Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate. (part 1 of 3)

Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

COMMENTARIES ON THE SURGERY OF THE WAR

IN PORTUGAL, SPAIN, FRANCE, AND THE NETHERLANDS,

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

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

SHOWING

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

REVISED TO OCTOBER, 1855.

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

SIXTH EDITION.

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

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

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

G. J. GUTHRIE.

PREFACE TO THE FIFTH EDITION.

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

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

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

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

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

PREFACE TO THE SIXTH EDITION.

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

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

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

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

LECTURE I.

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

LECTURE II.

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

LECTURE III.

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

LECTURE IV.

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

LECTURE V.

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

LECTURE VI.

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

LECTURE VII.

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

LECTURE VIII.

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

LECTURE IX.

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

LECTURE X.

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

LECTURE XI.

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

LECTURE XII.

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

LECTURE XIII.

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

LECTURE XIV.

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

LECTURE XV.

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

LECTURE XVI.

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

LECTURE XVII.

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

LECTURE XVIII.

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

LECTURE XIX.

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

LECTURE XX.

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

LECTURE XXI.

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

LECTURE XXII.

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

LECTURE XXIII.

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

LECTURE XXIV.

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

LECTURE XXV.

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

LECTURE XXVI.

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

LECTURE XXVII.

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

LECTURE XXVIII.

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

LECTURE XXIX.

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

LECTURE XXX.

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

ADDENDA.

REPORTS FROM THE CRIMEA.

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

REMARKS.

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

Index. pp. 591-608

Index of Cases. pp. 608-614

Medical Works pp. 615-624

COMMENTARIES ON SURGERY.

LECTURE I.

ON GUNSHOT WOUNDS, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE II.

ON INFLAMMATION, MORTIFICATION, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE III.

AMPUTATIONS, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE IV.

APHORISMS FOR AMPUTATIONS, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

AMPUTATION AT THE HIP-JOINT.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE V.

REMOVAL OF THE HEAD OF THE FEMUR, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

EXCISION OF THE ANKLE-JOINT.

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

REMOVAL OF THE OS CALCIS.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE VI.

PRIMARY AMPUTATION, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE VII.

SECONDARY AMPUTATIONS, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

ON COMPOUND FRACTURES.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

160. In making incisions for the removal of splinters of bone, both at an early and at a late period, particularly in the latter, when the soft parts are all impacted together, and nothing is gained beyond what is cut, the course of the trunks of nerves, as well as of the great arteries, should be carefully attended to, and those parts avoided; for a successful cure of the fracture will be much deteriorated in value, if accompanied by a loss of motion or of sensation in the hand or fingers.

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

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

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

No. 1.--RETURN OF SURGICAL CASES treated and CAPITAL OPERATIONS performed in the General Hospital at Toulouse, from April 10th to June 28th, 1814.

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

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

No. 2.--OFFICERS.

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

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

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

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

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

No. 4.--CAPITAL OPERATIONS performed in the Field with Divisions of the Army during the same period.

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

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

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

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

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

LECTURE VIII.

CHARACTERS OF HOSPITAL GANGRENE.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

RETURN of the NUMBER OF CASES of HOSPITAL GANGRENE which have appeared at the Hospital Stations in the Peninsula between 21st June and 24th December, 1813.

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

LECTURE IX.

ON WOUNDS OF ARTERIES, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE X.

PROPER TREATMENT OF WOUNDED ARTERIES, ETC.

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

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

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

181. The Hunterian theory implies:--

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

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

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

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

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

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

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

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

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

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

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

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

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

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

8th. That the collateral branches are capable of bringing blood into the artery above the aneurismal sac and between it and the ligature, is admitted in the Hunterian theory, which blood the aneurismal sac receives, and usually retains. When the artery is a wounded artery, and the ligature is applied at a distance above the wound, blood is often brought into it below the ligature in a similar manner; but as there is no aneurismal sac to receive and retain it, the patient bleeds perhaps to death, unless surgery come to his assistance.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On the 24th he died.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE XI.

THE FEMORAL ARTERY, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The seventh error committed in this case was in contravening the great surgical precept, formed on no inconsiderable experience during the early part of the war in the Peninsula, “not to perform an operation on an artery until it bleed.”

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

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

LECTURE XII.

MORTIFICATION, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE XIII.

WOUNDS OF THE ARTERIES, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE XIV.

LIGATURE OF THE COMMON ILIAC ARTERY, ETC.

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

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

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

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

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

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

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

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

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

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

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

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