- 
 osities of the humerus ought to be done in the following 
 manner : The arm being raised from the side, and an assist- 
 ant having compressed, or being ready to compress, the sub- 
 clavian artery, the surgeon commences his incision one or 
 two fingers' breadth beneath the acromion process, and car- 
 ries 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 tuber- 
 osities. 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 
 
EXCISION OF THE HEAD OF HUMERUS. 12 Y 
 
 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 prin- 
 cipal object the sparing of the deltoid muscle are unneces- 
 sary, 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 ap- 
 plied to the head of the bone in a line below, but imme- 
 diately 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 con- 
 nections, 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 
 
128 BALL IMBEDDED IN THE HEAD OF HUMERUS. 
 
 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 uncom- 
 mon, as was first shown during the late war, after operations 
 following extensive suppurations : — 
 
 "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 
 
 a. The head of the humerus sawn off below the tuberosities. 
 
 b. The ball. 
 
 c c. Fractures of the head of the bone. 
 
 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 in- 
 creased vocal resonance, but no crepitation, could be detected 
 on the right side on auscultation ; he complained also of pain 
 
BALL IMBEDDED IN THE HEAD OF HUMERUS. 129 
 
 in tbe hypogastrium and slight diarrhoea. At bedtime he 
 had a sedative antimonial draught, after which he rested 
 well, but perspired profusely. On being particularly cpies- 
 tioned, he admitted that he had had diarrhoea several times 
 since landing at Varna, and had had bloody stools after the 
 battle of Alma, for which, however, he had never been oif 
 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 appear- 
 ance, 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 counte- 
 nance flushed and anxious. On examination of the chest, 
 the lower two-thirds of the right lung were dull on percus- 
 sion ; bronchial breathing in the lower half, with crepitation 
 above ; in the left lung loud sub-crepitus ; diarrhoea had also 
 supervened during the day, but was checked for the time by 
 an opiate enema. From this date his strength gradually 
 sank ; the diarrhoea returned again and again, in spite of 
 repeated opiate enemata and small doses of Dover's powder 
 with hyd. c. creta. 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 re- 
 moval, 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 ana- 
 tomical 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 
 
130 PROFESSOR LANGENBECK'S OPERATION. 
 
 frothy serum ; the lower two-thirds of the right lung hepa- 
 tized ; 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 caecum 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 direc- 
 tion more transverse." These appearances precisely resem- 
 ble 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 del- 
 toid muscle, proposed and practiced the operation in the 
 following manner, during the Danish war in Sleswick-Hol- 
 stein, 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 hu- 
 merus 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 
 
CASES. 131 
 
 it a useful limb, whether by the formation of a ginglymoid 
 joint, or by anchylosis. In the present state of our knowl- 
 edge 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, how- 
 ever 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 frac- 
 tured 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. 
 
 Kobert Masters, 40th Regiment, was wounded at the bat- 
 tle 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 con- 
 stant application of cold, and low diet, the high inflamma- 
 tory 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 months 
 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 
 
1 32 CASES. 
 
 days afterward as a slight but peculiar wound, it was marked 
 as a case for excision, if circumstances should render it neces- 
 sary. No bad symptoms, however, supervened; the man 
 only complained of the restraint put upon him, and the low- 
 ness 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 dis- 
 eased 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 So- 
 braon, 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 acro- 
 mion 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 
 Bundelcund; 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 ac- 
 count he was recommended to proceed to Europe. On the 
 9th June, 1848, the wounds were healed, the last piece of 
 
M. BAUDENS ON RESECTION OF HEAD OF HUMERUS. 133 
 
 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 over- 
 looked, 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 ampu- 
 tation of the limb should be the exception — a point long 
 since settled in my surgical works. 
 
 He considers that surgical writers in general have sup- 
 posed 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 down- 
 ward, 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 
 
 12 
 
134 AMPUTATION OF THE ARM. 
 
 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 con- 
 tact 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 subse- 
 quently, 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, wiiieh 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 ex- 
 tremity 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 de- 
 mands this operation, the bone being uninjured. If, in 
 addition to a destructive flesh-v/ound, the bone be broken, 
 or if it be mashed with the muscles by an oblique stroke of 
 a round shot, or tlje forearm be carried away or destroyed, 
 it is admissible. It is to be done in the followinof manner : 
 
MR. LUKE'S OPERATION BY TWO FLAPS. 135 
 
 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 resem- 
 blance 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 com- 
 pleted 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 
 
136 EXCISION OF THE ELBOW- JOINT. 
 
 a part of the condyle of the humerus, or the head of the 
 radius, or a part of the uhia, 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 me- 
 dian 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 approxi- 
 mated by sutures and sticking-plaster, duly supported by 
 
AMPUTATION OF THE FOREARM, 13*7 
 
 compress and bandage, so that union may take place if pos- 
 sible, 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 elhoiv -joint has been recom- 
 mended, 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 oppo- 
 site 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, par- 
 ticularly when done a little above the wrist; to which opera- 
 tion Baron Larrey and the surgeons of France particularly 
 objected during the late war. Having done it most success- 
 fully since 1806, however, it is recommended as preferable 
 to any other, even when the injury admits of its being done 
 near the carpus. When the nature of the injurv does not 
 
 12* 
 
138 AMPUTATION AT THE WRIST. 
 
 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 inclina- 
 tion, 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 as- 
 sistant 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 diffi- 
 culty. The stump is to be dressed in the usual manner. 
 The operation may be done by cutting through the integu- 
 ments 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 
 
GUNSHOT WOUNDS OF THE HAND. 139 
 
 been recommeoded by some surgeons as preferable to am- 
 patation 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 pre- 
 cept 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 an- 
 tiphlogistic 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 ofi", but 
 not removed at the carpus, although an opening into the 
 
140 AMPUTATION OF THE PHALANGES. 
 
 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 possi- 
 ble, 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 fin- 
 gers 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 ex- 
 cisions 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 liga- 
 ments, 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 short- 
 ened but useful finger. In all these cases the flexor and 
 extensor tendons were from the first uniujured. 
 
 M. Langenbeck has also removed the metacarpal bone of 
 
SECONDARY AMPUTATION. 141 
 
 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 articu- 
 lating 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 re- 
 quest, 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 yil. 
 
 SECONDARY AMPUTATIONS, ETC. 
 
 130. Secondary amputations, or those performed after 
 the lapse of six or more weeks from the receipt of an in- 
 jury, 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 dis- 
 eases 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 affect- 
 ed by some of the accompaniments of inflammation, or are 
 in a state of irritation. In these causes the cellular or areo- 
 lar tissue has become firmer and more compact than usual ; 
 the muscles are not perfectly healthy ; the blood-vessels are 
 
142 SECONDARY AMPUTATION. 
 
 larger and more numerous, and ready to assume actions un- 
 usual 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 sur- 
 rounded by it. After a few hours' remission, the constitu- 
 tional symptoms often return, the wound sloughs, and sec- 
 ondary 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 at- 
 tempted, will as rarely succeed. 
 
 132. In these states of constitutional derangement, in- 
 flammation 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 consider- 
 ation. 
 
 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 inves- 
 tigation than has as yet been bestowed upon it by civil or by 
 military surgeons since attention was first drawn to ii by 
 me in 1815. 
 
 134. In secondary amputations in parts which have par- 
 taken 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 per- 
 
HEMORRHAGE AFTER SECONDARY AMPUTATION. 143 
 
 pendicularly, 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 lig- 
 ature 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 ob- 
 served. 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 
 
144 PROTRUSION OP BONE. 
 
 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 sec- 
 ondary amputation, particularly after serious injuries ; the 
 inflammation consequent on which has in some degree im- 
 plicated 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 par- 
 ticularly 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 dif- 
 ficulty 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 
 
COMPOUND AND COMMINUTED FRACTURES. 145 
 
 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 se- 
 cure 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, communi- 
 cating with the broken bone— a complication which usually 
 gives rise to ulcerative inflammation and suppuration through- 
 out the whole extent of the injury, preventing thereby those 
 milder processes being effected which, under the more favor- 
 able circumstances of the skin being unbroken, lead to a 
 speedy union of the broken parts ; whence the desire man- 
 ifested by the surgeon, in ordinary cases of compound frac- 
 ture, 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 perma- 
 nently reunited. 
 
 142. An arm or a leg, as a general rule, is not to be am- 
 putated 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 surgica.1 treatment. 
 
 143. It is not so with the thigh. After the battle of 
 Toulouse, forty-three of the best of the fractures of the 
 
 13 
 
146 GUNSHOT WOUNDS OP THE FEMUR. 
 
 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 con- 
 sidered 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 suf- 
 fered amputation at first. Of the officers with fracture of 
 the femur, one (having been taken prisoner during the ac- 
 tionj died under the care of the French surgeons, by whom 
 he was skillfally 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 un amputated, 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 amputa- 
 tions which died, two were at the little trochanter, by the 
 flap operation ; and the others were for the most part unfa- 
 vorable cases. In one case only was the head or neck of 
 the bone fractured. The man lived for two months, and, 
 from the dreadful sufi'erings he endured, it was much regret- 
 ted 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 pos- 
 sible 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 mate- 
 rials for their treatment were in profusion. The sick and 
 wounded (1359 in number, including 111 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 
 
GUNSHOT WOUNDS OF THE FEMUR. 14Y 
 
 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 in- 
 stance, 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 mod- 
 erate pension, instead of there being perhaps five, or at 
 most ten, nearly unable to do anything for themselves. 
 Baron Larrey, with the elite 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 parly 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 surgi- 
 cal care, and comfort may not be wanting ; without all which 
 a favorable result cannot be expected. 
 
 144. War is an agreeable occupation, trade, or profes- 
 sional 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 im- 
 pressed 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 
 
148 SPLINTERING OP THE BONE. 
 
 examination with any prospect of success, and prove them- 
 selves 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 hap- 
 pier 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 occa- 
 sions 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 re- 
 dressed. Old habits are not to be overcome but by public 
 opinion. 
 
 145. The peculiar difficulty in treating a gunshot frac- 
 ture takes place when the bone is sphntered for some dis- 
 tance, as well as broken. In these cases, inflammation 
 occurs internally in the membranous covering of the cancel- 
 lated 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 en- 
 veloped 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 affect- 
 ed by that disease, with this essential difference, that in the 
 idiopathic disease there is only one, as if worm eaten, se- 
 questrum, perhaps the length of the shaft of the bone, easily 
 removable by one operation, while there may be in the trau- 
 matic 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 
 
LODGMENT OF A BALL IN BONE. 149 
 
 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 instruct- 
 ive : " Lieutenant Timbrel!, 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 inconve- 
 Dience. 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, re- 
 moved 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 
 
 13* 
 
150 CASES FOR IMMEDIATE AMPUTATION. 
 
 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 trans- 
 versely, 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 inves- 
 tigation 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 trochan- 
 ters. 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 suffer- 
 ing, 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 
 
DILATATION OF THE WOUND — INCISIONS. 151 
 
 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 at- 
 tempted 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 ex- 
 amination 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 sufiBcient size or 
 extent in some degree dangerous. The thickness of the 
 muscular parts is not a sufficient reason for avoiding an in- 
 cision, 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 ex- 
 tent 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 dis- 
 charge 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 
 
152 DEPOSIT OF OSSIFIC MATTER ON SPLINTERS. 
 
 commenced, any handling or examination of the limb, how- 
 ever 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 os- 
 sific matter described as being formed by the inflamed perios- 
 teum. 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 reten- 
 tion is accompanied by a firm thickening of the part, and in 
 due course of time a spot of inflammation implies the forma- 
 tion 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 inter- 
 mixed with lime. If deferred until the bony matter is quite 
 hard, it must be cut through with the chisel, or bone scis- 
 sors 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 hor- 
 rible torments, many suffer unnecessarily. There is a very 
 good and even cheaper one in use in the London Hospital, 
 well worthy attention. An instrument or iron machine, 
 movable from bed to bed, has been invented by Dr. Thom- 
 
POSITION OF THE PATIENT. 153 
 
 son, of Stratford-on-Avon, whicli 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. Thom- 
 son 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 physi- 
 cally 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 physi- 
 cians and surgeons, it should be from their value, combined 
 with a due regard to a moderate yet sufficient length of serv- 
 ice, 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 ac- 
 tion 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 
 
154 FORM, SIZE, AND LENGTH OP SPLINTS. 
 
 in thickness, can be rendered soft and pliable by the appli- 
 cation 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 nec- 
 essary 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 por- 
 tions, or even parts, being taken away successfully, than 
 ought to be attempted in the thigh. A leg should, there- 
 fore, 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 re- 
 main 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'Lel- 
 lan, 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 ordi- 
 nary tapes. A splint made of copper, to prevent rust or 
 injury, hollowed to receive the leg, extending beyond the 
 
MR. Luke's cradle for the thigh and leg. 155 
 
 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 apphcation 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.* 
 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 ap- 
 paratus 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 maybe obtained when the 
 sufferer is obliged to be moved. 
 
 ■^ 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. 
 
156 APPARATUS FOR COMPOUND FRACTURE OF LEG. 
 
 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 rep- 
 sented, 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 gouttiere, to be 
 hereafter noticed. 
 
 158. Half-a-dozen pairs of long poles made light and of 
 tough wood, which might always be replaced without diffi- 
 culty, 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 excel- 
 lent 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 opera- 
 tion, and a ligature placed on each bleeding end. An addi- 
 tional or second wound in the forearm only complicates the 
 ease, 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 
 
SPLINTS FOR THE ARM. 157 
 
 no longer bear the drain upon thera. The head of the bone 
 should be removed, with as much of the shaft as may be in- 
 jured; the elbow-joint should be excised, if the condyles are 
 destroyed and tbe 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 ichat 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 suc- 
 cessful 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 mate- 
 rials, 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 suf- 
 ferer, 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 appropri- 
 ate medicines, good and sufficient diet, and a free circulation 
 of air, without all which little can be expected, to say no- 
 thing of absolute rest and those ordinary attentions and com- 
 forts so necessary for the restoration of health. 
 
 163. The following returns are illustrative of the princi- 
 ples recommened 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 
 
 14 
 
158 
 
 TABLES OF HOSPITAL RETURNS. 
 
 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 0/ Surgical Cases treated and Capital Operations 
 performed in the General Hospital at Toulouse, from April lO^A to 
 June 2^th, 1814. 
 
 DISEASES AXD 
 STATE OF WOTjXDS. 
 
 Head 
 
 Chest 
 
 Abdomen .... 
 Super'r extrem's 
 Infei'lor ditto . . 
 Comp'd fractures 
 Wounds of spine 
 Wounds of joints 
 
 Amputations- 
 
 Arm • . . 
 
 Leg and thigh 41 
 
 Total . 
 
 \] 
 
 '6 
 2 
 
 1 
 
 
 Discharged to 
 duty. 
 
 2 . 
 
 ll 
 
 ll 
 CM 
 
 tn 
 
 95 
 
 17 
 
 25 
 
 53 
 
 96 
 
 35 
 
 14 
 
 47 
 
 104 
 
 24 
 
 21 
 
 59 
 
 304 
 
 3 
 
 96 
 
 205 
 
 498 
 
 21 
 
 150 
 
 327 
 
 78 
 
 29 
 
 ... 
 
 49 
 
 3 
 
 3 
 
 • •• 
 
 
 16 
 
 4 
 
 ... 
 
 12 
 
 48 
 
 10 
 
 ... 
 
 38 
 
 1242 
 
 146 
 
 306 
 
 790 
 
 Cog 
 
 
 1 
 1 
 1 
 1 
 1 
 
 1 in 
 1 in 
 1 in 
 
 in 5] 7 
 
 in 2|| 
 
 in 43^ 
 
 in 101. 
 
 in 23f 
 920 
 
 1 in hVz 
 
 128 
 
 lin 8MI 
 
 Wounded oflBcers lit, not included, making a total of 
 1359, among whom thirteen cases of tetanus occurred, all 
 of which proved fatal. 
 
 No. 2. — Officers. 
 
 NATURE OF "WOUNDS. 
 
 Admitted. 
 
 Dis- 
 charged. 
 
 Sent to 
 Bordeaux. 
 
 Died. 
 
 Kemain- 
 
 ing. 
 
 Head 
 
 Chest 
 
 Abdomen .... 
 Sup'r extremities 
 Inferior ditto . . 
 Comp'd fractures 
 Slight wounds. . 
 
 Total . . . 
 
 6 
 10 
 
 1 
 33 
 49 
 
 7 
 11 
 
 4 
 
 2 
 
 "9 
 12 
 
 7 
 
 1 
 2 
 
 15 
 
 21 
 1 
 
 2 
 
 2 
 
 1 
 6 
 1 
 9 
 15 
 4 
 2 
 
 117 
 
 34 
 
 42 
 
 3 
 
 38 
 
TABLES OF HOSPITAL RETURNS 
 
 159 
 
 One secondary amputation of the arm occurred, and re- 
 covered ; 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 2\st of June and 'Ziih of 
 December, 1813, iricluding the battles of Vittoria, the Pyrenees, arid 
 San Sebastian, to the entrance into France. 
 
 Vittoria . 
 
 Santander. 
 
 Bilbao, 
 
 Passages. 
 
 Vera. . 
 
 OPERATIONS. 
 
 Shoulder-joint. . . 
 Upper extremities. 
 Lower ditto. . . . 
 
 Trepan 
 
 Upper extremities. 
 Lower ditto. . . . 
 
 Shoulder-joint. . . 
 Upper extremities. 
 Lower ditto. . . . 
 Aneurism 
 
 Shoulder-joint . . 
 Upper extremities. 
 Lower ditto . . . . 
 
 Trepan . 
 
 Aneurism 
 
 Upper extremities. 
 Lower ditto . . . . 
 
 Total . . . 
 
 Recapitulation :-^ 
 
 Shoulder-joint . . 
 Upper extremities. 
 Lower ditto , . . . 
 Trepan ....... 
 
 Aneurism 
 
 S o 
 o P 
 
 13 
 
 ft 
 
 13 
 
 ll 
 
 
 10 
 
 2 
 
 1 
 
 108 
 
 68 
 
 40 
 
 10 
 
 148 
 
 95 
 
 38 
 
 15 
 
 3 
 
 3 
 
 
 
 22 
 
 5 
 
 8 
 
 9 
 
 23 
 
 9 
 
 6 
 
 8 
 
 5 
 
 5 
 
 
 
 146 
 
 48 
 
 46 
 
 52 
 
 68 
 
 36 
 
 16 
 
 16 
 
 1 
 
 1 
 
 
 
 i 
 
 
 
 1 
 
 11 
 
 i 
 
 3 
 
 7 
 
 14 
 
 6 
 
 3 
 
 5 
 
 3 
 
 2 
 
 1 
 
 
 1 
 
 r 
 
 
 
 12 
 
 4 
 
 8 
 
 
 5 
 
 584 
 
 3 
 
 2 
 
 
 287 
 
 173 
 
 124 
 
 19 
 
 15 
 
 2 
 
 2 
 
 299 
 
 116 
 
 105 
 
 78 
 
 258 
 
 149 
 
 65 
 
 44 
 
 6 
 
 5 
 
 1 
 
 
 2 
 
 2 
 
 
 
 ' The great mim- 
 ber of amputa- 
 tions at tliis sta- 
 tion was iu part 
 occasioned by 
 hospital gan- 
 grene. 
 
 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 re- 
 covered, or a loss of more than one-half of the secondary 
 operations. 
 
160 
 
 TABLES OF HOSPITAL RETURNS. 
 
 No. 4. — Capital Operations performed in the Field with Divisions 
 of the Army during the same period. 
 
 Cavalry. 
 
 First di- 
 vision . 
 
 Second . 
 
 Third. . 
 
 Fourth . 
 Fifth . . 
 
 Sixth . , 
 
 Seventh. 
 
 Light di- 
 vision . 
 
 OPEEATIONS. 
 
 Upper extremities 
 Lower ditto ... 
 Shoulder-joint . 
 Upper extremities 
 Lower ditto ... 
 
 Trepan 
 
 Shoulder-joint • 
 Upper extremities 
 Lower ditto . . . 
 Aneurism .... 
 Shoulder-joint . 
 Upper extremities 
 Lower ditto . . . 
 Upper extremities 
 Lower ditto ... 
 Shoulder-joint . 
 Upper extremities 
 Lower ditto . . . 
 Shoulder-joint . 
 Upper extremities 
 Lower ditto . . . 
 Upper extremities 
 Lower ditto . . . 
 
 Shoulder-joint . 
 Upper extremities 
 Lower ditto . . . 
 Trepan 
 
 Total 
 
 Recapitulation : — 
 
 Shoulder-joint . . 
 Upper extremities. 
 Lower ditto . . . . 
 
 Trepan 
 
 Aneurism 
 
 1% 
 
 3 
 
 ;5 
 
 5 
 
 •a 
 a> 
 
 g 
 
 a 
 3 
 
 ■a 
 
 a 
 
 o 
 u 
 
 u 
 
 c 
 
 o 
 o 
 
 DD 
 
 s 
 
 1 
 
 3 
 
 1 
 
 2 
 
 
 
 3 
 
 2 
 
 1 
 
 
 
 3 
 
 .... 
 
 2 
 
 • ••• 
 
 
 14 
 
 1 
 
 3 
 
 5 
 
 
 10 
 
 2 
 
 • ••• 
 
 1 
 
 1 
 
 2 
 
 2 
 
 
 
 
 1 
 
 • ••• 
 
 1 
 
 
 
 16 
 
 • ••• 
 
 5 
 
 6 
 
 .... 
 
 21 
 
 3 
 
 6 
 
 7 
 
 
 1 
 
 .... 
 
 • ••. 
 
 1 
 
 
 1 
 
 • •>• 
 
 «••• 
 
 1 
 
 
 17 
 
 2 
 
 • •■• 
 
 15 
 
 
 10 
 
 .... 
 
 2 
 
 8 
 
 
 10 
 
 .... 
 
 10 
 
 
 
 20 
 
 .... 
 
 20 
 
 
 
 12 
 
 .... 
 
 8 
 
 2 
 
 .... 
 
 57 
 
 1 
 
 36 
 
 2 
 
 .... 
 
 ^ 41 
 
 10 
 
 13 
 
 2 
 
 ••>• 
 
 1 
 
 1 
 
 
 
 
 7 
 
 .... 
 
 5 
 
 • ••• 
 
 .... 
 
 6 
 
 1 
 
 1 
 
 3 
 
 .... 
 
 18 
 
 .... 
 
 3 
 
 1 
 
 • ••■ 
 
 9 
 
 1 
 
 .... 
 
 1 
 
 .... 
 
 1 
 
 
 
 
 
 21 
 
 •••• 
 
 • ••• 
 
 • ■•• 
 
 .... 
 
 8 
 
 • ••• 
 
 • ••• 
 
 • ••• 
 
 .... 
 
 4 
 
 .... 
 
 118 
 
 55 
 
 3 
 
 1 
 
 317 
 19 
 
 27 
 
 1 
 
 11 
 
 163 
 
 5 
 
 64 
 
 29 
 
 .... 
 
 128 
 
 19 
 
 43 
 
 22 
 
 .... 
 
 6 
 
 2 
 
 .... 
 
 
 .... 
 
 1 
 
 .... 
 
 .... 
 
 1 
 
 .... 
 
 BEMABES. 
 
 r I Sent to Gen- 
 n I eral Hospital. 
 
 5 "I Sent to Gen- 
 5 / eral Hospital. 
 
 2 
 18 
 
 Sent to Gen- 
 
 ^^ r eral Hospital. 
 
 2 "(Sent to Gen- 
 
 1 J eral Hospital. 
 14 I Sent to Gen- 
 
 7 J eral Hospital. 
 The whole of 
 these cases sent 
 
 (to the General 
 Hospital; results 
 not known at the 
 division. 
 
 41 
 65 
 44 
 
 4 
 
 Sent to Gen- 
 eral Hospital. 
 
TABLES OF HOSPITAL RETURNS. 161 
 
 Of 310 amputations 25 died, 112 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 num- 
 bers 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 ac- 
 counted for, when compared with Return No. 4, by the 
 army being constantly in motion and the hospitals at a dis- 
 tance. 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 Bout- 
 flower, 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 De- 
 cember 24th, 1813 — the number of sick and wounded amount- 
 ed to 37,144, a number nearly equal to that of the whole 
 army. 
 
 14* 
 
162 
 
 ' TABLES OP HOSPITAL RETURNS. 
 
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HOSPITAL GANGRENE. 163 
 
 LECTURE YIII. 
 
 CHARACTERS OF HOSPITAL GANGRENE. 
 
 164. This most destructive disease owes its names of hos- 
 pital gangrene, phagedena, gangrenosa, pourriture cfhopi- 
 tal, 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 1791, 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 1*198, 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, how- 
 ever large. The disease, as long as it remains unaltered by 
 
164 MR. BLACKADDER ON HOSPITAL GANGRENE. 
 
 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 extrem- 
 ity ; 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 precaution- 
 ary 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 ulti- 
 mately 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 ele- 
 vated 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 dis- 
 tance. The inflammation, however, gradually subsided, but 
 
OPINIONS OP DELPECH AND TICE. 165 
 
 the stinging, accompanied by a burning sensation, still con- 
 tinued, 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 com- 
 plete 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 mis- 
 fortunes and sufferings of the French army had a great de- 
 pressing influence on the soldiers, from which at other times 
 they would have been exempted, and that this aided the pro- 
 pagation 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 oppres- 
 sive gloom, amounting to despair. Expectation and hope 
 seemed to be exiled from their minds by the dominion of 
 painful despondency, which, prevailing in melancholy disor- 
 der, seemed uncontrolled or checked by the intrusive impor- 
 tunities of the present, or the consciousness of a future 
 existence." 
 
 A wound attacked by hospital gangrene in its most con- 
 centrated 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 con- 
 centric 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 direc- 
 tion, may be marked from hour to hour ; so that in from 
 
166 SLOUGHING OR PULPOUS FORM. 
 
 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, fre- 
 quently 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 ar- 
 rested 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. 
 
CIRCULAR FORM, AND PECULIAR ODOR. 167 
 
 About the end of the first week, and sometimes much later, 
 this kind of ulcer becomes more painful, the edges or the cir- 
 cumference 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, pu- 
 trid 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 striae of blood, from parts which 
 are not yet actually destroyed ; the mass is, however, adher- 
 ent, 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 pecu- 
 liar odor or stench. 
 
 1{)7. 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 indispu- 
 table ; 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 mis- 
 chief, is neither preceded nor followed by febrile or constitu- 
 tional 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, 
 
168 CONSTITUTIONAL AND LOCAL ORIGIN. 
 
 and occasionally resembles the bilious remittent of the sum- 
 mer and autumn in hot climates, and ends in typhus. It is 
 probable that a want of attention to these circumstances de- 
 cided 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 con- 
 stitutional 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 influ- 
 enced by the knowledge that the French surgeons more gen- 
 erally 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 de- 
 tergent applications, always failed, unless accompanied by 
 absolute separation, the utmost* possible extent of ventila- 
 tion, 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 treat- 
 ment, 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 inad- 
 missible—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 
 
USE OF fowler's SOLUTION OF ARSENIC 169 
 
 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 gan- 
 grene, 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 applica- 
 tions, he recommends cold water, alone or mixed with a small 
 portion of acetic acid, constantly applied and frequently re- 
 newed. 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 oint- 
 ments, 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 introduc- 
 tion of the use of Fowler's solution of arsenic as an escha- 
 rotic, 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. Blackad- 
 der, stationed on the same coast, within about forty miles of 
 Dr. Boggie at Bilbao, took a diametrically opposite view of 
 
 15 
 
ItO M. DELPEOH ON THE TREATMENT OF GANGRENE. 
 
 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 quan- 
 tity 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 in- 
 jury has been extensive, such as that of a penetrating gun- 
 shot wound." 
 
 Dr. Walker, who served at Bilbao at the same time, con- 
 cludes 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 in- 
 flammatory type, so as to require strong evacuants, and even 
 bleeding, which has been used with the greatest success by 
 Stafl"- 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 vege- 
 table and mineral acids, the Egyptian ointment, etc." Of 
 these he prefers vinegar applied on lint, after having rubbed 
 or scraped ofi" 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 tena- 
 cious discharge." Of constitutional treatment he evidently 
 thinks little ; and, while he admits the propriety and neces- 
 sity 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 be- 
 lieves that the suppression of the local disease materially 
 assists in arresting, in a great measure, such constitutional 
 
MR. TAYLOR ON HOSPITAL GANGRENE. ITl 
 
 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-Portu- 
 guese 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, In- 
 specteur au Service de Sante, 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 concen- 
 trated state was known to, and had been essentially intro- 
 duced 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 29tli 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, fl.orid 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 preva- 
 lence of the disease, this dark-red color of the face was nei- 
 ther well marked nor by any means so constant. In many 
 cases the disease seemed purely local ; but in the great ma- 
 jority there was certainly much feverish constitutional dis- 
 turbance accompanying the local affection, and often preced- 
 ing 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 in- 
 clined to try a-ny other. The plan adopted was, the appli- 
 cation of the strong nitric acid, so as completely to cut off 
 the diseased from the sound part, or part so far sound as 
 
172 MR. TAYLOR ON HOSPITAL GANGRENE. 
 
 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 circumfer- 
 ence, 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. Keither 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. 
 
 " AVhen speaking of the symptoms of this disease, I should 
 have mentioned that a burning, gnawing sensation was some- 
 times 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, cer- 
 tainly 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 hos- 
 pital 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 eveYitually checked 
 its progress. 
 
 "In no case that came under my obseivation did the gan- 
 
CONCLUSIONS. It3 
 
 grene directly prove fatal, though in many eases it contrib- 
 uted 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 clean- 
 liness 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 con- 
 stitutional 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 pro- 
 pagating 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 mortifi- 
 cation from ordinary causes, and alike obliterates their cavi- 
 ties. The separation of the dead parts is, therefore, accom- 
 panied by hemorrhage, which, w^hen 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 sufifering 
 from it. 
 
 Tenth. — The local disease is to be arrested by the appli- 
 
 15* 
 
It4 CONCLUSIONS. 
 
 cation of the actual or potential cautery : an iron heated red 
 hot, or the mineral acids pure, or a solution of arsenic, or of 
 the chloride of zinc, or of some other caustic which shall 
 penetrate the sloughing parts, and destroy a thin layer of 
 the unaffected part beneath them. If a sinus or sinuses have 
 formed under the skin or between the muscles, from the ex- 
 tension 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 ac- 
 cording 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 occa- 
 sioned by the disease, considered as distinct from the symp- 
 toms 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 ulcer- 
 ated 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 w^hatever 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 inflamma- 
 tory, and by less vigorous means if the fever prevaihng 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 sepa- 
 ration, cleanliness, and exposure to the open air, — the first 
 
CONCLUSIONS. 
 
 116 
 
 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 debili- 
 tating 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. 
 
 Ketubn of the Number of Cases of Hospital Gangrene which have 
 appeared at the Hospital Stations in the Peninsula between 2\st June 
 and 24:th December, 1813. 
 
 Santander 
 Bilbao 
 
 Vittoria... 
 Passages.. 
 
 Vera 
 
 00 -3 
 
 'd . 
 
 
 
 -e 
 
 6 ^ u 
 
 ill 
 
 Ti 
 
 53 J>^ 
 
 -3 = 3 
 
 dl§ 
 
 o § 
 
 
 s • 
 
 &-J3 a 
 
 
 160 
 
 72 
 
 35 
 
 53 
 
 25 
 
 972 
 
 557 
 
 387 
 
 28 
 
 183 
 
 441 
 
 349 
 
 88 
 
 4 
 
 74 
 
 41 
 
 2 
 
 2 
 
 
 • ••• 
 
 1614 
 
 980 
 
 512 
 
 85 
 
 282 
 
 Most of these 
 eases were sent 
 from "Vittoria. 
 
 Thirty - seven 
 transferred to 
 Santander. 
 
 Vera, being al- 
 most on the field 
 of battle, had no 
 case. 
 
116 
 
 STRUCTURE OF ARTERIES. 
 
 LECTURE IX. 
 
 ON WOUNDS OF ARTERIES, ETC. 
 
 1*73. 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 be- 
 comes 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 
 
STRUCTURE OP ARTERIES. 
 
 Ill 
 
 the general composition of a large artery, each particular 
 structure remaining to be examined. 
 
 1*74. 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, i-c, upon, OrjXrj 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 
 
 No.l. 
 
 three different stages — in the young person, in middle age, 
 and in the very old person ; one stage gradually degener- 
 ating 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 
 TToo of ^'^ i^^^"^ ^^^ diameter, the nucleus in each cell con- 
 taining within itself one or more nucleoli, and even several 
 paler granules. The epithelium has a thickness propor- 
 tioned 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 epithehum is 
 
178 STRUCTURE OF ARTERIES. 
 
 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 oesophagus; 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 jo'o 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 -o^oo of an inch 
 long, which are, during life, in constant motion. This kind 
 of epithelium, known as the ciliary, lines the whole respira- 
 tory 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 Xo. 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 per- 
 ceived. This is not always a hole or perforation, as it is 
 generally described to be, as may be seen and proved by the 
 
STRUCTURE OF ARTERIES. 
 
 179 
 
 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 fre- 
 quently the seat of disease. 
 
 No. 2. 
 
 The middle coat, as it was termed, forms by much tlie 
 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 unfre- 
 quently in a series of circular layers; when examined micro- 
 scopically, it is seen to be composed of two sets of fibers 
 arranged in a circular direction. The inner layer is com- 
 posed principally of muscular fibers, of the organic or 
 involuntary kind. (See line marked 3 on the circular dia- 
 gram.) The outer layer, marked line 4 on the same diagram, 
 is made up chiefly of elastic fibers, with a much smaller 
 
180 STRUCTURE OF ARTERIES. 
 
 amount of the muscular or contractile element. These con- 
 joined layers form the muscular coat of Mr. Hunter, the 
 librous or contractile coat of later anatomists, who denied 
 its muscalarity 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. Mulder 
 says, in his "Animal and Vegetable Chemistry," (Part II. 
 p. 307:) ''The combinations of sulphophospho 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 Miilder — 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 ley, 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 
 
STRUCTURE OF ARTERIES. 
 
 181 
 
 No. 3. 
 
 No. 4. 
 
 by firmer and more elastic fibers of a yellow color, seen col- 
 lectively in tlie circular diagram, as line 4, and separately in 
 diagram 3, fig. 4, and in diagram 4. 
 
 The iyivoluntary 
 muscular fibers of an 
 artery do not always 
 form a continuous 
 layer ; they are often 
 smaller than those 
 found in the intes- 
 tines, bladder, and 
 uterus, and occur as 
 fusiform cells, de- 
 tached 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 involun- 
 tary, in having cylin- 
 drical fibers of much 
 larger size, with trans- 
 verse and longitudinal 
 
182 
 
 STRUCTURE OP ARTERIES. 
 
 markings, unlike the flattened fibers of less size of the in- 
 voluntary rouscles, which have also a faintly granular ap- 
 pear ance, instead of the more determined transverse and 
 longitudinal lines of the voluntary muscles. 
 
 The Older or elastic layer of the ancient middle coat, 
 represented by line 4 in the circular diagram, contains mus- 
 cular 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, dif- 
 fering only in size from those found in the ligaments of the 
 spine, and in the ligaraentum nuchas 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- 
 
 No. 5. 
 
 a. Yellow elastic fibers. 
 c. Nuclei. 
 
 6. White inelastic fibers. 
 d. Fiber, with nucleus. 
 
 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 
 
STRUCTURE OF ARTERIES. 183 
 
 inelastic fibers are shown in diagram I^o. 3, fig. 5, with a 
 yellow elastic fiber curling round them. The constant cross- 
 ing and recrossing of these two sets of fibers form certain 
 spaces, which, when not in a compact form, become real 
 spaces, meshes, or areola, constituting what is now called 
 areolar tissue, rather than the cellular of the older anato- 
 mists, from the circumstance that the areolae 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 con- 
 taining oval nuclei, as seen and marked in diagram 3, fig. 5. 
 It is seen when unraveled in h, diagram 5. 
 
 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 sup[)lied 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 sup- 
 posed to be thus produced. In a shapeless, consistent, 
 sometimes almost gelatinous mass, to which the name of 
 c^/o-blastema or formative substance has been given, con- 
 taining the materials requisite for the production of cells, 
 small, round grains or nucleoli are perceived in the act of 
 formation. Around these grains a layer of granular matter 
 is deposited, which continually increases in thickness, and 
 constitutes the kernel or nucleus. ■ This is oval shaped or 
 round, almost always opaque, has a granular surface, and is 
 considered to be a vesicle, a little cell itself. From the sur- 
 
184 COLLATERAL CIRCULATION. 
 
 face of this kernel a small, very thin transparent vesicle is 
 raised, appearing as a segment of a sphere, which soon ex- 
 pands, and becomes so large, when full grown, that the ker- 
 nel lies as a minute corpuscle upon its interior wall ; the 
 material for its formation being supplied by the cyto-blas- 
 tema, it is converted into a vesicle by the kernel which is 
 jBrst 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 Miilder, 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, suscep- 
 tible 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 circu- 
 lation 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 
 
TWO KINDS OP COLLATERAL CIRCULATION. 185 
 
 operation has not been performed, the collateral vessels have 
 all been found larger and more fully shown than on the op- 
 posite 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 take 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 cat off from the 
 extremity, and the operation adds very little to the derange- 
 ment 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 enlargementof these particular collateral 
 vessels was an accidental play of nature, and existed pre- 
 viously to the commencement of the disease or injary 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 
 
 IG* 
 
186 TWO KINDS OP COLLATERAL CIRCULATION. 
 
 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 w^ounded, 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 through- 
 out. 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 prin- 
 cipal 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 communi- 
 cating branches, and the capillaries would have returned to 
 their accustomed duties. 
 
 1*78. During the first twenty-four hours after the division 
 of an artery such as the femoral, or the apphcation 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 
 
PROPER TREATMENT OF WOUNDED ARTERIES. 18*7 
 
 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 enlarge- 
 ment 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 inflic- 
 tion 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 suffer- 
 ing 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 na- 
 ture 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 Rolica, Yimiera, Oporto, and Talavera, 
 but did not receive their complete development until after 
 the battle of Albuhera. It was not until after that of Tou- 
 louse 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 di- 
 lated 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 immedi- 
 ately 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 
 
188 HUNTERTAN THEORY OF ANEURISM. 
 
 first lEstance; altlioiigh 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 contem- 
 plative mind, aided by his knowledge of anatomy and of dis- 
 ease, 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 suffi- 
 cient 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 liga- 
 ture should not be placed on the artery near the tumor in the 
 hani, 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 gen- 
 erally 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 amputa- 
 tion necessary, which \vas 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, wiiere 
 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 dis- 
 tance from the disease in the fore part of the thigh, and will 
 usually be followed by success as far as concerns the obliter- 
 ation of the artery immediately below the part on which it 
 is applied. 
 
HUNTERIAN THEORY OF ANEURISM. 189 
 
 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 dis- 
 appear, from the impelling force not being sufficient to pre- 
 vent a gradual coagulation taking place, which would soon 
 fill up the cavity of the sac, and thus prevent its further en- 
 largement; 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 disap- 
 peared, 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 im- 
 mortalized 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 regurgita- 
 tion, until it has become coagulated, when the sac is so tilled 
 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 ap- 
 plicable, 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 pre- 
 vious disease, and may be expected to take on those healthy 
 actions which, after the application of a ligature, lead to the 
 
190 OPPOSING THEORY AS TO WOUNDED ARTERIES. 
 
 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 
 wpjjer extremity in any part of its course, however near the 
 heart. 
 
 6th. That when the collateral vessels are capable of car- 
 rying on the circulation through the lower extremity, the 
 lower end of the divided artery bleeds dark or venou^- 
 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. 
 
 tth. 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 circum- 
 stance, 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. 
 
OPPOSING THEORY AS TO WOUNDED ARTERIES. 191 
 
 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 assist- 
 ance. 
 
 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 hemor- 
 rhage 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 re- 
 gurgitating 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 ap- 
 plication 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 con- 
 tinuous 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 oper- 
 ation 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, 
 (Etius, etc., down to Dr. Jones, the most important English 
 writer on this subject; but the methods of inquiry they all 
 
192 SUPPRESSION OF HEMORRHAGE BY NATURAL MEANS. 
 
 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 ob- 
 vious, 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 investi- 
 gated. 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 man on 
 the field of battle during the Peninsular war, and conse- 
 quently not liable to error. It was then proved that arteries 
 of moderate dimensions, such as the middle part of the fem- 
 oral 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 hemor- 
 rhage 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 with- 
 out 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 mortiJiGation 
 of the foot. 
 
 The upper end of an artery retracts on being divided, and 
 this retraction is accompanied by a contraction of the cut 
 
RETRACTION AND CONTRACTION OF AN ARTERY. 193 
 
 extremity of the vessel, which assames the shape of the neck 
 of a French wine-bottle or Florence oil-flask. The contrac- 
 tion 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 in- 
 ternal 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 ex- 
 ternal 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 era- 
 ployed 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 want- 
 ing, 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 hemor- 
 rhage, 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 floioing 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 
 
 It 
 
194 PROOFS OF CONTRACTION AND RETRACTION. 
 
 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 con- 
 ceals 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 in- 
 jured, 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 oftered by the very extremity of the artery 
 
ILLUSTRATIVE CASES. 
 
 195 
 
 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. 
 
 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 
 
 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 ex^josed 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 then- sheath. The artery bent distinctly to the 
 very base of the coagulum. 
 
 thought, he sa,ys, crossed my mind, as I held the artery be- 
 tween my finger and thumb, that it might be for the benefit 
 
196 ILLUSTRATIVE CASES. 
 
 of the patient to place a ligature on the artery at the high- 
 est point, exposed, cutting oflf 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 pres- 
 ence 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 down- 
 ward 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 bat- 
 tle, 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 gen- 
 tleman 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 01iven9a. 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 
 
ILLUSTRATIVE CASES. 197 
 
 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, althou.a;h 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 coagu- 
 lura, 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 com- 
 pletely 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 Eegiment, 
 was wounded at the battle of Rolica, 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 hemor- 
 rhage 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 Yimiera, 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 out- 
 side of the tibia : it bled considerably for some minutes, when 
 
 17* 
 
198 ILLUSTRATIVE CASES. 
 
 it ceased, and tbe hemorrhage did not return until the loth 
 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 fol- 
 lowed by a stream of arterial blood, which ceased on tight- 
 ening 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. 
 
 Beviarks. — 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 sud- 
 den 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 
 
ILLUSTRATIVE CASES. 199 
 
 hemorrhage from the lower eucl of the artery, which took 
 place on the 7th of May, when the limb was amputated, and 
 the man subsecpientlj 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 intro- 
 duced into it from above would not come out at the face of 
 the wound, although the impulse given to this part on mov- 
 ing it was observable in the middle of a large, yellowish- 
 green spot, which I had previously declared to be the situa- 
 tion 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 coagulnm. 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 con- 
 tracted 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, ou 
 the upper and fore part of the thigh ; it passed out behind, 
 in the direction of the femoral artery. He lost a great quan- 
 tity 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 ou 
 pressing his hand upon it. In the afternoon, on again mov- 
 ing, 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 rec^uisite to be performed in case of fur- 
 ther 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 re- 
 moved, there appeared some swelling about the wound, the 
 
200 ILLUSTRATIVE CASES. 
 
 opening of vvhicli was filled up by a coagulum : gentle press- 
 ure 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 natu- 
 ral, and the man returned thanks for the humanity and kind- 
 ness 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 ]eg, 
 which was as warm to the hand as the other, but the foot 
 was cold. The second day the swelling of the limb, its ap- 
 pearance, 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. Xo 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 Koyal 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 after- 
 noon of the next day, the 7th. The leg had ceased to bleed 
 before his arrival in camp. A substance could be felt on the 
 inner side of the patella, which, by the sensation communi- 
 
ILLUSTRATIVE OASES. 201 
 
 cated to the finger on moving, appeared to be the ball, which 
 was extracted. Some dark-colored blood issued from the 
 cavity ; the ball was lying loose and unconnected ; the fin- 
 ger, on being passed into the joint, which was swollen, dis- 
 covered 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. Arm- 
 strong, 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 w^as 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 pain- 
 ful, 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 vesi- 
 cations 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 appar- 
 ently 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 w^as amputated as 
 low down as possible. Sixteen vessels were tied ; the parts 
 w^ere 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 ; 
 
202 ILLUSTRATIVE CASES. 
 
 the popliteal vein was also entire, having a small tumor ad- 
 hering 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 cir- 
 cular 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 thicliness 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 T4th Regi- 
 ment, 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 con- 
 ceiving the numbness, coldness, and impeded power of mo- 
 tion 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 
 
EFFECTS OF A LIGATURE UPON AN ARTERY. 203 
 
 all the toes, it had the appearance of having ceased. Sat- 
 isfied that it would again extend, I left directions with the 
 assistant-surgeon that the limb should be amputated beloiv 
 the knee. 
 
 The surgeon, whom I had not seen, and who did not un- 
 derstand 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 afi'ected 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 wrin- 
 kled manner ; the ancient inner and middle coats of the ar- 
 tery, 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 
 
204 EFFECTS OF A LIGATURE UPON AN ARTERY. 
 
 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 ex- 
 ternal coat, which is tied around it by the ligature ; so that, 
 in fact, when a small ligature is firmly tied, its direct press- 
 ure is not applied to the inner coats, which have been di- 
 vided 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 sub- 
 jected 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 in- 
 flammation, which stops at the adhesive stage. This they 
 do by the effusion of lymph or fibrin both within and with- 
 out, 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 conse- 
 quence 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 sub- 
 sequent 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 ca- 
 pable 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. 
 
CONTRACTION NOT NECESSARY. 205 
 
 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 coagulura 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 ob- 
 servable, 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 re- 
 quired. 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 in- 
 stances 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 hemor- 
 rhage 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 
 
 18 
 
206 STRENGTH OF A LIGATURE. 
 
 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 liga- 
 ture 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 con- 
 tracted, 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 hithciio expected fronfi the neigh- 
 borhood 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 strangu- 
 lated and brought away with it. 
 
 181. A ligature should always be round and small, pro- 
 vided 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 
 
LIGATURE OF AN ARTERY. 20*1 
 
 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 haying 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 im- 
 portance. 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 re- 
 corded 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 
 
208 THE FEMORAL ARTERY. 
 
 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 pos- 
 sible 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 sub- 
 sequent time, some force is occasionally required for its 
 removal after amputation. 
 
 LECTURE XL 
 
 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 oflScer 
 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 indica- 
 tion 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 
 
LACERATED WOUNDS OF ARTERIES. 209 
 
 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 w^hich 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 ex- 
 tremity 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 what- 
 ever 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 w'as 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 extrem- 
 ities of snch 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 
 
 18* 
 
210 PUNCTURED WOUNDS OF ARTERIES. 
 
 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 con- 
 tinues 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 calil3re. 
 
 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 ap- 
 parently occasioned by friction against the cut edges of the 
 artery. This thrilling noise diminished, and the vessel im- 
 mediately 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. 
 
ILLUSTRATIVE CASES. 211 
 
 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 pro- 
 pensities 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 immedi- 
 ately 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 circum- 
 ference, and that the wound has healed without the canal 
 becoming impervious. A smaller luound 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 char- 
 acters 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 
 
212 COMPLETE DIVISION OP ARTERIES. 
 
 wound healed, leaving only a mark where the point of the 
 arrow had entered. Some time afterward he observed a 
 small swelling at tlie part, which, from its pulsation, was de- 
 clared 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 in- 
 crease 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 descrip- 
 tion. 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 press- 
 ure, especially when it can be applied against the bone. If 
 the artery is of a larger class, and continues to bleed, it 
 should be sufiQciently 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. 
 
DEEP WOUND OF AN ARTERY. 213 
 
 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 w^as secured by ligature when the tourniquet 
 was removed. Yenous-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 gen- 
 tleman perfectly recovered, and has continued well until this 
 day. The absolute necessity for two ligatures was here well 
 shown, as w-ell as the flow of dark-colored blood from the 
 low^er end of the artery. This gentleman is now an ofiicer 
 in the army, and suffers no inconvenience from his accident. 
 
 192. When a large artery is w^ounded 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 raptured artery is distinct. If a 
 large quantity of blood, partly in a fluid, partly in a coagu- 
 lated 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 quan- 
 tity, 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 ex- 
 travasated by the rupture of several small vessels, in conse- 
 quence of the passage of a wheel over the limb, especially 
 in the thigh, where a swelling containing fluid blood will 
 sometimes pulsate in a well-marked manner, until it gradu- 
 
214 SPURIOUS ANEURISM. 
 
 ally diminishes as the blood coagulates, when the motion 
 becomes a mere elevation at each stroke of the heart. The 
 whizzing sound or thrill attendant on a ruptured artery is in 
 these cases wanting, being a very diagnostic mark of this 
 accident ; although where there is true aneurism, and it has 
 burst, forming a diffused and spurious one, the thrill may be 
 wanting ; but the history of these cases enables a surgeon to 
 distinguish between them. If several ounces of blood are 
 thrown out, and remain fluid, they ought to be evacuated, or 
 suppuration will ensue. If they become coagulated, the 
 mass will be gradually absorbed. Fluid blood should be 
 evacuated by a small opening, and the part afterward treated 
 by compress and bandage. If the fluid or partly coagulated 
 blood should increase in quantity, and the swelling continue 
 to enlarge and pulsate, the extension of the mischief should 
 be arrested by opening the swelling and securing the artery 
 by ligature. When the external opening is enlarged, and 
 the clots which filled it up are at all disturbed, arterial blood 
 begins to flow, and the finger will readily follow the track 
 through which it passes down to the artery, if it should not 
 be too far distant. If the incision be made sufficiently large 
 to enable the operator to remove these clots of blood with 
 rapidity, the finger will more readily pass down to the wound 
 in the artery, which, if a large one, may be thus easily dis- 
 covered, 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 in- 
 jury. There is, then, not only a great and essential differ- 
 ence between these two kinds of aneurism as regards their 
 nature, but also with respect to the collateral circulation, 
 
NO LIGATURE ON AN ARTERY, UNLESS IT BLEED. 215 
 
 and the operation to be performed for their cure ; and the 
 surgeon raay not overhjok these facts. 
 
 A school-boy, about fourteen years of age, let a penknife 
 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 integu- 
 ments, 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, care- 
 fully 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 open- 
 ing 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 ex- 
 ternally, 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 oc- 
 curred within the last two years, in which, from neglect of 
 the precept inculcated by it, very distressing if not fatal 
 consec[uences 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 ar- 
 rested 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 
 
216 OBSERVATIONS ON THE PRECEPT. 
 
 battle of Salamanca by a musket-ball, which entered im- 
 mediately 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 re- 
 ceipt 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 open- 
 ings, 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 thighi 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 immedi- 
 ately 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 trans- 
 versely, continuing the incision until the opening was suf- 
 ficiently large to see to the bottom of the wound or the 
 bleeding part. It is necessary in such cases to be atten- 
 tive to the course of the great vessels and nerves, but not to 
 the safetv of muscular fibers, the division of which leads to 
 
OBSERVATIONS ON THE PRECEPT. 21 1 
 
 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 re- 
 lieved 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 likeli- 
 hood of mortification taking place, which in similar cases 
 has been known to occur ; and the possibility of the hemor- 
 rhage 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 surround- 
 ing parts, which by a little attention may be readily accom- 
 plished. 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 ad- 
 visable 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 
 
 19 
 
218 ILLUSTRATIVE CASES. 
 
 they may be prevented by efl&cient and well-appointed medi- 
 cal 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 ex- 
 hausted. 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 liga- 
 ture 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 neces- 
 sary, until the wounded vessel was discovered, which possibly 
 had not been completely divided by the ulcerative or slough- 
 ing 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 con- 
 tinuing to increase in size. Fomentations and poultices 
 were applied ; irritative fever set in, and the pain was in- 
 
CASE OF CAPTAIN SETON. 219 
 
 tense. At the end of a fortnight the small hole made by the 
 shot appeared to be healed over by a thin skin of a blue 
 color, which tint extended for some distance. The limb was 
 enormously swollen, with a feeling of distention, which in- 
 duced 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 sup- 
 pressed, and after a short time it returned at intervals with 
 augmented violence, until death ensued, three weeks after 
 the accident. 
 
 Rertiarks. — 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 ne- 
 cessity 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 con- 
 striction 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 counte- 
 nance 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, 
 
220 CASE OF CAPTAIN SETON. 
 
 and there was a narrow, faint blush of redness ronnd 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 (ecchymo- 
 sis) 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 diam- 
 eter 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 ap- 
 peared elastic but firm, very slightly tender, and not capable 
 of any perceptible diminution in bulk by gradual and con- 
 tinued 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 dif&culty 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 swell- 
 ing 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 pari- 
 etes, 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 sec- 
 ondary hemorrhage attaching to the operation of tying the 
 
CASE OF CAPTAIN SETON. • 221 
 
 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 possi- 
 ble, 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 alto- 
 gether 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 ten- 
 sion 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 ob- 
 served. Pulse quicker and small. Leeches were applied, 
 and three-grain doses of calomel, with a little Dover's pow- 
 der, 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 be- 
 came 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 scro- 
 tum, 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 
 
 19* 
 
222 ' REMARKS. 
 
 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 cel- 
 lular 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 quan- 
 tity of sero-purulent fluid was found in the abdominal cav- 
 ity ; 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 dis- 
 tended 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 experimentuni 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 
 
ERRORS DEMONSTRATED. 223 
 
 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 dis- 
 section report proved this case to be simply a small collec- 
 tion of blood, three ounces and a half, or seven small table- 
 spoonfuls — communicating v/ith 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 lead- 
 ing 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. 
 
 Theirs;; 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 w'as 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 tablespoon- 
 fuls. 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 swell- 
 ing 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 
 
224 ERRORS DEMONSTRATED. 
 
 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 liga- 
 ture 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 suc- 
 cessfully 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 con- 
 tents 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 peri- 
 toneum, to which accident he ought not to have been ex- 
 
ERRORS DEMONSTRATED. 225 
 
 posed, he would have died of mortification within forty 
 hours more, which had ah-eady 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 mortifica- 
 tion 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 hemor- 
 rhage. 
 
 If the femoral artery had been icounded, as was supposed 
 in this case, but not completely divided, it must and luould 
 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 conseciuence of the flow of 
 blood through this vessel preventing the obstruction and 
 consolidation of the main branch for a distance sufiicient 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 contra- 
 vening the great surgical precept, formed on no inconsider- 
 able experience during the early part of the war in the 
 
226 MORTIFICATION. 
 
 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 
 restrai7ied 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 im- 
 practicability 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, conse- 
 quent 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 
 
DRY MORTIFICATION FROM WOUND OF THE FEMORAL. 227 
 
 left thigh, parallel to but a little below Poupart's ligament, 
 from the shaft of a van. The late Messrs. Heaviside, How- 
 ship, and Chevalier were sent for immediately, and my at- 
 tendance was desired next day. I called the attention of 
 these gentlemen to the talloicy-ivhife and mottled appear- 
 ance 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 at- 
 tention. 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 delib- 
 erate consideration and trial. (See Aphorism 29.) Tlie 
 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 na- 
 ture seems capable of arresting the progress of the morti- 
 fication, 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 
 
228 AMPUTATION NOT ALWAYS TO FOLLOW. 
 
 place, the lower end of the artery should have been tied. 
 The upper end never bled, and the ligature on the iliac ar- 
 tery 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, amputa- 
 tion 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. Nev- 
 ertheless, 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 prin- 
 ciple laid down in opposition to those usually received by 
 the pi'ofession at large, and which have been entertained 
 from the fact that amputations done under these circum- 
 stances are commonly fatal. 
 
 Kichard 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 extravasa- 
 tion 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 sub- 
 sided, 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 
 
AMPUTATION NOT ALWAYS TO FOLLOW. 229 
 
 whole limb was manifestly about to pass into a state of gan- 
 grene, 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 poste- 
 rior 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 caus- 
 ing 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 tth 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 in- 
 jections ; 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, aud secured if found bleed- 
 ing, it is possible the mortification might have been pre- 
 
 20 
 
230 TREAT3IENT OF THIS FORM OF MORTIFICATION. 
 
 vented ; although it is probable, from the pressure arising 
 from the great extravasation and coagulation of blood, that 
 the collateral circulation was so much impeded as not to 
 have been able to maintain the life of the limb below even 
 during that time. The incision made on the 2d saved the 
 life of the patient, by taking off the tension of the part, and 
 relieving thereby in a remarkable manner the constitutional 
 irritation which hourly appeared likely to destroy him ; in- 
 deed, 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. 
 
 1'he 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 
 ]eg, may be sawn through at or below the line of separa- 
 tion, and nearly the whole of the mortified soft parts re- 
 moved, so as to leave little of those which are dead and 
 offensive. This operation is done without the patient feel- 
 ing it ; it gives rise to no irritation, inconvenience, or dan- 
 ger ; 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 pa- 
 tient, 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 
 
WOLNDS OF THE ARTERIES OF THE LEG. 231 
 
 and inward. It entered about two inches below and behind 
 the head of the fibula, and passed cut 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 morn- 
 ing 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 pero- 
 neal 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 incorrect- 
 ness 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 ampu- 
 tated. 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 liga- 
 tures on the wounded artery, would have saved this man's 
 leg and life. 
 
 Henry Yigarelie, 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, how- 
 ever, 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. 
 
232 ILLUSTRATIVE CASE. 
 
 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, increas- 
 ing 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 suppura- 
 tion 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 per- 
 ceived, 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 
 
ILLUSTRATIVE CASE. 233 
 
 little flaps, and gave greater facility in the use of the instru- 
 ments 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 dress- 
 ings, in lieu of the cold water, the stiffness becoming dis- 
 agreeable. 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 addi- 
 tional injury done to the nerves by the ball in its course 
 throuorh the leg. 
 
 This case, which has been followed by many others equally 
 successful, even after the femoral -artery had been ineffect- 
 ually tied, established the practice now followed in England 
 by all educated surgeons; and is another of those great 
 
 20* 
 
234 MODE OF ARRESTING HEMORRHAGE. 
 
 additions to surgery for which science is indebted to the 
 Peninsular war. 
 
 lyS. 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 posi- 
 tion the hemorrhage will be suppressed. It is more import- 
 ant 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 con- 
 cern 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 circum- 
 stances, 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 
 
WOUNDS OF THE AXILLARY ARTERY. 235 
 
 which is only to be acquired through precept supported 
 by experience, he surveys the scene with perfect cahnness: 
 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, repre- 
 sented me seated on a pack saddle on the back of a bourro, 
 (Anglice, a jack-ass,) on the top of the Pyrenees, expatia- 
 ting on their merits (which he did not believe) to the descend- 
 ants of the Bearnois of Henri Quatre on one side, and to 
 the children of the lieges of Ferdinand and Isabella on the 
 other; bat no one now disputes their accuracy. The sur- 
 gery 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 loiver extremity are equally to be 
 observed with respect to those of the iq^per. 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 subsclavian 
 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 favor- 
 able 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 
 
236 ILLUSTRATIVE CASE. 
 
 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 after- 
 ward, when a quantity of pus and blood, partly fluid, partly 
 >:oagulated, but very offensive, was discharged. The open- 
 ing WELS 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. Han- 
 cock, 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 exam- 
 ination 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 ap- 
 plied 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, hut 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 commu- 
 nicated with the artery, to which opening a small coagalum 
 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 
 
CAUSES ^F FAILURE. 23t 
 
 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 armputation. 
 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 pec- 
 toral 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 opera- 
 tion 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 
 
238 WOUNDS OF ARTERIES <fF ARM AND HAND. 
 
 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 par- 
 ticular, 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. 
 
 20T. 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 efi'ected 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 ap- 
 plied, and thus show the vessel injured. The 1)leeding point 
 should be fully exposed, and all coagula removed, when a 
 piece of lint, rolled tight and hard, but of a size only suffi- 
 cient to cover the bleeding point, should be laid upon it. A 
 
TREATMENT BY COMPRESSION. 239 
 
 second and larger hard piece should then be placed over it, 
 and so on, until the compresses rivse 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 neighbor- 
 ing 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 evac- 
 uated ; and if the back of the hand be then laid on a padded 
 splint, broader than the hand, a narrow roller may be so ap- 
 plied 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 cir- 
 culation 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, how- 
 ever 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 an- 
 swer 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, par- 
 ticularly 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 
 
240 REMOVAL OF METACARPAL BONES AND FINGERS. 
 
 events for a sufficient time to enable the injured parts to re- 
 cover 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 ac- 
 cidents, 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 meta- 
 carpal bone of the forefinger, should be cut through, and the 
 bleeding vessel exposed. They are the adductor pollicis on 
 the inside, and the abductor iudicis on back of the hand. 
 
PRIMITIVE CAROTID ARTERY NOT TO BE TIED. 241 
 
 LECTURE XIII. 
 
 WOUNDS OF THE ARTERIES, ETC. 
 
 211. The precept so strongly insisted upon, that no oper- 
 ation 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 opera- 
 tion 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 occur- 
 rence has been singularly overlooked by practical surgeons; 
 although proving, in a very marked manner, that the opera- 
 tion 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 diffi- 
 culty 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 knowl- 
 edge ; 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 ex- 
 ternal carotid which should be secured, rather than the 
 primitive trunk ; there not being sufficient reason for cut- 
 ting 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. 
 
 21 
 
242 WOUNDS OF THE VERTEBRAL ARTERY. 
 
 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. Bres- 
 chet, 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 vertebrae. 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 vertebrge. 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 com- 
 mon carotid was tied, but as this did not arrest the pulsa- 
 tions 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, ar- 
 rived, 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 
 oesophagus internally, and the common carotid artery, the 
 internal jugular vein, and the pneumogastric nerve ex- 
 ternally, 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 
 
WOUNDS OF THE VERTEBRAL ARTERY. 243 
 
 days, and had large doses of opium; she improved con- 
 siderably 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 oc- 
 casion. When, however, it broke out a third time, the 
 surgeons proceeded at once to search for the bleeding ves- 
 sel. 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 sup- 
 posing 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 favor- 
 ably at first ; the threads fell on the ninth day after the de- 
 ligatiou of the vessel, and the patient remained in a satis- 
 factory state for the next five days, when severe febrile 
 symptoms, uupreceded 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. 
 
244 WOUNDS OF THE VERTEBRAL ARTERY. 
 
 On the post-mortem examination, the course of the ball 
 was found as stated above, viz., it had run from the integu- 
 ments to the body of the sixth cervical vertebra, leaving the 
 trachea and oesophagus 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 ver- 
 tebra 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 aper- 
 ture, evidently of very recent formation. This aperture re- 
 sulted clearly from the necrosis of the thin shell of bone 
 which formed the bottom of the canal. The cancelous text- 
 ure 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 ex- 
 ternal carotid above the hole in the artery, which still con- 
 tinued 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 ex- 
 amination after death, the arteries referred to were found to 
 
UTTER INSUFFICIENCY OF ONE LIGATURE. 245 
 
 be obliterated for some distance above and below the parts 
 injured. 
 
 The utter inefficiency of everj'thing 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 ad- 
 mitted, 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 suc- 
 ceeded, and is therefore most approved. / am icilling, 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 liga- 
 ture 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 pro- 
 priety or fairness, nor ought the one to be compared with 
 the other, although it is done ; and thus the subject is mysti- 
 fied 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 
 
 21* 
 
246 OPINION OP M. VELPEAU. 
 
 the two operations are essentially distinct. The operation 
 of Anel for aneurism of the popliteal artery would be de- 
 structive ; the operation of Hunter for a wound of the 
 popliteal artery would be equally so. 
 
 This point must, however, be pressed further. Let us sup- 
 pose 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 impracticahle 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. 
 Yelpeau on this subject, as showing the greater advance 
 Parisian surgeons have made than even many of high attain- 
 ments 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 thy- 
 roid 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 : "Sur- 
 geons 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; hut this is not admissible in the present day.''^ 
 Operating for a tumor on the left temple, which he consid- 
 
DR. TWITCIIELL'S CASE. 24t 
 
 erecl aneurism al, he first tied the common trunk of the ca- 
 rotid, and then the internal. The tumor diminished in size, 
 but hemorrhage took place from the wound, and was fre- 
 quently 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, i^. 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, al- 
 though 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 down- 
 ward, 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 suc- 
 ceeded in separating the artery from its attachments ; and, 
 passing my finger under it, I raised it up sufficiently for my 
 assistant to pass a ligature round it. She tied it with a sur- 
 
243 LIGATURE OF TH£ INTERNAL CAROTID. 
 
 geon's knot, as I directed, about half an inch below the bifur- 
 cation." Dr. Twitchell removed his thumb, and sponged 
 away the blood, not doubting that the hemorrhage was 
 effectually controlled ; but, to his surprise and disappoint- 
 ment, 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 ob- 
 liquely 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 ofi". 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 in- 
 ternal 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 atten- 
 tion 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 ioeh, more or less, 
 as maybe-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 
 
DR. KEITH'S CASE. 249 
 
 of the lower jaw, until the end of it is opposite the lirst 
 molar tooth. This incision should divide the skin, super- 
 ficial 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 cel- 
 lular 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 inter- 
 nal carotid may be felt, seen, and secured by ligature with 
 comparative facility outside the tonsil, there being between 
 them the superior constrictor of the pharnx, which, in a case 
 of wound through the mouth, must have been divided. The 
 pneumogastric nerve should be drawn outward, and the ex- 
 ternal 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 oper- 
 ation requires a thorough knowledge of the anatomy of the 
 parts, is true ; and this can only be acquired by repeated dis- 
 sections. 
 
 21 1. 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 re- 
 moval. 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 
 
250 LIGATURE OF THE AORTA. 
 
 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 be- 
 low its angle. IS^o 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 oesophagus, 
 which it did to her great satisfaction and relief from further 
 anxiety. 
 
 LECTURE XIY. 
 
 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 man- 
 ner 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 opera;tion ; 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 carry- 
 ing the finger along the common iliac, the comparative situ- 
 ation of that vessel is next to be estimated. 
 
 The length of the two common iliac arteries varies accord- 
 ing to the stature of the patient, and the place at which the 
 
LIGATURE OF THE COMMON ILIAC ARTERY. 251 
 
 aorta bifurcates. The common iliacs again divide into the 
 external and internal iliaCvS, which division is usually opposite 
 to the sacro-iliac symphysis. The ienscth 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 com- 
 mon iliac into external and internal can always be ascer- 
 tained, during an operation, by tracing the external iliac up- 
 ward 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 becom- 
 ing 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 incon- 
 venience 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 up- 
 ward, 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 
 
252 LIGATURE OF THE COMMON ILIAC ARTERY. 
 
 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 pulsa- 
 tion. 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 pro- 
 ceeding, 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 
 
LIGATURE OF THE COMMON ILIAC ARTERY. 253 
 
 toward the ribs, ^reat diflBculty 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 transver- 
 salis, 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 diffi- 
 culty, 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 remem- 
 bered 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 
 
 22 
 
254 LIGATURE OF THE COMMON ILIAC ARTERY. 
 
 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 con- 
 tents, 1 found I could only get one hand, or a little more, 
 underneath it in search of the artery, the tumor below pre- 
 venting 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 en- 
 deavored 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 aneu- 
 rismal 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 peri- 
 toneum 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 burst- 
 ing asunder from the movements of the patient. This oper- 
 ation was only formidable, as a whole, from the circumstance 
 that space could not be obtained for the introduction of both 
 hands; for, strange as it may appear, the safety of and ease 
 in doing the operation depend on the first incision in the 
 fore part of the abdomen being so large that the peritoneum 
 containing the bowels may be freely drawn over by the ex- 
 
LIGATURE OF THE COMMON ILIAC ARTERY. 255 
 
 panded hands of the assistant, so that the operator can see 
 what he is doing beneath, in my first case the whole of the 
 parts under the peritoneum could be distinctly seen, and 
 several gentlemen (not in the profession) who were present 
 saw the common iliac artery in its natural situation. 
 
 The patient sufi'ered little or nothing from the operation, 
 which was performed on the Saturday; there was no aug- 
 mentation of the pulse until Sunday evening, when it rose 
 to 120; she then experienced some pain, which was mate- 
 rially 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 dimin- 
 ished, 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 caecum 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 an- 
 terior 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. 
 
256 LIGATURE OF THE INTERNAL ILIAC ARTERY. 
 
 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 pre- 
 vents 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 dis- 
 eased 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 ren- 
 dered unnecessary — a most important result, deduced from 
 the operation described. 
 
 220. If the inteinial 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 accompa- 
 nies, 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 spatulee curved 
 at the ends, so as to take up as little space as possible, and 
 not to injure the peritoneum. The surgeon should, if pos- 
 sible, 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 every- 
 thing 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, 
 
LIGATURE OF THE EXTERNAL ILIAC ARTER'f. 257 
 
 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 addi- 
 tional 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 di- 
 vided, 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 po'nt 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 circum- 
 flexa 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 obvi- 
 ous, 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 
 
 22* 
 
258 LIGATURE OF THE EXTERNAL ILIAC ARTERY. 
 
 best mode of proceeding when the aneurismal swelling in the 
 groin has encroached on Poupart's ligament. 
 
 Another method has been recommended bj 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 ex- 
 poses 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 abdo- 
 minis 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 cir- 
 cumflexa ilii arteries. The iliac artery is placed upon the 
 outer side of the vein ; the next step in the operation con- 
 sists 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 con- 
 taining 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 inci- 
 sion 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 
 
LIGATURE OF THE GLUTEAL AND SCIATIC ARTERIES. 259 
 
 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 
 Avail 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 opera- 
 tion 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 
 
2 GO DR. tripler's case. 
 
 woniid being always the best guide; care should betaken 
 in every instance to include nothing in the ligature but the 
 artery. 
 
 Dr. Tripler, of the TJiiited 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 he 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 hemor- 
 rhages 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 arte- 
 ries, 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 liga- 
 ture 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 
 sloiuhj 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 
 
LIGATURE OF THE FEMORAL ARTERY. 261 
 
 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 tiie 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 out- 
 ward, 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 liga- 
 ment. 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 rela- 
 tive 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 liga- 
 ment, 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. 
 
2C2 LIGATURE OF THE FEMORAL ARTERY. 
 
 The fascia lata is now to be divided, with that part of the 
 fascia transversalis which, descending beneath Poupart's b'ga- 
 ment, 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 den- 
 tists' 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 stick- 
 ing-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 wound- 
 ing the superficial femoral artery, will necessitate the appli- 
 cation of two ligatures, one above and the other below the 
 w^ound in the vessel ; but as the profunda under ordinary 
 circumstances is given off posteriorly at this spot, it is pos- 
 sible 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 pro- 
 funda sought for and tied. It has been argued that the 
 ligatures, being applied close to the origin of collateral 
 
OPERATION FOR POPLITEAL ANEURISM. 263 
 
 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 communi- 
 cated 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 
 
264 WARMTH OF THE LIMB TO BE MAINTAINED. 
 
 artery has been detached, and is to be tied with a double 
 knot. The wound is to be dressed as in the previous ease 
 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 inter- 
 ference with the sartorious is avoided. It is the improve- 
 ment 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 absorb- 
 ents; as to the saphena vein, it can always be seen, and its 
 course traced up the thigh and avoided. After the first in- 
 cision 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 circumstauces ; 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 main- 
 tained 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; 
 
WOUND OF THE POPLITEAL ARTERY. 265 
 
 if this continue until the third day, when the fear of mortifi- 
 cation 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 liga- 
 ture, unless wounded and bleeding. Under ordinary circum- 
 stances, 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 acci- 
 dent; 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 band- 
 age applied, and an assistant left in charge. The day fol- 
 lowing 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 com- 
 pression, 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 
 
 23 
 
266 LIGATURE OP THE POSTERIOR TIBIAL ARTERY. 
 
 pulsating strongly. In a few minutes a large stream burst 
 out, so large that 1 was satisfied it could not be from the 
 posterior tibial. I put mj finger in the sinus and found 
 that its direction was first backward, then backward and up- 
 ward. 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 pop- 
 liteal, 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 19t, 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 tibiahs 
 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 
 
COURSE AND LIGATURE OP THE PLANTAR ARTERIES. 26T 
 
 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 in- 
 cision 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 
 ofi* 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 gran- 
 ular 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 ordi- 
 nary 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 connect- 
 ing 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 
 
268 LIGATURE OF THE ANTERIOR TIBIAL ARTERY. 
 
 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 oper- 
 ation 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 pulsa- 
 tion 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 inter- 
 osseous 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 interosseoas ligament, between its two venae 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 in- 
 terosseous space or ligament. The bleeding is free, and from 
 the wound in the front of the leg, although the artery cannot 
 be secured, from the narrowness of the space between the 
 tibia and fibula, behind which space it is situated. This very 
 peculiar injury, which may, however, occur at any time, can- 
 
LIGATURE OF THE ANTERIOR TIBIAL ARTERY. 269 
 
 not be known until an incision has been made on the fore 
 part of the leg, and the bleeding point seen so deep between 
 the bones as not to admit of two ligatures being placed on 
 the artery above and below it. In such a case, an incision 
 is to be made through the calf of the leg, when the artery 
 can be secured without difficulty. Xo 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 im- 
 pede its effusion above the fascia and under the soleus mus- 
 cle, the distention of which and of the calf of the leg would, 
 to a careful observer, point out the evil, and lead to the oper- 
 ation 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 circula- 
 tion 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. 
 
 23* 
 
2 to LIGATURE OF THE CAROTID ARTERY. 
 
 LECTURE XY. 
 
 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 
 rayoides, 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-mas- 
 toideus muscle is then to be drawn outward, with any vein 
 which may be seen attached to its under edge. The pulsa- 
 tion 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 cross- 
 ing 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, particu- 
 larly 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 
 
LIGATURE OF THE CAROTID ARTERY. 211 
 
 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 undis- 
 turbed, 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 oesophagus, thoracic duct, or 
 thyroid artery, they are not likely to be injured by any com- 
 mon 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 sepa- 
 rate 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 be- 
 fore. The descendens noni nerve runs in general on the 
 outside of the artery in this part of the neck, and after- 
 ward 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 iutroducing 
 the aneurismal needle; and on bringing it out on the inside, 
 
2*r2 LIGATURE OF EXTERNAL AND INTERNAL CAROTIDS. 
 
 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 b'gature 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 pre- 
 cautions 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 in- 
 ward ; 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 ex- 
 ternal 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 recol- 
 lecting 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 en- 
 croach 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 
 
THE ARTERTA INNOMINATA. 2T3 
 
 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 innom- 
 inata, 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 
 
2*14 LIGATURE OF THE INNOMINATA, ETC. 
 
 of the scalenus anticus muscle is close to these two last ves- 
 sels. 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 sympa- 
 thetic 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 at- 
 tending 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 back- 
 ward, 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, avoid- 
 ing 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, 
 
CONNECTIONS OF THE LEFT SUBCLAVIAN ARTERY. 2t5 
 
 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. Graefe'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 efi'ects, 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 pos- 
 terior 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 ad- 
 heres to it, and can scarcely avoid being torn in putting a 
 
276 LIGATURE OF SUBCLAVIAN, ABOVE THE CLAVICLE. 
 
 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 oesophagus 
 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 sca- 
 lenus 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 de- 
 monstrate the impropriety of the operation. Aneurisms of 
 this nature are usually attended by some circumstances indi- 
 cating their more internal origin, independently of the in- 
 formation 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 accom- 
 panied by any alteration of the sterno-clavicular articula- 
 tion, the case is clearly one totally unfitted for any opera- 
 tion. The same may be said of any case of aneurismal 
 swelling, either internal or external to it, in which the stetho- 
 scope 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 cdrotid is more likely to be an 
 aneurism of the arch of the aorta, or of the arteria innomi- 
 nata, 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 maybe 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-raastoideus muscle, and carried outward to the 
 extent of three inches and a half or four inches. The pla- 
 tysma myoides and the superficial fascia are to be divided, 
 
LIGATURE OF SUBCLAVIAN, ABOVE THE CLAVICLE. 277 
 
 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-mas- 
 toideus 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 por- 
 tion 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 inter- 
 venes, 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-scapu- 
 lar artery and vein. The blunt knife, working in the trian- 
 gular 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 aneuris- 
 mal needle should be passed in preference from below up- 
 ward, by which the pleura will be avoided. After the liga- 
 ture 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 
 
 24 
 
2*78 LIGATURE OF THE AXILLARY ARTERY. 
 
 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-hjoideus 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 dan- 
 gerous 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 venae 
 comites. All other modes of attempting this operation are 
 unworthy consideration, and ought to be discarded as dan- 
 gerous and insufficient. 
 
 At the lower edge of the pectoralis minor, the artery is 
 crossed by the outer of the venae comites, which passes be- 
 tween 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 
 
LIGATURE OF THE BRACHIAL ARTERY. 2t9 
 
 root of the median nerve is in connection with the internal 
 cutaneous and ulnar nerves; the larger of the ven^ 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 fore- 
 arm, so as to cause the belly of the biceps to enlarge, when 
 pressure made immediately below it will arrest the circula- 
 tion 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 accom- 
 panied 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 superfi- 
 cial 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 integu- 
 ments 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 cuta- 
 neous 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 im- 
 mediately 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, 
 
280 COURSE OF THE ULNAR ARTERY. 
 
 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 ex- 
 cluding 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 ten- 
 don 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 in- 
 clines 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 raid- 
 die of the arm, and is then separated from it by the ulnar 
 origin of the muscle. The artery continues its course, in- 
 clining outwardly, under the pronator radii teres, the flexor 
 carpi radialis, the palmaris longus, and the flexor sublirais 
 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 ob- 
 liquely 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 con- 
 tinued 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 
 
LIGATURE OF THE ULNAR ARTERY. 281 
 
 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 inconve- 
 nience 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 pul- 
 sation 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, be- 
 neath 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 pro- 
 ceeding the artery will be readily exposed, which is not al- 
 ways 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 
 
 24* 
 
282 LIGATURE OF THE RADIAL ARTERY. 
 
 will be felt below the deep-seated fascia, and, on dividing it, 
 will be seen with its vense 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 venae 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 venae comites over 
 the insertion of the pronator radii teres and the radial ori- 
 gin 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 super- 
 ficial and deep fasciae 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 quad- 
 ratus, whence it turns below the styloid process of the radius 
 to the back of the hand. 
 
 The radial artery, on giving off the superficialis volae to 
 
INJURIES OF THE HEAD. 283 
 
 the palm of the hand, near the end of the radius, inclines 
 outward, and, when between its styloid process and the tra- 
 peziura, 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 be- 
 fore 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 inconve- 
 nience. 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 XYL 
 
 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 
 
284 INJURIES OF THS HEAD. 
 
 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 pres- 
 ence 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 indicted 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 after- 
 ward, 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 symp- 
 toms arose demanding the use of the trephine; as none oc- 
 curred, and the wound healed, the man was sent home to 
 Colchester, where he got drunk, and fell dead in the market- 
 place. 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 re- 
 cover 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 manage- 
 ment. In civil life, both in hospitals and among private 
 persons, injuries of the base of the cranium are most fre- 
 quently met with, because they are generally the conse- 
 quence of falls; while in military life injuries of the base of 
 
RESPIRATION CONSISTS OP FOUR MOVEMENTS. 285 
 
 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 fol- 
 lowed, 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 de- 
 stroyed, not by the removal of the hemisperes, 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 move- 
 ment 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 open- 
 ing of the mouth and dilatation of the nostrils; 2, the open- 
 ing of the glottis ; 3, the elevation of the ribs ; 4, the con- 
 traction of the diaphragm. The division of the dorsal 
 spinal marrow, below the origin of the phrenic nerve, para- 
 lyzes the movement of the ribs; above the phrenic nerves it 
 paralyzes the diaphragm, and respiration ceases ; the yawn- 
 ing or opening of the mouth and glottis alone remain. On 
 dividing the point of origin of the par vagum, the move- 
 ments 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. 
 
286 EXCITO-MOTOR SYSTEM OF DR. MARSHALL HALL. 
 
 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 accident- 
 ally on any one of these parts in him, without being pro- 
 ductive 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 mus- 
 cular 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 eye- 
 lashes 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 
 
CONCUSSION OF THE BRAIN. 2ST 
 
 on the face, and stimulating the nostrils ; hj 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 mis- 
 chief 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 cpiickly 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 abstrac- 
 tion of blood by a rupture of the heart. 
 
288 CONCUSSION OF THE BRAIN. 
 
 Modern surgery has in fact added nothing to our inform- 
 ation 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 coin- 
 cide 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 examin- 
 ation 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 impercep- 
 tible 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 incon- 
 venience ; 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 
 
SYMPTOMS OP CONCUSSION OP THE BRAIN. 289 
 
 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 appar- 
 ently lifeless, but it soon appeared that it was only stunned ; 
 it breathed deeply, looked about vacantly, and conld 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 subse- 
 quent day. 
 
 In more dangerous cases which ultimately prove fatal, 
 the laceration of the brain alluded to complicates the mis- 
 chief 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. 
 
 24t. 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 apo- 
 plexy;) 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 recoved 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 sub- 
 stances 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 dis- 
 tinct inspiration, repeated at so distant an interval as to 
 
 25 
 
290 SYMPTOMS OF CONCUSSION OF THE BRAIN. 
 
 render its recurrence uncertain. At last respiration is satis- 
 factorily established, and the pulse, which was doubtful at 
 the commencement of the restoration to existence, becomes 
 perceptible, although often irregular, and sometimes con- 
 tinues 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 Inngs 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 per- 
 sonal maltreatment; and in this condition he may remain 
 for many days ; he draws away or moves the part aggrieved ; 
 he may be able to answer in a monosyllable correctly or 
 otherwise to questions loudly put, as if to rouse him from 
 slumber ; but if the answer should be longer, it will generally 
 be incoherent. The pupils are for the most part in a medium 
 or in a contracted state, but rarely dilated. Stimulants 
 were formerly given at and up to this point, with a view of 
 reviving and restoring the patient to greater activity, and to 
 prevent a relapse into his former state. Dissection has, 
 however, proved that it is a state in which congestion is 
 about to be followed by inflammation of the brain or of its 
 membranes ; that the stage succeeding to this is one of active 
 inflammation, even if the patient should eventually recover; 
 and if he relapse into that state of stupefactive insensibility 
 which precedes death, sufficient evidence to account for his 
 decease may be found in the laceration of the substance of 
 the brain, in small extravasations in various parts, or in 
 other mischief which may not perhaps be expected. Pre- 
 
SYMPTOMS OF SECOND STAGE OF CONCUSSION- 291 
 
 viously to this stage of fatal termination, the muscles are 
 not relaxed, and do not lose their tone, as in a similarly 
 fatal case of compression of the brain ; the urine does not 
 flow involuntarily until after the spinal marrow has been 
 some time seriously implicated, and death is at hand. This 
 renders it necessary, in all cases of injury of the head, to 
 attend to the state of the bladder, which may become dis- 
 tended, 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 con- 
 venient 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 conscious- 
 ness 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, ot assoupissement, 
 
292 SYMPTOMS OP SECOND STAGE OP CONCUSSION. 
 
 continues, althougli 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 incor- 
 rectly ; 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 con- 
 tracted ; 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 — some- 
 times dilating on the admission of light, sometimes contract- 
 ing; 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 ob- 
 longata. 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 ; never- 
 theless he frequently speaks more or less incoherently, mut- 
 ters 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 ca- 
 rotids 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 con- 
 vulsions, the absolute loss of any sense, or paralysis of any 
 or the whole of a part, the case is complicated by laceration 
 
SYMPTOMS OP SECOND STAGE OP CONCUSSION. 293 
 
 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 ordi- 
 nary 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 per- 
 haps 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 numb- 
 ness, 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 danger- 
 ous sign of such mischief having taken place when it is per- 
 manent; 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, extravasa- 
 tion or lesion ; and the heavy or labored breathing to be 
 dependent generally on a derangement of fanction, which 
 is not perceptible on examination. If there be truth in 
 experimental anatomy, stertorous breathing ought to be de- 
 pendent 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 in- 
 capable of influencing the sphincter ani, which was soon fol- 
 
 25* 
 
294 SYMPTOMS OP SECOND STAGE OP CONCUSSION. 
 
 lowed by incontinence of urine. His intellectual faculties 
 were never affected after the first insensibility ; and on the 
 third day he rode on a mule, with care, twenty miles to 
 Lisbon. Many months elapsed before he recovered the 
 necessary command over the sphincter ani. Years have 
 elapsed, and he cannot now always retain his urine. In this 
 case the spinal marrow would seem to have been principally 
 affected. 
 
 It is important to recollect that the stupefaction or insen- 
 sibility 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 at- 
 tended 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 circu- 
 lation 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 com- 
 plaint than he could otherwise have done. 
 
 A laboring man, thirty years of age, fell from a height 
 
TREATMENT OE CONCUSSION. 295 
 
 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 sphinc- 
 ters. 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, accom- 
 panied 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 convul- 
 sions 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 neces- 
 sary to relieve the symptoms, or at least to cause a near ap- 
 proach to fainting, for nothing less can relieve such a person 
 efl'ectually, and give him a fair chance for life. The bleeding 
 must be steadily repeated as the symptoms recur until relief 
 
296 INFLAMMATION OF BRAIN, TENDING TO EFFUSION. 
 
 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 ipecacuanhse 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 fur- 
 ther evil was entertained until he awoke one morning, 
 evidently talking incoherently. As the gout had nearly dis- 
 appeared from his feet, sinapisms were applied to both ; pur- 
 gatives 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, with- 
 out advantage ; as all the symptoms appeared to be increas- 
 ing, at four in it^ 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 ob- 
 
TREATMENT OF CONCUSSION — ILLUSTRATIVE CASES. 297 
 
 ject 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 in- 
 flammation 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. Find- 
 ing the pulse at 60, regular and full, although compress- 
 ible, 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 
 
293 USE OF CALOMEL AND OTHER REMEDIES. 
 
 large; it should increase with the urgency for its abstrac- 
 tion, and diminish with the frequency of the repetition, being 
 always, however, carefully regulated by the effect. The in- 
 ability 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 adminis- 
 tered, 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 oint- 
 ment. 
 
 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 symp- 
 toms of concussion were complicated by those which are com- 
 monly 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, 
 
CONCUSSION COMPLICATED BY MANIA. 299 
 
 when he rallied, and answered questions, although imper- 
 fectly. 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 him- 
 self, 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 exam- 
 ination, a starred fracture without depression was found cor- 
 responding 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 proc- 
 esses, 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 extrav- 
 asated 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 mis- 
 chief. ' 
 
 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 
 
300 EFFECTS OF CONCUSSION AT A LATER PERIOD. 
 
 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 ; res- 
 piration deep and rapid, without stertor ; the sphincters not 
 relaxed. A turpentine enema was given, and a calomel pill 
 was swallowed with great difficulty. Tlie head was shaved, 
 and a cold lotion applied ; he soon afterward became vio- 
 lent, 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 acci- 
 dent. 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 t2 ; bowels open, and is free from restraint. 
 At seven in the evening, he suddenly started up in bed, say- 
 ing 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 insensi- 
 bility 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 
 
RELAPSES FROM IRREGULARITIES. 301 
 
 gig near Houuslow, 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 tem- 
 ples, 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 interrup- 
 tion 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 ex- 
 tremely frequent, and gradually but certainly undermine the 
 health ; they are, in fact, connected with chronic derange- 
 ment of the brain, or of its membranes ; and unless success- 
 fully 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 orig- 
 inally been of any apparent importance, such a state of irrita- 
 tion, if it occur, combined with debility , is very difficult to 
 
 26 
 
302 WOUNDS OF THE HEAD. 
 
 manage ; it requires a combination of local as well as of gen- 
 eral means for its cure. A few leeches and blisters may be 
 applied alternately over the part affected, with great advant- 
 age ; 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 efi&cacious remedy. 
 
 LECTURE XYIL 
 
 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 fliuid 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 sub- 
 stance, 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 circu- 
 lation ; 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 secret- 
 ing 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 
 
MOTIONS OF THE BRAIN. 303 
 
 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 conse- 
 quence 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, un- 
 less 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 dimin- 
 ished;" 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 pre- 
 vented from doing so by these means being adopted, which 
 they declare, nevertheless, to be very unladylike, although 
 they may be doctorial and efi'ective. 
 
 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. Eluid 
 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 sonie 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 
 
304 SYMPTOMS OP COMPRESSION OP THE BRAIN. 
 
 indistinct, even if they can be perceived. These two points, 
 viz., the protrusion into the opening and the absence of pul- 
 sation, 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 derange- 
 ment takes place in its integral parts, which may be best 
 understood by the word compression. If we further con- 
 sider 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 com- 
 pression, all, or nearly all, the vessels, as far as we can ascer- 
 tain, 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 frac- 
 ture of the cranium, immediately recover his senses after the 
 application of the trephine and the removal of a large coag- 
 ulum 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 ster- 
 tor, 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 
 
SYMPTOMS OP COMPRESSION OF THE BRAIN. 305 
 
 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 aflfected 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 doubt- 
 ful 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 irregu- 
 larly outward or inward, causing strabismus, which is, how- 
 ever, a more rare occurrence. If the eyelids should be par- 
 tially 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 convul- 
 sive 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 w^hen 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 
 
 2(.* 
 
306 PARALYSIS OP THE OPPOSITE SIDE TO THE INJURY. 
 
 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 de- 
 gree 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 ex- 
 tremity, 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 admit- 
 ting 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 evea of the cere- 
 bellum, 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 fi'om the same injury appar- 
 ently 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, 
 
PARALYSIS OP THE SAME SIDE AS THE INJURY. 30Y 
 
 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 par- 
 alyzed ; 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 oppo- 
 site, 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 out- 
 side 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 af- 
 terward. On dissection, the peculiar flatness of the convo- 
 lutions 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 with- 
 out 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 con- 
 
308 CONVULSIONS, GENERAL OR PARTIAL. 
 
 vulsive fits, are always important symptoms ; yet they seem 
 in some persons to be dependent on idiosyncrasy, particu- 
 larly when they appear early, and after the loss of blood, in 
 which case they are less dangerous. They occur at differ- 
 ent periods after the receipt of the injury, and have been 
 supposed to depend in general upon laceration of the sub- 
 stance 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 ob- 
 served 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 con- 
 vulsions on injury of the other. When the effect of the 
 mischief is so great as to cause complete paralysis, convul- 
 sive twitches do not take place, although they frequently 
 precede, and may in many cases be considered as premoni- 
 tory signs, while the evil which gives rise to the paralysis is 
 gradually accumulating. When the paralysis is not com- 
 plete, the side so affected suffers sometimes from slight con- 
 vulsive twitches, while well-marked spasms prevail in the 
 other, leading to the belief that, while paralysis is an affec- 
 tion 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 con- 
 fined to a part ; for partial convulsive motions do very fre- 
 quently 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 appar- 
 ently 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 sub- 
 stance, although they are frequently wanting. They may be 
 expected to take place about and after the fifth day in inju- 
 ries of the head, when inflammation of the brain or of its 
 
ILLUSTRATIVE CASES. 309 
 
 membranes is about to extend to or to become continuous 
 with the neighboring parts, and may be more or less severe, 
 varying from a slate 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 con- 
 traction of the limbs. It is far different with those convul- 
 sive movements which, at a late period, become nearly per- 
 manent, 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 fre- 
 quently 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 dif- 
 ferent 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 in- 
 sensible 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 l^g, 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 tre- 
 phine having been necessary. Immediately after the re- 
 moval 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 Yar- 
 mouth, never having had a bad symptom, the only defect 
 remaining on the right side being an inability to grasp any- 
 
310 ILLUSTRATIVE CASES. 
 
 thing in his hand with force. The pulsation of the brain was 
 
 still visible at the bottom of the wound for about the space of 
 half the circumference of the crown of the trephine. Septem- 
 ber 16th, 1815 : the wound has filled up with healthy granu- 
 lations, 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 hoth 
 parietal bones. When he had recovered his senses he suf- 
 fered 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 sick- 
 ness, lowness of spirits, and general illness immediately sub- 
 sided, and the loss of power in the lower extremities gradu- 
 ally 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 convul- 
 sions, 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 por- 
 tion of the latter, and beyond it; this, with a rather large 
 extravasation of blood under and in the course of the frac- 
 ture, appeared to be sufficient not only to destroy life, but 
 to have caused paralysis of the left side, which, however, it 
 
FISSURE OR SIMPLE FRACTURE OP THE SKULL. 311 
 
 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 
 fally to account for the paralysis which took place. on the 
 right side. According to the surgery of the French Aca- 
 demicians 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 oppo- 
 site to that practiced by many surgeons, almost unto the 
 present day. 
 
 If the integuments or scalp be divided, and the bone fis- 
 sured, 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 in- 
 sisted on \ji 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. sennas cum magnes. sulphate, were given, and acted 
 well, and he was greatly relieved. - The calomel was con- 
 tinued every six hours. In the evening, however, the pain 
 and tightness of the head returned, with a pulse of 110, 
 
312 THE TREPHINE NOT TO BE APPLIED. 
 
 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 quick- 
 ened 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 ad- 
 ministered 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 treat- 
 ment ; 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 symp- 
 toms 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 fol- 
 low, however, that blood must necessarily be poured out in 
 
SYMPTOMS FOLLOWING A FRACTURE. 313 
 
 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 inter- 
 ference 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 derange- 
 ments. 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 regu- 
 late 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 recover- 
 ing 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 
 
 27 
 
314 INJURY OP THE MIDDLE MENINGEAL ARTERY. 
 
 indicate essential mischief; they will be removed, if of a 
 temporary nature, by a further moderate bleeding, by purga- 
 tives, and by greater restriction in diet, through irregulari- 
 ties 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 consid- 
 erable extent without causing any particular symptoms, al- 
 though 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 con- 
 fidently 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 
 
ILLUSTRATIVE CASES. 315 
 
 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 iiTitation 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 Yimiera, on the British 
 Infantry under the command of the late Sir Ronald Fergus- 
 son. 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 ex- 
 tending 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 
 
316 FRACTURE FROM CONTRE-COUP. 
 
 no blood beneath the dura mater. The convolutions of the 
 brain were depressed and flattened bj 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 em- 
 ployed, 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 de- 
 pression at the inferior part of the parietal bone before and 
 above the ear. The end of the elevator having been intro- 
 duced, a small piece of bone was first raised, then another, 
 and a third, when a thick coagulum was exposed and re- 
 moved. 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. 
 
FRACTURE OF THE BASE OF THE CRANIUM. 31 Y 
 
 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 g:eneral 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 Hos- 
 pital, 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 per- 
 fect 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 six- 
 
 27* 
 
318 ILLUSTRATIVE CASES. 
 
 teen ounces, when his pulse rose to 76, and the breathin^r, 
 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 stu- 
 pidity, accompanied by extreme listlessness; answered ques- 
 tions 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 sub- 
 ject 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 after- 
 ward 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 re- 
 cently 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 con- 
 tained 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 
 
ILLUSTRATIVE CASES. 319 
 
 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 
 healtliy, 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 Yidian canal; the edges of this fracture, 
 both internally and externally, had been rounded by absorp- 
 tion ; 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 for- 
 ward. The connection between the articular processes of 
 the second and third cervical vertebrae 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 por- 
 tion, 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 be 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 ob- 
 served. Pulse 80. He was well purged, but lost no 
 blood, as he was apparently weak and the pulse soft ; it fell 
 
320 ILLUSTEATIVE CASES. 
 
 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 aifected, occasionally drinking in spite of all remon- 
 strance ; he then returned to his work on the piers of West- 
 minster 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 depres- 
 sion 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. Y. 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. Y. S. ad ^xiv relieved the pain in the head. 
 Pulse 56. 4th day. Restless and delirious at night ; pulse 
 60, regular; bowels open; headache. Y. S. ad ^xiv. No 
 discharge from the ears. 6th day. Slightly paralytic on 
 the left side of the face, tongue drawn to that side ; head- 
 ache, restless, delirious ; faces and urine passed unconsciously ; 
 pulse 80. Y. S. ad ^xx. Pulse rose to 100, and was weaker. 
 Calomel, gr. iii every six hours. *7th day. Pulse 88, com- 
 pressible ; 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 
 
FRACTURE OF THE INNER TABLE. 321 
 
 is generally better ; bowels well purged ; paralysis of the 
 face continues. Has taken a little farinaceous food. Con- 
 tinue calomel and inf. sennae. 10th day. Improved; slept 
 tolerably well. 12th day. Continues to improve. Omit 
 the calomel, but continue the infus. sennge. 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 XYIII. 
 
 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 Brus- 
 sels. A large splinter of the inner table was driven more 
 than an inch into the brain, and on its extraction the pa- 
 tient's senses and power of voluntary motion instantly re- 
 turned. 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 
 informatioTi 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 oc- 
 currence. I have never, in the great number of broken 
 heads I have had under my care on many different and 
 
322 - FRACTURE OF THE INNER TABLE. 
 
 grand occasions, actually known the inner table to be sepa- 
 rated 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 prepos- 
 sessed 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 prac- 
 tice 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 irrita- 
 tion 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 considera- 
 tion. 
 
 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 dis- 
 tinct fracture of the inner table, about three-quarters of an 
 inch long, was seen corresponding to the external part in- 
 jured, extending outwardly as far as the diploe, but no 
 farther. The dura mater adhered firmly everywhere, ex- 
 cept 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 
 
FRACTURE OF THE INNER TABLE. 323 
 
 in the course of the first treatment, but occur afterward ; or 
 the unfavorable symptoms, never having been entirely re- 
 moved, 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-look- 
 ing 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 con- 
 tinued 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 dis- 
 turbance of the cerebral functions. 
 
 During the following twelve months the symptoms re- 
 mained 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 West- 
 minster 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, im- 
 perfect, 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, 184L — 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 
 
324 PECULIAR FRACTURE OF THE INNER TABLE. 
 
 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 com- 
 mencing 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 sam.e 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 antiphlo- 
 gistic 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 
 
ILLUSTRATIVE CASES. 325 
 
 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 thick- 
 ness may be measured, and the presence or absence of the 
 inner table may thus be ascertained. If it should be sepa- 
 rated 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 Sco- 
 tia, 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 sufi*ered 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 Sco- 
 tia, was struck, in a drunken frolic, on the anterior part of the 
 left parietal bone, with his own sword, which was a straight, 
 
 28 
 
326 ILLUSTRATIVE CASES. 
 
 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 in- 
 creased, 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 spiculte of bone coming away 
 during the cure. Keturning to England, the vessel was taken 
 ofiF the Scilly Islands, and he was sent to Yerdun, where he 
 remained several years, until liberated by the peace of 1814, 
 when he rejoined his regiment, which had served in the Pen- 
 insula, 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 propen- 
 sity to set out walking for hours without apparently know- 
 ing 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 Eng- 
 land, 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 Bo- 
 den, in front of Ciudad Rodrigo, from a sword, on the top 
 of the head ; he accompanied me to Alfaiates, on the retreat 
 
TREPHINE AT DIFFERENT PERIODS. 32T 
 
 of the army. The bone was apparently only cut through, 
 yet the inner table was depressed, and felt rugged when ex- 
 amined 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 sev- 
 eral 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 Sala- 
 manca, were under my care, and among them there were sev- 
 ral 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 im- 
 mediate 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 observa- 
 tions 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 tre- 
 phining 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 
 Quy 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 hesi- 
 tate 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 suppu- 
 ration 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 
 
328 SPLINTERS OF BONE TO BE REMOVED. 
 
 is deadly, "la cliirurgie 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 vomit- 
 ing 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 for- 
 eign body. The brain under ordinary circumstances is much 
 more likely to recover from an injury, all foreign or irrita- 
 ting 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 Ibe 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 symp- 
 toms 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 
 
DEPRESSION IN A CHILD AND IN AN ADULT. 329 
 
 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 por- 
 tions 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 tre- 
 phine 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 shght depres- 
 sion or separation of the inner table, but that several points 
 of it have been driven into the dura mater. If one tre- 
 phine 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 
 spiculse 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 Pare 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 suffi- 
 cient 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 leav- 
 ing the broken portions of bone as a constant cause of irri- 
 tation. 
 
 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 per- 
 sons is softer and less consistent, and can accommodate itself 
 
 28* 
 
330 QUESTION AS TO THE DIVISION OF THE SCALP. 
 
 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 appli- 
 cation 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 evi- 
 dently depressed, thus rendering a simple although commi- 
 nuted 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 de- 
 pend 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 sur- 
 geon 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 differ- 
 ence between the two states in fractures of the skull has, 
 however, been much exaggerated ; so much so, that no reli- 
 ance 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, rais- 
 ing 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 
 
ILLUSTRATIVE CASES. 331 
 
 a result is not likely to be obtained, the practice recom- 
 mended 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 depres- 
 sion, 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 en- 
 tered 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 pass- 
 ing 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 exam- 
 ined 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 
 
332 ILLUSTRATIVE CASES. 
 
 upward and backward at least two inches, and could be dis- 
 tinctly 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 dimin- 
 ished, 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 1 6th of July, the wound began to open ; on 
 the 18th it was dilated and a portion of the cranium re- 
 moved 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. 
 Yenesection 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 8d. Doing remarkably well; the wound healthy; 
 the pulsation of the brain evident ; the power of speech per- 
 fectly 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 dis- 
 charged 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. 
 
ILLUSTRATIVE CASES. 333 
 
 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 sus- 
 picion 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. Y. 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 con- 
 siderable 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 
 
334 ILLUSTRATIVE CASES. 
 
 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 ex- 
 pose 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 in- 
 stance, as it certainly would have been after the 15th, if the 
 unfavorable symptoms had not yielded to the general treat- 
 ment; 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 
 
REMARKS ON THESE CASES. 335 
 
 admitted into the Depot de Mendicite 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 pur- 
 gative and a stimulating enema were ordered, and cold was 
 constantly applied to the head. 
 
 30th. He has been freely purged and appears more col- 
 lected ; 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 re- 
 peated, and ten ounces of blood were drawn from the tem- 
 poral 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 
 
336 DEDUCTIONS AS TO TREATMENT. 
 
 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 mat- 
 ter 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 oper- 
 ation for the relief of the patient after months of acute suf- 
 fering, 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 un- 
 equally 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 frac- 
 tured part, the surgeon must then decide, after the best esti- 
 mate 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 
 
FRACTURE AND COMPRESSION IN YOUNG PERSONS. 337 
 
 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 rup- 
 ture 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 neces- 
 sary for the formation of a scientific surgeon. 
 
 2T3. 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 depres- 
 sion 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 pre- 
 vent 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 depres- 
 sion reported to have been successfully treated without oper- 
 ation, 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 suflBciently 
 large to allow the offending body to be extracted through it, 
 
 2y 
 
338 SYMPTOMS OF CONCUSSION AND COMPRESSION. 
 
 the opening must be enlarged to enable it to be withdrawn 
 without further laceration. 
 
 27 4. Depressed portions of bone, accompanied by fracture 
 at the hack 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 be- 
 neath. When the principal symptom of compression is a 
 severe fixed pain in the part, although the state of the frac- 
 ture and depression would not alone have rendered the re- 
 moval 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 com- 
 pression 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 partic- 
 ularly 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, 
 
ILLUSTRATIVE CASE. 339 
 
 from which state he partially recovered, and vomited ; some 
 stupefaction, however, remained, although he could be made 
 to answer bv a little importunity. Pulse 62, irregular, breath- 
 ing 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 ques- 
 tioned. 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 im- 
 plicated 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 unaf- 
 fected, and the functions of ingestion and egestion were sat- 
 isfactorily 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 eftective, 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, demon- 
 strated 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 tlian 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 
 
340 TUMORS OF THE SCALP. 
 
 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 tremoussement is directly communicated to 
 the brain, giving rise to laceration or bruising of its struc- 
 ture 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, nu- 
 merous instances of which are given by the older French 
 authors. They were probably cases of laceration, the con- 
 sequence 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 mat- 
 ter was formed in a circumscribed spot on the other ; these 
 cases did sometimes, they say, although rarely, admit of re- 
 lief 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 exist- 
 ing at that part; although such operation, if done, might 
 accidentally be followed by success. 
 
 LECTURE XIX. 
 
 TUMORS OF THE SCALP, ETC. 
 
 21 6. 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 
 
SECONDARY TUMORS OF THE SCALP. 341 
 
 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 swell- 
 ing, 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 mat- 
 ter 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 oc- 
 cipital and parietal bones, if it were not for the absence of 
 all motion, which under such circumstances would be com- 
 municated 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 w^ere 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 re- 
 ceived, 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. 
 
 29* 
 
342 SUPPURATION ON SURFACE OP DURA MATER. 
 
 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 sec- 
 ondary 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 evacua- 
 tion, healthy granulations will spring up, and little or no ex- 
 foliation 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 be- 
 neath, on the dura mater, the bone should be removed by 
 the trephine. 
 
 Inflammation of the dura mater proceeding to suppura- 
 tion, 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 at- 
 tention has not perhaps been paid to another evil which fre- 
 quently 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 depres- 
 sion of the skull, and whose cases are recorded, suffered also 
 
ELEVATION OF THE DURA MATER. 343 
 
 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 propor- 
 tion 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 ad- 
 vantage, 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 de- 
 void, however, of that pulsatory motion which usually marks 
 its healthy state. An opening into it, under these circum- 
 stances, has allowed a quantity of blood or of purulent mat- 
 ter 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 pul- 
 sation are positive signs of there being a fluid beneath, re- 
 quiring 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 commence- 
 ment 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 
 
344 ELEVATION OF THE DURA MATER. 
 
 left parietal bone slightly, without depressing any part of it. 
 No symptoms followed requiring more than ordinary atten- 
 tion 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 com- 
 bined 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 in- 
 coherently ; 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, find- 
 ing him much worse, I directed it to be done by force, three 
 of his own regiment with others attending to assist the sur- 
 geons. 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 iu a state 
 of suppuration. He died that night ; and the next day they 
 saw the whole of the left hemisphere soft, yellow, and cov- 
 
ILLUSTRATIVE CASES. 345 
 
 ered 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 demand- 
 ing more than ordinary attention for the first fortnight, dur- 
 ing 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. Y. 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 be- 
 tween the dura mater and the bone at the base of the 
 cranium. 
 
 On the morning of the day that I performed this opera- 
 tion, I had done another of the same kind at the Hopital 
 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 con- 
 sequence of the tunica arachnoides which lines it being a 
 serous membrane; and that, if the inflammation which en- 
 
346 GUNSHOT WOUNDS OF THE SKULL. 
 
 sued did not cease at the adhesive stage, by the consolida- 
 tion 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 accu- 
 racy 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 in- 
 juries which occur in military warfare, in which large por- 
 tions 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 forma- 
 tion 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 irremedi- 
 able by art. 
 
 280. Grunshot 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 en- 
 larged 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 peri- 
 osteum 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 
 
BALLS PENETRATING THE BRAIN. 34Y 
 
 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 ap- 
 plied, 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 
 h ole 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 hap- 
 pens, although rarely, that a ball sticks so firmly in the bone 
 that it cannot be extracted by working round it in any ordi- 
 nary 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 suJbstance 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 
 
348 ILLUSTRATIVE CASES. 
 
 many days, until circumstances render it necessary to en- 
 deavor 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 occa- 
 sionally 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, how- 
 ever, 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 re- 
 ceived 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, to- 
 gether 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 Sala- 
 manca 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 
 
SUTURES SEPARATED BY MUSKET-BALLS. 349 
 
 the loall 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 for- 
 ceps before the remaining portion of the ball could be drawn 
 from under the bone, which was not depressed, the ball hav- 
 ing 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 divid- 
 ing 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 hap- 
 pen in young persons in whom the sutures are not obliter- 
 ated 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 attrib- 
 uted to the blow on the head, where a tumor was observ- 
 able. This, on being divided, showed a separation of the 
 
 30 
 
350 WOUNDS OF THE FRONTAL SINUS AND ORBIT. 
 
 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 longitu- 
 dinal 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, bat 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 regi- 
 ments 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 
 
WOUNDS OF THE ORBIT. 351 
 
 thick iron wire on the right eye, which blackened it. There 
 was no external wound; but as there was some bloody che- 
 mosis 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 exam- 
 ining 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 
 
352 PROTRUSION OF THE BRAIN HERNIA CEREBRI. 
 
 free discharge of the blood poured out, is of comparatively 
 little consequeuce. 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 con- 
 siderable portion of the skull has been lost or removed, the 
 brain then being ableto expand to such an extent as the in- 
 flammatory 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 danger- 
 ous occurrence. 
 
 In the first kind of protrusion, the dura mater must neces- 
 sarily 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 accom- 
 panied, 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 dis- 
 ease. 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 recoverd. 
 
 In the second kind of protrusion, or that which usually 
 although not necessarily takes place when the first or active 
 
ILLUSTRATIVE CASES. 353 
 
 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 prac- 
 tice 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 in- 
 stances, 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 in- 
 stances, 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 por- 
 tions 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 re- 
 moved, 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. Y. S. ad5xxiv. 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. 
 
 30* 
 
354 ILLUSTRATIVE CASES. 
 
 The wound looks clean ; the discbarge 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 en- 
 large rather at the base than at the upper part ; it was 
 touched slightly with lunar caustic without any pain or un- 
 pleasant 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. Dis- 
 charge 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 depress- 
 ing the fungus is perfectly distinct ; no constitutional de- 
 rangement. Was discharged cured to Bordeaux. 
 
 William Donaldson was admitted, on the 13th of April, 
 1814, into the Depot de Mendicite Hospital, having received 
 a gunshot wound in the head on the 10th of April, which frac- 
 tured the right parietal bone to a considerable extent. The 
 brain protrudes ; pulse quick and small ; bowels open. Y. S. 
 ad 3xvi. — 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. Y. S. ad Ixvi. Continue the 
 purgatives. — 15th. The pulse and bowels natural, the pro- 
 trusion 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 some- 
 thing better in appearance ; the fungus does not increase. — 
 19th. Is doing well, and does not complain of pain ; func- 
 tions 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 dimin- 
 ished ; secretions natural ; a small quantity of bone has come 
 away; discharge diminished. — May 4th. The wound is 
 
ILLUSTRATIVE CASES. 355 
 
 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 inci- 
 sion. Discharged cured to Bordeaux. 
 
 Gentle pressure was made on the protrusions, according 
 to the feelings of the individaals, 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 faint- 
 ing, 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 be- 
 came stationary, and during its diminution and secession. 
 The pressure was continued until after the wound had 
 healed. 
 
 I had occasion, at Santaiider, 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 Divi- 
 sion, 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 Yera, which had frac- 
 tured 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 de- 
 
356 EXFOLIATION OF THE CRANIUM. 
 
 gree of miscbief which gave rise to them. In the fatal cases 
 I have seen, the protrusion was manifestly a part of the sub- 
 stance 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 cir- 
 cumstances not less important, which led me to enjoin that 
 rigid system of management insisted upon in all cases of in- 
 jury 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 some- 
 times 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 fol- 
 lowed 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 ad- 
 heres firmly to the bone beneath, instead of sliding loosely 
 over it, and a deep hollow is formed, which would imply 
 
EFFECTS OF EXFOLIATION OF THE CRANIUM. 357 
 
 that g:reater 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 array, 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 with- 
 out 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, coma- 
 tose, 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 in- 
 tolerable pain in the part injured, as well as in the head 
 generally, as to be desirous of seeking relief by an opera- 
 tion, even at the risk of life. 
 
 These injuries are often accompanied during their prog- 
 ress 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 conven- 
 tional one has even been adopted, under my own observa- 
 tion. 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 
 
358 THE OPERATION OP TREPHINING. 
 
 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 circum- 
 stance; 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 open- 
 ing 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 
 
LOSS OF A LARGE PORTION OF THE SKULL. 359 
 
 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 dis- 
 coverable 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, how- 
 ever, 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 Xavarre, say that 
 in the year 1686 they took away nearly both parietal bones, 
 and the patient recovered and lived for thirty years after- 
 ward, 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 after- 
 ward. 
 
 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 Xaval Hospital at Plym- 
 outh 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 oc- 
 cipital.) 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 Xaval Hospital at Chatham. 
 During the six years he has been under observation, there 
 have been repeated attacks of erysipelas, followed by pro- 
 fuse suppuration. Both tables of the bones have suffered in 
 
360 REMOVAL OP BLOOD FROM THE DURA MATER. 
 
 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 excep- 
 tion 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 ac- 
 cordingly ; although their practice should not be implicitly 
 followed, repeated observation has shown that modern sur- 
 geons 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. 
 
WOUNDS OF THE SCALP AND SKULL. 361 
 
 A layer of blood is often extravasated very thinly over tlie 
 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 extrav- 
 asated 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 per- 
 ceived on or in that part, the removal of the bone is permis- 
 sible. 
 
 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 de- 
 stroyed. 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 turn- 
 ing 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 tlie 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 G-erman dragoon was brought to me in front of Ma- 
 
 31 
 
362 WOUNDS OF THE SCALP AND SKULL. 
 
 drid, who had received a slicing cut of this kind on the top 
 and side of the head, which caused a portion of the scalp and 
 parietal bone to be turned down over the ear, uncovering the 
 dura mater. Replaced and retained in its situation, the flap 
 and bone appeared to adhere, and the man recovered. In 
 the case of a Portuguese soldier cut down by the French 
 cavalry in a sortie during the second investment of Badajos, 
 a portion of bone cut off with a flap was quite loose, and was 
 removed. The patient did equally well. 
 
 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 cer- 
 tain 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 open- 
 ing 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 de- 
 posited in its circumference, so as in part to fill up the open- 
 ing, 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 
 
ERYSIPELAS OF THE SCALP. 363 
 
 any manageraent, 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 re- 
 quired ; 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 dis- 
 charge 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 w^ould follow; which neither bleeding, purging, nor 
 the other constitutional remedies which the state of fever 
 may indicate will remove. If it should be neglected, sup- 
 
364 INCISED OR PUNCTURED WOUNDS. 
 
 puration and sloughing will extend under the tendon of the 
 occipito-frontalis, or the fascia of the temporal muscle, and 
 the greatest danger will be incurred from this additional 
 cause. 
 
 LECTURE XX. 
 
 WOUNDS or THE CHEST. 
 
 295. Wounds penetrating the wall of the chest, and im- 
 plicating 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 sur- 
 geon. 
 
 296. Incised ov 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 de- 
 pends, 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 pneumo- 
 nia, 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 ITth August, 1808, in the act of leaving the vil- 
 lage of Colombeira to ascend the heights of Roli9a, a sol- 
 dier 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 pene- 
 trate, but gave him great pain. A third received a ball on 
 
NON-PENETRATING WOUNDS. 365 
 
 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 Yimi- 
 era, ready for the fight next morning. 
 
 A soldier was struck on the hill of Talavera,* 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 in- 
 dented 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 disem- 
 boweling 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. 
 
 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 breath- 
 ing considerable ; cough hard, with little expectoration ; pulse 
 90, skin hot, appetite gone, tongue white. Y. S. ad ^xvj, 
 and aperients. 9th. Better; painless; expectoration more 
 in quantity, and viscid. Y. S. ad o^ii; antimonials. 10th. 
 Pain still felt on coughing ; expectoration reddish ; difficulty 
 of breathing greater. Pil. cal. et antim. c. opio ; Y. S. ad 
 ^xvj. He gradually recovered (his mouth having become 
 slightly sore) from what was manifestly an attack of pneu- 
 monia. 
 
 * The Duke of Wellington received a blow from a spent ball at the 
 same time, near the left clavicle. 
 
 31* 
 
366 ILLUSTRATIVE CASES. 
 
 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 symp- 
 toms increased on the fourth day, he was more carefully ex- 
 amined. His right side could not bear pressure. The 
 respiratory murmur was distinct, but accompanied by a 
 crepitating rhonchus under the part injured. Cough troub- 
 lesome ; expectoration mucous, viscid, and of a reddish tinge. 
 Antim. p, tart, and sulphas magnesiae, every four hours. Y. 
 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 dis- 
 tinct, y. 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 morn- 
 ing of the 15th of July, 1813, in front of the village of 
 Yera, 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 Bias 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 in- 
 dented 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 unsuc- 
 cessful 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 
 
DISTINCTION OF SOUNDS. 36T 
 
 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 in- 
 ward 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 per- 
 cussion, 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 respi- 
 ratory murmur, and is dependent on the air fully permea- 
 ting 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 sono- 
 rous, equable, and during inspiration continuous. In child- 
 hood 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 
 
3^)S DISTINCTION OF SOUNDS. 
 
 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 ster- 
 num, 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 natu- 
 ral 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 dis- 
 ease 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 dura- 
 tion 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 mur- 
 mur can be heard after symptoms of inflammation have ex- 
 isted for some time, the case is very serious, implying that 
 
NUMBER OF INSPIRATIONS AND OF THE PULSE. 369 
 
 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 gase- 
 ous 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 dis- 
 tended stomach after a long fast, afford good examples of 
 these elementary sounds. To employ percussion success- 
 fully, 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 ascer- 
 tain 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 dia- 
 phragm. 
 
 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 attrac- 
 tion of the lung, which when distended endeavors by its elas- 
 
3Y0 EXPIRATION — INSPIRATION — FROTTEMENT. 
 
 ticity to return upon itself, and to occupy less space than the 
 capacity of the chest will afford. The lung, invested by an 
 elastic, special, and transparent membrane, and covered by 
 the pleura pulmonalis, is composed of an immense number of 
 air vesicles, the largest being equal in size to the fourth part 
 of a millet-seed. These air vesicles, crowded together, each 
 communicating with a fine bronchial tubule, are separated 
 from each other into groups by a condensed cellular tissue, 
 thicker where it surrounds these lobules, which alternately 
 form, when aggregated together, a lobe, whence it is called 
 interlobular tissue. An artery and vein form a very minute 
 net-work around each vesicle. These vesicles may become 
 filled with water ; when dilated by air, they constitute what 
 is called emphysema of the lung. The lung in man is con- 
 stantly 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 mus- 
 cles of a young animal be removed to a sufiBcient 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 col- 
 lapse, 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 'Fv^\ic\\ 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 in- 
 vestigated 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 conse- 
 quences 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 com- 
 
ACUTE IDIOPATHIC INFLAMMATION OF THE PLEURA. 371 
 
 mences by rigors, preceded perhaps by some signs of general 
 uneasiness, which soon become those of great febrile excite- 
 ment. Pain is early felt in the side in the course of the sixth, 
 seventh, and eighth ribs, or at the point corresponding gen- 
 erally to the seat of the inflammation. It is usually sharp 
 and darting, is called a stitch, occupies rather a small space, 
 (the point de cote 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 impli- 
 cating 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 bron- 
 chitis ; of pneumonia, if reddish. The patient usually lies 
 on his back while the pain is severe, and has a great indispo- 
 sition 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 breath- 
 ing, 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 sub- 
 servient to the feelings of the patient, who is sometimes com- 
 fortable 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 
 
3'72 EFFUSION INTO THE CAVITY OF THE PLEURA. 
 
 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 ex- 
 ternal 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 
 pleura, this murmur becomes fainter, and when it is com- 
 plete, 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 corre- 
 sponding 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 tempo- 
 rarily impervious, or have become solidified under the con- 
 tinuance 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 resem- 
 ble that of a child — in fact, to be puerile. 
 
 When the lung begins to be compressed by the circum- 
 ambient 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 tuber- 
 cular disease when the lung is solidified. When the voice is 
 heard through the stethoscope in these complaints, the pecu- 
 liar sound emitted is called bronchophony. 
 
SYMPTOMS OF PNEUMONIA. 373 
 
 In pleuritic efifusion, the voice, when carefully examined, 
 sometimes obtains a character not previously noticed, but of 
 comparatively little importance, called oegophony, 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 oegophony 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 completel3^ It 
 has besides another peculiar character, which is constant, and 
 from which I have taken its name. It is a trembling, bleat- 
 ing, 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 dis- 
 ease it is not heard, as in that complaint fluid is not thrown 
 out into the cavity of the pleura. 
 
 801. 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 dyspnoea varies in different people. In 
 some it is only a slight embarrassment of breathing, admit- 
 ting 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 inflam- 
 mation, from which, when they are so frequent, persons 
 rarely recover. The patient can scarcely speak or lie down, 
 
 32 
 
374 CHARACTERS OF THE EXPECTORATION. 
 
 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 idio- 
 pathic pneumonia, rarely recurring by paroxysms, and is 
 without any particular indication ; it is soon, however, accom- 
 panied 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 indi- 
 cating 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 striae of blood, as in catarrh ; nor 
 is it pure blood, as in hemoptysis. Each sputum is either 
 of a yellow, or rusty, or even red color, according to the 
 quantity of blood intimately mixed with the mucus. These 
 sputa are at the same time tenacious and viscous, adhering 
 so intimately together as to form a homogeneous transparent 
 whole, readily gliding, however, from the basin in which they 
 are held on sufficient inclination being given to it. At this 
 period or stage of the disease, the sputa adhere strongly to 
 each other, but the mass is not sufficiently viscid to stick to 
 the sides of the vessel. When no further change takes place 
 in the sputa the inflammation rarely passes beyond the first 
 stage of obstruction or engorgement, or swelling. When 
 they attain to a more viscous state, and adhere to the inside 
 of the vessel in which they have been received, the progress 
 of the inflammation to the second stage, or that of hepatiza- 
 
DELIRIUM — CREPITATING RIIOXCHUS. 315 
 
 tion, maybe 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 reappear- 
 ance of the other symptoms will show. When the inflamma- 
 tion 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 dis- 
 charged; 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 can- 
 not be mistaken for either of the others which preceded it. 
 If the pneumonia pass into the chronic state, the expectora- 
 tion becomes yellowish, or somewhat greenish, and at last is 
 purely catarrhal. 
 
 Delirium is not an uncommon symptom, when the inflam- 
 mation of the lung is intense in persons of powerful constitu- 
 tions, particularly during the exacerbation of fever in the 
 night. It yields with the other symptoms when relief is ob- 
 tained. 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 parch- 
 
376 BRONCHIAL RESPIRATION AND BRONCHOPHONY. 
 
 merit ; 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 crepita- 
 ting 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 con- 
 tinuance ; 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 r^espiration, 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 per- 
 vious 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 
 7^honchus or crepitating rale or sound is not present, and 
 bronchial respiration and bronchophony only can be dis- 
 tinguished, 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 expecto- 
 rated, 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 through- 
 out 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 
 
EFFECTS OF INFLAMMATION OF THE PLEURA. 3*77 
 
 marked; the first is to diminish, if not to annul, the secre- 
 tion 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 differ- 
 ence by some uneasy internal sensation ; the auscultator, by 
 a rubbing or creaking sound emitted as the inflamed pleurae, 
 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 re- 
 turns, as if by jerks, three or four times repeated in succes- 
 sion. 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 number- 
 less small vessels, carrying red blood, which are principally 
 seated in the subserous cellular tissue, reddening the mem- 
 brane 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 mem- 
 branes ; 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 some- 
 times deposited in small drops or spots ; in others, in 
 patches of a greater or less size, varying according to the 
 extent of the inflammation whicii 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, 
 
 32* 
 
3Y8 SEROUS EFFUSION. 
 
 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 mem- 
 branes thus formed, resembling areolar tissue in their prop- 
 erties, may ultimately become cartilaginous, and even bony. 
 When simple adhesions form between the pleurae, they be- 
 come 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 con- 
 sequence of injury, it is often tinged with blood, forced out 
 from the capillary vessels of the pleura, or of the false mem- 
 brane, 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 posi- 
 tion of the patient, unless, when from old adhesions between 
 the pleur®, it is confined to particular parts. When the 
 cavity of the pleurae 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 aug- 
 mented in density as to be useless for the purposes of res- 
 piration. 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 in- 
 ternal pressure for a considerable length of time, even for 
 w^eeks ; 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 
 
PURL'LEXT EFFUSION. 3T9 
 
 chest, the effused fluid becomes purulent, the lung, com- 
 pressed 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 be- 
 come 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 ap- 
 pears 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 prob- 
 ability 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 in- 
 stances to prevent the lung from again dilating, the sub- 
 stance 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 ad- 
 hesion 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 com- 
 plicated. 
 
 304. The changes which take place in the structure of 
 the lung in pneumonia are three in number: 1. Engorge- 
 
380 MOEBID CHANGES IN THE LUNGS IN PNEUMONIA. 
 
 ment. 2. Hepatization. 3. Purulent infiltration. The 
 formation of an abscess or vomica, and the occurrence of 
 gangrene, may be omitted, as well as of chronic disorders, 
 in the views about to be taken of the disease from injury. 
 
 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 cut- 
 ting 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 appear- 
 ance of liver in solidity and weight — the lung does not crep- 
 itate, 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 differ- 
 ent directions; while many little granular points can be dis- 
 covered, especially with a glass, apparently of a more solid 
 material than the surrounding parts. 
 
 The word solidity, or solidification, is sufficiently explana- 
 tory in contradistinction to the naturally pervious and crepi- 
 tating 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 under- 
 stand, 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 
 
MORBID CHANGES IN THE LTJxVGS IN PNEUMONIA. 381 
 
 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 respi- 
 ration and voice gradually, or after a time, diminish, until 
 they entirely disappear ; while a mucous rale or rattle com- 
 mences, 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 inter- 
 mixture 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 per- 
 vades 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 inter- 
 lobular septa. 
 
 These three degrees or stages of inflammation may be 
 met with in the same lung, for the most part gradually in- 
 termingling 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 tuber- 
 cular 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. 
 
382 GENERAL BLOOD-LETTING. 
 
 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 
 
ILLUSTRATIVE CASES. 383 
 
 disease, when accompanied by pain and p'eat oppression of 
 breathing. Whenever the pulsations of the heart are pro- 
 portionally 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 com- 
 plete 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 at- 
 tacked 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 effu- 
 sion, 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 insuffi- 
 cient. What was to be done ? My sixteen ounces of blood 
 were increased to thirty, but it would not do. It was evi- 
 dent 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 inch.es 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 
 
384 ILLUSTRATIVE CASES. 
 
 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 cir- 
 cumstances 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 diffi- 
 culty 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 quan- 
 tity 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 recur- 
 rence 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 posi- 
 tion ; and as it is advisable to take away a sufficient quan- 
 tity 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 sub- 
 ject to and who are not readily recovered from it. In the 
 second stage of the complaint, profuse and repeated bleed- 
 ings 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. Tiie 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, 
 
EFFECTS OF BLEEDING — TARTAR EMETIC. 385 
 
 blood should be carefully abstracted, until it becomes mani- 
 fest that the effect has been to quicken the pulse, while it 
 materially diminishes its power, when it is forbidden. 
 
 30t. 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 ; cup- 
 ping 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 tem- 
 poral 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 dif- 
 ferent 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 pleuritide." 
 
 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 emi- 
 nently beneficial, the difference being dependent on climate 
 and the impaired vigor of the sufferers. 
 
 The remedy first to be administered, and most to be de- 
 pended 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, 
 
 33 
 
386 CALOMEL — ANTIMONY — OPIUM. 
 
 the vomiting usually ceases, the stomach tolerates its intro- 
 duction, 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 per- 
 spiration. 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 expectora- 
 tion, so as to lead the patients and the attendants to believe 
 that recovery is about to take place ; after a few hours, how- 
 ever, 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 inflamma- 
 tion 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 physi- 
 cians 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 mer- 
 cury ; 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 whetlier 
 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 
 
CALOMEL — ANTIMONY — OPIUM. 38t 
 
 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 pos- 
 sible. This is not effected in some cases by any of the quan- 
 tities 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 sig- 
 nify which method is adopted in strong and healthy persons, 
 although the smaller doses are most satisfactory to all par- 
 ties when the patient is weak and irritable, while the large 
 and less frequent doses often excite great apprehension. It 
 is argued that calojuel in large doses never causes the dysen- 
 tery 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. Yery 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 diarrhoea, 
 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 in- 
 flammation ; in which case its use should be superseded by 
 leeches to the epigastrium, and saline aperients, lest the irri- 
 tation, vomiting, and purging should increase the evil. But 
 
388 TYPHOID PNEUMONIA. 
 
 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-enternte 
 of the French physicians, are not to be mistaken for gas- 
 tritis. Mercury, in the form of calomel, is more to be de- 
 pended 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 indi- 
 cated 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 rube- 
 facients, 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 shonld be allowed. 
 As soon as the inflammatory action has subsided, the lightest 
 farinaceous nourishment, gradually augmented by the addi- 
 tion of broths, jellies, eggs, fish, and lastly of animal food, 
 should be substituted. The temperature of the room olight 
 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 im- 
 portant symptoms. A moderate diarrhoea and a profuse 
 perspiration are also signs of a favorable crisis. 
 
 312. Inflammation of the chest has been hitherto con- 
 sidered as accompanied by inflammatory fever as an essen- 
 tial 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 accom- 
 panied by general symptoms of a low asthenic type of fever, 
 combined with those of marked derangement of the stomach, 
 
TREATMENT OF TYPHOID PNEUMONIA. 389 
 
 intestines, or liver, as shown by a dry black, or red black, or 
 brown tongue, offensive breath, diarrhoea, 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 suffi- 
 cient food, bad air, or other depressing causes. It is some- 
 times epidemic. The fever is typhoid, the local inflamma- 
 tion latent, and the symptoms of it masked. It may be 
 complicated with inflammation of the stomach and intes- 
 tines; 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 affec- 
 tion 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 sliglit 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 quan- 
 tities. Mild aperients only should be employed, and ano- 
 dyne 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 
 
 33* 
 
390 TYPHOID PLEURITIS — EMPYEMA. 
 
 place, and with which it is sometimes removed, that it de- 
 pends more on passive congestion, and on a typhoid altera- 
 tion 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 ex- 
 pectoration 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 dis- 
 ease 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 ev, in, and -oo^^, 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 symp- 
 toms 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 tur- 
 bid when the result of ordinary inflammation, although the 
 presence of albuminous or purulent matter is not constant. 
 Whether colorless, transparent, turbid, or purulent, it re- 
 mains fi'ee from fetor, unless gangrene has occurred inter- 
 
CAUSES AND SYMPTOMS OF EMPYEMA. 391 
 
 Dally, or some coramnnication with tlie 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 inflamma- 
 tion, 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 sur- 
 gical 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 inflam- 
 mation in effusion may be known : are dyspnoea, or diflBculty 
 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 re- 
 placed 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 
 
392 LATER SYMPTOMS OF EMPYEMA. 
 
 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 per- 
 sons may be more or less filled up, rendering the whole sur- 
 face smooth and soft. In some very severe cases the exter- 
 nal parts become edematous, so that the ribs cannot be felt, 
 and this sign, although not always present, is certainly pa- 
 thognomonic when it takes place at a late period of the dis- 
 ease. 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 disagree- 
 able. 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 cell- 
 ular membrane beneath the skin, over the whole space occu- 
 pied by the blood within. That the first two symptoms do 
 
TREATMENT OF EMPYEMA. 393 
 
 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. Yalentin 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 con- 
 siderable 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 in- 
 deed of serous fluid to a considerable extent, so as to dis- 
 place 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 
 dow^n by adhesions that it cannot be expanded by the con- 
 tinued process of respiration, a cure can only be accom- 
 plished 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 
 
394 OPERATION FOR EMPYEMA. 
 
 surface often do good. When these means fail, the opera- 
 tion 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 get- 
 ting 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 Pare was the 
 first who recommended a trocar and canula, and many in- 
 stances 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 rea- 
 son 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 with- 
 drawn. 
 
 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 vertebrae, or two-thirds from the middle of 
 the sternum. If there should be any protrusion of the in- 
 tercostal 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 resist- 
 ance has been overcome. It is entered nearer the lower rib 
 to avoid the intercostal artery, and yet not touching the rib 
 lest it should induce a too forcible contraction of the inter- 
 
THE OPERATION BY NECESSITY BY INCISION. 395 
 
 costal muscles, by which the operator might be inconve- 
 nienced. 
 
 If the person should be very fat, or the puffing of the in- 
 teguments 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 ensiforra 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 carti- 
 lage, can always be ascertained in front, and an error of im- 
 portance cannot well take place, as the object in making a 
 puncture by measurement is to avoid the diaphragm. Fre- 
 teau, 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, com- 
 mencing the incision close to the edge of the latissiraus 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 posi- 
 tion 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 in- 
 dicates 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 "op- 
 eration 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 
 
396 DR. HUGHES ON PNEUMOTHORAX. 
 
 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 tliat 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 imme- 
 diately 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 preven- 
 tion, but it is scarcely possible to prevent some air getting 
 in. It is often seen to do so ; ittas been proved by ausculta- 
 tion 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 with- 
 drawn ? 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 consid- 
 eration, 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 com- 
 municates, but this is not the effect of the admitted air. 
 
 Dr. H. M. Hughes has published several cases of pneumo- 
 thorax in the first part of the eighth volume of " Guy's 
 Hospital Reports" for 1852. In the sixth ease, which he 
 calls a genuine example of pneumothorax from rupture of 
 one or more of the vesicles of an emphysematous lung, the 
 patieut died speedily ; and, on examination, he says : " It 
 is also an interesting fact that no evidence of inflammatory 
 
FISTULOUS OPENING INTO THE CHEST. 39t 
 
 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 mat- 
 ter ; 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, com- 
 mon 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. When- 
 ever 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 consist- 
 ent 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 dif- 
 ficulty of breathing, of fever, should be met by the abstrac- 
 tion 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 
 
 34 
 
398 ILLUSTRATIVE CASES. 
 
 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, particu- 
 larly when there is an adventitious cause keeping up the irri- 
 tation, 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 profes- 
 sional 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 empy- 
 ema, 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 impend- 
 ing. 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 gradu- 
 ally 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 re- 
 moved 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 
 
ILLUSTRATIVE CxVSES. 399 
 
 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 symp- 
 toms 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, dyspnoea, 
 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 puru- 
 lent 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 discharg- 
 ing 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, im- 
 mediately below and in front of the inferior angle of the 
 scapula. He spat and coughed up blood, and lost so much 
 
400 ILLUSTRATIVE CASES. 
 
 from the wound that he became insensible, the bleeding hav- 
 ing been stopped by a part of his shirt being bound upon it 
 tightly by means of his woolen sash. Brought to the village 
 of Yalverde, my attention was drawn to him some days after- 
 ward, 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 swell- 
 ing 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 en- 
 larged, 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 Yalentin 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 out- 
 side 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, dif- 
 ficulty 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 introduc- 
 ing the finger through the opening, appeared to be very 
 much thicker than usual, A large quantity of pus was dis- 
 charged, 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- 
 
ILLUSTRATIVE CASES. 401 
 
 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 dis- 
 eased throughout. 
 
 At Santander, in October of the same year, 1813, I re- 
 ceived some eight hundred wounded in the affairs of Le Saca, 
 Yera, 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 enter- 
 tained of his recovery, until after I left Santander in Decem- 
 ber, to join the army in France, when he suffered a relapse 
 of inflammation, and died. 
 
 A soldier of the German Legion was. wounded at Water- 
 loo by a lance between the sixth and seventh ribs of the left 
 side. He spat up much blood for several days, and was car- 
 ried to Antwerp, where he remained for several months, suf- 
 fering 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 Hos- 
 pital, 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 in- 
 flamed, and full of purulent fluid, which caused his death. 
 The left or wounded side was found to contain a small quan- 
 tity 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 adven- 
 titious membrane, and bound down against the spine, leaving 
 a long, small space between the pleurae, 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 
 
 34* 
 
402 PNEUMOTHORAX. 
 
 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 oppo- 
 site 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 stand- 
 ing, 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 continu- 
 ance 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 exceed- 
 ingly quick and small, countenance pale, nights sleepless. 
 The affected side is oftentimes evidently dilated, and the in- 
 tercostal spaces may be less marked, or partly filled up, when 
 the respiratory motion given to the parts under ordinary cir- 
 cumstances 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 indi- 
 cating 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 
 
PERCUSSION — METALLIC TINKLING. 403 
 
 the absence of respiration, when the chest is fully expanded, 
 discovers no respiratory murmur ; but a peculiar sound called 
 tintement metallique, or metallic tinkling, is heard at inter- 
 vals, 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 Mon- 
 day, 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 be- 
 hold ; 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 re- 
 opened and enlarged; the pulse fell to 120; the metallic 
 tinkling ceased to be heard ; the patient took some nourish- 
 ment 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 chast. 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 
 
404 ILLUSTRATIVE CASES. 
 
 serous fluid. The pleurse costalis and pulmonalis presented 
 marks of inflammation of a few weeks' standing — viz., some 
 thin false membranes, which were easily separated by scrap- 
 ing 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 quan- 
 tity 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 cica- 
 trized, 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, dyspnoea, 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 ex- 
 tremely fetid character, occasionally mixed with blood. His 
 respiration was hurried, the right side of the chest expand- 
 ing much more freely than the left ; the lower three-fourths 
 of the affected side were dull on percussion ; tubular respira- 
 tion 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 measure- 
 ment no difference in the relative size of the chest was ob- 
 served, but the intercostal spaces of the left side remained 
 motionless during expiration. The heart could be felt feebly 
 pulsating at the epigastrium. 
 
 October 15th. — He suffered from a violent paroxysm of 
 
ILLUSTRATIVE CASES. 406 
 
 coughing, during which great dyspnoea 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 pneumo- 
 thorax. 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 re- 
 lieved. 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 acces- 
 sions of fever toward evening, and perspires very profusely 
 during the night ; the cough is less frequent, and be expec- 
 torates 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 parox- 
 ysm 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 — 
 
406 
 
 ILLUSTRATIVE CASES. 
 
 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 free- 
 dom as that passing by the trocar. Expectoration has con- 
 tinued 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. 
 
 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, commu- 
 nicating with a small cavity, 
 the interior of which was 
 lined by the same thick mem- 
 brane met with in cases of 
 chronic phthisical disease ; 
 from the upper part of this 
 cavity two other sinuses were 
 formed, the one passing ex- 
 ternally 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 
 
 ^. Section of the lung, made vertically. WaS at itS loWCr part firmly 
 
 B. Section of the abscess communicating j,ffopV,p^ fn fhp r-iKc hv irifpr- 
 
 by the sinus, C, with the circumscribed aildLUeu lU lue llUb uy lUiei- 
 
 cavity, D, in which the bullet had been vcning falsC membrane, wllilc 
 
 lodged after its entrance by the sinus, E. ,^ , /. ■^ 
 
 F. The sinus by which the ball had the Upper part was tree, ana 
 
 passed into the pleural cavity, G J^^d bcCOmC COmprCSSed to- 
 
 Opposite the 7th and 8th ribs the lung is """-' ^v^ w ^ ^ |ji.v^oov.x^ w 
 
 quite adherent. wai'd the spiual columu. The 
 
 ^- ^^^ ^''^^- substance of that part of the 
 
 lung not involved in the abscess was infiltrated with pus, and 
 
ILLUSTRATIVE CASES. 401 
 
 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 bj 
 rugged layers of false membrane of irregular thickness, but 
 readily detached. jSTo trace of tubercular deposit could be 
 found, and the lung of the opposite side w^as 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 pro- 
 jection 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 mur- 
 mur 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 : 
 Tbirty-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; dur- 
 ing the first ten hours five 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 adminis- 
 tered. 
 
 14th. — Eight o'clock: Slept after -four o'clock; on wak- 
 ing took an aperient draught, and is much easier; pulse 120, 
 soft, small, and weak. — Three p.m.: On the dyspnoea return- 
 
408 ILLUSTRATIVE CASES. 
 
 ing twenty-one leeches were applied, and the oppression was 
 relieved ; an enema given, which acted freely. — Half-past 
 twelve : A returning oppression relieved by eleven leeches ; 
 calomel repeated, and thirty minims of solution of opium. 
 
 15th. — Eight A.M.: Slept at intervals; little or no expec- 
 toration, no blood ; thinks he would faint if he sat up in 
 bed ; pulse 130, soft, small, and weak ; little pain ; lies tol- 
 erably flat; respiratory murmur distinct on both sides. — Nine 
 P.M.: Oppression returned; twenty-four leeches ; repeat calo- 
 mel and colocynth ; an enema, after which the bowels be- 
 came 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 AM.: Slept during the night, and is better; 
 pulse 108, soft; breathes freely; no pain. — Evening: lias 
 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 rest- 
 less ; 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 bleed- 
 ing ; blood cupped and buffy ; twenty leeches ; enema ; 
 calomel and opium. In the night, at two o'clock, the dys- 
 pnoea 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 ex- 
 haustion, sick, and faint. A little arrow-root relieved the 
 faintness; discharge from the wound free, and accompanied 
 
ILLUSTRATIVE CASES. 409 
 
 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 Ms side, but 
 fears to hurt himself; wound discharges freely; has had a 
 small piece of bread for the first time. — Four p.m. : Rest- 
 less, 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 dif- 
 ficulty ; can turn in bed with ease ; slept well ; the dis- 
 charge 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 
 ^vas 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 metal- 
 lique 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 intro- 
 duced, so as to enlarge the track of the ball, and give pas- 
 sage 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 instru- 
 ment was withdrawn, instantly ceased, but could be repro- 
 duced 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 ITth. — Better; pulse 100; bowels open; cough 
 
 35 
 
4]0 EMPHYSEMA. 
 
 easier ; expectorates freely a rouilUe, 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 pneumo- 
 thorax 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 ev and (foffaw, to inflate ; the dif- 
 fusion 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 inspira- 
 tion ; 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 sur- 
 gical 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. Vehicular and Inter- 
 lobular — 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 in- 
 terlobular 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 mor- 
 bid 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 
 
EMPHYSEMA. 411 
 
 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 ma}'' be fully distended. 
 
 Emphysema most commonly occurs from fractured ribs, a 
 point from one or more of which abrades the surface of the 
 lung. Til rough 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 gradully causes to collapse under the 
 pressure exercised by the act of expiration; while, at the 
 same time, the mediastinum yielding, the opposite lung suf- 
 fers 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 equal- 
 ization 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 ap- 
 plication 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 in- 
 vade a considerable portion of the body, the further dilFusion 
 of air should be prevented by punctures made through the 
 skin in such places as may be thought necessary, and in ex- 
 
412 NO EMPHTSEMA IN GUNSHOT WOUNDS. 
 
 treme 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 gun- 
 shot 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 re- 
 markable 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 
 Kolica and Yimiera, 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, wiiich had passed slant- 
 ingly 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 hiuiself 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 
 
COLLAPSE OF THE LUNG NOT CONSTANT. 413 
 
 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 oface, although imper- 
 fectly, 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 con- 
 fined 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 open- 
 ing 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 en- 
 tirely, in spite of the breach in it, and the mediastinum and 
 heart return to their natural situation, the distress in breath- 
 ing 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 "taiUades^^ 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 
 
 35* 
 
414 SIMPLE INJURIES OF THE CHEST. 
 
 the ear or the stethoscope should be resorted to at least 
 three times in every twenty-four hours, in every case, how- 
 ever trifling it may appear to be, until the absence of danger 
 has been ascertained. 
 
 LECTURE XXIL 
 
 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 con- 
 sidered 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 pleurae 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 pleurae preventing it, they will be for the 
 advantage of the sufferer. 
 
 In a simple incised wound, injuring the lung perhaps ex- 
 tensively, 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 im- 
 mediately 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, gen- 
 erally the drum-major of the regiment, when the patient 
 was a soldier; and the consequences, although in some 
 
PATIE.NT TO LIE ON THE WOUNDED SIDE. 415 
 
 instances apparently miraculous, were in others cjuite 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 attract- 
 ing the natural fluids to the parts, and thus causing them to 
 swell so as to be placed in apposition in the most advanta- 
 geous manner for their reunion. Punctured wounds of small 
 size, therefore, may be sucked chirurgically if any one be 
 willing to do it, after Vv'hich 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 fur the pur- 
 pose of allowing any effused blood or fluid to flow out, un- 
 less some particular reason require the precaution of keep- 
 ing 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 pro- 
 cess 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 sur- 
 gery, 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 opinioLS 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 in- 
 jured. 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 
 
416 SIMPLE INCISED WOUNDS. 
 
 within. The external parts or skin and cell alar 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 hap- 
 pily 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 resto- 
 ration 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 reac- 
 tion 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 
 
WOUNDS THROUGH BOTH SIDES OF THE CHEST. 417 
 
 commeDcing 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 per- 
 sons 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 treat- 
 ment. Whenever it is concluded that adhesion between the 
 two pleurae 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 cor- 
 rect 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 Rolica, on the 11th August, 1808 — one particu- 
 larly 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 atten- 
 tion to me, for the few minutes he lived after I saw him ; he 
 had coughed up a little blood, and died gasping, as if suffo- 
 cated, 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 
 
418 RELIEF OF OPPRESSION OF BREATHING. 
 
 contents of the cavity, which gave way to full and repeated 
 bleeding from the arm, with perfect rest and almost starva- 
 tion. 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 oc- 
 curred 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 de- 
 pends. 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 9lh Regiment was wounded at Roli9a, 
 in 1808, by the point of a sword in the left side ; it pene- 
 trated 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 
 
CLOSURE OF THE WOUND. 419 
 
 havinpc 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 plas- 
 ter, two sutures were applied through the skin, and the man 
 was desired to lie on the injured side, with the hope that ad- 
 hesion 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 Yimiera, 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 ^vound 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 allevi- 
 ated, and after the supervention of some serious inflamma- 
 tory 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 w^hich 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-pneu- 
 monia 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. 
 
420 EFFUSION INTO THE CHEST. 
 
 If the union of the divided parts should tal^e place ex- 
 ternally, 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 percus- 
 sion, if the latter can be borne, become of the greatest im- 
 portance. 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 elec- 
 tion, 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 immedi- 
 ately 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 
 
THE IMPORTANT QUESTION OF HEMORRHAGE. 421 
 
 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 c^uite unopposed ; the lung had receded 
 from the opening. 
 
 332. The important question ofliemorrliage, in cases of 
 incised wounds adnaitting 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 Ciuantity, should be allowed to discharge 
 itself, the wound being kept open ; the other, that under all 
 circumstances, whether the quantity of blood poured out be 
 small or great, the wound should be closed, and the result 
 awaited. The right course is, I apprehend, to remove all 
 the blood which can be evacuated by position, provided it 
 can be done without danger to the patient, rather than to 
 allow it to fill the chest; but as the bleeding vessel in the 
 lung cannot readily be got at, if seen, nor be secured by 
 ligature with advantage, it is advisable, if the bleeding 
 continue, to close the wound, and allow the cavity of the 
 pleura to be filled, until the lung shall be sufficiently com- 
 
 36 
 
422 TREATMENT TO BE PURSUED. 
 
 pressed to cause the hemorrhage to cease, if the person 
 survive so long. The first object is to save life ; after that, 
 if time be given, the next will be to relieve the loaded cavity. 
 After the wound has been closed, and the patient has so 
 far recovered that reaction has begun to take place, it may 
 be concluded that the bleeding has ceased. The chest 
 should then be most carefully auscultated from day to day, 
 so that its respiratory state may be known, particularly with 
 regard to the increase of effusion, which will then be serous. 
 This will not take place until after the third, and not perhaps 
 before the fifth or sixth day, in any considerable quantity; 
 when, if it should have occurred, the wound should be re- 
 opened, or another opening made at the most convenient 
 place for the evacuation of the eft'used 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 evacu- 
 ated, 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 puruluent, 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 re- 
 sulting empyema, may be unavailing. Whenever, therefore, 
 the adhesive process between the pleurse 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 
 
ILLUSTRATIVE CASES. 423 
 
 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 assist- 
 ance. The cure, however, will not only be assisted, but 
 mainly effected, by procuring a depending opening by means 
 of the small trocar and cauula introduced as low down as 
 auscultation will autliorize ; the introduction of this instru- 
 ment 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 Yalvercle, he appeared ten days afterward to be 
 dying from difficulty of breathing. On enlarging the open- 
 ing 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 puru- 
 lent. 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 
 opeuiug, 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 
 
424 M, VALENTIN ON ECCHYMOSIS. 
 
 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 con- 
 tinued 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, lie 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 tres eclairci.) 
 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 
 
CONCLUSIONS. 425 
 
 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 whetlier 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 se- 
 cured 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, al- 
 though 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 extrava- 
 sated 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 ex- 
 travasation which does take place is usualily less than is 
 generally supposed — a point which auscultation will in all 
 probability disclose. 
 
 /. 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 — in- 
 stances of which are said to have taken place, and the prac- 
 tice should therefore be borne in mind. 
 
 3G* 
 
426 STATISTICS OF WOUNDS OF THE CHEST. 
 
 LECTURE XXIII. 
 
 WOUNDS OF THE CHEST, ETC. 
 
 335. Gunshot wounds of the chest, penetrating the cav- 
 ity, 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. Meniere, in giving an account of the wounded 
 carried to the Hotel- 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 per- 
 forated, 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 Hotel-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 dis- 
 cussion, and, I doubt not, of public reprobation. That the 
 wounds of the chest with the army in tlie Crimea will afford 
 a more satisfactory result, cannot, I fear, be expected, and 
 for similar reasons. 
 
 836. When a musket-ball fairly passes through the cavity 
 
ENLARGEMENT OF SUCH WOUNDS. 421 
 
 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 difiicult, 
 countenance pale, extremities cold, pulse variable — symp- 
 toms 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, de- 
 pendent 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 fas- 
 cia covering the intercostal muscles, it is usually marked by a 
 tenderness in its course on touching the part and a discolor- 
 ation 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 in- 
 dicative 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, how- 
 ever, 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 re- 
 moved 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 ex- 
 traneous bodies or for the evacuation of blood, etc. When 
 a wound from a musket-ball appears likely to have pene- 
 trated the cavity of the chest, and is too small to admit the 
 
428 GUNSHOT FRACTURES OF THE RIBS. 
 
 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 pur- 
 pose 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 
 Charite 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 posi- 
 tion 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 spiculse of bone into the surface of the 
 
A MUSKET-BALL PASSING THROUGH THE LUNGS. 429 
 
 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 coramencement 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 instru- 
 ment. 
 
 A ball, when striking obliquely but with force on the 
 chest, will frequently penetrate, and then run round, be- 
 tween 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 
 
430 ILLUSTRATIVE CASE OP SIR G. L. COLE, G C.B. 
 
 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 hemor- 
 rhage 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 com- 
 pressed 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 oflScer's tent I always carried 
 with me. Under repeated bleedings, and the strictest anti- 
 phlogistic treatment, several splinters having come away, 
 and a large piece of the rib and of the scapula having ex- 
 foliated, he gradually recovered, so as to be able to resume 
 the command of the Fourth Division in October at Madrid. 
 
ILLUSTRATIVE CASES. 431 
 
 The subclavian artery never resumed its power, and the 
 radial always beat less forcibly on the left side. He per- 
 fectly 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 Kifle Brigade, at the passage of 
 the Nivelle, on the 10th Xovember, 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 w^as 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 com- 
 mand. 
 
432 ILLUSTRATIVE CASES. 
 
 More than forty years afterward I found the lung pervi- 
 ous ; 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 con- 
 veyed to the ear on auscultation. He suffered little or no 
 subsequent inconvenience from the injury, and died in Janu- 
 ary, 1855, aged 82. 
 
 Case of 3Iajor- General Broke, by himself. — Toward the 
 close of the battle of Orthez, on the 2Yth 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 sen- 
 sation 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 exceed- 
 ingly painful in a day or two, and I felt nearly suffocated, 
 when, in the evening, my brother. Sir Charles Broke Yere, 
 arrived with ray friend, Mr. Guthrie, who examined me care- 
 fully. 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 inter- 
 ruption. He afterward left me to visit some other wounded 
 men, and returned in about three hours, when I told him 
 that 1 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. 
 
CASE OF THE DUKE OF RICHMOND. 433 
 
 He is now, in 1855, in perfect health, the respiratory mur- 
 mur 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 5 2d Light Infantry. He was stand- 
 ing 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 subse- 
 quent 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 rest- 
 less, and the pain returned, with a full, hard, and frequent 
 pulse. The wound has again discharged a very considera- 
 ble quantity of blood. Bleeding repeated as before. 
 
 Nine P.M.: Deputy-Inspector Thomson and Staff- Surgeon 
 Maling examined the wound. Mr. Maling introduced his 
 
 37 
 
434 CASE OP THE DUKE OF RICHMOND. 
 
 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 2'7th of Feb- 
 ruary and the morning of the 2d of March, the cough, ex- 
 pectoration, 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, col- 
 lapse or recede from the wall of the chest, but quickly re- 
 covers 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 
 
EFFUSION THE MOST FREQUENT CAUSE OP DEATH. 435 
 
 raay 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 en- 
 tered 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 in- 
 jured 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 he attended 
 to in the treatment of pisiot loounds of the chest, or those 
 made by smalt balls ivhich do not pass out. All the per- 
 sons I have seen die from small balls have died with the af- 
 fected 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 
 
436 ILLUSTUATIVE CASES. 
 
 insufficiency of tlie 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, what- 
 ever 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 dif- 
 fused itself over the whole surface of the lung ; but dissec- 
 tion 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 res- 
 piratory 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 open- 
 ing 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 mis- 
 chief at that part, so as to admit of an operation for its re- 
 moval. 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 stetho- 
 scope was then unknown, the ear was not in use ; my older 
 colleagues were obstinate ; they would not hear of an oper- 
 ation 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 cir- 
 cumstances, from the ball having lodged, and from his ad- 
 vanced 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 
 
ILLUSTRATIVE CASES. 437 
 
 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 indica- 
 ting effusion ; such, particularly, as great oppression, diffi- 
 culty of breathing, and inability to lie in the recumbent posi- 
 tion, 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 re- 
 peated 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 ; breath- 
 ing 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 1 6th of June, 1815, at Quatre Bras, by a musket-ball, 
 
 3t* 
 
438 ILLUSTRATIVE CASES. 
 
 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 respira- 
 tion ; 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 remain- 
 ing undiscovered. 
 
 A soidier 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 after- 
 ward, 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 re- 
 covered, 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-pneumo- 
 nia. Colonel Harcourt slowly recovered, and died Marquis 
 d'Harcourt, near Windsor, more than twenty-five years after- 
 
ILLUSTRATIVE CASES. 439 
 
 ward, sufifering little or no inconvenience from his chest, 
 when I last saw him. 
 
 Captain Cane, 23d Fusiliers, was wonncled at the affair of 
 Saca Parte, in front of Alfdiates, 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 down- 
 ward 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 in- 
 duced, 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 re- 
 moved from the wound, and several portions of bone gradu- 
 ally 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 examin- 
 ing 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 ; ex- 
 pectorates 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 be- 
 hind 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, 
 
440 ILLUSTRATIVE CASES. 
 
 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 pos- 
 terior, 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 tolera- 
 bly good, but his breathing by no means free ; no expectora- 
 tion. 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 Water- 
 loo, where I was bled, which relieved me from the great dif- 
 ficulty 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 pos- 
 sible 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, 
 
ILLUSTRATIVE CASES. 441 
 
 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 difiSculty 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 ap- 
 plied ; salts, etc. proving of no avail, took digitalis, com- 
 mencing with ten drops every four hours, increasing to fifteen 
 from the second day. 
 
 • X.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. DUMAEESQ. 
 
 The ball in this case was lodged in the rib, which ulti- 
 mately 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 inflam- 
 mation, suppuration of the cavity, and death, which must 
 almost always ensue in such cases, unless the ball can be re- 
 moved, and the matter evacuated by an operation to be here- 
 after 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 re- 
 
442 APPEARANCES AFTER DEATH. 
 
 covered from the injury as to be able to undertake several 
 parts of his duty before he was invalided ; thus proving the 
 advantage of a shot, however large, going through rather 
 tlian remaining in the chest. 
 
 LECTURE XXIY. 
 
 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 poste- 
 rior 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 vomicae or small abscesses, 
 from which the matter expectorated was secreted. The 
 track of the ball was nearly filled up, although the part im- 
 mediately 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 be- 
 hind in nearly a straight line, close to the spine. Left on 
 the field of battle for five days before he was brought to Brus- 
 sels, 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 inflamma- 
 tion and of all his bad symptoms took place, destroying him 
 at the end of four weeks from the receipt of the injury. On 
 
ILLUSTRATIVE CASES. 443 
 
 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 suppu- 
 rating 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 Koth, of the 5th battalion of the 60th Kegiment, 
 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 expec- 
 toration ; 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 medi- 
 cines. 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 invokintarily ; and on the 13th 
 he died, his body being covered by petechise. 
 
 The head, on examination, showed pus under the dura 
 mater, at and behind the situation of the wound he had re- 
 ceived. 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 
 
444 MR. drummond's case. 
 
 Friday. On Saturday morning at five o'clock lie sufi'ered 
 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 diffi- 
 culty 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 tea- 
 spoonful 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, an^ Mr. Jackson were added in consultation on 
 Monday at twelve, when the jerk became worse, the oppres- 
 sion 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 in- 
 ferior 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 
 eft'usion of blood from some small vessel which had sloughed, 
 the blood being partly coagulated and partly diffused to the 
 
REMOVAL OF SPLINTERS, ETC. FROM THE CHEST. 445 
 
 amount of many ounces ; its loss appeared to have been the 
 immediate cause of death. 
 
 A gamekeeper's gun burst at the Ked 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 treat- 
 ment ; 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 under- 
 went during respiration ; there was also a mark on the peri- 
 cardium 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 mem- 
 brane almost equally thickened across the chest, the lower 
 part of which was filled in the upright position by the dis- 
 charge, which was only evacuated in quantity when the open- 
 ing 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 por- 
 tion 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 quan- 
 tity of sero-pui'ulent bloody matter. The Inng 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 
 
 38 
 
446 ILLUSTRATIVE CASES. 
 
 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 orig- 
 inal opening can do no harm, and if the lung should not col- 
 lapse, 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 suf- 
 fered 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 re- 
 moving the seton, and was extracted ; a splinter was also 
 felt, but so deeply that it could not be removed without en- 
 larging 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 
 
ILLUSTRATIVE CASES. 44*1 
 
 more harm than good, and the thirty-first bleeding was 
 effected. The next morning the patient complained of some- 
 thing 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 
 vertebrae 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 opera- 
 tion 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 
 spiculEe 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 G-erman Legion was wounded at the 
 battle of Waterloo, the 18th 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, 
 
448 LOOSE SUBSTANCES IN THE CAVITY OF THE CHEST. 
 
 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 mat- 
 ter, 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 proba- 
 bility 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, wad- 
 ding, 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 atten- 
 tion 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 insuSiciency 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 sup- 
 puration, 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 
 
ILLUSTRATIVE CASES. 449 
 
 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 Inng, 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 in- 
 
 38* 
 
450 ILLUSTBATIVE CASES. 
 
 flicted, the ball entering at the upper edge of the fourth rib, 
 about an inch from its junction with the cartilage. By 
 means of a bent and flexible sound introduced through the 
 wound, he distinguished a hard, metallic substance at the 
 bottom of the cavity of the chest, which he supposed to be 
 the ball, nearly in the situation of the place where the oper- 
 ation 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 re- 
 moved 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, mus- 
 cular man, of full habit, was vfounded 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 fur- 
 nished me with these particulars of the case, which 1 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 sufi'ocation, 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 be- 
 tween 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 sec- 
 ond 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, 
 
CASES BY M. BAUDENS. 451 
 
 was secreted. From this time he gradually recovered, and 
 was seut to England, cured, in November. 
 
 347. The presence of a ball, rolling about on the dia- 
 phragm, can now be ascertained by means of the stetho- 
 scope 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 puru- 
 lent, 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 d 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 day, 
 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 sud- 
 denly 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 be- 
 hind them, the size of a hen's q^%, containing several splin- 
 ters 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 
 
452 NECESSITY FOR A DEPENDENT OPENING. 
 
 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 per- 
 ceived 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 de- 
 stroyed him. The ball had fallen on the diaphragm, where 
 it was lying loose, surrounded by a quantity of purulent 
 matter. 
 
 M. Baudeus 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 afiBxed 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 dis- 
 charged 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 sur- 
 geons 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 work- 
 room of the College of Surgeons by Mr. Quekett, with the 
 following results : — 
 
 348. — 1. That a trocar and canula pushed in between the 
 
ANATOMY OF THE PARTS CONCERNED. 453 
 
 eleventli 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 expira- 
 tion, 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 opera- 
 tion, when required on man, should always be done cau- 
 tiously 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, com- 
 mencing 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 pro- 
 prium.) From this part extends another aponeurotic arch 
 along the lower border, to the end of the last rib, called the 
 false ligamentum arcuatum, (ligament cintre 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 inter- 
 costal 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 ofi" 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 tlie pillar of 
 the diaphragm, ascend on leaving the vertebras 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- 
 
454 ANATOMY OF THE PARTS CONCERNED. 
 
 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 
 ang es 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 dif- 
 ferent 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. Tlie vein is situated above the artery, and pro- 
 ceeds 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 con- 
 tinued over the inside of the twelfth rib to line the different at- 
 tachments 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 latissi- 
 mus dor si 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 latis- 
 simus dorsi, from the spinous processes of the three superior 
 lumbar vertebree 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 re- 
 flected, the posterior spinal or long muscles running in and 
 
THE OPERATION BY INCISION FOR EMPYEMA. 455 
 
 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 spinae or the sacrospinal 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 pre- 
 cede them, except the first, have only one surface of articu- 
 lation with the corresponding vertebrae, 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 car- 
 tilaginous 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 usu- 
 ally 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 vertebrae, 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 
 
456 HERNIA OP THE LUNG. 
 
 scratched through or separated in the middle of the inter- 
 space 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 exist- 
 ence 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 ap- 
 plied 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 dia- 
 phragm, 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 mat- 
 ters confining them in that situation. 
 
 LECTURE XXY. 
 
 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 occur- 
 rence. It appears to take place when the intercostal mus- 
 
HERNIA OF THE LUNG. 451 
 
 cles have been much injured and are deficient, the opening 
 through them being merely covered by the common integu- 
 ments 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 crepi- 
 tation, 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 ex- 
 piration, when the wound is left open and the lung is suffi- 
 ciently 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 pro- 
 truded 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 adhe- 
 sion 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 
 
 39 
 
458 WOUNDS OF THE DIAPHRAGM. 
 
 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 sep- 
 arated 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 Pare ; 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 suf- 
 ferer, 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 bat- 
 tle 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 smooth- 
 ing off as if they were inclined to become round; this open- 
 ing 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 2'7th 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 car- 
 ried to Alfaiates, and there he threw up a small quantity of 
 bloody matter by vomiting. The posterior wound was en- 
 larged and continued to discharge some blood, the intercos- 
 tal 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. 
 
ILLUSTRATIVE CASES. 459 
 
 ^ Sept. 29th. — BleediDg to eighteen ounces; on the 80th 
 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 suffer- 
 ing from considerable internal mischief; wandered occasion- 
 ally ; 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. 
 
 15ih. — 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 re- 
 lieved by opium in large and repeated doses. 
 
 On the 18th the spasmodic afi'ection 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 ten- 
 dinous 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 gener- 
 ally slightly yellow, as if tinged with bile in small quantity. 
 The skin did not show a yellowish tinge, neither were the 
 conjunctivae 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 re- 
 
460 ILLUSTRATIVE CASES. 
 
 moved after an enlargement of the wound by incision, when 
 the opening into the cavity of the chest was manifest, air 
 being discharged freely from it. The shock in the first 
 instance was great ; but after a time reaction took place, 
 and he lost a considerable quantity of blood in six bleedings 
 during the first sixty hours. The discharge, at first serous 
 and bloody, gradually became purulent, and the occurrence 
 of jaundice showed that the diaphragm and liver had in all 
 probability been injured. Under the administration of calo- 
 mel, antimony, and opium, this symptom was gradually dis- 
 appearing, 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 ante- 
 rior opening of the wound soon healed, but the posterior 
 one did not do so for a considerable period, when he became 
 affected by s-uch 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 inter- 
 vals 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 trans- 
 verse 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 Chat- 
 ham, No. 68, 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 Vv^aterloo, which entered behind 
 between the eighth and ninth ribs, near the spine, and lodged 
 
ILLUSTRATIVE CASES. 461 
 
 internally. After many severe symptoms and mucli suffer- 
 ing, he died on the 1st of December, worn out by the dis- 
 charge, 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 sur- 
 face, 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 with- 
 drawn. 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 in- 
 creased, 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, pen- 
 etrated the thorax, appeared to have passed through the 
 diaphragm, the point of the weapon coming out on the op- 
 posite 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, 
 
 39* 
 
462 WOL'NDS IN THE DIAPHRAGM NEVER HEAL. 
 
 the wliole of the intestmes, with the exception of the duo- 
 denum, 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 ; w^hile, 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 pro- 
 truded through the aperture in the diaphragm, by which it 
 was so firmly embraced as to render the communication be- 
 tween 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, 184*7. 
 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 oesophagus. The stomach, colon, and omentum 
 adhered firmly, at one part, to the pleura covering the dia- 
 phragm 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 vertebrae ; the other be- 
 tween the eighth and ninth ribs, three inches and a half from 
 the cartilages. The preparation is in the museum at Chat- 
 ham. 
 
 352. These cases confirm the fact that wounds of the dia- 
 phragm, 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 vis- 
 cera of the abdomen which may receive an impulse in that 
 direction. That parts of these viscera do pass upward and 
 back again, cannot be doubted ; and it is probable that in- 
 
PROBABILITY OF HERNIA INTO THE CHEST. 463 
 
 carceration may take place for a length of time before stran- 
 gulation 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 in- 
 jury to both, although they are principally referable to that 
 of the chest, and are those of intense inflammation, accom- 
 panied 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, hic- 
 cough, pain on the top of the shoulder, and loss of power of 
 the arm, which were all more or less present, in all proba- 
 bility 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; vom- 
 iting 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 re- 
 maining in the erect position for some time after each meal ; 
 he should carefully avoid a stooping posture and all muscu- 
 lar 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 
 
464 WOUNDS OF THE HEART. 
 
 incision througli the wall of the abdomen, large enough to 
 admit the hand, immediately over the part where the dia- 
 phragm 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 formi- 
 dable, 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 imme- 
 diately 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 vicin- 
 ity 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 aus- 
 cultation 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 be- 
 tween 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^ sub- 
 clavian vein and to the arch of the aorta crossing the tra- 
 chea, the center of the second bone to the upper edge of the 
 
THEORY OF THE SOUNDS OP THE HEART. 465 
 
 appendix of the right ventricle, and the center of the third 
 bone to the right side of the ri^ht auricle, the right ventri- 
 cle 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 be- 
 hind 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 be- 
 neath 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 distin- 
 guishable in a healthy heart — one duller and more pro- 
 longed, the other clearer and shorter ; between these there 
 is scarcely an appreciable interval The period of repose 
 is sufficiently marl^ed 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 account- 
 ing 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 membra- 
 nous, 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 
 
466 ENDOCARDIAL AND EXOCARDIAL SOUNDS. 
 
 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 desig- 
 nate 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 sur- 
 face. 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 over- 
 whelming, 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 with- 
 out 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 peri- 
 cardium 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 mem- 
 brane of the pericardium, gives out less marked but some- 
 what similar sounds (the ''frottemenV^ 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 mem- 
 brane 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 
 
SYMPTOMS ATTENDING WOUNDS OF THE HEART. 467 
 
 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, al- 
 though no local pain, no palpitations, no irregular move- 
 ments of the heart be present. 
 
 When a murmur or sound is heard of a different kind, 
 possessing the character of friction, of surfaces moving back- 
 ward and forward on each other, or to and fro, it is the 
 sign of inflammation of the membrane covering the heart, 
 as w^ell as of that lining the fibrous external tissue of the 
 pericardium. The signs of both external and internal in- 
 flammation may be present at the same time, and they fre- 
 quently 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 ; w^hile the anxiety is increased by pain, 
 sometimes intolerable, referred to the part. These symp- 
 toms 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, accom[)anied 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 inflam- 
 mation of the pericardium, may be absent ; it will not be 
 discernible, if a layer of blood be effused into the cavity of 
 that membrane ; w^hile the natural sounds of the heart are 
 rendered more indistinct as the heart is separated from the 
 w^alls of the chest by the effusion which distends the peri- 
 cardium, and impedes the regular action of the heart, but 
 cannot compress it, as an empyema does the lung. If in- 
 flammation take place without an effusion of blood, the fric- 
 tion 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 
 
468 DEATH BY HEMORRHAGE. 
 
 effused and attached portions of Ijmph 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 in- 
 stances, is indisputable ; and it would seem, from a consider- 
 ation 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 to- 
 ward 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 hemor- 
 rhage 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 ac- 
 curately 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 suffoca- 
 tion, 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 in- 
 stance, if the flow of blood be excessive and appear likely 
 to endanger life. It seems to be as little doubtful that the 
 
M. LARREY ON OPENING THE PERICARDIUM. 469 
 
 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 neces- 
 sarily follow, although it is more than probable it will be so, 
 that its place will be occupied by a farther extravasation of 
 blood, which will prove fatal. It is a choice of difficulties, 
 and death from hemorrhage is easier than death from suffo- 
 cation. 
 
 In the case of the Due de Berri, whose right ventricle was 
 wounded, and who died from loss of blood, Steifensand re- 
 prehends 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 carti- 
 lages 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 peri- 
 toneum 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 in- 
 clines 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 
 
 40 
 
4*70 SKIELDERUP'S OPERATION. 
 
 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 dia}>hragm. 
 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 Regi- 
 ment 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, with- 
 out attention being particularly drawn to the cicatrix of the 
 w'ound. 
 
 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 peri- 
 cardium 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 cica- 
 trix. 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. 
 
ILLUSTRATIVE CASE OF WOUND OF THE HEART. 4tl 
 
 If this man had lived long enough, he raight have fur- 
 nished 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, t, No. 156. 
 
 a, right ventricle; ft, left ditto; c. right auricle; d, left ditto; e, aorta; /, pulmonary 
 artery; g. coronary ditto; /(, 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 veutiicle; 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 Yilleneuve 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 
 
4t2 LACERATIONS AND RUPTURES OP THE HEART. 
 
 heart, need not be doubted, and that they do die when little 
 blood is lost, is admitted. History preserves the fact that 
 Latonr 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, anti- 
 mony, 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 difi^erent 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 sev- 
 eral places ; and that these results were in an inverse propor- 
 tion to those which occurred after blows or contusions : the 
 
 a J 
 
 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. 
 
WOUNDS OF THE INTERNAL MAMMARY ARTERY. 4t3 
 
 LECTUKE XXYI. 
 
 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 nu- 
 merous than the case requiring them, and that no notice need 
 be taken of them, they being as unnecessary as they are use- 
 less. I have never had occasion to see a distinct case of 
 hemorrhage from an internal mammary artery, but if bleed- 
 ing 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 he 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 difSculties 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 mus- 
 cular fibers of the inner intercostal muscle are to be sepa- 
 rated and torn through with a director, until the artery and 
 its two venae 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, 
 
 40* 
 
4*74 WOUNDS OP THE INTERCOSTAL ARTERY. 
 
 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 hemor- 
 rhage. 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 reap- 
 peared 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 
 
WOUNDS or THE NECK. 4t5 
 
 turpentine, applied on a dossil of lint, and pressed on the 
 bleeding spot by the fingers of assistants until the hemor- 
 rhage 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 stand- 
 ing 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 inter- 
 costal 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 hemor- 
 rhage 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 
 
4Y6 WOUNDS OF THE FACE. 
 
 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 oesophagus 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 liga- 
 ture. 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 
 %l.e 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. Greneral 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 advant- 
 ages 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 fellovi^- 
 creatures in distress. A Minister at War would not per- 
 haps be the worse for a little personal experience in this 
 matter. 
 
 3G5. Wcunds of the face made by swords or sharp-cut- 
 ting 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 
 
WOUNDS OF THE EYE AND EYELIDS, ETC. 477 
 
 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 after- 
 ward as may be necessary. They may remain for three or 
 more days, as circumstances seem to require. If the eye be 
 w^ounded, any part protruding beyond the sclerotic coat 
 should be cat 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 eye- 
 ball, which may in general be efi'ected, 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 integu- 
 ment dislodged from the neighboring parts — a proceeding 
 requiring a separate consideration. Injuries from musket- 
 balls are often attended by considerable laceration, particu- 
 larly 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 manage- 
 ment. 
 
 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 instru- 
 
478 GUNSHOT WOUNDS OF THE EYEBALL. 
 
 ment. When a shot or piece of a copper cap is driven 
 through the cornea, into the iris, or lies in the anterior cham- 
 ber, 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 amau- 
 rosis, 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 con- 
 tused 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 pro- 
 trusion, 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 re- 
 moval 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 mus- 
 cles attached to it, a stump remains, against which an arti- 
 ficial 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 pa- 
 tient ; 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. 
 
PENETRATING WOUNDS OF BONES OF THE FACE. 419 
 
 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 implicatiog the bones of the 
 face are always distressing. When the bones of the nose are 
 carried away, there must always be some deformity remain- 
 ing, 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 in- 
 cised wound open until the external one is closed. If a sali- 
 vary 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 occur- 
 rence, it will be best treated by actual or potential cauteriza- 
 tion, if moderate pressure should fail When these wounds 
 are of some extent, they are often followed by partial pa- 
 ralysis, 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 suf- 
 fering, 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 wo.unded 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 stand- 
 ing sideways toward the enemy. It entered a little below 
 the outer part of the cheek-bone on the left side, and, taking 
 an oblique direction downward and forward, shattered and 
 destroyed in its course several of the double teeth in the 
 upper jaw, fracturing the palate from its posterior part, for- 
 
480 WOUNDS OF THE LOWER JAW. 
 
 ward to the front teeth. The ball then took a direction 
 obliquely upward, destroying the teeth of the opposite side 
 of the upper jaw, which bone it also broke, and lodged under 
 the fleshy part of the cheek. These wounds gave great pain, 
 and until the ball was removed, the left ear was totally in- 
 sensible 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 after- 
 ward. 
 
 The treatment of this wound, however, was most painful ; 
 the extraction of several pieces of bone was necessary at dif- 
 ferent 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 increas- 
 ing 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 difiSeult 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 w^ere 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 tem- 
 poral bone. He then carried it downward, and a little ob- 
 liquely 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 
 
INCISED AND GUNSHOT WOUNDS OF THE TONGUE. 481 
 
 the attachments of the buccinator, temporal, and pterygoid- 
 eus 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, ]\L 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 Hotel 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 mus- 
 cle 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 
 
 41 
 
482 STRUCTURE OF INTESTINE. 
 
 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 use- 
 ful. 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 Cap- 
 tain 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 ap- 
 pearance 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 XXYII. 
 
 STRUCTURE OF AN INTESTINE, ETC. 
 
 3*72. 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 mu- 
 cous, 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 difl'erent parts. Be- 
 ginning from without, viz., serous or peritoneal, areolar or 
 sub-serous; longitudinal muscular, areolar; transverse mus- 
 cular, areolar or sub-mucous, and epithelial. The mucous 
 
STRUCTURE OF INTESTINE. 483 
 
 coat ia man has a peculiarity not observable in animals, of 
 ledp^es 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 tolera- 
 bly smooth appearance, gradually, however, becoming irregu- 
 lar 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 valvule conniventes. They 
 are most strongly marked in the jejunum, and gradually dis- 
 appear 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, al- 
 though they sometimes bifurcate. They have a velvety 
 appearance, which has obtained for this" coat the name of 
 villous as well as that of mucous. 
 
 Yalvulas 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 valvulse 
 conniventes of the human subject ; but, on a careful exam- 
 ination, 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, some- 
 what like the valvulse conniventes, or large villi ; but they 
 are not villi, as each process is covered with other projec- 
 tions 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 appear- 
 ance 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 lac- 
 teal. A nerve has not been discovered, although it is pre- 
 sumed to exist. These villi are longest in the duodenum, 
 and gradually diminish in number and in size from tt^^ to -^^ 
 of an inch. Between these villi or projections, holes or 
 openings are observable, termed the follicles of Lieberkiihn, 
 who first described them; they resemble inverted villi, being 
 
484 STRUCTURE OF INTESTINE. 
 
 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 cov- 
 ered, 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 epithehum 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 cir- 
 culates in the capillaries of the gut. In consequence of this 
 increased flow of blood, or from some other cause, the inter- 
 nal 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 ^^t^s 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 epithe- 
 lia, 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 be- 
 come more distinctly vesicular, although no distinct commu- 
 nication can be detected between them. The blood-vessels 
 
PROCESS OF DIGESTION. 485 
 
 and capillaries shown Iq 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 appear- 
 ance 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 debris 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 de- 
 velopment of new vesicles ceases, the lacteals empty them- 
 selves, 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 pre- 
 sumed 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 epithe- 
 lium 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 re- 
 sembling much in appearance those of the intestine ; but in 
 the stomach minute tubes are found opening into the bottom 
 
 41* 
 
486 GLANDS OF BRUNNER, GREW, AND PETER. 
 
 of each follicle, fulfilling in all probability a different office, 
 the follicles being lined by colamnar epithelium, the tubes 
 by spheroidal or glandular epithelium ; it is therefore pre- 
 sumed 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 commence- 
 ment 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 resem- 
 bling 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, project- 
 ing through among the villi or the follicles. They are com- 
 posed of cells, supplied by capillary vessels, which Mr. 
 Quekett says have the pecuharity 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, 
 
STRUCTURE OF INTESTINE. 48t 
 
 and when injected the parts around are more vascular, the 
 ulcerated portion being less so than usual. 
 
 The Holitary glands are best seen in the coscura and ap- 
 pendix verraiformis. They are well developed in the foetus, 
 projecting slightly above the mucous membrane. Each gland 
 may be considered as one of the agminated form much en- 
 larged, 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 dis- 
 ease, 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 intes- 
 tine, 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 mus- 
 cular coat, and in it the blood-vessels and nerves are sup- 
 ported 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 striae 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 striae or stripes, although the interior appears 
 granular, with an occasional nucleus. The heart is a re- 
 markable 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 
 
488 WOUNDS OF THE ABDOMEN. 
 
 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. Open- 
 ing 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. 
 
 Captnin 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 sup- 
 posed that the sufferers would recover without any perma- 
 nent 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 
 
INJURIES OF THE ABDOMINAL PARIES. 489 
 
 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 capabihty 
 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 ulcer- 
 ation 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 battle- 
 field. 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 indiffer- 
 ence ; the part on which the ball impinges is usually distin- 
 guished 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 oblicjuely 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 
 
490 ABSCESSES IN THE ABDOMINAL PARIES. 
 
 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 pre- 
 vail 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 in- 
 convenience. 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 derange- 
 ment. 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 antiphlo- 
 gistic 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 
 
ILLUSTRATIVE CASES. 491 
 
 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. 
 
 879. 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 inflamma- 
 tion, 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, 
 witliout much vomiting; the abdoro.en was constantly fo- 
 mented 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 ITth. 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 cratch 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 etfect 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 
 
492 EFFECTS OF A RUPTURE OF THE VISCERA. 
 
 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 bruised, 
 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 dis- 
 tance 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 conse- 
 quence 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 ap- 
 plied. 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 inflam- 
 mation which had taken place. 
 
 If the injury should not destroy the patient, but prove 
 
INCISED WOUNDS OF THE ABDOMINAL PARIES. 493 
 
 sufficient to give rise, after several weeks, to effusion into 
 the cavity, the fluid should be evacuated by the trocar. 
 
 When the fixed viscefa are ruptured by severe blows, 
 such as those received by falls or from cannon-shot, the suf- 
 ferers usually die from hemorrhage and not from inflamma- 
 tion. The arm has been carried away, and the liver rup- 
 tured 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 per- 
 fect 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 ap- 
 peared to have taken place in the first instance, and a her- 
 niary 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 co- 
 hesion of the parts, while it exposes the sufferers to all the 
 dangers which the irritation of sutures commonly occasions, 
 thus ofi'ering another instance of the improvement surgery 
 owes to the war in the Peninsula. 
 
 Chelius recommends " several flat ligatures to be intro- 
 duced through the skin and muscles, the needle being placed 
 close to the muscular surface of the peritoneum." Graefe 
 (section 514) is declared to be of the same opinion, he rec- 
 ommending, 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 mod- 
 erate 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 with- 
 out 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 
 
 42 
 
494 ENTRANCE OF AIR THE BUGBEAR OF SURGEONS. 
 
 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 effect- 
 ive support should be also given by strips of adhesive plas- 
 ter 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 sup- 
 port 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 apposi- 
 tion ; for although the omentum and intestines are often ca- 
 pable of undergoing a considerable degree of motion from 
 side to side, independently of that peculiar wormlike move- 
 ment on themselves which in the intestines is called peri- 
 staltic, 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 adhe- 
 sion through the medium of lymph or fibrin deposited be- 
 tween them. If this adhesion take place, it extends for 
 some little distance from the wounded part, which it thus 
 closes up and cuts ofi" from all communication with the gen- 
 eral 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 inflam- 
 mation extending to a certain point, and ending in the depo- 
 sition of fibrin. When it exceeds this, the secretion of a 
 quantity of serous fluid, together with threads of flocculeut 
 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. 
 
RIGID TREATMENT OF WOUNDS OF ABDOMEN. 495 
 
 382. Absolute quietude is no less to be observed. It 
 must, however, be steadfastly continued ; the slightest alter- 
 ation 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 main- 
 tained 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 physiologi- 
 cal and surgical principles on which it ought to be founded, 
 a condemnation the accuracy of which is now universally ad- 
 mitted, although the source from which it is derived is not 
 so universally acknowledged. No purgative medicine what- 
 ever should be given to a person with a penetrating wound 
 of the abdomen. Xo food should enter his mouth ; and no 
 more water even should be allowed than may be found requi- 
 site 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 satis- 
 factory it would be, cannot always be obtained, and ought 
 not in the generality of instances to be sought for, the re- 
 striction 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 in- 
 jury 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 probabil- 
 ity have occurred. When nature shall point out by the sen- 
 sations 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 
 
496 GENERAL AND LOCAL BLEEDING. 
 
 arrangements being made by bedsteads of a proper con- 
 struction, or by other simple means which are suflBcieutly 
 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 ex- 
 perience did not sanction, and it could not therefore be ap- 
 proved. 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 re- 
 sult in favorable cases. It tends to prevent the agglutina- 
 tive 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 reg- 
 ulated 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 Cri- 
 mea, 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 lias 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, par- 
 ticularly 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 efi*ect has 
 been ascertained, will often ask for them himself on the re- 
 currence 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 op- 
 pression than on the apparent state of the circulation. Be- 
 fore general and local bleeding cease to be employed with 
 
PENETRATING WOUNDS OF THE BELLY. 49T 
 
 advantage, calomel, antimony, and opium will render essen- 
 tial, nay, most important, service. 
 
 The extensive incisions made of late years into tbe abdo- 
 men 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 sup- 
 posed 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, 48d Regiment, was 
 accidentally wounded, March 19th, 1812, by a comrade, the 
 small end of a ramrod entering about two inches below tlie 
 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 occa- 
 sionally 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 al- 
 lowed a small proportion of bread with his tea. 
 
 42* 
 
498 WOUNDS TENETRATING THE WALL OF THE BELLY, 
 
 28tli. — So far recovered as to be able to be removed to 
 Elvas.* 
 
 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 Pare, 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 re- 
 coveries of a similar nature must be considered as exceptions 
 to general rule. 
 
 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 ex- 
 pansion, under the cicatrix formed by the common integu- 
 ments. 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 direc- 
 tion 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 pro- 
 trude 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 with- 
 out the slightest pressure or possible strangulation, in order 
 that by its retention it may more readily adhere to these 
 edges, and thus form a more certain barrier against the ex- 
 
 * He marched with his regiment, in the summer, to Vall.adolid, and 
 was drowned in the Douro. — G. J. G. 
 
WITH PROTRUSION OF ITS CONTENTS. 499 
 
 tension of inflammation than is likely to take place when 
 moving at liberty in the cavity of the abdomen, however 
 closely it may be supposed to be applied to the inner surface 
 of its paries. 
 
 It sometimes happens that a portion of omentum is alto- 
 gether 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 sub- 
 ject 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 enlarge- 
 ment 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 in- 
 stances, but no inconvenience follows small openings not ex- 
 ceeding a quarter of an inch in length, when they are prop- 
 erly covered over by the healthy parts. It is therefore im- 
 portant 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 pro- 
 truded, 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 sup- 
 puration 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 gradu- 
 ally retract and be withdrawn into the cavity of the abdo- 
 men. 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 
 
500 ILLUSTRATIVE CASES. 
 
 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, j^o 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 
 
OMENTUM MAY BE CUT OFF. 501 
 
 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 Tou- 
 louse 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 reduc- 
 tion 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 
 
502 ORDINARY TREATMENT DISAPPROVED. 
 
 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 Eng- 
 lishmen) 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 there- 
 fore 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 obsta- 
 cle 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 taken 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 
 
ILLUSTRATIVE CASES. 503 
 
 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 in- 
 testine, 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 neces- 
 sary 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 breath- 
 ing, the skin being hot and the pulse quick and hard. The 
 cellular membrane around the wound in the back was em- 
 physematous ; there was a slight cough, accompanied by an 
 expectoration slightly tinged with blood. The bleeding re- 
 moved 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 natu- 
 rally 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 
 
504 PROPER TREATMENT OF WOUNDED INTESTINE. 
 
 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 conse- 
 quence, 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 con- 
 sider the abdomen as devoid of cavity during life and health, 
 the contained parts being so gently pressed upon by the con- 
 taining 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 effu- 
 sion of the contents of a bowel when ruptured, if the wound 
 be half an inch in length, or that it will prevent the extrava- 
 sation of blood from an artery or vein of moderate dimen- 
 sions, if torn, is contrary to facts now considered indisputa- 
 ble, 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, with- 
 out 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 in- 
 stances will be adduced — the general cavity may be filled ; 
 but when the injury is less extensive, or the lesion less im- 
 portant, 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 
 
EFFUSION OF BLOOD INTO THE ABDOMEN. 505 
 
 pressure of the wall of the abdomen and the resistance offered 
 by its contents, to a particular spot, whence it may be ab- 
 sorbed after coagulation; or, by commencing decomposition, 
 give rise to irritation, and be discharged through the exter- 
 nal 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 Albu- 
 hera, 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 Yalverde, 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 mis- 
 chief 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 wiueglassful 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 peri- 
 toneal inflammation. That small ones may be absorbed, can- 
 not be doubted. I have seen instances of their having been 
 discharged by the bowel, although I have never been so for- 
 tunate 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 efi'ect. 
 
 The important conclusions to be deduced from the ob- 
 servations of those who have made experiments on the intes- 
 tines 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 extravasa- 
 tion of the contents of the intestinal tube ; and that, in the 
 
 43 
 
506 EXPERIMENTS ON WOUNDS OF THE INTESTINES. 
 
 majority of cases, nainre, properly aided by art, is fully com- 
 petent 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 invaiiably, followed 
 by the escape of the contents of the bowel, and the conse- 
 quent 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 por- 
 tion 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 ex- 
 ternal 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 con- 
 nection between the divided parts was firm and organized." 
 
 Similar effects are produced when a small ligature is ap- 
 plied 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 
 
TREATMENT OF A DIVIDED INTESTINE. 50Y 
 
 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 repro- 
 duction, 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 thir- 
 teenth 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 Mau- 
 beuge, in the beginning of the eighteenth century, apparently 
 unaware of what had been done before his time, brought for- 
 ward 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 w^ound 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, DiHputat. Anatom., vol. vi., 
 Obaerv. Med. Mtscel, 18.) Since his time, many of the most 
 
508 TREATMENT OF INCISED WOUNDS. 
 
 eminent surgeons of France, Italy, America, and Great Britain 
 have turned their attention to this subject ; but the conclu- 
 sion 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 sur- 
 faces 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 intes- 
 tine should be returned into the cavity of the abdomen, and 
 events awaited. Kecoveries 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 XXYIIL 
 
 TREATMENT OF INCISED WOUNDS, ETC. 
 
 392. When an incised wound in the intestine is not sup- 
 posed 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 at- 
 tempt to probe or to meddle with the wound, for the pur- 
 
TREATMENT OP A PUNCTURED INTESTINE. 509 
 
 pose of examining the intestine, sbould 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 wnll not be warranted in 
 enlarging the wound in the first instance to see what mis- 
 chief has been done. It may be argued that a wound four 
 inches long has been proved to be oftentimes as little dan- 
 gerous 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 ex- 
 tent. Few surgeons, even then, would like to enlarge the 
 wound to ascertain the fact, unless some considerable bleed- 
 ing 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 pro- 
 ceeding. 
 
 393. A puncture or cut which is filled up by the mucous 
 coat so as to be apparently impervious to air does not de- 
 mand 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 wdth success in wounds of the 
 internal jugular vein without impairing its continuity; or 
 the opening, if larger, may be closed by two or more con- 
 tinuous 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 longitu- 
 dinal or transverse direction, or is completely divided as far 
 
 , 43* 
 
510 TREATMENT OF EFFUSION OF BLOOD. 
 
 as or beyond the mesentery, the continuous suture is abso- 
 lutely necessary. 
 
 394. When the abdomen has been penetrated, and con- 
 siderable 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 epi- 
 gastric, 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 ca9ador on picket was wounded at the sec- 
 ond siege of Badajos in a sally made by some EVench cav- 
 alry. 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 exter- 
 nal wound was sewed up. The peritoneum was open to a 
 small extent, but the bowel did not protrude ; and the pa- 
 tient (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 en- 
 large 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 me- 
 thodically 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, 
 
SUPPURATION IN THE CAYITY OP THE ABDOMEN. 511 
 
 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 im- 
 mediate relief. When the belly becomes very painful, tense, 
 and manifestly full after a punctured wound, and not tympa- 
 nitic 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 cav- 
 ity and to allow the issue of blood extravasated in the quan- 
 tity alluded to, should be enlarged to such an extent as to 
 effect that object. 
 
 396. Blood effused in moderate quantity, and circum- 
 scribed 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, suppura- 
 tion, if the patient survive so long. This occurs, for the 
 most part, after the first inflammatory symptoms have sub- 
 sided, 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 cir- 
 cumscribed 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 
 
512 ILLUSTRATIVE CASES. 
 
 do such an operation, it may safely be preceded by an ex- 
 ploring 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 ap- 
 proach 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 in- 
 undated 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 sup- 
 ported 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, t6th Regiment, aged twenty-two, was 
 admitted into tlie Garrison Hospital, Portsmouth, upon the 
 13th of June, r^45, with all the symptoms of strangulated 
 inguinal hernia of the left side, of two days' standing, for 
 
ILLUSTRATIVE CASES. 613 
 
 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 excite- 
 ment 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 anti- 
 phlogistic remedies. On the morning of the seventeenth 
 day from the performance of the operation, a piece of in- 
 testine came away with the fecal contents of the bowels, 
 after which the patient experienced relief in all his symp- 
 toms, 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 open- 
 ing. I accordingly made an incision over the site of the 
 former wound, and carefully opened the intestine, to the ex- 
 tent only to allow the tube of the stomach-pump to be in- 
 serted, when there was an immediate discharge of flatus and 
 some feculent matter, and the patient expressed himself re- 
 lieved. 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 ap- 
 peared 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 inconveni- 
 ence 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 
 
514 ENLARGEMENT OF THE WOUND. 
 
 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 in- 
 guinal 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 farmed 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 intes- 
 tinal tube. By this wonderful provision of nature the 
 healthy functions were uninterruptedly carried' on, and per- 
 manently 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 inflamma- 
 tion, are so rare in natives of our northern climates tnat 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 pro- 
 priety, 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 sur- 
 geons, 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 
 
MUSKET-BALL PENETRATING CAVITY OF THE BELLY. 515 
 
 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 {dehridant 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 be- 
 come 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 oppor- 
 tunity 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 continu- 
 ous 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 
 
516 ILLUSTRATIVE CASES. 
 
 died under similar wounds, during the war beginning with 
 the battle of Roli9a in Portugal, in August, 1808, and end- 
 ing with that of Waterloo, in June, 1815, may be read with 
 a melancholy interest, as showing what sometimes will hap- 
 pen in a few rare instances, and even then as more depend- 
 ent 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 in- 
 fantry 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 bady. The bowel pro- 
 truded 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 en- 
 gaged 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 vons, mon offi- 
 cier,' 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 hesita- 
 tion 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 
 
ILLUSTRATIVE CASES. 51 1 
 
 blood, which had trickled through to the floor, and had 
 escaped from the wouud behind. 
 
 "Before a month had elapsed I and all the wounded were 
 removed to Elvas on hidlock-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, fol- 
 lowed by an angry-looking protrusion, which was carefully 
 washed with warm water, and poulticed ; when the inflam- 
 mation 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 disgust- 
 ing 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 
 
 44 
 
518 ILLUSTRATIVE CASES. 
 
 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 vertebrae. 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; diarrhoea during the night; the 
 feces were mixed with blood; pulse 120; skin hot. Bleed- 
 ing to twelve ounces ; blood sizy. 
 
 22d. — Slept a little during the night; had several alvine 
 evacuations of a bilious fluid mixed with blood. The ten- 
 sion 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. R. — Hydrarg. 
 chlorid. gr. iv; conf. ros^e, 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 adnatee have a yellow tinge; in other 
 respects he is doing well. R. — Chlorid. hydrarg. gr. x; 
 extr. Colocynth. comp. 5j ' to be made into ten pills, one to 
 be taken three times a day. 
 
 20th. — The wound perfectly healed; is cleaning his ac- 
 coutrements, boots, etc. Was discharged on the 28th of 
 July, perfectly recovered. 
 
 Owen M'Caffrey, aged thirty-three, first battalion 95th 
 
ILLUSTRATIVE CASES. 519 
 
 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 
 liuea alba. When admitted into the Minimes General Hos- 
 pital 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 irrita- 
 bility 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 por- 
 tion, getting into the cavity of the abdomen. 
 
 26th. — The high inflammatory action having been re- 
 duced, 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 injec- 
 tions. 
 
 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 umbili- 
 cus 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 open- 
 ings. 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 
 
520 ILLUSTRATIVE CASES. 
 
 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 en- 
 tered 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 Gal- 
 lega, 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 Regim.ent, 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 prac- 
 tice was pursued during the 12th, 13th, and 14th, venesec- 
 tion 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 
 
ILLUSTRATIVE CASES, 521 
 
 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 quantites at a time, were all that was allowed him for 
 food and drink. 
 
 April 15th. — Pulse above 100, weak and small; tempera- 
 ture natural; the tongue clean. Continued affected with a 
 degree of nausea and vomiting, after drinks especially; and 
 some diarrhoea 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. — Diarrhoea and tenesmus troublesome during the 
 night; hall voided with the feces at six A.^i.\ it is some- 
 what flattened, as if from impinging on a stone; has felt 
 easy since. Continue antiphlogistic regimen. 
 
 19th. — Diarrhoea abated ; but the abdomen is tense and 
 painful on pressure. He is distressed with nausea and vom- 
 iting; 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 con- 
 tinued. 
 
 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 stom- 
 ach, nor thirsty. To keep himself warm, particularly the 
 belly. 
 
 11th. — Suspect he has been rather irregular in diet. 
 
 44* 
 
522 ILLUSTRATIVE CASES. 
 
 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; tem- 
 perature 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, acaciae, 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 witli his case, particularly his man- 
 ner 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 abdo- 
 men not urgent; no vomiting, but is affected with nausea. 
 Digitalis continued. Four o'clock. — Pulse 100; feels nau- 
 seated ; 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 iu 
 any quantity; skin hot; thirst great; tongue red; two mo- 
 tions; 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. 
 
 l*7th. — 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 pro- 
 duced. 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 
 dyspnoea, attended by cough and pain of chest, both in- 
 creased hj full inspiration. Pulse 120 ; face flushed ; says 
 he caught cold from exposure to the night air. Bled im- 
 
ILLUSTRATIVE CASES. 523 
 
 mediately, and as much blood taken as his strength would 
 permit ; foot-bath repeated in the evening. 
 
 25th. — Six ounces of blood drawn ; surface buflFj ; bad 
 night ; cough, pain, and pyrexia abated this morning ; in 
 the evening severe dyspnoea ; cough and pain of chest have 
 recurred ; pulse 120. Six ounces of blood to be drawn, 
 should strength permit ; mucilaginous mixture to be con- 
 tinued ; 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 um- 
 bilicus, 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, al- 
 though, 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 
 
524 ILLUSTRATIVE CASES. 
 
 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. 
 
 bth 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 per- 
 ceived 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 ray 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 per- 
 ceived a musket-ball. Previous to extracting it, however, I 
 
ARTIFICIAL ANUS. 625 
 
 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 por- 
 tion 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 contain- 
 ing 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- 0. Regiment. 
 
 Camp before Sebastopol, August Sth, 1855. 
 
 LECTURE XXIX. 
 
 ABNORMAL OR ARTIFICIAL ANUS, ETC. 
 
 401. In some cases of wounds of the intestine the con- 
 tinuity 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 occur- 
 rence 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 
 
526 ARTIFICIAL ANUS. 
 
 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 ad- 
 hesion 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 j^^omonfoire, valve or spur, 
 ridge or septum ; it directs the fecal matter through the ex- 
 ternal 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 satis- 
 factorily made out — and it is sometimes wanting — the ex- 
 ternal 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 mesen- 
 tery upon it at the point of union of the divided extremities 
 outside where the eperoyi or valve is formed ; and it is said 
 that this dragging has even led to the gradual disappear- 
 ance 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 elon- 
 gation of the membrane formed under the adhesive process, 
 
ARTIFICIAL ANUS. 527 
 
 by which the intestine is attached to the inside of the wall 
 of the abdomen in the same manner as adhesions are elon- 
 gated between the pleurae, and a sac or pouch is thus formed 
 between the cut ends of the intestine and the fistulous exter- 
 nal opening which Scarpa was the first fully to demonstrate 
 and explain, and which he called an entonnoir, infundihu- 
 lum, or funnel. If, then, in an old case, a small portion of 
 the wall of the abdomen be removed in the form of a Y, the 
 internal opening at the apex of the Y, 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 pre- 
 vent 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 
 sufBciently to destroy its life. The separation of the valve 
 included within the forceps would take place by the usual 
 processes of ulceration in its immediate proximity, and by 
 adhesion of the parts external to the bowels to those sur- 
 
528 MR. trant's instrument for artificial anus. 
 
 rounding them. The inflammation, however, did not always 
 stop at the adhesive stage, and death has been the result as 
 well as a successful cure. 
 
 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 in- 
 strument 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 consid- 
 erable 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 pre- 
 vented, 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 sim- 
 ilar cases. Whatever may be the method employed for the 
 cure of an artificial anus lay 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 suc- 
 cessful cases, a small aperture will frequently remain, consti- 
 tuting a fecal fistula instead of an artificial anus. This will 
 sometimes become irritable, inflame, ulcerate, or burst, dis- 
 charging 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 
 
WOUNDS AND INJURIES OF THE LIVER. 529 
 
 from the twelfth or fourteenth day after the primary symp- 
 toms 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 abdo- 
 men, with the addition of those peculiar to the organ — pulse 
 often smaller and less perceptible than in peritonitis ; dis- 
 coloration 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 inflamma- 
 tion ; 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 
 
 45 
 
530 ILLUSTRATIVE CASES. 
 
 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 dis- 
 tinguished 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, *r9th 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 sup- 
 posed 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 re- 
 peated, 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 
 
ILLUSTRATIVE CASES. 531 
 
 was repeated the next day. The bilioas discharge ceased in 
 the middle of August, and on the 2d of September he was 
 discharged convalescent. 
 
 Lieutenant Edward Hooper, first battalion, 38th Regi- 
 ment, was wounded by a musket-ball on the 9th of Decem- 
 ber, 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 inter- 
 mitting ; the breathing hurried and laborious, and in a short 
 time the tunicae conjunctiva 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 nour- 
 ishment was allowed. From tliis day a gradual amendment 
 took place. The calomel was continued until his mouth be- 
 came 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. 
 
532 ILLUSTRATIVE CASES. 
 
 A soldier of the 48th Regiment was struck by a musket- 
 ball at Albuhera, on the upper part of the right hypochon- 
 drium, over the liver ; it came out behind, at a point imme- 
 diately 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 Yal- 
 verde, 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 ayellow 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 Pyre- 
 nees, by a musket-ball, which penetrated the outer part of 
 the right hypochrondriura, 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 ori- 
 fice 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 ex- 
 tract 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, i'f 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 
 
WOUNDS OP THE STOMACH. 533 
 
 wounded through the liver, to whom little subsequent incon- 
 venience was occasioned. 
 
 406. Portions of the liver have been removed in some in- 
 stances; in one case, related by Blanch ard, 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. Diefifenbaeh 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 re- 
 lated the case of a Hindoo, a large piece of whose liver pro- 
 truded 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 liga- 
 ture 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 re- 
 turned 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 withiu 
 the divided parts of the wound was agreeable to the princi- 
 ples I have inculcated with respect to wounds of all the 
 cavities. 
 
 40T. 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 con- 
 sequent inflammation, can scarcely fail to ensue. It is fortu- 
 nate for the patient, when they occur, that the stomach should 
 be empty. If it should not be so, the contents may possibly 
 be ejected shortly after the receipt of the wound, but it is 
 not advisable to excite vomiting by remedies, or by means 
 adapted for that purpose. In a perfectly quiescent state, the 
 general compression of the contents of the abdomen by its 
 walls may prevent effusion under ordinary circumstances, and 
 this state should be maintained as rigidly as possible. The 
 apparent course of the wound indicates the probable mis- 
 
 45* 
 
534 AVOUNDS OF THE STOMACH. 
 
 chief, which is especially confirmed by vomiting of blood, 
 great anxiety, depression of countenance, a cold, clammy 
 skin, pain in the part, hiccough, and by the discharge of the 
 contents of the stomach, if the wound be sufficiently open to 
 allow it ; pulse low and sometimes intermittent. If effusion 
 of the contents of the stomach should not occur, the external 
 wound, if an incised one, should be closed by suture, and 
 the patient kept in the utmost state of quietude, in a some- 
 what 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 desira- 
 ble that the wound should be enlarged, if a doubt be enter- 
 tained 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 hith- 
 erto 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 sur- 
 geons shall be in sufficient numbers on the field of battle to 
 
FISTULOUS OPENINGS. 535 
 
 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 sev- 
 eral 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 ex- 
 ternally, if they show any disposition to be thus evacuated. 
 The external wound should be dilated as far as the peri- 
 toneum, 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 ex- 
 pected 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 remark- 
 able. 
 
 Hevin has related some of the most interesting cases of 
 those who had swallowed knives, etc., by design or by acci- 
 dent, 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 hav- 
 ing failed, Marchetti was applied to. He prepared a hollow 
 tube two feet long, large enough to receive the thickest part 
 
536 WOUNDS AND INJURIES OF THE SPLEEN. 
 
 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 impos- 
 sibility 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 pos- 
 sible, 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, espe- 
 cially 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 suf- 
 ferers, 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 
 
WOUNDS OF THE KIDNEYS. 537 
 
 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 remain- 
 ing 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 exter- 
 nal, 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 ap- 
 plication 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 adminis- 
 tration 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 suppu- 
 ration 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 dan- 
 gerous, 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 
 
538 ILLUSTRATIVE CASES. 
 
 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 dis- 
 charged from the front wound, but some came through the 
 posterior one, accompanied by a small quantity of urine, in- 
 dicating 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 De- 
 cember, 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 de- 
 scription, 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 four- 
 teen 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 con- 
 sequence 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 dis- 
 charged several ounces of matter of a urinous odor. An- 
 other 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 malie water was incessant ; but it passed only 
 by drops, and brought him to a state of frenzy ; the dis- 
 charge 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, 
 
WOUNDS OF THE SPERMATIC CORD. 539 
 
 forcing out with it a hard lujup, 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 cov- 
 ered by a black crust, and was thought to be a stone when 
 passed. It could not, however, have been long in the blad- 
 der, 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 be- 
 hind, injuring apparently the fourth and fifth lumbar verte- 
 brae. 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 Yalverde, three days after- 
 ward, in a most distressing state. The inflammatory symp- 
 toms 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 Jiindly 
 do the act of a friend and give them to him myself. He 
 died at the end of ten days, after great sufi'ering, 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. 
 
540 WOUNDS OF THE PENIS. 
 
 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 med- 
 ullary sarcoma. I removed the testis, and the wound healed 
 kindly. The lumbar glands had, however, taken on the dis- 
 ease, 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 Diefifen- 
 bach and others for the formation of a new urethra by bor- 
 rowing 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 Roli9a, in August, 1808, by a small mus- 
 ket-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 an inconvenient curve or twist, 
 such as often takes place when the corpora cavernosa and 
 the corpus spongiosum are injured or ruptured from other 
 causes. 
 
WOUNDS OF THE PELVIS. 541 
 
 LECTURE XXX. 
 
 WOUNDS OF THE PELVIS, ETC. 
 
 413. Wounds of the pelvis from musket-balls injuring 
 its contents are of common occurrence, and, although fre- 
 quently 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 in- 
 formation. 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 sur- 
 geon can form an estimate of the evil which has been com- 
 mitted ; 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 onfy are injured, the paralysis is not com- 
 plete ; 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 usu- 
 ally 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 de- 
 sirable to ascertain its situation, in order that it may be at 
 
 46 
 
542 ILLUSTRATIVE CASES. 
 
 once removed, if it can possibly be done with but little com- 
 parative danger ; for balls which lodge in these flat bones 
 may often be removed, and the comfort of the patient as- 
 sured 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 nar- 
 rowly 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 con- 
 tinued from the wound for several years, with a certain de- 
 gree 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 sud- 
 denly 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 Bareges 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 
 
ILLUSTRATIVE CASES. 543 
 
 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, ren- 
 dering 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 with- 
 out 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 uritiary 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 
 
544 ILLUSTRATIVE CASES. 
 
 iramediately 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 stimu- 
 lants 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 
 28ih, eleven days after the receipt of the injury. On exam- 
 ination 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 
 
EXTRACTION OF BALLS — CASES. 545 
 
 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 observa- 
 tion. 
 
 A grenadier was wounded at the batile of Dettingen, in 
 1*743, by a musket-ball, which entered above Poupart's liga- 
 ment, 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 in- 
 cisions 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 
 
 ■ 40* 
 
646 ILLUSTRATIVE CASES. 
 
 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 para- 
 lyzed; 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 con- 
 taining 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 ab- 
 stracted, although occasionally almost fainting on any move- 
 ment ; 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 i-n 
 the left leg and thigh. 
 
 415. The general opinion which formerly prevailed, that 
 wounds of the bladder, by musket-balls, were for the most 
 
WOUNDS OF THE BLADDER. 54t 
 
 part mortal, is now known to be erroneous. When the blad- 
 der is wounded below, where it is not covered by the peri- 
 toneum, persons do sometimes recover by what may be con- 
 sidered the almost unaided efforts of nature. A large num- 
 ber of cases came under my observation at Brussels and at 
 Antwerp, and many had already died. Persons rarely re- 
 cover 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 ab- 
 domen, 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 ob- 
 tained 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 mis- 
 chief 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 intro- 
 duced too early, while the bladder was very sensitive, the 
 patients have been much relieved by. its removal. The prin- 
 ciple 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 
 
548 TREATMENT OF WOUNDS OF THE BLADDER. 
 
 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 gen- 
 eral 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 peri- 
 toneum, 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 pas- 
 sage is often obstructed; the elastic catheter, if not used be- 
 fore, 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 advisa- 
 ble. The permanent use of the catheter in these cases will 
 often pravent the urine from forming any devious paths as it 
 proceeds outward, ending in abscesses and fistulous open- 
 ings, 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 eCBciently used, surgery 
 must come with more immediate aid to the assistance of the 
 sufferer, by making a clear and free opening from the peri- 
 neum for the evacuation of the urine and of the discharge 
 from the wound. If a ball lodge in or near the bladder, or 
 
ILLUSTRATIVE CASES. 549 
 
 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 Yera, in the Pyrenees. A musket-ball had en- 
 tered 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 tirst a diffi- 
 culty 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 dif- 
 ficulty, 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 con- 
 stant 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 fol- 
 lowed 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 
 
550 ILLUSTRATIVE CASES. 
 
 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 imme- 
 diately 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 suf- 
 fered 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 possi- 
 ble. Under this treatment he gradually improved ; the an- 
 terior wound first healed, and subsequently the posterior 
 one, leaving him comparatively well when he left me for 
 Lisbon on his way to England. 
 
ILLUSTRATIVE CASES. 551 
 
 418. These cases give, however, a brighter view of the 
 nature of these wounds than they frequently justify ; extrav- 
 asation of urin^e, inflammation, and death are not of infre- 
 quent 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 mus- 
 ket-ball, which entered the left groin immediately over Pou- 
 part'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 pain- 
 ful 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 respi- 
 ration 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 intro- 
 duced — 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 car- 
 ried thence on board ship, and landed at York on the morn- 
 ing of the 9th of July, the fourth day after he received his 
 wound. 
 
 July 9th. — Abdomen tense and painful to the touch ; se- 
 vere 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 at- 
 tempted to be passed without success. Ordered an ounce 
 and a half of caster-oil immediately. 
 
 10th. — Passed a restless night ; had two copious stools ; 
 voided a few drops of urine by the. urethra; still great in- 
 clination to pass urine. Ordered two grains of extract of 
 opium made into a pill. 
 
 11th. — All the painful sensations much relieved; abdomen 
 
552 ILLUSTRATIVE CASES. 
 
 less tense ; a small piece of iDone 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 ex- 
 tracted 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 natu- 
 ral passage, mixed with pus. 
 
 At first it was supposed that only the fundus of the blad- 
 der 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, prob- 
 ably, 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 blad- 
 der 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 ap- 
 peared 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 
 
ILLUSTRATIVE CASES. 553 
 
 little bloody urine at first ; the external wound closed with- 
 out 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 med- 
 ical 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 conse- 
 quence 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 1 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 ori- 
 fice of the bladder, and which, being dislodged, had fortu- 
 nately 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 Han- 
 over, 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 Chillian wallah a simi- 
 lar wound took place ; the ball formed the nucleus of a cal- 
 culus, and was removed successfully by a gentleman in the 
 
 47 
 
554 ILLUSTRATIVE CASES. 
 
 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 quan- 
 tity of bloody urine. This induced him to enlarge the open- 
 ing, 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 oppo- 
 site 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 ex- 
 perienced ; 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 eifected, from the pros- 
 tatic 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 uriue 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 
 
WOUNDS OF RECTUM — CONCLUSIONS. 555 
 
 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 de- 
 prived 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, al- 
 though 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 com- 
 manded, 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 
 
556 CONCLUSIONS. 
 
 abstraction of blood, and by the early use of retaining band- 
 ages. 
 
 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, fre- 
 quently 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 some- 
 times 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 approx- 
 imated 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 neces- 
 sary, 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 treat- 
 ment. An intestine, when incised to an extent exceeding 
 the third part of an inch, should be sewn up by the con- 
 tinuous 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 
 
CONCLUSIONS. 55t 
 
 closely applied to the cut edges of the peritoneum. Abso- 
 lute rest, without the slightest motion, should be observed. 
 Food and drink should be restricted, when not entirely for- 
 bidden. 
 
 12. If the belly swell, and the propriety of allowing ex- 
 travasated 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 av/aited. 
 
 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 sur- 
 faces 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 abdo- 
 men should never take place, unless in connection with some- 
 thing 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 liga- 
 ture. 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 pres- 
 ence should prove injurious, from excess of irritation, not re- 
 moved 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 
 
 47* 
 
558 OPERATION FOR ARTIFICIAL ANUS IN THE BACK. 
 
 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 adminstra- 
 tion of enemata, and the early exhibition of mercury, and 
 especially of opium, in the different ways usually recom- 
 mended, 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 dis- 
 ease 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 
 spinae 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 lobu- 
 lated fat will be seen, which should be partly removed and 
 partly displaced by the blunt end of a director, in the verti- 
 cal 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 
 
OPERATION FOR ARTIFICIAL ANUS IN THE BACK. 559 
 
 ligature above and below it, if the intestine should not ap- 
 pear to be firmly held in its place. If a vessel in its wall 
 should bleed, it must be tied. Inflammation, pain, and rest- 
 lessness should be obviated as far as possible by fomenta- 
 tions, 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 rae from vari- 
 ous 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, F.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 con- 
 sidering it necessary to remove it, was brought under the 
 influence of chloroform, but, according to his (the surgeon's) 
 statement, only about 5ij could have been inhaled. He had 
 commenced the operation, when the patient suddenly ex- 
 pired. 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 mor- 
 bid appearance existed. The usual restoratives were resorted 
 to, but ineffectually. 
 
 The following case, furnished by Assistant-Surgeon Han- 
 nan, 49th Kegiment, 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, ex- 
 tending from its middle third to the bead of the bone. The 
 integuments of the outer and upper part of the shoulder 
 were carried away. There was also a contused and lacer- 
 
 (561) 
 
562 USE OF CHLOROFORM IN THE CRIMEA. 
 
 ated wound of the left knee, opening into the joint, with 
 comminuted fracture of the patella, these injuries being 
 caused by pieces of shell. He was seen a quarter of an 
 hour after admission by Dr. Gordon, P.M.O., who removed 
 the arm at the shoulder-joint, making a suflScient flap from 
 the integuments of the axilla. The thigh was then ampu- 
 tated in its lower third. These operations were performed 
 in immediate succession without the administration of chlo- 
 roform. 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 disturb- 
 ance further than three slight attacks of diarrhoea. He is 
 now up and about, and goes to England by the next oppor- 
 tunity. 
 
 In the worst cases of amputation at the hip-joint, or at 
 the upper third of the thigh, chloroform has appeared to 
 cause insf*nsibility 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 suf- 
 fered, the frequent insufficiency of their food, the want of 
 proper clothing, with other depressing causes, had so de- 
 prived 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 opera- 
 tions usually done on the upper third of the thigh, in conse- 
 
AMPUTATIONS UNDER, CHLOROFORM. 563 
 
 quence of their almost certain failure, preferring to let the 
 injuries take their course, even unto the death of the suf- 
 ferers, 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- Gen- 
 eral 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 influ- 
 ence of chloroform, and in no single instance have either the 
 medical officers of the Division, or myself, seen any bad re- 
 sults 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 re- 
 moved 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 opera- 
 tion, and with the best results. Both feet were much injured 
 
564 EXCISION OF HEAD, NECK, ETC. OF FEMUR. 
 
 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 articu- 
 lar 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 Edin- 
 burgh. 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 there- 
 fore 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 expecta- 
 tions 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 per- 
 formed 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 
 
ILLUSTRATIVE CASES. 565 
 
 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. Xo 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 en- 
 courage 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, 68/^ Light Infantry. 
 
 Camp, 4tli Division, Crimea, Sept. 14, 1855. 
 
 The bones removed are in the museum of the Royal Col- 
 lege of Surgeons. 
 
 The fourth case is given at length by Staff- Surgeon Cre- 
 rar, 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 sus- 
 pended over the left hip, and then made an opening or wound 
 about the size of a shilling nearly a quarter of an inch pos- 
 terior 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 tro- 
 chanter had taken place, but was quite unable to ascertain 
 to what extent upward and downward the fracture extended. 
 
 48 
 
5^6 ILLUSTRATIVE CASES. 
 
 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 chlo- 
 roform,) the femur was discovered to be comminuted. Ex- 
 cision 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 supe- 
 rior 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 re- 
 moved. 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 
 ofif 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 in- 
 duced ; only one small bleeding point was secured near the 
 tail of the wound, and the divided parts were brought to- 
 gether by two sutures and bands of adhesive plaster. 
 
 At twelve a.m., two hours after the operation on the Tth 
 instant, his pulse being rather feeble, he was ordered some 
 wine and water. 
 
 tth, 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 ; re- 
 tracted 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 comfort- 
 able ; skin moist ; pulse 120 ; sutures were removed, and the 
 wound allowed to gape ; it has a remarkably healthy ap- 
 pearance. To go on with the simple water dressing, chicken 
 broth, arrow-root, and wine. 
 
ILLUSTRATIVE CASES. 567 
 
 Yespere. — Has been very cheerful all day; limb has re- 
 tracted about another half inch ; pulse 112. 
 
 10th — Passed a more restless night, in consequence of 
 not havinp: the morphia drauo^ht 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 comfort- 
 able; 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 bed- 
 time. 
 
 11th. — Slept soundly all night; when I visited him, at 
 six A.M., he had just awoke ; pulse 115, soft ; appears con- 
 tented and comfortable. 
 
 Yespere. — 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. 
 
 Yespere. — The progress of the case is most satisfactory ; 
 had a fresh egg, tea, and toast for breakfast, his own selec- 
 tion, 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 suc- 
 cessful issue. 
 
 14th. — A small slough at the lower part of the wound, re- 
 mainder healthy and clean ; tongue a little too dry this morn- 
 ing, and he has more thirst than usual ; pulse 118. To have 
 
568 ILLUSTRATIVE CASES. 
 
 effervescing draughts of bicarbonate of potassa and citric acid 
 three times a day ; to continue simple water dressing. 
 
 Yespere. — 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 bed- 
 time. 
 
 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. 
 
 Yespere.— 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 ; dis- 
 charge 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. 
 
 Yespere. — Tongue more moist, less thirst. When asked 
 how he felt, he replied, with a great deal of life in his coun- 
 tenance, "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 symp- 
 toms 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. — Yery 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. 
 
 Yespere. — 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. 
 
 Yespere. — No change to report. 
 
ILLUSTRATIVE CASES. 669 
 
 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. 
 
 Yespere. — 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 sur- 
 faces 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 
 naturae is not sufficient to carry our sick through such for- 
 midable 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 un- 
 doubtedly, have been a failure. Our Minie rifle-ball frac- 
 tures 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, QSih Rpgiment, 
 
 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, bv Dr. Hyde, ended fatally on the sixth day. 
 
 48* 
 
5t0 ILLUSTRATIVE CASES. 
 
 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 tro- 
 chanter, and, passing inward and a little forward, had passed 
 out at the groin of the same side, about an inch below Pou- 
 part's ligament, externally to, and a little in front of, the 
 femoral vessels. The lower fragment of the fracture pro- 
 truded 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 opera- 
 tion was performed in the presence of Deputy Inspector-Gen- 
 eral 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 httle 
 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 dis- 
 lodge 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 spiculse of bone removed. The edges of the 
 incision were then brought together by sutures, and a band- 
 age 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. 
 
CASE OP WOUND OF THE LARYNX. 5tl 
 
 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. Yespere : 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, Bala- 
 klava, 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 Au- 
 gust, 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, i)7th Regiment. 
 Camp, Sebastopol, Sept. 14th, 1855. 
 
 Private John Purcell, 5Yth Regiment, aged twenty-one, 
 was wounded upon the 18th of June, in the unsuccessful 
 assault upon the Redan, by a Minie 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. Tiae excised bone is in the 
 museum of the Royal College of Surgeons. 
 
 W. H. McANDllEW, M D., 
 
 Surgeon, bith Regiment. 
 Camp, Sebastopol, Sept. 14th, 1855. 
 
 The following case of wound of the larynx is instructive : — 
 Lieutenant Charles H. Evans, 55th Regiment, aged nine- 
 
572 CASE OF WOUND OP THE LARYNX. 
 
 teen years, was wounded on the evening of the 5th of Aufrust, 
 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 pha- 
 rynx and larynx were wounded, and the trachea was con- 
 tused and displaced. Respiration somewhat hurried ; a 
 quantity of mucus collects in the trachea, and is expecto- 
 rated in fits. 
 
 About seven o'clock p.m. of the 6th, the respiration be- 
 coming 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 rest- 
 less 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, \st Class, in Med. Charge, Id 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. 
 
WOUNDS OF PHOFUNDA AND POPLITEAL ARTERIES. 513 
 
 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 Minie-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 w^ith 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 prostra- 
 tion 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 de- 
 termined 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 com- 
 presses 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 hemor- 
 rhage, 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 1*7 th, 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. 
 
5T4 STRYCHNIA IN INJURIES OP SPINAL CORD. 
 
 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 tourni- 
 quet was applied, and was consequently so much collapsed 
 that an operation was out of the question. He was there- 
 fore dressed and the tourniquets (two had been put on) re- 
 moved. 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. 
 
 E. V. DE LISLE, 
 
 Surgeon, 4:th 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 blad- 
 der. 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 
 
STRYCHNIA IN INJURIES OF SPINAL CORD. 5*1 5 
 
 of morphia 5j was prescribed without any effect. (5j con- 
 tains 1 gr.) The dose was gradually inci'eased to 5ij 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 ffrain three times a day. 
 
 20th. — Continues much the same, with slight twitchings 
 of the face. 
 
 25th. — Has been unconscious for three days. Now com- 
 plains of intense pain in the back and violent cold prespira- 
 tion. 
 
 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 ex- 
 tremities, and the urine is still passed involuntarily. One- 
 eighth of a grain of strychnia was ordered twice a day. 
 
 olst. — Is powerfully under the influence of the remedy, 
 with convulsive movements of the upper and lower extremi- 
 ties ; 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 com- 
 paratively 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 arras. The strychnia was re- 
 sumed 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 
 
5T6 CASE OF INJUR r TO ABDOMEN. 
 
 from the use of the strychnine. Lower extremities de- 
 cidedly improved both in motion and sensation. 
 
 June 1st. — Maintains his improved condition. Recom- 
 menced the strychnine to-day, without any marked effect at 
 the moment. 
 
 ]Oth. — 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 ordi- 
 nary 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 
 w^eather — 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 inju- 
 ries 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 in- 
 teguments of the right hand and forearm greatly lacerated, 
 the wrist-joint laid open, the bones of the carpus commi- 
 nuted ; the radius and ulna were also fractured at the middle 
 third. There was a lacerated wound in the right iliac re- 
 gion, 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 
 
CASE OF INJURY TO THE ABDOMEN. 51 Y 
 
 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 supe- 
 rior 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 9Lh) 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 abdo- 
 men ; 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. 0. 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 nour- 
 ishment 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 reg- 
 ularly ; the bowels have not acted. The abdomen is quite 
 
 49 
 
bis CASE OF INJURY TO RIGHT ARM AND THIGH. 
 
 soft and fallen, not the slightest tenderness on pressure. To 
 continue on the same plan. He could now give some ac- 
 count of the way in which he was wounded. He stated that 
 he thought it must have been a rouud 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 red- 
 ness of the skin, and pitting upon pressure. Stump dressed 
 to-day and looiiing well. 
 
 13th. — No unfavorable constitutional symptoms. The 
 outer part of the thigh is tender and the skin red ; free in- 
 cisions were made ; the fascia was sloughy. He takes nour- 
 ishment; 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 tlie 
 13th. The bowels have not been moved ; he complained 
 to-day of not being able to pass his. motions. Two injec- 
 tions 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 ex- 
 posed ; healthy granulations are springing up from the bot- 
 tom of the wound. Stump healing favorably. 
 
 July 26. — The case has progressed without a bad symp- 
 tom. 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 an- 
 terior 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 contract- 
 ing, 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 
 
CASE OF GUITSHOT FRACTURE OF THE FEMUR. 5Y9 
 
 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 cov- 
 ered 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 con- 
 stitutional 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 with- 
 out pain. He can raise the knee from the pillow, but can- 
 not 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 ex- 
 tending through the acetabulum. Immediately below Pou- 
 part's ligament, to the outside of the femoral artery, a hard 
 substance is felt beneath the skin. This, when he was ad- 
 mitted, 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 w^ounded 
 in the left thigh before the Redan, on the 18th of June. He 
 
580 CASE OF EXCISION OF THE ELBOW- JOINT. 
 
 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 pos- 
 terior; 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, grad- 
 ually wasted, suffered from diarrhoea, and finally sank on the 
 6th of August. On examination post mortem, I found the 
 chief organs in a normal condition. There was some con- 
 gestion of the ilium, and the colon presented a few points of 
 ulceration. The condition of the parts in the left lower ex- 
 tremity 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 in- 
 tense disorganizing process, extending through the greater 
 part of the limb, has presented itself in several of my exam- 
 inations of somewhat similar injuries, and appears to me to 
 be connected with a peculiar pathological state in which all 
 the vital organs remain sound, hut the vis vitse is remark- 
 ably reduced below par. The fractured bone it is unneces- 
 sary 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 21th of June, wijile 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 
 
CASE OF EXCISION, WITH INJURY OP LEFT HIP. 581 
 
 being sent to camp, the joint was excised by Mr. Dowse, sur- 
 geon 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, oGth 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, lacer- 
 ating 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 perito- 
 neum, 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, consti- 
 tutional disturbance ; elbow extremely painful ; the pain 
 accompanied with partial paralysis of the little and ring fin- 
 gers. StaS"- 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 forearni 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 
 
 49* 
 
582 WOUND OF THE SUPERIOR MAXILLART BONE, ETC. 
 
 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- Surg eon, Zlsl Reg. in died. Charge. 
 
 Camp before Sebastopol, Sept. 1, 1855. 
 
 Private Anthony Murray, aged twenty-eight, 41st Regi- 
 ment, a healthy man, was struck, while on duty in the trenches 
 before Sebastopol, on the night of the 23d of July, 1 855, 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 fol- 
 lowing manner: a straight incision was made along the pos- 
 terior 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 man- 
 ner ; 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, ilst Regiment. 
 
 August 31st, 1855. 
 
 Private Jesse Lockhurst, 81st Regiment, aged twenty-six, 
 was wounded in the advanced trenches, 17th of August, 
 1855. 
 
 August nth. — Six o'clock a.m., carried into regimental 
 hospital, having received an extensive lacerated wound of 
 right cheek : very little apparent hemorrhage, bat 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 
 
GUNSHOT WOUND OF THE RIGHT TEMPLE. 583 
 
 at the bottom of the wound, lying on left palate, and, as far 
 as could be ascertained, on the back of pharynx. Staff- Sur- 
 geon 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 imme- 
 diate relief after the operation, sat up in bed, washed out his 
 mouth, and drank some water ; he seemed extremely thank- 
 ful, 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 hem- 
 orrhage 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 re- 
 strained 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- Surg eon, 
 
 2>\st 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 
 
584 CASES OF GUNSHOT WOUND OF THE BRAIN. 
 
 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 admis- 
 sion, 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, IMh 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 
 
CASES OF GUNSHOT WOUND OF THE BRAIN. 585 
 
 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, SSth 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 ad- 
 vanced 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 in- 
 stant 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 con- 
 tact, and it was presumed to be an ordinary case of fracture 
 with depression simply. Some very minute portions of cere- 
 bral 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. 
 Xo relief of symptoms followed. The dura mater bulged 
 slightly upward into the opening." On passing the finger 
 over its surface, a little beyond the space exposed by the 
 trephine, a defined cut edge was felt about an inch in ad- 
 
586 COMMENTARIES ON THE PRECEDING CASES. 
 
 vance 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 sub- 
 stance ; 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 cannel- 
 ures — was cat 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 de- 
 pression 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, 
 
 Suryeon, l^th 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 function- 
 aries 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. 
 
COMMENTARIES ON THE PRECEDING CASES. 58 1 
 
 The operation for removing the head of the femur from 
 its connection \Yith 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 be- 
 yond 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 cir- 
 cumstances, and perhaps with greater restriction. The suc- 
 cess 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 considera- 
 ble portion of the shaft of the femur has been removed with 
 the head and neck in the cases alluded to, so that an ap- 
 proximation 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 advan- 
 tageous 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 12t.) 
 
 It has been already stated that the loss of life after auipu- 
 tations 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 aban- 
 doned. 
 
 The Russians, at the commencement of the siege of Sebas- 
 
588 COMMENTARIES ON THE PRECEDING OASES. 
 
 topol, made use of a conical rifle bullet, flat at the base, 
 weighing nearly one ounce and three-quarters. Latterly 
 they have used a larger conical one, with three grooves 
 around the circumference of the base of the cone, which is 
 hollowed out to receive a cup, and shows a projection on 
 the inside of the hollow. This ball is near two inches 
 long, and weighs somewhat more than one ounce and three- 
 quarters. 
 
 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 dan- 
 gerous operations, each splinter possibly requiring a sepa- 
 rate 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 sup- 
 plying 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 
 
COMMENTARIES ON THE PRECEDING CASES. 589 
 
 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 Sur- 
 geons, 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 uneasi- 
 ness. 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 Yarna ; and four medical ofiB- 
 cers, 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 hos- 
 pitals 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 ad- 
 mitted by foreigners to be a wonderful people in the mis- 
 management of our affairs in the first instance, however im- 
 portant 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. 
 
 50 
 
590 COMMENTARIES ON THE PRECEDING CASES. 
 
 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 suc- 
 cessful. 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 in- 
 clination 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, 1 have since 
 learned I am indebted to Deputy Inspector-General Mac- 
 gregor; and I am particularly so to Assistant- Surgeon 
 Gregg, of the ITth 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 abdo- 
 men have been no less fatal than those of the lower extremi- 
 ties. 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 (o, 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. 
 Abernethy'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 elhow-joint, 137. 
 
 place of election for, in local mortification of a limb, 46. 
 of the fingers, 139. 
 
 (591) 
 
592 INDEX. 
 
 Amputation of the foot, 114. 
 
 by Ptoux's plan, 108. 
 of the foreaxm, 137. 
 
 by the flap operation, 137. 
 
 by the circular incision, 138. 
 for gunshot wountls 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. 
 
 eases 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. 
 
 Dupuytven'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. 
 
IXDEX. 693 
 
 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 treat- 
 ment 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. 
 
 50* 
 
594 INDEX. 
 
 Ball, 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, 
 
 operation for empyema, 452. [451. 
 
 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, 1G9. 
 Bone, lodgment of a ball in, 36, 14.:). 
 
 protrusion of, after amputation, 89. 
 
 exfoliation of, after amputation, 89. 
 Bones of the face, penetrating wounds of, 479. 
 Brachial arter-y, 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, 288. 
 
 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. 
 
INDEX. 595 
 
 Calcis and astragalus, operation for the removal of, 115. 
 
 removal of, 104. 
 Calculus farmed on a ball in the bladder, 553. 
 
 operation for extraction of, 554. 
 Cannon-shot, liemoirhage after the carrying away a limb by, 25. 
 wind of, 43. 
 
 causes mortification of a limb, by destroying its internal tex- 
 tures, 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, 498. 
 Chest, wounds of, 364, 590. 
 
 effusion into, 371, 378, 420. 
 
 purulent effusion, etc. into, 378, 390, 420, 485. 
 
 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. 
 
596 INDEX. 
 
 Chloroform, amputation under the influence of, in the Crimea, 561. 
 case of death from, 5G1. 
 
 Deputy Inspector- General Taylor on, 64, 662. 
 
 Deputy Inspector-General Alexander on, 663. 
 Circulation, collateral, 184. 
 
 Colon, Hilton's operation for opening into, 658. 
 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, 268. 
 Cranium, fracture of the base of, 317. 
 Ceepitating rale, 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, 465. 
 
 wounds of, 458. 
 
 may cause internal hernia, 463. 
 Dupuytren's forceps for artificial anus, 627. 
 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. 
 Eifusion, 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. 
 
INDEX. 597 
 
 Empyema, 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. 
 Erysipehis 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, 500. 
 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, 
 
 laceration of, 208. [226. 
 
 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. 
 
598 INDEX. 
 
 Foot, ampul ation 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, 580. 
 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, 235. 
 extraction of the ball in, 32. 
 of the foot, 107, 112. 
 
INDEX. 599 
 
 Gunshot -wounds of the knee joint, 94, 574. 
 shouldei' -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. 
 
 inyolving 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. 
 Madder, 546. 
 rectum, 555. 
 
 inflammation consequent on, 30. 
 Guthrie, Mr., mode of amputating at the hip-joint, 79, 80, 
 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, 
 compression in wounds of, 238. [46, 235, 
 
 Head, injuries of, 283. 
 
 aifecting the brain, 283. 
 causing abscess of the liyer, S56, 
 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. 
 
600 INDEX. 
 
 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. JBrownrigg's, 82. 
 
 injury to, with excision of elbow-joint, 581. 
 Hemorrhage after a gunshot wound, 25. 
 
 secondary, 208. 
 
 from the intercostal artery, 474. 
 
 after tlie 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, 238. 
 
 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. 
 Hiacs, common, relative situation of, 251. 
 ligature of, 252. 
 
INDEX. 601 
 
 Immediate amputation, question as to, 51. 
 cases for, 150. 
 tumors of the scalp, 340. 
 Incisions, use of, in erysipelas phlegmonorles, 40. 
 Inflammation consequent on gunshot wounds, 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, 471. 
 Internal carotid, wounds of, through the mouth, 245. 
 operation for, 245, 248, 272. 
 mammary artery, wounds of, 478. 
 
 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, 34Q. 
 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. 
 
 51 
 
602 INDEX. 
 
 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 tlie 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 insufiicient to control hemorrliage 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, 188. 
 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 tvounds. 
 
INDEX. 603 
 
 Neck, wounds of, 242, 475. 
 
 VelpeMu 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. 
 
 Occiprx, depression and fracture of, 338. 
 
 (Egophony, 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. 
 
 ]*aralysis, the re-^ult 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. 
 Peiicanlium. Larrey's operation for opening, 469. 
 
 Skielderup's ditto, 469. 
 Peroneal artery, ligature of, 2G6. - 
 Peyer, ghmds of, 48'). 
 Phagedena gangreno-a, 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. 
 Pleuta, 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. Huglies on, 396. 
 Popliteal aneurism, operation for, 263. 
 
 artery, not to be tied, unless wounded and bleeding, 265. 
 wound of. 573. 
 Pourriture d'hopital, 163. 
 
604 INDEX. 
 
 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, 288. 
 operation for, 282. 
 Ramdohr on the treatment of divided intestine, 507. 
 Ravaton on protrusion of omentum in penetrating wounds of ab- 
 domen, 501. 
 Piectum, 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, 850. 
 
INDEX. 605 
 
 Sinuses, longitudinal and lateral, wounds of, 351. 
 Skielderup's operation for opening tlie pericardiLin"!. 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 slumps, hemori-hage 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, 
 Spine, effects of strychnia in injury of, 574. [226. 
 
 Spleen, wounds and injuries of, 536. 
 
 removal of, 538. 
 Splints for fractures, 153. 
 
 Splinters, removal of, from a wounded lung, 445. 
 Slatham'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, sepai^ated 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. 
 
606 INDEX. 
 
 Taylor, Deputy Inspector-General, on tlie 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. 
 Tram'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, withoiit de- 
 pression, 312. 
 
 manner of applying, 358. 
 
 use of, at diiferent periods, 327. 
 
 frequent application of, 359. 
 Trochanter, head and neck of the femur, excision of, 564. 
 Tumors, immeiliate and secondary, of the scalp, 341. 
 Typhoid pleuritis, 390. 
 
 pneumonia, 388. 
 
 Ulnar artery, ligature of, 281. 
 wound ot; 238, 281. 
 
 Valvule conniventes, 483, 
 Veins, inflammation of, 60, 62. 
 
 i\Jr. Hunter on, 70. 
 
 Mr. Henry Lee on, 70. 
 
 Dr. Hughes Bennett on, 71. 
 Velpeau on wounded arteiies 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. 
 
 Waklet, 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 b ills, pieces of shell, etc., 28. 
 
 guiishiit. toi'maiion of sinuses in. 31. 
 
 extraction of ball and other foreign substances, 32. 
 
INDEX. 607 
 
 Wounds, gunshot, the bone struck oi' penetrated, not broken, the 
 ball lodiiino:. 36. 
 of the skull, 3-16, 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 Tay-lor on, 572. 
 of the orbit, 350, 583. 
 of the longitudinal or lateral sinus, 351. 
 of the arm, 121, 56. 
 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. 
 
 no?e 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 kne.e-j( int, gunshot, 94. 
 of the patella, ditto, 95. 
 of the leg, 154. 
 of the foot, 107. 
 
608 INDEX. 
 
 Wounds of the tongue, 481. 
 
 of the liver, 528. 
 
 of the gall-bladder, 530. 
 
 of the stomach, 583. 
 
 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 fem- 
 oral artery and vein, 26. 
 
 Generals Sir Lowry Cole, Sir E. Packenham, and Colonel Duck- 
 worth ; 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, caus- 
 ing 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 sci- 
 atic 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 pneumo- 
 nia, 67, 68. 
 
INDEX. 609 
 
 Sloughing of a speai'-wound of the arm, G9. 
 Cnpfain Flack: cannon-shot wound of left thigh, 77. 
 Excision of the head and neck of the femur, 94. 
 Colonel Donellan; musket-shot "wound of knee-joint, 96. 
 Excision of knee-joint, by Dr. Gurdon Buck, 97. 
 
 by ^h\ Jones of .Jersey. 97, 98. 
 Amputation of the foot, by Eoux's operation, 108. 
 Ball lodged in the astragalus, 110. 
 Excision of the astragalus and calcis, llo. 
 
 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 ; for- 
 mation 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 ; hem- 
 orrhage from a deeply-seated vessel; ligature of the common fem- 
 oral; 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 extrem- 
 ity, 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, re- 
 newal of the hemoiThage, amputation, death, 230. 
 of the peroneal artery, hemorrhage and formation of an aneu- 
 rism ; ligature of the wounded vessel; recovery, 231. 
 Axillary aneurism from a bruise; ligature of the subclavian; rup- 
 ture of the sac: death, 236. 
 Shell injury ; amputation of right leg and arm ; secondary hemor- 
 rage ; ligature of the subclavian near the seat of the bleeding. 237. 
 Wounds of the vertebral artery, recorded by Breschet, Chiai'i, Kama- 
 glia, and Maisonneuve. 242. 
 
 52 
 
610 INDEX. 
 
 Vround of the exterunl cnroiiJ during an operation; utter insuffi- 
 ciency of one ligature, 244, '24o. 
 
 Gunshot wound of head, face, and neck; injury of external carotid 
 and its branches; partial slougli of internal carotid; ligature of 
 latter vessel ; compression; recovery, 247. 
 
 AVound of internal carotid through the mouth ; successful ligature 
 of the vessel, 249. 
 
 Ligature of the common iliac artery, 252. 
 
 AVound of the gluteal artery; ligature of that artery and of the in- 
 ternal iliac ; death, 260. 
 
 "Wound of the popliteal artery by a mortising chisel; secondary 
 hemorrhage ; ligature of the femoral unsuccessful ; cure by liga- 
 ture of tlie popliteal, 265. 
 
 Balls lodging in the brain, 284. 
 
 Concussion in a child, 280. 
 
 Coup-de-soleil, 208. 
 
 Concussion of the brain, passing into excitement, etc , 294. 
 
 Gouty intlammatioii, transferred to the brain, 296. 
 
 Illustrative of the treatment of concussion, 297. 
 
 Concussion, complicated by the symptoms of compression, 298. 
 fullowed by mania, oUU. 
 
 Illustrative of the after-eifects of concussion, 331. 
 
 Fatal paralysis, caused by compression of the brain, 307. 
 
 Illustrative of the diiferent forms of paralysis following compression 
 or irritation of the brain, 309. 
 
 Fracture of the skull without depression, 311. 
 
 Fracture of the skull, Avith 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 hemiphlegia of the rigiit side; operation with the 
 trephine two years afterward, 823. 
 
 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. 
 
 G-unshot fracture of the left parietal, with suppuration on the sur- 
 face 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, 340. 
 
 Gunshot injury to the frontal sinuses, 350. 
 
 Wounds of the orbit, 351. 
 
 Fungus cerebri, 353. 
 
 Major D.: gunshot wound of the for.^head ; incomplete recovery, 357. 
 
INDEX. 611 
 
 Loss of a large portion of the skull; reported b^ 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. Coicish; pneumothorax and phthisis, 408. 
 
 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 tiie 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., 445. 
 
 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 pneu- 
 monia 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. 
 
 AVounds of the diaphragm, 458. 
 
 Captain Prevost. 458. 
 
 The Due 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 differ- 
 ent occasions, 476. 
 
612 INDEX. 
 
 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 tlie 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 
 eiFusion, 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 proti'usion 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 intes- 
 tine, etc., 512. 
 
 Gunshot wounds of abdomen, with protrusion or injury of intestine, 
 516. 
 
 A Russian ofiicer, with a gunshot wound of abdomen, a tape-worm 
 cut in two by the ball, causing intense sufi'ering until it was ex- 
 tracted, 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 wiiich 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, 640. 
 
 Gunshot wound of the penis, 540. 
 
 Pistol-shot wound in the last dorsal or upper lumbar vertebra, caus- 
 ing 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 
 
INDEX. 613 
 
 the spine, causing paralysis of the left lower extremity, etc. ; lodg- 
 ment of the ball, 543. 
 
 Gunshot wound of the external and common iliac arteries, 544. 
 
 of the pelvis, tlie ball lodging, extracted on the forty-fifth day 
 after tiie 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 Avound 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, E,. X. ; 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 IX THE ADDENDA. 
 
 Amputation of finger ; death caused by exhibition of chloroform, 561. 
 
 Successful amputation of the arm at the shoulder-joiut, 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, re- 
 ported by Mr. O'Leary, 564. 
 reported by StaflF-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, re- 
 ported 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, Patholo- 
 gist to the Army in the East, 579. 
 
614 INDEX. 
 
 Excision of tbe elbow-joint for a gunsliot 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, re- 
 ported by Dr. Scott, 582. 
 Grape shot wound of the superior maxillary and malar bones, re- 
 
 poi'ted by Mr. Atkinson, 582. 
 Musket shot wound of the right temple, fracturing the supra-orbital 
 
 ridge, reported by ]\Ir. De Lisle, 583. 
 Musket-shot fractures of the skull, reported by Mr. Ward, Mr. Wall, 
 and Mr. Longmore, 584, 585. 
 
 THE END 
 
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