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 2 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. (part 2 of 3)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE XV.

THE COMMON CAROTID ARTERY, ETC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE XVI.

INJURIES OF THE BRAIN.

242. Injuries of the head affecting the brain are difficult of distinction, doubtful in their character, treacherous in their course, and for the most part fatal in their results. The symptoms which appear especially to indicate one kind of accident are frequently met with in another. It may even be said that there is no one symptom which is presumed to demonstrate a particular lesion of the brain, which has not been shown to have taken place in another of a different kind. Examination after death has often proved the presence of a most serious injury the existence of which had not even been suspected; and death has often ensued immediately, or shortly after the most marked and alarming symptoms, without any adequate cause for the event being discovered on dissection. One man shall lose a considerable portion of his brain without its being productive at the moment of the slightest apparent functional inconvenience; while another shall fall, and shortly die without an effort at recovery, in spite of any treatment which may be bestowed upon him, after a very much slighter injury inflicted apparently on the same part. During the war with the United States, in 1814, a soldier in Canada was struck by a ball which lodged in the posterior part of the side of the head; the wound healed, and the man returned to his duty. Twelve months afterward, having got drunk, he fell in the streets of Montreal, and died. The ball was found lying on the corpus callosum, where it had made a small hole or sac for itself. After the battle of Waterloo, I recommended, in the case of a soldier similarly wounded, that nothing should be done unless symptoms arose demanding the use of the trephine; as none occurred, and the wound healed, the man was sent home to Colchester, where he got drunk, and fell dead in the marketplace. The ball was lodged deeply in a cyst in the posterior lobe of the brain. Persons rarely live with a foreign body lodged in the anterior lobe of the brain, although many recover with the loss of a portion of the brain at that part. An injury of apparently equal extent is more dangerous on the forehead than on the side or middle of the head, and much less so on the back part than on the side. A fracture of the vertex is of infinitely less importance than one at the base of the cranium, which, although not necessarily fatal, is always attended with the utmost danger. The treatment of these several injuries (although they may be at first sight apparently similar) cannot, and must not be alike in all--a fact which should always be borne in mind in their management. In civil life, both in hospitals and among private persons, injuries of the base of the cranium are most frequently met with, because they are generally the consequence of falls; while in military life injuries of the base of the skull are rare, and those of other parts are common. The practice of the military surgeon, with respect to injuries of the cranium and its contents, is therefore more successful, all things considered, than that of the surgeon in civil life, and particularly in a great metropolis; this may perhaps account for some of the discrepancies in opinion which have existed between them.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE XVII.

WOUNDS OF THE HEAD.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

LECTURE XVIII.

INJURIES OF THE HEAD.

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

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

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

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

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

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

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

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

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

April 1st, 1841.--Mr. Guthrie this day removed a disk of bone from the exact point in the parietal region to which she referred the pain. The portion of bone presented no evidence of disease; its thickness varied from two and a half to four lines, the latter measurement corresponding to the part most distant from the sagittal suture; the vessels of the diploe bled freely, the dura mater was quite healthy, and without any very evident motion.

On visiting her an hour after the operation, she raised the previously paralytic arm several inches from the bed, and was able to bend and extend the fingers. The pain in the head was considerably less, and her countenance, before dull and heavy, was now remarkably animated. Sensation had returned in the arm, and partially in the leg. Her pulse was calm, and the skin cool.

Ten hours after the operation she was attacked with rigors, followed by pyrexia and all the symptoms of commencing inflammation of the brain. By the immediate abstraction of blood, which was three times repeated during the succeeding twelve hours, whenever the pain in the head or the force of the circulation increased, every bad symptom was removed. In the course of three days the paralysis had completely disappeared, sight and hearing again became perfect, and after passing through a speedy convalescence, she quitted the hospital completely recovered.

She has since had some relapses of pain and uneasiness in the head, but is altogether a different person, although of a very hysterical temperament. The cicatrix on the head is firm, and she considers herself to have been cured by the operation.

264. The inner table is sometimes broken in a peculiar manner, and to this attention was first drawn in my lectures, since trepanning has ceased to be the rule of practice in all cases of fractures. It occurs from the blow of a sword, hatchet, or other clean-cutting instrument, which strikes the head perpendicularly, and makes one clean cut through the scalp and skull into the brain. This kind of cut is usually considered as a mere solution of continuity, and not as a fracture, the bone being apparently only divided, with scarcely any crack or fissure extending beyond the part actually penetrated by the instrument. When the outer table alone has been divided, the wound in the scalp should be treated as a simple incised one, and united as quickly as possible, a practice of which I have seen several successful instances. When the instrument even penetrates to the diploe, the same course should be pursued; for although the external wound may not unite by the adhesive process, and some small exfoliations may occur, it is not common for serious consequences to ensue under that strictly antiphlogistic plan of treatment to which all persons with such injuries should be subjected.

265. When the sword or ax has penetrated the inner table, the case is of a much more serious nature; for this part will be broken almost always to a greater extent than the outer table. It may be separated from it, and driven into the membranes, if not into the substance of the brain itself, the surface of the bone showing merely a separation of the edges of the cut made into it. These cases should all be examined carefully. The length of the wound on the top, or side, or any part of the head which is curved and not flat, will readily show to what depth the sword or ax has penetrated. A blunt or flat-ended probe should in such cases be carefully passed into the wound, and being gently pressed against one of the cut edges of the bone, its thickness may be measured, and the presence or absence of the inner table may thus be ascertained. If it should be separated from the diploe, the continued but careful insertion of the probe will detect it deeper in the wound. A further careful investigation will show the extent in length of this separation, although not in width; and will in all probability satisfy the surgeon that those portions of bone which have thus been broken and driven in are sticking in or irritating the brain. In many such cases there has not been more than a momentary stunning felt by the patient; he says he is free from symptoms, that he is not much hurt, and is satisfied he shall be well in a few days.

An officer was struck on the head, in Halifax, Nova Scotia, by a drunken workman with a tomahawk, or small Indian hatchet, which made a perpendicular cut into his left parietal bone, and knocked him down. As he soon recovered from the blow, and suffered nothing but the ordinary symptoms of a common wound of the head with fracture, it was considered to be a favorable case, and was treated simply, although with sufficient precaution. He sat up, and shaved himself until the fourteenth day, when he observed that the corner of his mouth on the opposite side to that on which he had been wounded was fixed, and the other drawn aside; and that he had not the free use of the right arm so as to enable him to shave. He was bled largely, but the symptoms increased until he lost the use of the right side, became comatose, and died. On examination, the inner table was found broken, separated from the diploe, and driven through the membranes into the brain, which was at that part soft, yellow, and in a state of suppuration.

Mr. B., of the 29th Regiment, when in Halifax, Nova Scotia, was struck, in a drunken frolic, on the anterior part of the left parietal bone, with his own sword, which was a straight, heavy one, and a wound about two inches long was made in the side of his head through the bone. His little finger was cut at the same time, and it was not until the finger had been dressed that I was asked to look at the head, which he declared had nothing the matter with it. He was vomited, and purged, and the next morning bled, and as symptoms of inflammation of the membranes of the brain came on or increased, the bleedings were repeated, the quantity taken at each time being gradually diminished. He lost 250 ounces of blood in five days, after which he gradually although slowly recovered, some small spiculæ of bone coming away during the cure. Returning to England, the vessel was taken off the Scilly Islands, and he was sent to Verdun, where he remained several years, until liberated by the peace of 1814, when he rejoined his regiment, which had served in the Peninsula, and had returned to North America. It was soon found that he became outrageous on drinking a very little wine, and was odd in his manner, and had a great propensity to set out walking for hours without apparently knowing what he was about, or where he was going. When his regiment came immediately in front of the enemy, he was found going over to their lines, without being aware of what he was doing; and he was at last obliged to be sent to England, having evidently become deranged. This gentleman has ever since been confined in a private mad-house. His brother offered to allow the bone to be removed; but after thirty years of derangement a recovery could not be expected, and it was declined. If the examination I have since learned to be proper in such cases, had been made at the time, the inner table of the bone would have been found broken and depressed; and he might now have been in health both of mind and body.

I removed, in Lisbon, in the hospital appropriated to the wounded French prisoners in 1812, a portion of bone by the trephine, which had been fractured by a sword some months before: the wound had not healed, and some pieces of bone were depressed. One piece, in particular, of the inner table, was sticking in and irritating the dura mater, and was in all probability the immediate cause of the fits from which the patient had been suffering. He recovered.

A British soldier received a wound at the affair of El Boden, in front of Ciudad Rodrigo, from a sword, on the top of the head; he accompanied me to Alfaiates, on the retreat of the army. The bone was apparently only cut through, yet the inner table was depressed, and felt rugged when examined with the probe. The symptoms of inflammation increasing on the fourth day, and not being relieved by copious bleeding, I removed a central portion of the cut bone by one large crown of the trephine, and took away several small pieces which were sticking into the dura mater, after which all the symptoms gradually subsided.

266. The whole of the French wounded, who remained on the ground or were taken prisoners after the battle of Salamanca, were under my care, and among them there were several severely wounded by sword-cuts received in the charges of heavy cavalry made by Generals Le Merchant and Bock. The cerebellum was laid bare in two cases without any immediate bad effect. In one particular case, which recovered, (after the battle of Waterloo,) the brain was seen pulsating for several weeks; and the statements made to me by the different officers at Brussels and Antwerp, and afterward at Yarmouth and Colchester, entirely confirmed the observations I had made, and the recommendations I have inculcated on this particular point as resulting from the practice of the Peninsular war.

267. It would appear that too much stress is laid upon a difference which is supposed to exist in the danger of trephining a man on the first or on the seventh day after an accident; and that an error may be committed in believing that the trephine is a more dangerous instrument on the first day than on the seventh. The question is not whether the man is to be trephined or not, but which will be the best and safest day or time to do the operation. I do not hesitate to say the first, believing the violence to be greater when done on parts already in a state of inflammation, than when they are sound. When the inner table has pierced the membranes and gone into the brain itself, the individual will in most cases ultimately die miserably of the accident if not relieved by art. It is less safe to let him designedly run the certain risk of cerebral irritation, which when once excited is often indomitable, than to remove the cause, and endeavor to prevent the evil. If the cerebral irritation only manifested its effects on the surface of the dura mater by causing suppuration there, delay might be admitted; but as it usually gives rise under these circumstances to the formation of matter on the surface, and even in the substance of the brain, where it is deadly, “la chirurgie expectante” cannot be allowed. Lastly, there is not more danger of a hernia cerebri, as has been supposed, when the operation is done early, than when it is done at a later period; on the contrary, the patient has a much better chance of escape from hernia cerebri, and from all other evil, when the local and the general treatment are decided and efficient.

If, on attempting to remove a fragment buried in the brain, serious convulsive movements should be excited, it would be proper to desist from all further attempts to extract the splinters until the brain has become more quiescent.

It is necessary to recollect that the brain appears to be insensible, or nearly so, when first exposed; and it has rarely occurred that a serious convulsion or anything beyond vomiting has taken place on the removal of a piece of bone from the brain; nor will any difficulty be found in removing such small fragments as can be seen with a pair of forceps duly adapted for the purpose. It is impossible to say at what period of time the brain may become irritable, and no longer admit of its being touched without convulsive movements ensuing; but when this state of irritation has commenced, and its existence is proclaimed by the excitement which takes place on touching the fragment of bone, the surgeon should at once desist from all attempts to remove the foreign body. The brain under ordinary circumstances is much more likely to recover from an injury, all foreign or irritating matters having been removed, than when suffering from their presence.

268. The establishment of the principles which ought to regulate the practice of surgery in cases of fracture with depression of the inner table of the skull, is of the greatest importance. The principle being laid down that it is right and proper to examine all such wounds with a blunt, flat probe, in order to ascertain if possible whether the inner table be depressed and broken, the question necessarily arises, what is to be done when such depression and breaking down of the inner table have been ascertained to have taken place? There can be no hesitation in answering, that in all such cases the trephine should be applied, although no symptoms should exist, with the view of anticipating them. The old doctrine, it may be said, in regard to fractures generally, is revived in these cases, but on a principle with which our predecessors were not sufficiently acquainted. A patient very often survives a mere depression of the skull; he may, and occasionally does survive, a greater depression of the inner than of the outer table; but it has not been shown that he ever does survive and remain in tolerable health, after a depression with fracture of the inner table, when portions of it have been driven into the dura mater. If cases could be advanced of complete recovery after such injuries, they would not supersede the practice recommended, unless they were so numerous as to establish the fact that injuries of the dura mater and brain by pieces of bone sticking in them are curable without an operation, and without leaving any serious defects. There are great objections to the trephine being applied in ordinary cases of fracture, not attended by symptoms of further mischief; but the nature of the cases particularly referred to having been ascertained, the practice should be prompt and decisive in every instance in which the surgeon is satisfied that there is not merely a slight depression or separation of the inner table, but that several points of it have been driven into the dura mater. If one trephine will suffice, the central point being applied close to the edge of the middle of the wound in the bone, it should be applied there; but if the cut be longer, and the spiculæ of bone extend upward and downward in its length, a small trephine should be applied as near each end as may be judged advisable, and one edge of the cut bone should be removed by the straight saw, of which Paré and Scultetus made such use in ancient times, and which Mr. Hey of Leeds revived in modern surgery; or the small straight saw may be used alone, if the object of removing a portion of bone can be attained without the trephine. By these means sufficient room will be obtained to remove the broken pieces of bone which are irritating the dura mater and brain. The danger resulting from the application of the trephine, in such cases, bears no proportion to the risk incurred by leaving the broken portions of bone as a constant cause of irritation.

269. There is an essential difference between a depression of the skull in a CHILD and in an ADULT. In the child the inner table is not brittle--it bends equally and does not break; it very often does little mischief when depressed, and gradually recovers its level. The brain in young persons is softer and less consistent, and can accommodate itself more readily to pressure for a limited time, without ultimate mischief, than the brain of an adult; so that a continuance of the most urgent symptoms can alone authorize the application of the trephine in children, and in young persons under fifteen or sixteen years of age. A similar bending of the long bones in young children is often observed at an early period in life.

270. The propriety of dividing the scalp in an adult, in order to examine the state of the bone beneath, when evidently depressed, thus rendering a simple although comminuted fracture a compound one, is a matter of very great importance, the decision of which rests upon the still more essential point--viz., whether a depressed portion of bone ought or ought not to be removed? This again must depend upon the nature and extent of the depression, for many persons who have suffered from such a misfortune have recovered without the depressed portion being raised. It is a question of degree or extent, upon which every surgeon must form a judgment from his own observation and experience.

The difference between a simple and a compound fracture of the leg is often considerable; it is more often dependent on degree. When the fracture is nearly transverse, and the skin is cleanly divided, the difference between it and a simple fracture of the same part is little more than one of time. This may be the case with an injury of the head; the difference between the two states in fractures of the skull has, however, been much exaggerated; so much so, that no reliance can be placed on the supposition that there is more real danger in a case of fracture with depression in which the scalp has been divided, than when it has been only bruised, and not divided. I admit that theoretically it ought to be otherwise, but theory and practice do not always correspond. In all cases in which a fracture with marked depression is known to have occurred in an ADULT, it is good practice to ascertain the nature and extent of the depression. It is imperatively necessary if accompanied by symptoms of compression.

If the result of a great number of comparative trials should be in favor of never, under any circumstances, raising a depressed portion of bone in an adult, but of leaving it to the efforts of nature, an incision in order to ascertain the state of parts below ought not to be made; but as such a result is not likely to be obtained, the practice recommended appears to be the best.

The scalp should be divided, in such cases as may require the operation, by a straight, crucial, or such other shaped incision as may be found most convenient to the surgeon; but no part should be removed which can be preserved with the hope of maintaining its life.

271. The cranium, together with the fracture and depression, being exposed, the question whether the trephine should be applied or not is next to be determined. If the operation by the trephine, or that of sawing a piece of bone out of the head, were not in itself dangerous, there could be no hesitation about its use; but it is a dangerous operation, especially in crowded hospitals, and ought not to be resorted to when it can be avoided. If any ten healthy persons were trephined in a hospital, one would in all probability die from the effects of the operation, and three or four more might have a narrow escape from the inflammation of the brain and its membranes, or the other consequences which would probably ensue. It is not the admission of air, which has been even lately supposed to do mischief, that is to be dreaded in these cases, but the same kind of irritation which often follows the abstraction of a piece of bone under other and more ordinary circumstances at a later period of time.

The following cases are illustrative of many important points:--

William Rogers, aged nineteen, of the 32d Regiment, was wounded on the 16th of June by a musket-ball, which entered at the inferior angle of the left parietal bone, knocked him down, and for a few minutes rendered him insensible. On recovering his mental powers, he found that he was unable to speak, not so much (as he said afterward) from the want of power to form words, as from the incapacity of giving them sound. He was conscious of everything passing around him, and reasoned correctly. He retired out of the reach of shot, and then lay down for the night. On the following morning, he went to Brussels, where he was examined and dressed. On the morning of the 18th he reached Antwerp on horseback, very giddy, and overwhelmed with fatigue, fasting, and watching; he was admitted into the Minimes General Hospital and put to bed, when he soon fell into a sound sleep, which with some tea refreshed him much.

June 19th. The ball was found to have passed obliquely upward and backward at least two inches, and could be distinctly felt with a probe. It gave more the idea of having raised the outer table than that of having depressed the inner. The defect in speech was in some measure diminished, and this with giddiness were the only symptoms of compression. A poultice was placed over the wound, a brisk purgative given, and spoon diet ordered.

20th. The pain and giddiness having increased, with annoyance from noise and exposure to light, twenty-six ounces of blood were taken from the arm. The following day the purgative was repeated, and the patient was much relieved. Everything went on well, the wound was nearly healed, and he was considered almost fit to be discharged, when, on the 16th of July, the wound began to open; on the 18th it was dilated and a portion of the cranium removed by the forceps; this was soon followed by symptoms of inflammation of the brain; twenty ounces of blood were taken immediately from the arm, purgatives and diaphoretics were ordered, and the strictest abstinence enjoined. 23d. Venesection was repeated, as well as the other means usually adopted to reduce high action. 24th. Completely relieved. 26th. Another portion of the cranium removed, the dura mater being fully exposed; the general health in the best state.

August 3d. Doing remarkably well; the wound healthy; the pulsation of the brain evident; the power of speech perfectly restored. The ball yet remains in, according to the opinion of the patient, (who is a fine, intelligent lad,) and he thinks it has gradually descended toward the petrous portion of the left temporal bone. Sent to England at the end of the month, the wound being healed.

When I saw this man at Antwerp I gave my opinion, without hesitation, that the bone and the ball ought to have been removed in the first instance, when he would have had a better chance for perfect recovery. The operation, when afterward performed for the removal of the loose pieces of bone, placed his life in great jeopardy. He was discharged the service with the ball lodged, and it is more than probable that he did not long survive, which he might have done if the ball had been removed when it was first felt within the skull.

In the following case the ball could not perhaps have been removed in the first instance with propriety; it might, however, have been lying on the dura mater, or near it, within reach, and the actual state of things ought to have been ascertained, the surgeon afterward deciding whether any further operation were necessary.

Thomas O’Brien, 28th Regiment, aged twenty-three, was wounded by a musket-ball on the 16th of June at Quatre Bras; the bullet penetrated the occipital bone below and to the right of the junction of the lambdoidal and sagittal sutures. On his arrival at Colchester, the wound was healthy in appearance and healing rapidly. It appeared from his own account that for some hours after the injury he was totally deprived of sight; since that time he has been constantly more or less affected with headaches, for which he has been prescribed occasional cathartics and low diet. He has also been affected with pain and weakness in both eyes, but more particularly in the right. While at Brussels, and during his progress to Ostend, he lived very irregularly, and was frequently intoxicated. The external wound was entirely healed on the 20th of July, and no suspicion existed that the ball was lodged in the brain. On the 25th matter was perceived under the scalp, and was evacuated yesterday. To-day, the 27th, he complains of increase of headache; pulse small and quick. V. S. ad ℥vj. Haust. cathart. statim. 28th. In the course of this day his symptoms have become very urgent; he is restless, with a very quick pulse; an extensive crucial incision was made in the site of the original wound, and now for the first time it was discovered that the ball had penetrated the brain; several loose pieces of bone were extracted; a considerable quantity of arterial blood was suffered to flow from the small vessels divided in the incision. His bowels had been well opened by the cathartic. The most vigorous treatment was continued, but the symptoms notwithstanding increased, and he died on the morning of the 29th of July.

The ball was found lodged nearly two inches deep in the substance of the right posterior lobe of the brain; a considerable quantity of pus surrounded it; some inflammation of the brain and its membranes was observed, but much less than might have been expected.

A. Clutterbuck, 61st Regiment, aged twenty-five, was wounded in the back of the head by a musket-ball at the battle of Toulouse, on the 10th of April, 1814. He felt little inconvenience from the wound during the first two days. On the 14th he complained of severe pain in the head, giddiness, and dimness of sight; the face was flushed, pulse hard and frequent. Twenty ounces of blood were taken from the arm, and the wound enlarged so as to expose the cranium. The upper part of the os occipitis was found fractured by the ball, and a circular portion of it, about the size of a shilling, was depressed and fractured. 15th. Pain in the head much abated; no giddiness, dimness of sight, or any unfavorable symptom; pulse still hard. V. S. ad ℥xx. To be well purged. 19th. He was bled again this day to the extent of twelve ounces, as a matter of precaution. 23d. Continues free from any bad symptom. May 8th. The wound is now much contracted, and he feels no inconvenience. A small portion of the bone still feels bare to the probe, but the greater portion of the depressed piece is covered with healthy granulations. No exfoliation has taken place. May 24th. The wound is nearly healed; he is in good health and spirits, and without inconvenience.

This case may be properly contrasted with that of O’Brien, as showing by the result the difference between an uninjured and an injured brain. If the fractured and depressed bone had not been at the back part of the head, it is probable the depressed portion would have been removed in the first instance, as it certainly would have been after the 15th, if the unfavorable symptoms had not yielded to the general treatment; but the bone would then have been removed under much more unfavorable circumstances than at first.

The following case is related to show the extent to which blood-letting may frequently be carried to preserve life. There having been no reason to believe that the symptoms depended on fractured and depressed bone, the scalp was not divided; and as the symptoms were coeval with and not consecutive to the injury, they were therefore supposed to depend on concussion rather than on compression of the brain. If the trephine had been applied on the fourth day because the insensibility continued, the additional injury would in all probability have proved fatal. If the depletion of all kinds had been less effective, the inflammation of the brain or of its membranes would certainly have terminated in the effusion of lymph or the formation of matter, which the use of the trephine would not have prevented nor removed.

George Mills, an artillery driver, aged twenty-eight, was admitted into the Dépôt de Mendicité Hospital, Toulouse, May 29, 1814, in consequence of having been thrown from his horse on his head against the ground. He had fallen on the right side of the os frontis, immediately above the eye, where the surface of the skin appeared to be scratched and bruised, but the bone was not depressed: he was bled freely, but remained insensible. The next morning he was again bled to twenty ounces, which operation was repeated in the evening. On the 29th, the temporal artery was opened, and a vein in his arm at the same time, the breathing being strong and sonorous, the eyes closely shut, and he lying quite insensible; the pulse before the bleeding was quick and small; after he had lost about eight ounces of arterial and eight ounces of venous blood, it became fuller, and the breathing was somewhat relieved; the slightest touch gave him pain, and he shrunk from pressure made directly above the eye. The temporal artery was again opened in the evening, and ten ounces of blood were taken away. A purgative and a stimulating enema were ordered, and cold was constantly applied to the head.

30th. He has been freely purged and appears more collected; the pulse is still quick and small; breathing very free; the irritability continues and he complains of pain on pressing the head. The purgative and the enema were repeated, and ten ounces of blood were drawn from the temporal artery, after which he attempted to speak. 31st. Passed a good night; the pulse is quick and small; pain in the head still great; was again bled to twelve ounces, and the purgative was repeated. June 1st. Pulse quick; there is not so much pain in the injured part, and he appears more sensible; was bled to twenty-four ounces, and the purgative was repeated. 3d. Was again bled to ten ounces. From this time until the 20th, he gradually improved, and was then discharged cured.

The treatment in these cases was the same, although in one there was no fracture, and in the other two there was fracture with depression. The broken portions of bone did not, in Clutterbuck, appear to press unequally on the dura mater, and it was presumed that the moderate degree of pressure which ensued from the depression might be borne with impunity, as it did not seem likely to be accompanied by the projection inward of any pointed pieces which might irritate the brain. The result confirmed the supposition and justified the treatment. If the examination of the depressed part had led to the apprehension that such points of bone did exist, and were sticking into and irritating the dura mater or brain, they would have been removed, in the belief that although they might not at the moment have given rise to any other symptoms than those which depended on the blow, the time would come when they would scarcely fail to cause those which usually accompany the formation of matter within the skull. If this danger should also be avoided, the subsequent evils which have been noticed as occurring at a later period, and which ultimately require the same operation for the relief of the patient after months of acute suffering, might be encountered; for although a person may temporarily recover from an injury in which a portion of bone has been allowed to remain a source of irritation to the brain, it does not follow that such recovery should be permanent. If there be a doubt on the mind of the surgeon, whether there be or be not any pieces of bone depressed and irritating the brain or its membranes, he should wait; this is the real difference between the surgery of the latter part of the Peninsular war and that of the olden time.

272. When a fracture is accompanied by depression, and the broken portion or portions of bone would seem to be driven into the dura mater or the brain, or to press so unequally upon them that as much mischief is likely to ensue from leaving as from removing them, especially in an adult or a middle-aged man, less harm will in general follow from ascertaining the fact by dividing the scalp and removing the broken pieces than by doing nothing, more particularly when the presence of a foreign body has been ascertained. If there be no symptoms indicative of mischief below the fractured part, the surgeon must then decide, after the best estimate he is able to make, of the probable evil which will occur from allowing the broken or depressed portions of bone to remain.

A French grenadier was brought to the field hospital the second day after the battle of Salamanca; he had received a blow on the left side of the head, probably from a piece of shell, which had caused a contusion and swelling on the left parietal bone, with a graze of the scalp, but without any opening communicating with the bone. This swelling, on examination, was so soft, and the feeling of depressed bone beneath so distinct, combined with the fact of the continued lethargic state of the patient, that an incision was made into it, when the bone beneath was found broken into several small pieces. On clearing away the blood, two pieces which were loose were readily raised and removed by the elevator and forceps, and egress given to an ounce or two of blood, which were extravasated beneath, apparently from the rupture of the vessels passing between the dura mater and the bone. The patient regained his senses in the course of the night and morning of the third day, and under a strictly antiphlogistic regimen gradually recovered, some other small pieces of bone coming away, one or two others apparently reuniting to the uninjured parts, showing that it is not always necessary to remove every portion of bone which may be broken, provided any bond of union remains, and principally that which exists between it and the dura mater.

These different cases stand out in bold relief as eminently successful and opposed to those said to have been equally so under la chirurgie expectante. They tend to show that however good a general rule may be, it may admit of many and important exceptions; and they prove that experience, aided by sound and correct observation, is essentially necessary for the formation of a scientific surgeon.

273. In young persons the brain will bear a greater degree of pressure and of irritation with impunity than it will in persons of mature age. By far the greater number of cases in which recovery has taken place after fracture and depression of the skull with injury of the brain, and even loss of its substance, have occurred in children or in persons under the adult age; greater reliance may therefore be placed on the powers of nature in them; and recourse may be had less frequently to the aid of operative surgery in order to prevent mischief than in older persons, even when the bone is fractured as well as depressed. It will be found, and the remark is important, that the cases of fracture and depression reported to have been successfully treated without operation, have occurred principally in young persons.

The result of my experience has rendered it imperative to remove at once all portions of bone or foreign substances which have materially injured the dura mater in adults, although no symptoms of compression should be observed. If the wound in the dura mater should not be sufficiently large to allow the offending body to be extracted through it, the opening must be enlarged to enable it to be withdrawn without further laceration.

274. Depressed portions of bone, accompanied by fracture at the back part of the head, need not necessarily be removed in the first instance. When the fractured and depressed bone is accompanied by symptoms of compression in an adult, which continue after the usual antiphlogistic means and remedies have been employed in vain, and appear to increase rather than to diminish, the broken and depressed portion should be raised; for although the brain will bear and accommodate itself to pressure in many persons in a manner which could not be either foreseen or expected, it will not do so in all; and the removal of the bone offers the best chance for relief, whether the mischief has arisen from the pressure made by it or occurs from the extravasation of blood beneath. When the principal symptom of compression is a severe fixed pain in the part, although the state of the fracture and depression would not alone have rendered the removal of the bone positively necessary, it is advisable to do so when this symptom is present.

The greatest discrimination is required in cases where the extent of the injury is not so manifest and in which there is more room for doubt. In most cases in which a slight or moderate degree of fracture and depression of the skull has taken place, the symptoms of concussion are present as well as those of compression. The symptoms of concussion are, however, coeval with the injury, and although those of compression may take place almost instantaneously, they more usually occur at a later period of time. The symptoms of concussion may nevertheless continue for days, more particularly the insensibility, or that state which is approaching to it, complicating the case and embarrassing the practitioner. In a child or young person the symptoms of compression or irritation, when they appear even at a secondary period, may pass away under further moderate depletion; but in an adult any undue delay in giving the necessary relief, by the removal of the depressed portion of bone, will in general be destructive to the patient. It is the irritation caused by the depressed bone on the dura mater, and communicated to the brain, which gives rise to the unfavorable symptoms and to the formation of matter which follows them.

A gentleman received a blow on the side of the head, which knocked him down and deprived him of his senses, from which state he partially recovered, and vomited; some stupefaction, however, remained, although he could be made to answer by a little importunity. Pulse 62, irregular, breathing slow, the pupils contracting under the influence of light; the integuments where the blow was received were soft and swollen, in all probability from an extravasation of blood beneath. The next day the pulse was full and regular, the pupils were dilated, vomiting had taken place several times, and the patient answered correctly on being sharply questioned. He was bled largely, purgatives were administered, and cold was steadily applied to the head. He was bled the next day; on the third the left arm became paralytic, the pupils continued dilated, and on the fifth day paralysis implicated the left leg as well as the arm. There could now be no doubt that the brain was suffering from compression; but as the nerves of the excito-motory system were unaffected, and the functions of ingestion and egestion were satisfactorily accomplished, it was thought advisable to trust to the efforts of nature. The swelling of the scalp was painful.

A week afterward the general symptoms were the same, or only slightly augmented by fever; but, as the swelling of the scalp was more painful, it was opened, and a quantity of matter was evacuated, the bone beneath being fractured and depressed. As this operation gave some relief, it was thought advisable to wait, with the hope that the benefit thus obtained might prove permanent. The patient did not improve, however; and as the symptoms of fever increased, and were accompanied at last by rigors and great pain in the head, the depressed portions of bone were removed, and about half an ounce of purulent matter escaped from between the dura mater and the bone. The relief given this time was effective, and the patient perfectly recovered. “La chirurgie expectante” placed this man’s life in the greatest jeopardy. It was only saved at the last moment by the aid of that surgery which ought not to have been withheld when the paralysis, by affecting the leg as well as the arm, demonstrated the extension of the mischief within the head. In this instance the operation was successful, but it is not in general so serviceable when delayed to so late a period. It is in cases of this serious nature often a means of prevention rather than of cure.

275. When a severe blow, accompanied by a shock, as from a fall, has been received on the head, and the skull is so thick and strong as to be able to resist the violence thus offered without being broken, or is only slightly fractured, the vibration or trémoussement is directly communicated to the brain, giving rise to laceration or bruising of its structure in various situations, to the rupture and separation of the vessels of the dura mater from the bone to which they are attached, and to derangement of other parts, which will in all probability be followed by inflammation, and may even terminate in the formation of matter under the dura mater as well as above it, and even in the brain itself. It is said to take place by “contre-coup” when the mischief occurs in any other part of the head than that which is struck, numerous instances of which are given by the older French authors. They were probably cases of laceration, the consequence of concussion of the brain, and not relievable by the art of surgery; but the injury which the older surgeons particularly distinguished as by “contre-coup” was where the blow was on one side, and a fracture took place or matter was formed in a circumscribed spot on the other; these cases did sometimes, they say, although rarely, admit of relief by operative surgery. These cases, unaccompanied by fracture, do not appear to take place under the improved method of treatment by larger depletion, by antimony, and by the early use of mercury. In the event, however, of their occurring, there is no surgeon of the present day who would attempt an operation of exploration on the opposite side of the head to the injury, without some sign of mischief existing at that part; although such operation, if done, might accidentally be followed by success.

LECTURE XIX.

TUMORS OF THE SCALP, ETC.

276. When the periosteum covering the bone is bruised, or the bone is merely deprived of this membrane, it does not follow that it should die or exfoliate. In many instances the wound will gradually close up and heal, as if no such accident had happened. A blow or bruise on the head often gives rise to a swelling or tumor, from the rupture of the small vessels passing into the cellular membrane between the scalp and the pericranium; the tumor in these cases appears immediately after the receipt of the injury as a soft swelling, and is usually found to contain blood, which in most instances is removed by absorption in the course of from two to three weeks. In some cases inflammation supervenes, and one part becomes tender and appears to point; into this a small incision should be made to allow the blood and matter to escape, when gentle compression should be resorted to in order to induce the parts to unite. Swellings of this kind in new-born infants, occurring from pressure during delivery, may be readily mistaken for deficiencies of the occipital and parietal bones, if it were not for the absence of all motion, which under such circumstances would be communicated to them from the brain. The blood effused in the cellular membrane raises the border of the swelling, which becomes harder than the neighboring parts, while the center remains soft and yielding, giving a sensation to the finger as if the bone beneath were wanting, or, after a blow, the idea that the bone beneath is depressed. If such a swelling be unnecessarily opened, considerable inflammation and suppuration will often follow, to the great inconvenience of the patient; this will in general be avoided by the use of a moderately stimulating cold lotion.

277. In other cases of tumors, which are called secondary in contradistinction to the preceding, the patients go on well for eight, nine, or more days, at the end of which time they complain of headache, giddiness, nausea, restlessness, thirst, and generally of fever. A few days more, frequently from the thirteenth to the fifteenth day, rigors, sometimes severe, are superadded, and a swelling, if not observed before, is now perceived on the spot where the injury had been received, if the integuments have not been divided; or, if there be a wound, it loses its healthy red appearance, and assumes a yellowish, unhealthy color, which is accompanied by a thinner and more acrid discharge. From this time the symptoms gradually increase, the patients become delirious, convulsed, comatose, and die; and matter is found between the skull and the dura mater, or in or on the substance of the brain. If this secondary swelling be divided, and the fluid evacuated, which is not good pus, the pericranium will be found detached and the bone bare.

It has been stated that a bone so circumstanced would not be found to bleed on being scraped, and that, by attending to the want of hemorrhage from the outside of the cranium, the extent of the evil might be ascertained, and that so long as a denuded, discolored bone will bleed on being scraped, it may be considered that the dura mater is attached below, and that no operation should be performed.

The essential difference between the primary and the secondary swellings is to be found in the fact that, although the bone be exposed, and even in some degree may have changed its color in the primary swelling when matter has formed, the febrile symptoms will subside after its evacuation, healthy granulations will spring up, and little or no exfoliation will take place. In the secondary swelling none of these favorable symptoms or appearances will take place, for the bone is incapable of maintaining its life, and must die. If the outer table only be implicated, it may exfoliate; but if there be reason to believe that matter has collected beneath, on the dura mater, the bone should be removed by the trephine.

Inflammation of the dura mater proceeding to suppuration, or the formation of matter between it and the bone, appears to have been a much more common consequence of injuries of the head in former times than at present. It is not now of frequent occurrence in London hospitals.

As blows on the head and the structure and functions of the brain are the same at present as formerly, the difference in regard to such cases can only depend on the difference of treatment. It is, in fact, infinitely more depletory now, and therefore less operative. Blood is taken away in larger quantities, although to this there are exceptions, depending on the constitution of the patient, which will not always admit of it, while the potassio-tartrate of antimony and mercury are by most surgeons administered at an early period.

Suppuration, or the formation of pus on the surface of the dura mater, not being, under the strictly antiphlogistic and mercurial system, so common as formerly, sufficient attention has not perhaps been paid to another evil which frequently accompanied it in former times, viz., suppuration on the surface and in the substance of the brain itself; for the greater number of those who died with fracture and depression of the skull, and whose cases are recorded, suffered also from alteration of the structure or substance of the brain, and the formation of matter within it or upon its surface. This termination might not have taken place in a large proportion of the cases in which it occurred if the depressed bone had been raised to its level, and the irritation arising from undue or unequal pressure had been avoided. It must be admitted, however, that an internal part of the brain may receive such a shock at the moment of injury, as well as an external part, that no treatment can arrest the progress of the mischief, although it may be delayed; and when the patient dies, after four, five, or more weeks of alternate hope and suffering, matter may be found in some part of the brain where an injury was not suspected.

Purulent matter may be formed beneath the dura mater in a confined spot, or it may be diffused generally over the surface of the brain, in which case the sufferer has no chance of relief.

278. The operation of incising the dura mater, to admit of the discharge of blood or matter from beneath, and even of puncturing the brain, has not been much resorted to in England; this may be an error. The records of surgery supply many cases where it might have been done with advantage, and some in which it was done with the greatest benefit to the patient. It is not an operation which ought to be performed without signs sufficiently demonstrative of the necessity for doing it.

I have seen, on the removal of a portion of bone by the trephine, the dura mater rise up rapidly into the opening so as to attain the level of the surface of the skull, totally devoid, however, of that pulsatory motion which usually marks its healthy state. An opening into it, under these circumstances, has allowed a quantity of blood or of purulent matter to escape, proving that the unnatural elevation of the dura mater was caused by the resiliency of the brain when the opposing pressure of the cranium was removed. This tense elevation, its abnormal color, and the absence of pulsation are positive signs of there being a fluid beneath, requiring an incision into the dura mater for its evacuation. It is a point scarcely noticed in English surgery--one which was not in the slightest degree understood at the commencement of the war in the Peninsula.

A. Monro, of the 42d Regiment, was wounded on the 10th of April, at Toulouse, by a musket-ball, which fractured the left parietal bone slightly, without depressing any part of it. No symptoms followed requiring more than ordinary attention until the 23d, up to which time he had been kept on low diet, for the most part in bed, and had been bled and purged. On the evening of that day he became feverish, and hasty and odd in manner, and the pulse quickened; he declared himself, however, to be quite well, and submitted to be bled and physicked with great reluctance, calomel combined with opium being given him at short intervals. On the 24th he complained of pain in the head, which he said was very slight, and that upon the whole he was quite well, and would not be bled nor have anything done. He was bled largely by force, which lowered the strength of the pulse, but did not relieve any of the symptoms of irritation of the brain. On the 25th he was evidently worse, although he declared himself to be quite well; he talked a little incoherently; the pupils were dilated; the pulse quick but regular; the countenance was changed; he was sensible, apparently, upon all points except that of being much worse, which he resolutely denied, saying he was better and would soon be well. Satisfied that matter was forming, or had formed, in or on his brain, I desired that the trephine might be applied on the fractured part and the bone removed. This, however, he would not permit the officers in charge to do, and they awaited my return in the afternoon, when, finding him much worse, I directed it to be done by force, three of his own regiment with others attending to assist the surgeons. He called upon these men by name not to allow him to be murdered in cold blood, declared he was getting well, and would get well if let alone, and prayed them to avenge his death on the doctors if they meddled with him. The surgeons were dismayed, and requested that the operation, which they said required great care, should be performed by me, their chief. I therefore removed the bone; and the moment it was taken away the dura mater rose up in the opening to the level of the surrounding bone, and remained without any pulsatory motion. I had no doubt of matter being beneath, and that, from his general state, the man would die. I did not therefore think it prudent, under all the circumstances, to do more than warn his comrades that, when dead, they would see the whole brain beneath in a state of suppuration. He died that night; and the next day they saw the whole of the left hemisphere soft, yellow, and covered with matter, to their great surprise and satisfaction at the accuracy of the diagnosis.

Absalom Lorimer, of the 42d Regiment, was wounded by a musket-ball on the 10th of April, 1814, at the battle of Toulouse, which carried away a small portion of the scalp just above the right temple, fracturing the bone slightly, but without any depression. No symptoms occurred demanding more than ordinary attention for the first fortnight, during which period he had been bled once, purged, and kept on low diet. On the 25th, he complained of pain in his head around the wound, shooting to the back part; pulse 60; pupils dilated. An incision having been made to the bone, the pericranium was found detached, and the bone fractured, but without any obvious depression. V. S. ad ℥xx, calomel and colocynth: as the pain continued, the bleeding was repeated in the evening. 26th. Pain in the head greatly relieved; pulse 60; bowels torpid. Ten ounces of blood were taken from the temporal artery, and the calomel and colocynth, salts and senna were repeated. On the morning of the 29th, the symptoms of compression having increased, the trephine was had recourse to, and the fractured portion of bone was removed: a layer of coagulated blood was found on the dura mater, which puffed up into the opening. In the evening he became convulsed, the pulse intermitted, and he died. On examination, a large abscess was found in the right hemisphere of the brain, having the ventricle for its base, with some matter on the surface of the brain, and between the dura mater and the bone at the base of the cranium.

On the morning of the day that I performed this operation, I had done another of the same kind at the Hôpital des Minimes; the dura mater rose up in a similar manner without pulsation into the opening made by the removal of the circular piece of bone by the trephine; on puncturing it a considerable quantity of pus oozed out. The opening was enlarged; and the flow of matter was daily encouraged, until it gradually diminished, and ceased with the formation of granulations, and the drawing in and cicatrization of the part.

279. It has been supposed theoretically that a wound through the dura mater was particularly dangerous, in consequence of the tunica arachnoides which lines it being a serous membrane; and that, if the inflammation which ensued did not cease at the adhesive stage, by the consolidation of the surface which covered the pia mater with that which lined the dura mater, a diffuse inflammation would necessarily follow, which might spread over its whole extent. This has not been found practically to be the case; and if a simple wound of the dura mater be a danger that ought to be avoided, the risk run cannot be put in comparison with that which accompanies the continuous irritation depending on the presence of a spicula of bone, which has passed through the dura mater, and is irritating the brain beneath. It has also been supposed theoretically that the danger would be diminished if the pia mater were wounded also, as the brain would project and fill the wound; but the accuracy of this opinion may be doubted. If the dura mater were injured through error or design, I should not think the evil lessened by adding to it a wound of the pia mater, and perhaps also of the brain.

By those who have been accustomed to the terrible injuries which occur in military warfare, in which large portions of the brain are sometimes exposed, and even lost, without much inconvenience following, the exposure of or the opening into the dura mater is not considered of so much importance as it is by those who have had fewer opportunities of seeing such awful cases; while the formation and retention of matter below the bones of the cranium is, on the other hand, more dreaded by those who have often seen their ill effects than by those who have not had many occasions for observing them; by whom, however, they are often considered, when they do take place, to be irremediable by art.

280. Gunshot wounds of the skull are attended by certain peculiarities. In ordinary circumstances there is usually an external wound and a fracture more or less comminuted, with depression; this wound will almost always require to be enlarged by a simple incision, so as to show the extent of the depression or the size of the broken and depressed portions of bone. When the bone is scarcely injured, and the periosteum is only bruised, or when the bone is even deprived of this covering, it does not follow that it should die or even exfoliate. In many instances the wound will gradually close in and heal, as if no such evil had occurred; and in those which do not terminate so favorably, the cure may only be delayed by the exfoliation of a layer or scale of bone from its outer surface, unless the mischief should have implicated the parts beneath.

A musket-ball striking directly against a bone sometimes makes a hole not larger than itself, with or without any radiating fracture; and one large trephine, if properly applied, will often embrace the whole of the mischief, and admit of the removal of the broken pieces. As a center-pin cannot be used, the trephine may be made to turn very well in most cases in a flat but thick bar of iron, having a hole in the middle, of such a size only as will allow the polished outside of the trephine to turn in it. Sufficient support for the instrument will be obtained by this means until it has made a groove in the bone for itself, when the operation may be continued as it would be in an ordinary case after the removal of the center-pin.

When a musket-ball ranges along the side or top of the head, it may break the outer, and depress and fracture the inner table to a considerable extent, for the space even of three or more inches. The broken portions of bone may in general be removed by means of good forceps and a straight saw; and no good reason can be given for delaying the operation unless the nature of the injury be doubtful, when it may be as well to wait for symptoms. It sometimes happens, although rarely, that a ball sticks so firmly in the bone that it cannot be extracted by working round it in any ordinary way with a pointed instrument. The difficulty usually arises from the ball having half buried itself in the diploe, so little of it being exposed as not to admit of a firm hold being taken of it. The large trephine, used in the way pointed out, has several times overcome this difficulty. The removal of the outer table has been sufficient where the inner one has not been driven into the dura mater; when any doubt is entertained on this point both should be removed.

281. A ball or other foreign substance may penetrate the brain directly or obliquely. When the ball penetrates the brain directly, it is not often that it can be removed, and the sufferer very rarely survives beyond a few days, even if the ball has been extracted; more particularly if the injury have occurred in the anterior part of the substance of the brain; several persons, however, have recovered, in whom the injury occurred toward the back part of the head, the ball being allowed to remain. It will be better in all such cases to allow the ball to remain, which it will often do for many days, until circumstances render it necessary to endeavor to find it. When it can be felt immediately under the surface of the brain, it ought to be removed like any other foreign substance.

Dr. Rogers relates the history of an excellent case, in which a young man aged nineteen received a wound on the frontal bone, just above the center of the left superciliary ridge, from the bursting of a gun on the 10th of July. It was not until the 4th of August that he discovered a piece of iron lodged within the head, in the bottom of the wound, (from which a considerable quantity of brain had come away,) which he extracted the next day. It proved to be the breech-pin of the gun, three inches in length, and three ounces in weight. By the tenth of December his patient was perfectly cured.

When a ball strikes the head obliquely, it may enter and pass out or lodge. Nearly all these cases die, but one occasionally escapes, and none should be allowed to die without assistance. When the entrance and exit of the ball are obvious, and not far distant from each other, the splinters of bone should be removed; and if the little bridge between the openings should be injured, the whole should be taken away by the straight saw; an operation which cannot, however, be necessary in the first instance, if the portion of bone be apparently sound.

At the battle of Talavera, a soldier of the 48th Regiment was brought to me in a state of insensibility; he had received a musket-ball on the upper part of the right side of the frontal bone, where it had entered, and had evidently passed backward; it could be followed by the probe rubbing against the bone for nearly four inches. The scalp over this point was soft, as if blood were effused below; and on dividing it, a fracture was seen bulging rather outward. The trephine was applied forthwith, and the bone removed, together with the ball, which only wanted a little more impetus to have come through. The brain was injured, and the man died two days afterward.

A French grenadier was wounded at the battle of Salamanca by a musket-ball, which struck him on the right side of the head, penetrated the temporal muscle, and lodged in the bone beneath, giving rise to symptoms of compression. On dividing the parts, I found that the ball had fractured and driven in a part of the temporal bone, one portion of the ball being above, and the other below the broken bone. The upper half of the ball was readily removed, but several small portions of bone were raised by the elevator and forceps before the remaining portion of the ball could be drawn from under the bone, which was not depressed, the ball having been cut in two by its edge. The dura mater was bruised, but not torn through. The wound suppurated freely; several pieces of bone exfoliated, and the patient was ultimately discharged in progress toward a cure.

A small ball sometimes becomes so flattened by striking against the skull as to remain undiscovered when care is not taken in the examination. A soldier was wounded at the storming of San Sebastian by a ball on the side of the head, which was supposed not to have lodged. The wound did not heal, a small opening remaining, although no exfoliation took place, and the bone did not seem to be bare. On dividing the scalp to ascertain the cause of the delay in healing, a small ball, quite flat, was found; it had sunk down a little below the hole left for the discharge to which by its irritation it had given rise.

When a larger ball or a piece of a shell strikes the head, the fracture is usually extensive, and portions of bone, or a piece of the shell itself, are often lodged in the substance of the brain. There is nothing peculiar in the management of these cases, which are for the most part unfortunate.

282. A suture may be separated by a musket-ball, which impinges with a moderate degree of force directly upon it, but not without great danger. It can, however, only happen in young persons in whom the sutures are not obliterated as they are in elderly ones; in general it takes place when the ball happens to lodge as it were between the bones concerned in the formation of the suture. The first case of the kind which came under my observation occurred at the taking of Oporto. I met with a second at Albuhera, a third at Salamanca, and a fourth in a slighter degree at Orthez.

A heavy dragoon was wounded at the battle of Salamanca by a musket-ball in the body, which caused him to fall from his horse, injuring the top of his head. Little attention was paid to him until mischief was suspected from the lethargic state into which he fell, which could only be attributed to the blow on the head, where a tumor was observable. This, on being divided, showed a separation of the edges of the sagittal suture, from which some blood flowed. Two crowns of the trephine were applied on the twelfth day, in order to admit of the free discharge of some blood which had been extravasated from a wound in the longitudinal sinus, after which the symptoms subsided, and the patient gradually recovered.

A ball may pass apparently through the fore part of the head from side to side without doing much mischief beyond depriving the sufferer of sight. It does not in these cases injure the brain, but passes immediately below it and through the back part of both orbits. In four such cases the recovery was rapid, but the blindness was irremediable.

283. The danger of injury to the frontal sinuses has been greatly exaggerated, and vanishes in a great degree when attention is paid to their structure. The uncertainty of the depth of the cavity between the tables of the bone, and the irregularity of the exposed surface of the inner table, which may through carelessness be mistaken for depression, should be remembered.

A soldier of the 29th Regiment was wounded at the battle of Talavera by a ball, which struck him on the lower part of the right side of the forehead, fracturing the external wall of the frontal sinus. On examination, the ball could be felt lodged in the sinus, whence it was readily removed by enlarging the opening, and the man recovered without any bad symptoms.

At the storming of Badajos, a soldier of one of the regiments engaged at the little breach was struck by a small ball about the size of a swan-shot; it penetrated the frontal sinus of the right side, and stuck in the inner table, the outer being considerably injured and splintered by the blow. The splinters having been removed, the small ball could be seen sticking in the inner table of the bone, whence it was easily extracted, leaving the dura mater bare beneath. He was sent to Elvas, and recovered with a good and firm cicatrix.

After a wound of the frontal sinus has healed, the air has been known to raise up the integuments of the forehead into an elastic crepitating swelling whenever the patient blew his nose, so that a compress and bandage on the part were required for its relief; but these cases are very rare.

284. Wounds of the bony parts within the orbit are often attended by the most serious consequences. A boy, nine years of age, was struck by his playfellow with the end of a thick iron wire on the right eye, which blackened it. There was no external wound; but as there was some bloody chemosis at the upper part and the inside, there was a probability of the wire having penetrated deeply, although the opening could not be discovered by the probe. The accident had happened two days before, but he did not think himself ill. He was well purged, and cold water was applied externally. Two days after, he complained of sickness, headache, and some pain over the brow. He was bled freely from the temple of that side by leeches, and well purged by calomel and jalap. On the sixth day his mother reported him as having been delirious and restless all night. He was found stupefied, answering with difficulty and incoherently; pulse very quick, skin hot and dry, with some convulsive twitches of the face and arms; pupils slightly obeying the influence of a strong light, but not dilated. He was again bled freely from the temple, but his breathing became more difficult, he fell into a comatose state, and died in the night. On examining the head, the stiff iron wire was found to have passed under the upper eyelid, between it and the eye, through the posterior part of the orbitar plate of the frontal bone and into the anterior lobe of the brain, which was softened at that part, and bedewed with matter.

A woman, who had been struck by her husband on the left eye with a tobacco-pipe, while preparing her frying-pan for cooking, knocked him down with the pan, and ruptured his right eye, which was lost. She then pulled out a piece of the pipe which was sticking in the orbit, between the lid and upper and inside of her own eye, which was uninjured. She complained of little but the bruise, and rather brought her husband than herself for advice. Bled and purged, she did not complain of anything for several days, when she said she had been very ill all night, with nausea, headache, and shivering; with hot and dry skin, pulse very quick, the upper eyelid paralytic; she looked very ill, became delirious at night, and died two days after the first complaint of serious illness. On examination, half an inch of the red waxed end of the tobacco-pipe was found to have gone through the sphenoid bone, by the side of the sella turcica, and to have lodged in the brain, whence it was removed bedewed with pus, the brain being yellow and softened around it.

A wound of the longitudinal or lateral sinuses, allowing a free discharge of the blood poured out, is of comparatively little consequence. It is, on the contrary, a very fatal injury when the blood is permitted to accumulate.

285. A protrusion of the brain, often improperly called a fungus cerebri, is of two kinds, and occurs at different periods of time. The first kind is principally composed of coagulated blood, usually appears immediately after, or within two days after, the injury, and is generally fatal. The second takes place at a later period, although it has occurred on the third or fourth day, and is formed for the most part of brain. These protrusions rarely take place when a considerable portion of the skull has been lost or removed, the brain then being able to expand to such an extent as the inflammatory impulse from within may render necessary. When the opening is small, and the dura mater has not been injured, it has seldom been observed. It is then principally when the opening in the skull has been of greater extent than the size of one piece of bone removed by the trephine, the dura mater having yielded either in consequence of the injury or by ulceration, that this evil takes place; it is not, under proper treatment, a fatal, although it is always an extremely dangerous occurrence.

In the first kind of protrusion, the dura mater must necessarily be torn to some extent, and the tumor which comes through it is of a dark-brown color, glazed and covered in general by the pia mater. These protrusions were accompanied, in every case I have seen, by delirium and other symptoms of inflammation of the brain and of its membranes, and not by coma, until near the fatal termination of the disease. I have seen them torn off by the patients themselves during life, or before death; and satisfied myself that they all arose from hemorrhage into the substance of the brain, probably immediately below its surface, which became more elevated as the inflammation proceeded, and was gradually protruded at the part where there was the least opposition. When the tumor was torn off, little hemorrhage ensued, but a dark-brown blood cavity was seen in the substance of the brain; and when cut off and examined, the protruded part seemed to be covered by the pia mater, with or without a layer of cerebral matter, and was made up generally of coagulated blood. No case of this kind recovered.

In the second kind of protrusion, or that which usually although not necessarily takes place when the first or active inflammatory symptoms are on the decline, the tumor is formed of the substance of the brain. It has been supposed that in whatever manner a case of hernia cerebri may arrive at a favorable termination, there must inevitably be a loss of brain proportionate to the extent of the protrusion--a conclusion which the experience of the Peninsular war did not confirm, while it may lead to the establishment of an erroneous practice for the too early removal of the protrusion. The loss of a portion of one of the hemispheres of the brain is now known to occasion little or no inconvenience in many instances, either to the intellectual or corporeal faculties; nevertheless, as the precise quantity of brain which a person may lose with impunity has not been ascertained, it may be as well not to deprive a patient of any, provided its removal can be dispensed with; and that it may be so dispensed with, the practice of that war gave positive proof in several instances, by the protruded part being gradually withdrawn within the skull, the wound having afterward healed by the ordinary processes of nature.

There were three cases of recovery from a protrusion of the brain after the battle of Toulouse.

Bernard Duffy, 40th Regiment, aged twenty-four, was wounded on the 10th of April, and admitted into the Caserne de Calvete Hospital, on the 13th, with fracture and depression of the upper part of the os frontis. Some portions of detached bone were removed; he was largely bled and purged.

On the 14th, he complained of severe pain in the head, giddiness, dimness of sight, and drowsiness. The pupils were much dilated; pulse 60, and full. An incision was made down to the bone, and the divided arteries were allowed to bleed freely. One perforation was made by the trephine, and the whole of the detached and depressed pieces of bone, which were of considerable size, were removed, one of them having penetrated the dura mater.--15th. Has less pain in the head; pulse full and slow; pupils dilated, with a tendency to coma, but he is sensible when spoken to. V. S. ad ℥xxiv. Continue the purgatives.--18th. Is less drowsy; pupils more contracted. The surface of the dura mater is sloughy, and a small, dark-colored excrescence is rising up through the opening in the cranium.--22d. The fungus cerebri has considerably increased in size during the last few days; in other respects he is doing well.--24th. The wound looks clean; the discharge is healthy. The fungus increases in size, and is rather above the edges of the wound; some sloughs have separated from it, and it has now a red and tolerably clean appearance.--26th. The wound granulates regularly; the excrescence seems to enlarge rather at the base than at the upper part; it was touched slightly with lunar caustic without any pain or unpleasant symptom being produced.--30th. Continues doing well. The pupils are still somewhat dilated, but contract readily on the admission of light; appetite good; bowels regular; and the patient says he has no complaint. Discharge from the wound healthy; the fungus is prevented from increasing by a slight application of the argenti nitras every second day. He has not required any medicine for some time past.--May 6th. The wound has closed around the fungus, which is a little above its edges; it is touched slightly every day with lunar caustic or the sulphate of copper. The pulsation of the brain elevating and depressing the fungus is perfectly distinct; no constitutional derangement. Was discharged cured to Bordeaux.

William Donaldson was admitted, on the 13th of April, 1814, into the Dépôt de Mendicité Hospital, having received a gunshot wound in the head on the 10th of April, which fractured the right parietal bone to a considerable extent. The brain protrudes; pulse quick and small; bowels open. V. S. ad ℥xvi.--14th. The pulsation of the brain is evident, and the protrusion increases; he complains of no particular pain; the discharge is profuse, and of a thin, black, watery quality; pulse 90; bowels freely open. V. S. ad ℥xvi. Continue the purgatives.--15th. The pulse and bowels natural, the protrusion has scarcely increased; discharge profuse, and still gleety; a small compress was laid over the dressings, and a bandage was lightly applied.--16th. Pulse and secretions natural; the wound looks more healthy; the discharge something better in appearance; the fungus does not increase.--19th. Is doing well, and does not complain of pain; functions natural; the protrusion somewhat less; discharge good. A small quantity of cloth has come away.--21st. Discharge improved. Continue the purgatives.--26th. The protrusion evidently diminishes, and begins to heal at the edges.--30th. The hernia cerebri has considerably diminished; secretions natural; a small quantity of bone has come away; discharge diminished.--May 4th. The wound is healing rapidly; the patient is now permitted to get out of bed, and has half diet. Another very small piece of bone has come away.--10th. The wound is now nearly healed.--Between the 15th and the 25th several small pieces of bone came away.--On the 26th, on introducing the probe, a small piece of bone followed it; and on further examination a large piece was felt quite loose, and was removed by incision. Discharged cured to Bordeaux.

Gentle pressure was made on the protrusions, according to the feelings of the individuals, in both these cases; when made too firmly, it gave rise to swimmings and pain in the head, retardation of the pulse, a sense of sickness and fainting, and on one occasion to syncope. Pressure could only be borne when very lightly applied while the protrusion was increasing, but could be gradually augmented when it became stationary, and during its diminution and secession. The pressure was continued until after the wound had healed.

I had occasion, at Santander, to remove a portion of bone, including the upper part of the lambdoidal suture of the right side, from the head of a soldier of the Light Division, in consequence of symptoms of irritation having come on after an irregularity in drinking. He had been wounded by a musket-ball on the heights of Vera, which had fractured and depressed the skull at that part some weeks before. A piece of bone was depressed, and had irritated the dura mater at the part; the membrane had some matter upon its surface, and was evidently abraded. The operation gave relief, but a tumor soon sprang up, evidently composed of brain. The patient was again bled, purged, and starved; calomel and opium were given in moderate doses, and the protrusion ceased to increase; about the same time it changed color, became yellow, fetid, softer, and soon wasted away, pieces of dead matter separating at each dressing, until it sunk within the level of the skull; after which healthy granulations sprung up, and the wound healed.

In the fatal cases, paralysis, accompanied by stupor and other symptoms of compression of the brain, invariably supervened before death.

The preceding cases prove that persons may recover after having had a protrusion of the brain, without as well as with the loss of a portion of its substance, the difference in all probability between the cases being dependent on the degree of mischief which gave rise to them. In the fatal cases I have seen, the protrusion was manifestly a part of the substance of the brain, and firmer than the hemisphere beneath, which was soft, pulpy, and of a yellow and sometimes of a reddish color, the lateral ventricle being filled with a sero-purulent matter, pus being also spread over the surface and intermingled with the pulpy structure, into which the brain had been changed. The protrusion was the consequence of low inflammation of the brain; and greater caution had been necessary during the progress of the mischief than had been enforced. It was the observation of this, and of other circumstances not less important, which led me to enjoin that rigid system of management insisted upon in all cases of injury of the head. There can be no doubt that the formation of many of these protrusions was aided by the opening made in the dura mater, which would have restrained their growth if it had been sound. The dura mater therefore should never be opened if it can be avoided.

It has been proposed to destroy protrusions of the brain with escharotics, and by ligature; and more faith has sometimes been placed in the knife for their early removal than in the more deferred operations of nature. Greater reliance may, however, be placed on the efforts of nature, assisted by a methodical treatment of the low inflammatory state of the brain, and by such pressure at a later period as can be borne with comfort, and persisted in with propriety.

286. It has been supposed that abscess of the liver followed injuries of the head in a more peculiar manner than injuries of other parts of the body, an opinion upon which too much reliance should not be placed; for experience has induced me to think that unless the liver be really injured by a fall or blow, it only becomes affected in a secondary manner, in a similar way to the lungs or other viscera, or to the joints or other parts. The new disease in these cases is always insidious in its nature and progress, and for the most part fatal in its result, as has been explained at length, (Aph. 59, p. 62, et seq.)

287. When a person has received a serious blow on the head, which has given rise to an exfoliation of the bone, or to a very slight depression of the skull, he is rarely restored to his previous healthy and natural state. The scalp adheres firmly to the bone beneath, instead of sliding loosely over it, and a deep hollow is formed, which would imply that greater mischief had been done and a greater loss of bone had been sustained than had actually occurred. This is the more remarkable when pieces of bone have been removed. Major D., of the Indian army, was wounded on the left side of the forehead, at its upper part, by a musket-ball, at the assault of Maheidpoor. Several pieces of bone were removed, and the pulsation of the brain was evident under the discharge. The point of a little finger passes into the hole left by the cicatrization of the wound, to a greater extent than might be expected. This officer suffers from headaches, augmented or brought on by any exertion of body or mind. He cannot bear exposure to the heat of the sun. He can scarcely drink three glasses of wine without feeling their effect. Persons so afflicted can bear no great exertion of any kind. They fall down under exposure to heat. They are easily inebriated, rendered furious by a small quantity of liquor, and often become stupefied, comatose, or even die suddenly. In addition to these evils, which may be avoided by care, many are subjected to fits, which are apparently epileptic; and others suffer from such intolerable pain in the part injured, as well as in the head generally, as to be desirous of seeking relief by an operation, even at the risk of life.

These injuries are often accompanied during their progress by mental defects which time does not always remove. The memory is very often much impaired; it is frequently defective as to things as well as to persons. The sight of one or of both eyes may be impaired, or even lost. Ptosis, or a falling of the upper lid, is not an uncommon although a more curable defect. Speech is not only difficult, but the power of uttering certain words is often lost; a language is occasionally for a time forgotten, and a sort of conventional one has even been adopted, under my own observation. The more serious evils which befall these unfortunate sufferers are aberrations of mind, rendering some degree of restraint necessary, or a state of fatuity, which is not less distressing. These intellectual defects are often accompanied by various states of lameness or debility, from which there is but little hope of recovery. Pathologists have supposed that concussion of the brain is frequently accompanied by, and may indeed be essentially dependent on, small extravasations of blood in various parts of or throughout the brain, not larger than the point or head of a small pin, constituting, in fact, a derangement which, when general, is destructive of life, and, when partial, may sometimes be the cause of the various defects which follow injuries of the head.

288. It is an interesting fact that a person who has been shot in the head, or has fallen from the top of a house, so as to become insensible, has no knowledge of the circumstance; and when, after several days or weeks, he regains his senses, he has no recollection of the injury, or of having received the wound; or if he should have fallen from a height, he only remembers that he was aware he was about to fall, but of the actual descent, or of the injury, he knows nothing.

289. The trephine, which is worked by turning the hand, and makes therefore only a half turn, necessarily saws unequally; but the operator has the advantage of being able to press with it on any particular part as the sawing of the bone draws to a close, and can thus cut any portion of the bone which is thicker than the rest without wounding the dura mater. The division and yielding of the last layer of bone is very sensibly felt by the hand, and when sawing, the surgeon can use the trephine as a slight lever with great effect, by pressing on a particular part, or from side to side, and the inner layer of the vitreous table may be in this manner as much broken as sawn through. The piece to be removed should never be brought away in the crown of the trephine, but should be raised by the forceps and lever; whenever a rough edge of the inner table remains, it should be carefully rounded off with the lenticular or blunt-ended instrument commonly used for that purpose.

290. Whenever there has been a loss of the integuments or scalp, so that this part cannot be brought over the opening made by the removal of the bone, some fine soft cotton should be laid on the dura mater, so that a slight degree of support may be given to that membrane, more particularly when it is thought that it may not be necessary to examine it for two or three days. When circumstances appear to render a daily inspection necessary, the cut portions of the scalp should be brought over the opening, and retained by a slight compress and bandage kept constantly wet and cold. The dura mater usually changes color and becomes more red; a layer of lymph is seen adhering to it, from which granulations arise and spring up until they touch the scalp, to which they unite, or cicatrization takes place. When the patient dies early from other causes, and the calvarium has been raised, the discolored spot on the dura mater marks the place from over which the bone was removed. I have seen this in a state of slough, and the only apparent discoverable mark of disease.

One of the improvements in modern surgery is to be found in the restriction which has gradually been placed on the repeated use of the trephine on the same person, and on the removal of large portions of the skull. Cases are not, however, wanting in the older authors which would appear to justify the proceeding, although it may perhaps be said that they only show how great an extent of injury may sometimes be committed with impunity.

Saviard trepanned one person twenty times. Russ Martel and Le Gendre, surgeons to the King of Navarre, say that in the year 1686 they took away nearly both parietal bones, and the patient recovered and lived for thirty years afterward, half his body, however, being paralyzed. Marechal applied the trephine twelve times successfully, Gooch thirteen times, Desportes twelve times. Saviard says that he had under his care a woman whose parietal bones, together with a great part of the occipital and frontal, separated at the end of two years after a blow; the bones thus separated resembled a calvarium sawn off a dead person. No fungus or hernia took place, and she lived for several years afterward.

Dr. Drummond, deputy inspector-general of hospitals, has published the case of a seaman belonging to H.M.S. “Mutine,” who in 1845 fell down some stone steps at Sierra Leone, receiving a contused wound on the scalp, for which he was admitted into the Royal Naval Hospital at Plymouth in October of the same year. The bone, which was not supposed to have been injured, was then found to be denuded of its pericranium to some extent, (left side of occipital.) After an attack of erysipelas, followed by numerous purulent deposits under the scalp, necrosis went on rapidly; there was oozing of pus from beneath the diseased bones, and gaping of the coronal and sagittal sutures, the brain pulsating very distinctly in the spaces. In July, 1846, he was removed to Melville Naval Hospital at Chatham. During the six years he has been under observation, there have been repeated attacks of erysipelas, followed by profuse suppuration. Both tables of the bones have suffered in some places; in others only the external. About five square inches have been lost from the right side of the frontal, right parietal, and squamous part of the right temporal. The whole of the occipital to within a short space of the foramen magnum is deficient, with the exception of about two inches in the center of the bone, which are now undergoing the process of separation. On the left side, Dr. Drummond adds, there has been less destruction of the bones, but extensive caries was going on there, and fetid pus was being discharged from several openings at the date when the case was reported, (April, 1851.) At no point was there any tendency to reproduction of bone, or arrest of the disease.

291. The removal of a large portion of the skull may be necessary where the broken portions are deprived of their natural support and connections, but as little should be taken away as possible. When the loss of sense and motion is accompanied by fracture, and continues to increase rather than to diminish, after the necessary and usual means have been adopted for its relief, a piece of bone should be removed. If blood should be found in any quantity on the dura mater, it may be necessary to take away more bone to admit of its free discharge; for although the gradual pressure of the brain from within will tend to expel it, this object may not be attained in sufficient time, and the patient may be lost. The older surgeons in these cases were anxious to ascertain how far or to what extent the dura mater was separated from the skull, and they often removed large portions of bone accordingly; although their practice should not be implicitly followed, repeated observation has shown that modern surgeons have often fallen too much into the opposite extreme of doing nothing. When blood has been evacuated in this manner, the parts must pass from a state of inflammation into that of suppuration before the dura mater can again adhere to the superincumbent bone, and care must be taken that the matter shall have a free discharge. If symptoms of fever, followed by those of commencing compression, should supervene from the granulations arising from the dura mater filling up the opening and preventing its exit, they should be excised; or if the matter should have gravitated in a direction which does not admit of its being discharged, the opening in the skull should be increased so as to remove the impediment, and thereby lessen the danger.

A layer of blood is often extravasated very thinly over the whole surface of the brain and cannot be removed, although it may be absorbed. It is, on the other hand, often collected in larger quantity on the basis of the cranium, whence it will not be absorbed and cannot be removed. It may be extravasated without reference to the part on which the blow has been received, giving rise in the end to symptoms of epilepsy or apoplexy, for the relief of which no surgical operation can avail; but when a blow has been undoubtedly received on a part of the skull, and any sign of mischief can be perceived on or in that part, the removal of the bone is permissible.

292. The wind of a cannon-ball has been supposed to exert some influence on the brain when passing close to the head; there is, however, no valid foundation for the opinion. An officer of the fifth division was struck by a cannon-shot, during the assault of Badajos, on the right side of the head and face. It carried away the right eye and the whole face, the left eye hanging in the orbit, the floor of which was destroyed. A part of the lower jaw remained on the left side, but a great part of the tongue was gone. He had lost a large quantity of blood, but was quite sensible. In the middle of the next day he suffered much from the want of water to moisten his throat, which could not be procured. After a distressing delay of three or four hours under a hot sun, a small quantity was obtained, the arrival of which he observed; and while I was giving directions relative to its distribution, I felt a gentle tap on my shoulder, and on turning round saw this unfortunate man standing behind me, a terrific object, holding out a small cup for water, not one drop of which he could swallow. Alone among strangers, he felt that every kindness in our power to offer was bestowed upon him, and he contrived to write his thanks with a pencil, which he gave me when he pressed my hand at parting at eleven at night. I was glad at sunrise to find he had just expired.

293. When a portion of bone is as it were sliced off with the scalp and adheres to it firmly, the scalp and bone should be reapplied; and the cure will often be effected without difficulty. When the portion of bone cut off and hanging to the scalp, which is turned down, has but little adherence, it should be removed.

A German dragoon was brought to me in front of Madrid, who had received a slicing cut of this kind on the top and side of the head, which caused a portion of the scalp and parietal bone to be turned down over the ear, uncovering the dura mater. Replaced and retained in its situation, the flap and bone appeared to adhere, and the man recovered. In the case of a Portuguese soldier cut down by the French cavalry in a sortie during the second investment of Badajos, a portion of bone cut off with a flap was quite loose, and was removed. The patient did equally well.

In the museum of the Royal College of Surgeons there are ten skulls which have suffered from very severe slicing cuts. They appear to have been collected from the burial-place of some establishment for invalid soldiers in Germany. The portions of bone thus sliced, and they are large pieces, were once detached, and afterward reunited a little out of their proper places, so that the points of separation and of union can be distinctly seen. These fissures are all in a certain state of progress toward being filled up by bone, and the patients must have lived some months, if not years, after the receipt of their respective injuries; for bone is deposited apparently with difficulty and most carefully in all such cases, so as not to irritate the membranes of the brain. The opening in the first instance is filled up by granulations, over which a thin skin is formed; this afterward becomes firmer and harder, being in some cases, where the trephine had been used, a thin but strong membranous expansion extending from one edge of bone to the other. In others it is thicker and more solid, and in a few instances osseous matter is deposited in its circumference, so as in part to fill up the opening, the edges of the bony circle made by the trephine becoming gradually thinner as they appear to grow inward. It is common for an exfoliation to take place in such cases from the edges of the cut bone, and from the circle made by the trephine. It has been occasionally observed, after death, that the circular cut edge of the bone does not become thin in the manner described, but that a sort of ridge forms around and within it.

When the scalp is torn down without being much bruised, and a large flap extending from the occiput to the forehead falls down on the shoulder, covered with blood or dirt, the flap should be cleansed and restored to its place. When it is large, two or three sutures may be necessary to keep it in its proper situation. The flap may not entirely adhere under any management, but it will do so in parts; and care should be taken to evacuate at an early period any matter which may form by small but sufficient incisions made where required; this will in general be above and about the ear. When the flap is much bruised, the attempt at adhesion by close apposition will be useless until after suppuration has taken place, when a well-regulated pressure will do much toward expediting the cure.

294. Erysipelas occurs in two forms: when the skin has the ordinary redness characteristic of the complaint, and when the color of the skin is not altered or is whiter than natural, but puffed, tense, and shining, the inflammation being seated beneath the tendinous expansion of the occipito-frontalis muscle.

The general treatment should be regulated by the powers of the patient and the state of the constitution, (Aph. 24, page 39.) The local treatment of the first form essentially depends on puncturing the red and inflamed skin all over with the point of a lancet, assisting the flow of blood by warm fomentations. The punctures should be repeated, if necessary. The second form is to be treated by incisions, perhaps the greatest improvement of the surgery of the Peninsular war.

The scalp in such cases is in a state of general puffiness, causing the head to look considerably larger than usual, but without redness; it retains the impression of the finger. Incisions are to be made in the scalp from two to four or six inches in length, united by others, if necessary. The scalp will often be upward of an inch in thickness, and filled with a fluid partly serous, partly purulent. The small arteries bleed freely, and should be allowed to do so as long as may be desirable, when the hemorrhage should be arrested by pressure. The head should be fomented. The essential points are, to take off tension, and to allow the free discharge of any fluid which may be secreted. The moment the parts around a wound have become puffy, the surface of the wound changing from a red to a yellowish color, with a thin discharge instead of good pus, an incision should be made through them, and repeated, if necessary. It relieves the tension and the irritative fever, and prevents the delirium which would follow; which neither bleeding, purging, nor the other constitutional remedies which the state of fever may indicate will remove. If it should be neglected, suppuration and sloughing will extend under the tendon of the occipito-frontalis, or the fascia of the temporal muscle, and the greatest danger will be incurred from this additional cause.

LECTURE XX.

WOUNDS OF THE CHEST.

295. Wounds penetrating the wall of the chest, and implicating any part or portion of its cavity or contents, are among the most dangerous of injuries. They require in their treatment a more careful attention and a greater extent of knowledge than most others which befall mankind. The means which the improved methods of auscultation have afforded cause the progress of the symptoms which follow to be less obscure, and lead to a less doubtful practice than formerly; while they render a knowledge of this branch of medical science an essential part of the education of a surgeon.

296. Incised or punctured wounds, from swords, lances, bayonets, or knives, require a treatment essentially distinct on many points from that of gunshot wounds, especially in the commencement. On this early treatment so much depends, that details of the more serious or more important cases are rarely found among the records of injuries sustained on the field of battle, where so much is often to be done, and so few are to be found to do it.

The simplest of the more serious results from injuries not penetrating the chest is the occurrence of inflammation, either of its lining membrane, giving rise to what is called pleuritis, or of the substance of the lung, termed pneumonia, or of both, constituting what has been named pleuro-pneumonia; but many severe blows on the chest are not followed by such serious consequences.

On the 17th August, 1808, in the act of leaving the village of Colombeira to ascend the heights of Roliça, a soldier was shot in the leg: he jumped up three or four feet, and made a considerable outcry. A second was struck at the same time by a ball on the shoulder, which did not penetrate, but gave him great pain. A third received a ball on his buff-leather belt, on the right breast. The noise made by these two blows was unmistakable. I saw this man fall, and supposed he was killed: the ball, however, had only gone through his belt, and made a mark on his chest, over the cartilage of the fourth rib, the hardness and elasticity of which had prevented further mischief. He recovered in a short time, spat a little blood in the night, and after a large bleeding was enabled to accompany me on the 20th to Vimiera, ready for the fight next morning.

A soldier was struck on the hill of Talavera,[4] on the breast-plate by a ball, which, as he believed, had gone through his body. He was as white as a sheet, and desperately frightened. On opening his coat, I found the ball had indented the breast-plate, and made a round, red mark on the skin, without going deeper. I did not see him again for several days, until after crossing the bridge of Arzobispo, on the retreat to Truxillo. He was then engaged in disemboweling a fine fat wild hog, among a herd of which we had, unluckily for them, just fallen. He recognized me at once; said that, as I told him, he had been more frightened than hurt; that he had been bled largely and well physicked, and after two or three days had thought no more of it. I am bound to add that, in gratitude, he offered me a leg of the pig, which, having nothing to eat, I could not but accept. It supplied a dinner for three others who are now no more.

[Footnote 4: The Duke of Wellington received a blow from a spent ball at the same time, near the left clavicle.]

A soldier of the 40th Regiment slipped from the ladder on which he was attempting to scale the wall near the great breach of Badajos, and fell on his cartridge-box, which hurt his left side so much as to render him unable to move for some time. On the 8th of April he was much worse. The part injured was painful to the touch; the difficulty of breathing considerable; cough hard, with little expectoration; pulse 90, skin hot, appetite gone, tongue white. V. S. ad ℥xvj, and aperients. 9th. Better; pain less; expectoration more in quantity, and viscid. V. S. ad ℥xii; antimonials. 10th. Pain still felt on coughing; expectoration reddish; difficulty of breathing greater. Pil. cal. et antim. c. opio; V. S. ad ℥xvj. He gradually recovered (his mouth having become slightly sore) from what was manifestly an attack of pneumonia. A gentleman, in 1835, fell from his shooting-pony on his powder-horn, which bruised his right side from the seventh to the last rib, and, as he said, knocked the breath out of his body, and hurt him so much as to render him incapable of walking from one room to another from pain in the side, back, and thigh. No bones were broken. The pain, on the second day, was augmented on breathing and on attempting to cough. The third day he was purged, and blooded to sixteen ounces, which gave some relief; but as the symptoms increased on the fourth day, he was more carefully examined. His right side could not bear pressure. The respiratory murmur was distinct, but accompanied by a crepitating rhonchus under the part injured. Cough troublesome; expectoration mucous, viscid, and of a reddish tinge. Antim. p. tart. and sulphas magnesiæ, every four hours. V. S. ad ℥xiv. On the fifth day, the symptoms being little altered, he was cupped on the part affected to fourteen ounces. On the sixth, the pain was only felt on coughing, or on drawing a very full breath; expectoration redder and thicker; pulse quicker. The rhonchus was quite as distinct. V. S. ad ℥xij, and the medicines to be continued. After this he quickly recovered and the natural respiration became distinct.

Lieutenant Cooke Tylden Patterson, of the Light Division, was struck on the left breast by a musket-ball, on the morning of the 15th of July, 1813, in front of the village of Vera, in the Pyrenees. He fell on his back breathless, as if he were killed. While waiting the order to advance, he had been reading Gil Blas in Spanish, and on receiving it, had hastily put the book in the breast pocket of his coat. The ball had struck this, but, unable to penetrate it, had fallen on the ground at his feet, completely flattened on one side, and marked with the impression of the braid of his coat. A piece of the cover of the book, about the size of a half-crown, was driven in, and the leaves throughout were indented by the ball. It was some days before the effects of the blow entirely subsided.

A soldier of the 97th Regiment was struck at the unsuccessful assault of Fort Christoval, opposite Badajos, by a musket-ball, which went through his brass breast-plate and coat, drove his shirt through the skin, and against the sternum, which it was not able to penetrate. He fell, and was supposed to be killed, but he soon recovered and ran to the rear. The ball was found flattened between his shirt and coat. The part of the chest was very black next day, the spot struck by the ball being much bruised. It was necessary to bleed him largely. When the integuments are painful, although merely bruised, the diluted tincture of arnica is a useful application, and Scheele’s hydrocyanic acid, six drops to an ounce of water, is said to be efficacious.

Major Lightfoot was struck by a musket-ball on the left breast; it went through his clothes, the integuments and the outer part of the great pectoral muscle, and slanted inward for three inches toward the sternum, to which distance its track could be followed. It was evident that the ball had neither lodged nor penetrated, for no serious symptoms ensued. In all probability it had been ejected the way it went in by the elasticity of the cartilages of the ribs near the sternum.

297. In order to understand, or to become in any way acquainted with the changes from the natural structure which are going on under derangement in the chest, even from simple injuries, it is always necessary to have recourse to auscultation, and sometimes, although more rarely, to percussion, if the external parts are not too tender. Under all circumstances both sides of the chest should be examined by the stethoscope. As the ordinary breathing of an individual is rarely sufficiently strong to enable the auscultator to hear it with distinctness, the patient should be desired to inspire fully and more quickly than usual, without much effort, and without noise from the mouth or nose, or retaining his breath. The inspiration and the expiration are both to be carefully observed.

When the ear is firmly and equably applied to the chest of a healthy young person, a very distinct and long-continued sound is heard at the moment of inspiration, and another at that of expiration. This is called the vesicular or respiratory murmur, and is dependent on the air fully permeating and distending the air-vesicles of the lungs. It has been poetically compared to the sound of a gentle gale rustling in a thick summer foliage--to the whisper of a retiring wave on a sandy beach in a calm day. It is soft, scarcely sonorous, equable, and during inspiration continuous. In childhood it is louder than in adult persons, arising probably from the greater activity of the lungs in young than in elderly people. This is called, and especially when perceptible in adults, puerile respiration, as opposed to their ordinary, or what in old persons may be called senile. It is more marked during inspiration.

When the stethoscope is applied in the situation of the great bronchial passages, as over the first bone of the sternum, under the clavicle, in the center of or between the shoulder-blades, a different sound is usually but not always distinguishable, when the patient breathes fully, arising from the passage of the air through these bronchial tubes. It is compared to the noise made on blowing through a reed or quill, and is called bronchial or tubular respiration. When heard in other parts of the chest, it is a morbid sound. If the stethoscope be applied over the trachea, the sound is louder, rougher, and more intense, and is called tracheal respiration. On listening over the trachea during speaking, the voice sounds as if it were passing into the ear, and the words are distinct--tracheophony. This, if heard in any other part of the chest, is a sign of disease, for in the natural state the voice is heard only to resound through the chest, but the words are not heard if the other ear be stopped. When heard, the sound has been called pectoriloquy, and is supposed to imply the existence of a cavity at that part; but the word is unnecessary, or, if used, it means that the cavern or hollow communicating directly with the trachea gives forth a similar or nearly similar sound, a natural sound in an unnatural position. The essential difference between bronchophony and tracheophony in the investigation of disease is, that in the latter the voice apparently speaks through the stethoscope into the ear of the auscultator, while in the former it is heard with scarcely less distinctness, but at the distal end of the instrument. Over the larynx it is louder, hoarser, and rougher.

The length of the sound in inspiration, as compared with that of expiration, has been said to be as five to two. One is louder and longer than the other, a difference requiring attention from the circumstance that morbid sounds of great import are heard in inspiration, which do not prevail during expiration. When any other difference is perceptible between them, so that they more nearly resemble each other in duration or in intensity, or when expiration is prolonged, some structural alteration may be suspected in old persons, some disease in young ones. When little or no respiratory murmur can be heard after symptoms of inflammation have existed for some time, the case is very serious, implying that effusion into the cavity, or condensation of the lung, has taken place to a considerable extent.

298. The number of inspirations in a minute in the adult and elderly persons varies from eighteen to twenty-two in a state of health: from twenty-two to twenty-six in children. The stroke of the pulse is generally as four to one. If the inspirations are eighteen, the pulse will in general be seventy-two. Both may be slower, although they are often quicker under disease. When the breathing is slower, it commonly indicates some affection of the nervous system; when very rapid, some important lesion within the chest.

The theory of percussion is founded upon three elementary sounds, which are produced when a solid, a liquid, or a gaseous body is struck; all others are varieties of these. The sensation of resistance which is experienced at the same time bears an exact relation to the density of these bodies--hence the resistance when a solid substance is struck is greater than when a gaseous one is under percussion. The liver, the thorax in a case of pleuritic effusion, and the distended stomach after a long fast, afford good examples of these elementary sounds. To employ percussion successfully, it is necessary that the strokes be uniform in force and quickness, and that the finger or pleximeter be so applied to the surface that no space exists between them, otherwise such a sound will be elicited as may give rise to an incorrect diagnosis.

It having been stated that a sound lung never fills the bag of the pleura, particularly toward the diaphragm, at least during ordinary respiration, I requested Mr. Quekett, the Resident Conservator of the College of Surgeons, to ascertain this by experiments on some sheep at the moment of their being killed; and it appeared from them that the base of the lung is always in contact with the surface of the diaphragm.

299. In ordinary expiration the chest diminishes in size. The ribs which have been raised recede, by the elasticity of their cartilages, and by the return of the ligaments, to their state of rest; the elevated muscles become relaxed, while others belonging to the lower part of the trunk and abdomen contract. The diaphragm is relaxed, and pushed upward by the viscera of the abdomen, pressed upon by the muscles of its wall, if it should not be drawn upward by the attraction of the lung, which when distended endeavors by its elasticity to return upon itself, and to occupy less space than the capacity of the chest will afford. The lung, invested by an elastic, special, and transparent membrane, and covered by the pleura pulmonalis, is composed of an immense number of air vesicles, the largest being equal in size to the fourth part of a millet-seed. These air vesicles, crowded together, each communicating with a fine bronchial tubule, are separated from each other into groups by a condensed cellular tissue, thicker where it surrounds these lobules, which alternately form, when aggregated together, a lobe, whence it is called interlobular tissue. An artery and vein form a very minute net-work around each vesicle. These vesicles may become filled with water; when dilated by air, they constitute what is called emphysema of the lung. The lung in man is constantly applied to the internal surface of the chest, the pleura or serous membrane covering the lung being closely applied to the pleura lining the wall, and one surface glides upon the other, moistened by a secretion in just sufficient quantity to effect this object. If the lower intercostal muscles of a young animal be removed to a sufficient extent, the lung and the diaphragm may be seen applied to the inside of the pleura lining the rib, and ascending and descending in concert, the lungs moving vertically, not horizontally. The diaphragm ascending, covered by its pleura, is in a similar manner applied to the lower part of the wall of the chest, which had been filled by the lung during inspiration. After death the lung remains closely applied to the pleura, recedes on an opening being made into that membrane, and may collapse, provided no adhesions exist to prevent it.

300. When inflammation of the pleura takes place, the gliding motion is not effected silently, but with a peculiar noise, called by the French frottement. When the lung is inflamed, the respiratory murmur is changed in that part, or is overcome by a peculiar sound, which can be distinctly investigated by the ear--rhonchus crepitans. Hence the great value of auscultation.

In the following observations it is not intended to give a history of, or even the whole of the symptoms and consequences of inflammation of the pleura and the lungs; but only to draw attention to such of the principal facts as it may be necessary to consider when these inflammations and their consequences are caused by external injuries.

Acute idiopathic inflammation of the pleura usually commences by rigors, preceded perhaps by some signs of general uneasiness, which soon become those of great febrile excitement. Pain is early felt in the side in the course of the sixth, seventh, and eighth ribs, or at the point corresponding generally to the seat of the inflammation. It is usually sharp and darting, is called a stitch, occupies rather a small space, (the point de côté of the French,) and is always increased by drawing a full breath or by coughing. The breathing is short, from the disinclination to fill the chest, by which the pain would be increased; it is hurried, and sometimes takes place as if by jerks, from the necessity for its repetition, in consequence of the smallness of the quantity of air admitted at each attempt. When the attack is very severe the patient tries to breathe with the healthy side only, the lower ribs of the affected side being moved but slightly, and with evident caution. If the inflammation have been caused by extreme violence, pain will also be felt, particularly at the part injured.

When inflammation has affected the pleura covering the diaphragm, especially when caused by external violence, the pain will be felt lower down, so as to lead to the suspicion that it is also abdominal. When jaundice supervenes, it occurs from the extension of disease through the substance of the diaphragm, as is occasionally seen in wounds implicating the chest, the diaphragm, and the liver.

A cough is not a constant accompaniment of the first stage of disease; when present, it is usually dry, slight, infrequent, and does not attract attention, unless accompanied by a thin, frothy mucous expectoration, indicating the presence of bronchitis; of pneumonia, if reddish. The patient usually lies on his back while the pain is severe, and has a great indisposition to turn fully on to the affected side. At a later period, when effusion has taken place, the pain usually subsides, and he turns on the side affected to relieve the difficulty of breathing, caused by the pressure of the fluid on the sound lung through the bulging of the mediastinum; but the manner of lying, or decubitus, is of little importance, and should be subservient to the feelings of the patient, who is sometimes comfortable only when raised to nearly an erect position.

When the complaint is not subdued at an early period, an effusion of serous fluid, more or less in quantity, takes place. The whole cavity of the side affected has been known to be filled in from twenty-four to forty-eight hours, giving rise to symptoms dependent on the degree to which the effusion has taken place; this is the evil which in injuries penetrating the cavity of the chest is most to be feared. When the external wound has been closed, or is so partially closed as not to allow the escape of the effused fluid, it is commonly the immediate cause of the death of the patient. Its secretion and early evacuation are therefore the most important points to be attended to in wounds of the chest.

The respiratory murmur becomes less distinct as soon as the pain prevents the ordinary distention of the affected side of the chest, and diminishes the quantity of air which usually penetrates the lung in any given time. As soon as a thin layer of fluid commences to be thrown out between the pleuræ, this murmur becomes fainter, and when it is complete, it ceases. If the patient can bear percussion, the side affected yields a dull, dead sound instead of the ordinary clear, sonorous one of health. The position of the patient when erect, by causing the fluid to descend, may allow of the respiratory murmur being heard at the upper part of the chest; and it may be perceived in front, but not behind, when he lies on his back, until the cavity is filled, when the sound altogether ceases. At the spot in the back corresponding to the root of the lung, or at any other point at which a previously formed adhesion may retain the lung against the wall of the chest, some respiratory murmur may yet be distinguished, until this part of the lung shall also have yielded to the general compression, so as to be temporarily impervious, or have become solidified under the continuance and extension of disease. While this is taking place in the affected side, the other lung is called upon to make up the work of aerification of the blood; it labors harder, its functions become more energetic, and that side of the chest is more distended; the respirations become quicker, fuller, and louder, and the vesicular murmur is said to resemble that of a child--in fact, to be puerile.

When the lung begins to be compressed by the circumambient fluid and the respiratory murmur ceases, a peculiar modification of the respiration through the large bronchial tubes may be heard, constituting bronchial respiration. It occurs in pneumonia, in pulmonary apoplexy, and in tubercular disease when the lung is solidified. When the voice is heard through the stethoscope in these complaints, the peculiar sound emitted is called bronchophony.

In pleuritic effusion, the voice, when carefully examined, sometimes obtains a character not previously noticed, but of comparatively little importance, called œgophony, a sound which may be easily confounded with bronchophony, of the latter of which it is a modification more often alluded to than observed. Laennec says: “Simple œgophony consists in a peculiar resonance of the voice, which accompanies or follows the articulation of words. It appears to be sharper than natural, more acute and somewhat silvery, vibrating, as it were, on the surface of the lung more as an echo of the voice than as the voice itself. It rarely enters the tube of the stethoscope, less frequently traverses it completely. It has besides another peculiar character, which is constant, and from which I have taken its name. It is a trembling, bleating, or shaking sound, like that of a goat, the tone of which animal it greatly resembles. When it occurs near a large bronchial tube, as in the root of the lungs, a more or less marked bronchophony is often superadded.” This sound may pervade the whole side; it is usually, however, most distinct near the inferior angle of the scapula, the patient being erect. It only exists where the effused fluid is small in quantity, and is never a dangerous symptom; its return, after it has been present and has disappeared, is a sign that a part of the effused fluid has been removed. It is a sign principally of value in distinguishing between pleuritis and pleuro-pneumonia and pure pneumonia, in which latter disease it is not heard, as in that complaint fluid is not thrown out into the cavity of the pleura.

301. In pneumonia or inflammation of the substance of the lung, as distinct from any implication of the pleura, which, however, most frequently obtains after blows on, and in cases of penetrating wounds of, the chest, the symptoms differ. The ordinary febrile symptoms are similar to those of pleurisy, only more intense; they usually precede for a day or two the local symptoms of difficult respiration, pain, and cough. The dyspnœa varies in different people. In some it is only a slight embarrassment of breathing, admitting of partial removal by accelerating the number of the respirations, which are augmented from twenty to thirty, forty, and upwards, and in children to sixty and seventy, marking a great degree of distress and of extent of inflammation, from which, when they are so frequent, persons rarely recover. The patient can scarcely speak or lie down, and is obliged to be supported in that which he finds to be the least uneasy position. Pain is not always present; it is even said to be more frequently absent when the substance of the lung is affected, and not the pleura. That pain is not a necessary concomitant of pneumonia, is admitted, but that it is usually present, and with great intensity in many cases, cannot be doubted. When present, it is usually an early symptom, deep seated below the sternum, under the breast, extending to the scapula. When in the sides it is more acute and fixed, and is probably conjoined with the pain of pleurisy.

The pulse is quick and sharp, occasionally full and hard, at the commencement of this complaint in young and healthy persons, although it is sometimes small and weak from the beginning, where there is little general power; but this rarely occurs in cases of injury, and is not to be relied upon in opposition to other symptoms.

The cough is usually dry in the commencement of idiopathic pneumonia, rarely recurring by paroxysms, and is without any particular indication; it is soon, however, accompanied with a slight mucous expectoration, which, after some twenty-four or forty-eight hours, begins to assume certain and peculiar characters of the utmost importance as indicating the existence and the different stages of the disease. On the second or third day the expectoration becomes bloody. Each sputum, spit, or crachat of the French is composed of mucus intimately combined with blood--that is, not simple streaks or striæ of blood, as in catarrh; nor is it pure blood, as in hemoptysis. Each sputum is either of a yellow, or rusty, or even red color, according to the quantity of blood intimately mixed with the mucus. These sputa are at the same time tenacious and viscous, adhering so intimately together as to form a homogeneous transparent whole, readily gliding, however, from the basin in which they are held on sufficient inclination being given to it. At this period or stage of the disease, the sputa adhere strongly to each other, but the mass is not sufficiently viscid to stick to the sides of the vessel. When no further change takes place in the sputa the inflammation rarely passes beyond the first stage of obstruction or engorgement, or swelling. When they attain to a more viscous state, and adhere to the inside of the vessel in which they have been received, the progress of the inflammation to the second stage, or that of hepatization, may be feared. In almost every case where the viscidity of the expectorated matter increases, respiration becomes dull or bronchial, percussion of the chest yields a duller sound than before, and the inflammation has attained its highest degree. The expectoration, after being some time stationary, changes its character. If the complaint is to terminate by resolution, or by death, or to pass into a chronic state, the redness and viscidity gradually diminish, and at last disappear. If the rust color and the viscidity should return, there has been a relapse, which the reappearance of the other symptoms will show. When the inflammation is of the most serious nature, and about to terminate fatally, the expectoration diminishes, and at last ceases. In some cases it only diminishes because it cannot be discharged; it accumulates in the trachea, in the larynx, and in the bronchi, until the patient is destroyed. In some rare cases the matter secreted is spit up nearly to the last, and in others, still more rare, the approach of death in the last stage is characterized by a brown expectoration which cannot be mistaken for either of the others which preceded it. If the pneumonia pass into the chronic state, the expectoration becomes yellowish, or somewhat greenish, and at last is purely catarrhal.

Delirium is not an uncommon symptom when the inflammation of the lung is intense in persons of powerful constitutions, particularly during the exacerbation of fever in the night. It yields with the other symptoms when relief is obtained. When, however, it comes on at a later period of the complaint, or when the accompanying fever is not purely inflammatory, or in persons weakened by exhaustion and privation, it is usually a fatal symptom if continued. When mild, it often occurs after repeated and efficient bleedings, which have subdued, but not entirely removed the disease; and yields to opiates and gentle stimulants, by which the pain is removed, although it sometimes remains in a milder degree than before.

The ear discovers, soon after the commencement of the disease, that the natural murmur cannot be distinctly heard, it having been at first partly obscured, and after a time entirely superseded by a peculiar noise, called a crepitating or crepitous rattle or rhonchus. In its purest state it has been likened to the sound of a lock of hair rubbed close to the ear, or to that made by rumpling a fine piece of parchment; or again, to that which is produced by what under ordinary circumstances is called the crepitation of salt, when scattered in small quantities on red-hot coals. This crepitating rhonchus is heard at first in a small part of the lung, generally at the lower rather than at the upper part; it marks the first stage of the disease. It is not of long continuance; the vesicular murmur is either restored, or the crepitating rhonchus ceases to be heard, in consequence of the second stage to this, or that of hepatization, having commenced; the small air-vesicles are no longer pervious; the sound of the breathing, which is now heard, is that of the air more forcibly driven into the larger bronchial tubes causing bronchial respiration, which is no longer a vesicular or crepitating, but a whiffing sound, like that caused by blowing forcibly through a quill, or as if little gusts of air were blown in or blown out. The voice betrays to the ear of the auscultator another sign; it descends into the pervious bronchi, and being conveyed to the ear through the solid lung, gives rise to that peculiarity of voice called bronchophony, a correct knowledge of which can only be acquired by repeated observation.

When the inflammation of the lung is confined to a small and deeply-seated spot, auscultation may not at first reveal the evil; or it may possibly be overlooked, through the sound part of the lung becoming more active, and giving forth in consequence a stronger and more puerile breathing, which may mislead the listener.

When the vesicular murmur cannot be heard, when the rhonchus or crepitating râle or sound is not present, and bronchial respiration and bronchophony only can be distinguished, the case is one of great anxiety and danger. The second stage of hepatization is passing into the third, or purulent infiltration, of which auscultation shows no further signs, although the matter secreted may be expectorated, in proof of what has taken place. Pus is thus formed, which it is steadily maintained by some pathologists is not deposited in the form of abscess, but is infiltrated throughout the parenchymatous substance of the lung, finding its way into larger bronchial tubes, or being poured out from some parts of their secreting surface; the accuracy of this statement, however, as a rule, may be doubted, from some dissections having proved the reverse.

302. The effects of inflammation of the pleura are well marked; the first is to diminish, if not to annul, the secretion of the exhalation, or halitus, by which it is lubricated; so that its surfaces can no longer glide without noise upon each other. The patient is often made aware of the difference by some uneasy internal sensation; the auscultator, by a rubbing or creaking sound emitted as the inflamed pleuræ, no longer smooth and polished, rub against each other, and become covered by a thick, effused matter, although not actually separated by a liquid. It is a sound which cannot exist after separation has taken place by the intervention of a fluid, or after adhesions have formed; it is, therefore, an early and transitory sign, is frequently interrupted, and returns, as if by jerks, three or four times repeated in succession. The pleura when inspected, after being attacked by inflammation, shows at first but little sign of derangement on its serous surface. It quickly, however, exhibits numberless small vessels, carrying red blood, which are principally seated in the sub-serous cellular tissue, reddening the membrane more deeply in one part than another. These soon begin to take on a new action, leading to the deposition of coagulable lymph or fibrin, which adheres to the inflamed surfaces. These deposits soon assume the determinate form of very thin layers, constituting what are called false membranes; while a serous or sero-purulent effusion takes place, even to filling the cavity of the chest, and which may or may not be ultimately absorbed. When coagulable lymph is first deposited, and about to form a false membrane, it is soft, of a grayish-white color, and does not possess any appearances of organization. Red points are, after a time, perceived in it, which soon become red lines or streaks, on the surface. This organization of the lymph does not depend on the period which has elapsed from the commencement of the complaint. It is seen in the first day of the disease in some cases; it is altogether absent in others, and depends much on the state and habit of the patient. The lymph is sometimes deposited in small drops or spots; in others, in patches of a greater or less size, varying according to the extent of the inflammation which has produced them. When a false membrane is once fully formed, it becomes itself a secreting surface, and may go on augmenting its thickness to so great a degree as materially to diminish the cavity of the chest. I have seen the pleura with a solid deposit of this kind much more than an inch in thickness. In general, it is found in distinct layers, superimposed one upon the other. Whatever may be their thickness, they commonly admit of being separated from each other. The false membranes thus formed, resembling areolar tissue in their properties, may ultimately become cartilaginous, and even bony. When simple adhesions form between the pleuræ, they become lengthened with time; and, although they impede the motion of the lung at first, and may give rise to some uneasy sensations, they gradually become elongated, and give no further inconvenience. The fluid thrown out is serous; is often mingled with flocculi or lymph, which are seen floating in it; it is therefore more or less turbid, resembling whey. It is often nearly colorless and transparent; when the consequence of injury, it is often tinged with blood, forced out from the capillary vessels of the pleura, or of the false membrane, if not caused by the deposition of the fluid coagulated in the first instance after the receipt of the injury.

The quantity of fluid thus thrown out varies from an ounce to several pints; it gravitates according to the position of the patient, unless, when from old adhesions between the pleuræ, it is confined to particular parts. When the cavity of the pleuræ is free, and the fluid is in quantity, it compresses the lung, and diminishes its size by pressing or squeezing the air out of it; it is thus pressed toward the vertebral column, and so greatly diminished in size and augmented in density as to be useless for the purposes of respiration. While the lung is undergoing this compression to its utmost, the mediastinum also yields, and bulges into the opposite side of the chest, carrying the heart more or less with it; so that when the left side of the thorax is thus affected, the heart is seen and heard to beat on the right. The diaphragm now yields in turn, more on the left than on the right side, from the obstacle to its descent afforded by the liver. The intercostal muscles and ribs resist the internal pressure for a considerable length of time, even for weeks; they at last, however, yield; the ribs may even turn a little outward, while the interspaces in thin persons are said to fill out, so as to render that side of the chest nearly smooth, the size of that side, when measured, being larger than the other, in some instances even by two inches, but this rarely occurs unless the fluid within is purulent, and the disease of long standing.

303. After a time, and particularly in wounds of the chest, the effused fluid becomes purulent, the lung, compressed to a small, flattened surface, adheres to the spine by what was its root, if no adventitious attachments have retained it in a different position; and the pleura has become a thick, yellowish-white, irregular, honey-combed sort of covering for it, as well as completely lining the chest. The serous as well as the purulent effusion are both free from any unpleasant odor; unless a kind of gangrene has taken place, when the latter becomes very offensive, and of a greenish-black color, as well as the substance of the false membranes extending to and sometimes beneath the pleura covering the condensed lung, into which openings have even thus been made.

In some cases the surface of the pleura is covered with small tubercles, some as large as a filbert; in others it appears to have a reticular or honey-combed appearance; and in particular cases, large irregularities or excavations may be observed in it when much thickened, being evidently spots of ulceration, which, if they had proceeded, would have ended by allowing passage to the matter outward, until it formed an external abscess, implicating in all probability one or more of the ribs; thus giving rise to an exfoliation which, by being separated internally, might in time be the cause of further mischief, if not previously covered by a thin layer of false membrane. When chronic pleurisy succeeds to a more acute attack, or they alternate with each other, particularly after penetrating wounds of the chest, several layers seem to be laid down one upon the other. This deposit is never so thick upon the pleura pulmonalis; nevertheless it is thick enough in most instances to prevent the lung from again dilating, the substance of it being generally quite permeable to, although so compressed as to be deprived of, air. It is then flattened, drawn upward toward its root against the mediastinum and spinal column, unless by some previous adhesion such a course has been prevented, and it adheres, as it has been often known to do, to the side of the chest. As that adhesion may occur in more than one spot, so may the effusions or deposits take place between them, constituting circumscribed sacs, and rendering the case more complicated.

304. The changes which take place in the structure of the lung in pneumonia are three in number: 1. Engorgement. 2. Hepatization. 3. Purulent infiltration. The formation of an abscess or vomica, and the occurrence of gangrene, may be omitted, as well as of chronic disorders, in the views about to be taken of the disease from injury.

In the first stage of inflammatory obstruction, or that of engorgement, the lung has assumed externally a livid-red or violet color. It is heavier and firmer than in its healthy state, and the natural feeling of crepitation, although greatly diminished, is not extinct. The lung retains the impression of the finger, and pits on pressure as if it contained a liquid, although air-bubbles can yet be distinguished in it, and its cellular or spongy texture is still to be observed. On cutting into it, a quantity of sanguineous or turbid fluid flows from it, mingled with numerous minute air-bubbles. In some places the color of the incised surface is darker and more compact, showing that some progress has been made toward the stage of hepatization. It nevertheless tears with greater facility than in a healthy state.

In the second stage, or that of the red softening of Andral, the hepatization of Laennec--the latter term being in most common use, from the lung assuming somewhat the appearance of liver in solidity and weight--the lung does not crepitate, no air-bubbles pass out of it, but a thick, bloody fluid exudes on pressure, and it sinks for the most part in water. The color is somewhat less red or violet than in the first stage, and lighter and more varied in color when cut into. The openings of the larger vessels and of the bronchi, when cut across, are observed as white specs; the interlobular tissue is thicker and more marked in lines running in different directions; while many little granular points can be discovered, especially with a glass, apparently of a more solid material than the surrounding parts.

The word solidity, or solidification, is sufficiently explanatory in contradistinction to the naturally pervious and crepitating state of the lung. Andral believed that hepatization arises from an excessive congestion of blood, and not from any deposition of lymph. It is not easy, however, to understand, in the present state of our knowledge, how acute inflammation can go on for three or more days without secretion and deposition being added to congestion. That hepatization, or impermeability to air, may take place in the typhoid pneumonia in twenty-four hours, and that it as suddenly seems to be removed, is hardly conclusive, as it shows merely that a thoroughly well-loaded lung ceases to be permeable to air until a part of the load shall have been displaced.

When the lung, inflamed to the second stage, or that of hepatization, is about to be restored to a state of health, a slight crepitation or crackling begins again to be heard at the end of each inspiration; and as this increases, (the rhonchus crepitans redux of Laennec,) the bronchial respiration and voice gradually, or after a time, diminish, until they entirely disappear; while a mucous râle or rattle commences, the index of that free expectoration by which pneumonia usually terminates.

In the third stage of morbid change, or that of purulent infiltration, the lung is of a lighter color, from the intermixture of a new matter in its substance, although in the first degree it preserves its firmness and granular structure. The new secretion is of an opaque, straw or yellow color, and puriform in its nature. This is discoverable more particularly in spots; but as the disease proceeds, it pervades the whole substance of the lung, which becomes softer and more moist, and is easily broken down by the fingers, the granular structure having disappeared. It is more or less a purulent sort of sponge, in which all of the lung that can be perceived under a strong light may be resolved into small blood-vessels, bronchial tubes, and interlobular septa.

These three degrees or stages of inflammation may be met with in the same lung, for the most part gradually intermingling one with the other. The lower part of the lung being ordinarily first affected, is usually the seat of the purulent infiltration of the third stage; while in the tubercular affection, which ends in phthisis, the disease commonly begins in the upper part.

Resolution or recovery from even this, the last of the morbid changes which have been observed, may take place, although it is less likely to do so after idiopathic than traumatic inflammation, in which the lung was previously healthy, and the constitution unimpaired.

LECTURE XXI.

GENERAL BLOOD-LETTING, ETC.

305. The first and most essential remedy in the treatment of pleuritis and pneumonia from injury is bleeding, which should be resorted to in every case, whenever the febrile excitement is really inflammatory. All old people, under such circumstances, unless in a cachectic state, bear at least one bleeding well; they often bear more; and no fact is more important, in opposition to the opinions commonly entertained on this subject. In young people, who have not been reduced in health and strength by privations and hard service, the bleeding should be repeated until the desired object has been effected; the quantity required to be drawn in inflammation, particularly after injuries, is often very great. It may almost become a question, in some cases, whether a patient shall be allowed to die of the disease, or from loss of blood; for convalescence is rapid in proportion as the inflammation is of small extent, and has been early subdued. As the first stage of pneumonia only lasts from twelve hours to three days before it passes into the second, and the second from one day to three before matter begins to be deposited, no time should be lost to prevent these evils taking place, if the patient is to be saved, without incurring a risk, from which few escape with health, even if life be ultimately preserved. Bleeding in inflammation of the pleura, in young and healthy persons, should therefore be effected with an unsparing hand, until an impression has been made on the system--until the pain and the difficulty of breathing have been removed--until the patient can draw a full breath, or faints; and the operation should be repeated, from time to time, every three or four hours, according to the intensity of the recurrence, or the persistence of the essential symptoms. The pulse does not often indicate the extent or severity of the inflammation, although it often expresses the amount of the constitutional irritability of the person. It is sometimes exceedingly illusory as a guide, and is never to be depended upon in the earlier stages of disease, when accompanied by pain and great oppression of breathing. Whenever the pulsations of the heart are proportionally much stronger than those of the arteries, we may bleed without fear, and with the certainty of finding the pulse rise; but if the heart and pulse are both weak, the abstraction of blood will almost always occasion complete prostration of strength, and may be fatal.

306. When many years ago in charge of a regiment of infantry, on the top of the Berry Head, the outermost point of Torbay, the men thus greatly exposed were attacked by pneumonia. According to the practice taught in London, I bled my patients three and four times in the first forty-eight hours. I first drew sixteen ounces, then fourteen, then twelve, then abstracted, as the complaint continued, eight ounces; gave tartar emetic, so as to keep up nausea; then calomel, antimony, and opium, and lost my patients. I examined the bodies of all, and found that they had lived to what is now called the third stage of pneumonia, combined in almost all with pleuritis, with effusion, and the formation of false membranes. The disease was essentially a pleuro-pneumonia, varying in different degrees, as the pleura or the lungs were principally affected; and I saw with regret that the disease had not in any way been arrested; that the means employed had been insufficient. What was to be done? My sixteen ounces of blood were increased to thirty, but it would not do. It was evident that, to succeed, no limit should be placed to the abstraction of blood in the first instance, but the decided incapability of bearing its further loss. Every man was therefore bled, when he came into the hospital, until he fainted, and the bleeding was repeated every four hours, or even oftener, as long as pain or difficulty of breathing remained; under this improved practice all recovered.

The lesson learned at Berry Head was not forgotten during the five subsequent years passed in British North America. The men were as healthy, the winds were sharper and colder, the vicissitudes of all kinds greater. Rum was cheaper, newer, and stronger than the gin of Torbay. The local inflammations were often as severe, whether of the pleura or of the lungs, and by no means less so of the bowels. A grenadier, some six feet three inches high, broad, and well framed in proportion, had drank a gallon of rum during the afternoon, and very narrowly escaped, even with the loss of nearly as much of his blood, abstracted in a few hours. His first bleeding was into the washhand-basin, until he fainted, lying on his back, and the bleedings were repeated as soon as he began to feel pain, and whenever he felt a return of the pain he used to put his arm out of bed to have the vein reopened, for Jack Martin was a very gallant fellow. This is given as an extreme case, to be borne in mind under circumstances somewhat similar, particularly after injuries. In common cases of well-marked pleuritis from injury in strong and healthy persons, it is now not unusual to abstract blood by those who rely on its efficiency, until the pain and difficulty of breathing are relieved, or fainting is about to take place. The patient should be raised in bed, the opening in the vein should be large, the flow of blood free. The quantity will vary from sixteen ounces to three times that amount in different people; but the important point is to repeat it as soon as the pain or difficulty in breathing returns. It rarely happens that one bleeding, to whatever extent it may be carried, will suffice to remove the symptoms; and recurrence should be had to this remedy as often as the pain and oppression require, and THE FORCE OF THE HEART will bear it, especially during the first two or three days. It will often be necessary to have recourse to it in smaller quantities for the next four or six days, and again in less quantity on any return of the inflammatory symptoms. Where the patient is likely to faint, he should be bled in the recumbent position; and as it is advisable to take away a sufficient quantity of blood, great care should be taken, by arresting its flow for a time, by giving stimulants, by admitting fresh air, and by sprinkling with cold water, to prevent syncope, which is sometimes dangerous in elderly persons, who may be subject to and who are not readily recovered from it. In the second stage of the complaint, profuse and repeated bleedings do not answer as well; they do not remove the evil which has occurred, although they may prevent its increase. Blood should then be drawn in such quantity only as will relieve the action of the heart, restless under its efforts to propel the blood through a hepatized lung. The quickness of pulse, the cough, the difficulty of breathing, must now be aided and relieved by other means; for although the pulse is not a certain indication, on which dependence can be placed in the early stage of this complaint, the breathing generally is; and as long as the respiration is oppressed, blood should be carefully abstracted, until it becomes manifest that the effect has been to quicken the pulse, while it materially diminishes its power, when it is forbidden.

307. A cupped and buffy state of the blood, together with a firm coagulum, is a satisfactory proof of the propriety of bleeding in the first stage of the disease; but after the effect of mercury on the system has been produced, it cannot be depended upon with the same degree of certainty. When the propriety of further venesection is doubtful, the greatest advantage may be obtained from the use of leeches and from cupping, particularly in cases of injury to the chest. Leeches may be applied by tens and twenties at a time; and when they have ceased to bleed into a warm bread and water or evaporating poultice, they may be replaced by as many more, until the pain and the oppression are removed. Cupping is always to be had recourse to when leeches cannot be obtained, and, when well done, it is frequently to be preferred; cupping to sixteen ounces will usually be found equivalent to forty or more leeches. Both these means often relieve to a greater extent, with less general depression, than a smaller quantity of blood taken from the arm, and are, therefore, at such times more advisable. When blood cannot be obtained from the veins, the arteries must furnish it; and both temporal arteries have been opened with the best effect in injuries of the chest, when blood could not be obtained from the arm, or from the external jugular vein.

308. The effects of bleeding were of old found to be different under different circumstances and in different climates. Asclepiades remarks that while phlebotomy was fatal at Rome and at Athens, it was beneficial in the Hellespont. Nevertheless, at a much later period, Baglivi says: “In Romano, phlebotomia est princeps remedium in plenritide.”

In the Crimea blood-letting has not been so favorably viewed, nor found so serviceable nor so necessary; although the abstraction of smaller quantities than those indicated above, and less frequently repeated, has been found eminently beneficial, the difference being dependent on climate and the impaired vigor of the sufferers.

The remedy first to be administered, and most to be depended upon in the first stage, is tartar emetic, which usually gives rise to vomiting, purging, and possibly to sweating; it should not be omitted because such effects are produced in the first instance. After a few, perhaps three or four doses, the vomiting usually ceases, the stomach tolerates its introduction, and its gradual increase from six to nine, twelve, twenty, or more grains in the twenty-four hours, is often borne not only with impunity, but with great advantage. Vomiting and purging are not desirable, as the effects of tartar emetic are more rapid and beneficial when they give rise to no particular evacuation beyond that of general perspiration. The most valuable remark of Laennec on its use is, “that by bleeding we almost always obtain a diminution of the fever, of the oppression, and of the bloody expectoration, so as to lead the patients and the attendants to believe that recovery is about to take place; after a few hours, however, the unfavorable symptoms return with fresh vigor; and the same scene is renewed often five or six times after as many venesections. On the other hand, I can state that I have never witnessed these renewed attacks under the use of tartar emetic.” He further says that the same favorable results do not occur from its use in pleurisy or in inflammation of serous membranes, as in pneumonia.

309. Mercury is a remedy of the greatest importance in serous inflammations, such as pleuritis, although of less value than tartar emetic in the first stage of pneumonia, than which it would appear to be more efficient in the later period of the stages of hepatization and infiltration, though some physicians place entire confidence on its efficacy in all. It is of most value when combined with opium. Some suppose that the opium merely prevents the irregular action of the mercury; others, in some papers printed in the journals for 1801, state that opium has a distinct curative effect, being capable, when given in large doses, of subduing inflammation, and more particularly of allaying pain, relieving the cough and irritation, and of procuring sleep; in which opinion I fully concur. Opium is highly advantageous in irritable and nervous persons, and will frequently relieve the nervous pain, the pleurodynia which remains after pleuritis, when nothing else succeeds. Calomel in large doses is usually preferred to all other forms, but a difference of opinion has occurred as to what is a large dose; whether two, three, four, six, ten, or twelve grains are large doses, and whether they shall be given every one, two, three, four, or six hours. It has been attempted to solve this question by supposing that in highly inflammatory cases in healthy persons, from three to six, and even to twelve grains, may be given twice or three times a day, with better effect than smaller ones more frequently repeated; but this has not been made manifest.

In cases less inflammatory or complicated with gastric derangement, the disease assuming more of a general than of a local character, the excretions being vitiated, the skin dry and hot, and the tongue loaded, from gr. iss to gr. iij of calomel, combined with three grains of Dover’s powder, may be advantageously given every second or third hour, the great object being to affect the gums as quickly as possible. This is not effected in some cases by any of the quantities given until after a considerable lapse of time, while in others it is accomplished by less than half a dozen grains of the remedy. It has not been ascertained that twenty-four or forty grains given in two or four doses in twenty-four hours will affect the mouth more rapidly than three grains every two hours for the same time, neither is it less liable to cause irritation; while the third or half a grain of opium given every two hours seems to keep up the effect of that remedy with great advantage. It does not materially signify which method is adopted in strong and healthy persons, although the smaller doses are most satisfactory to all parties when the patient is weak and irritable, while the large and less frequent doses often excite great apprehension. It is argued that calomel in large doses never causes the dysentery nor the severe ptyalism produced by smaller doses; that it acts more quickly, and that after giving twenty grains, and repeating it in six hours, any other medicines may be given without interfering with it, although the strictest attention must be paid to diet, generally confining it to very small sups of warm whey. Very serious derangements do, however, follow the exhibition of the large as well as of the small doses, inasmuch as it is impossible to know beforehand what quantity will cause a severe salivation or diarrhœa, which it may be difficult to arrest.

310. It may be concluded that, of the two heroic internal remedies, tartar emetic and calomel, recommended for the cure of inflammation of the chest, tartar emetic is the more appropriate for inflammation of the lungs or pneumonia, provided it be not accompanied by symptoms of gastric inflammation; in which case its use should be superseded by leeches to the epigastrium, and saline aperients, lest the irritation, vomiting, and purging should increase the evil. But care must be taken that one inflammation shall not be allowed to increase, while attention is principally paid to the other, and symptoms of irritation, the gastro-enterite of the French physicians, are not to be mistaken for gastritis. Mercury, in the form of calomel, is more to be depended upon in inflammation of the pleura, over which, as well as over inflammation of serous membranes in other parts of the body, it exercises a remarkable influence.

311. Blisters are never useful during the continuance of acute inflammation of the chest, although their use is indicated when the patient is much exhausted, the pulse weak, and the breathing continues difficult; or in cases in which the disease proceeds slowly, or is becoming chronic, when they often do much good. The same may be said of dry cupping, mustard poultices, and other cutaneous rubefacients, such as the ol. terebinth. used hot, which often do much good in the commencement and termination of slight attacks, or of their supervention on chronic disease, or after injuries.

In the acute stages simple drinks only should be allowed. As soon as the inflammatory action has subsided, the lightest farinaceous nourishment, gradually augmented by the addition of broths, jellies, eggs, fish, and lastly of animal food, should be substituted. The temperature of the room ought to be moderate and equal.

Inflammation of the lungs frequently terminates by the deposition of a white or lateritious sediment in the urine, which is considered a critical evacuation, not however to be relied upon, unless accompanied by a remission of the important symptoms. A moderate diarrhœa and a profuse perspiration are also signs of a favorable crisis.

312. Inflammation of the chest has been hitherto considered as accompanied by inflammatory fever as an essential character, but this is by no means always the case. In large cities, and among troops after hard service, in which they have been subjected to much privation, and in certain epidemics, the accompanying fever often partakes of a low or typhoid character, and becomes infinitely more dangerous. This modification of disease I have known from my earliest years, in different climates, in all of which it proved most fatal. It is a disease formed of a local inflammation accompanied by general symptoms of a low asthenic type of fever, combined with those of marked derangement of the stomach, intestines, or liver, as shown by a dry black, or red black, or brown tongue, offensive breath, diarrhœa, vomiting of a dark-colored or greenish fluid, watery or sanious expectoration, great thirst, headache, a feeble and quick pulse, low delirium, and great prostration of strength. It was marked, on the banks of the Guadiana, by the discharge of lumbrici by the mouth and by the anus. This disease has always appeared to arise from peculiar circumstances, and to disappear when they ceased to exist; such as great privations and exposure to cold and fatigue, the use of ardent spirits without sufficient food, bad air, or other depressing causes. It is sometimes epidemic. The fever is typhoid, the local inflammation latent, and the symptoms of it masked. It may be complicated with inflammation of the stomach and intestines; it may occur in cases of erysipelas, or after wounds or injuries attended with large secretions of purulent matter, or with other complaints. While the symptoms of low fever are general and well marked, those of the latent affection of the lung are not so prominent or even observable. The patient complains but little, and sometimes not at all, of his chest, until attention is drawn to it by a slight cough, and difficulty of respiration, attended by a character of countenance which usually indicates embarrassment in the functions of the lung. It may be brought on by a common non-penetrating injury of the chest.

In typhoid pneumonia, general bleeding, if admissible, is to be had recourse to with extreme caution, even in young and robust persons. Local depletion is oftentimes useful, and perhaps ought to be alone relied upon. The great dependence is on calomel and opium, and after such local depletion as may be thought advisable, counter-irritation by blistering, and the administration of stimulants, such as camphor, ammonia, and wine, in small and repeated quantities. Mild aperients only should be employed, and anodyne injections are frequently useful. While auscultation has thrown a clear and steady light on the nature of the mischief which is going on, it has added little or nothing dissimilar to the practice pursued some forty years ago. The nature of the hepatization or solidification which takes place in the lung in typhoid pneumonia has given rise to some difference of opinion among morbid anatomists, who incline to believe, from the rapidity with which it takes place, and with which it is sometimes removed, that it depends more on passive congestion, and on a typhoid alteration of the state of the blood, than on an altered action in the vessels of the part. This opinion does not seem to be fully supported by dissection, unless it be generally admitted that gray hepatization, and the third stage of disease of the lungs in pneumonia, mean simple congestion.

When the patient survives the imminence of danger in which he is placed by the attack of the disease, and the expectoration becomes copious, with great emaciation, quick pulse, and hectic fever, a slight infusion of senega or of cinchona with ammonia, with a mild and well-regulated diet, and change of air and climate, answer best in aiding recovery.

A typhoid pleuritis is presumed to exist, as a distinct disease from typhoid pneumonia, although the analogy between them is admitted to be close; like it the disease is latent and more frequently pointed out by the sinking of the powers of life than by any new suffering. The signs of effusion may be discovered on auscultation, and the treatment is essentially similar; blistering and counter-irritants being perhaps more useful, if time be granted for their application.

313. Empyema, from εν, in, and πυον, pus,--a name given to all collections of fluids in, and to the operation for evacuating them from, the cavity of the chest. Empyema is not a special disease, but the result of another; commonly of acute or chronic pleurisy, or of injuries of the chest, which give rise to inflammation, ending in suppuration. When it occurs from the effusion of a serous fluid, constituting a local dropsy, it is usually the result of disease of the heart, or of the great vessels, and is accompanied or preceded by symptoms indicating the existence of those complaints, in which case it is not likely to be benefited by any operation. The disease is then denominated hydrothorax. The serous fluid is generally transparent, although more or less tinged with blood, when thrown out in persons who die within a few days after receiving a wound of the chest. It may, and does occasionally, contain in these cases a large quantity of blood; but an early effusion of blood is not uncommon in very acute cases of pleuritis. It is usually more or less turbid when the result of ordinary inflammation, although the presence of albuminous or purulent matter is not constant. Whether colorless, transparent, turbid, or purulent, it remains free from fetor, unless gangrene has occurred internally, or some communication with the atmosphere has taken place by an external opening.

While the fluid remains transparent, the appearance of the pleura is little changed, but when it has become turbid in any great degree, or flocculent, or purulent, the pleura has lost its natural appearance. In its simplest character, when the fluid is puriform, particularly if the inflammation have not been very active, it is covered with a layer of whitish inorganic sediment, which can be scraped off by the scalpel. This is sometimes quite red, as if loaded with blood which had been deposited upon it. Whenever pleuritic symptoms continue beyond the ordinary period of about three weeks, or, after a temporary abatement, are followed by those of effusion, which are not in turn removed, the occurrence of empyema may be suspected.

Empyema may form from a pulmonic abscess bursting, or a gangrenous spot being detached and falling into the cavity of the pleura. An abscess in the liver or other parts may also communicate with the pleura, and abscesses formed from injury or otherwise in the wall of the chest may also give rise to it. It is usually, however, caused by acute inflammation, by penetrating injuries, or by the introduction of foreign substances. It should, however, be borne in mind that when it occurs from wounds, the external opening must have healed, or the complaint would be simply a wound in the chest, with a discharge from the cavity of the side affected. A true surgical case of empyema, following an injury of the chest, in which the wound has healed, is not to be ascertained but by the same means as in a case arising entirely from internal causes, unless the protrusion of the cicatrix should indicate the presence of matter behind it.

314. The symptoms by which the termination of inflammation in effusion may be known: are dyspnœa, or difficulty of breathing, which is greater when the effusion has taken place rapidly, less when it has been gradual; subsidence of pain; inability to lie on the unaffected or sound side, which subsides, or is entirely removed, after the operation has been performed and the fluid evacuated, although it should be replaced by air in consequence of the lung being unable to resume its natural position. When the effused fluid has filled one side of the chest, that side is evidently enlarged, and this can be distinctly seen when the dilatation does not exceed half an inch, measuring by a tape from the spinous process of a vertebra behind to the center of the sternum. The ribs are nearly, if not quite, immovable, and partially raised, offering a strong contrast to the active motion of the ribs on the other side. The intercostal spaces in these persons may be more or less filled up, rendering the whole surface smooth and soft. In some very severe cases the external parts become edematous, so that the ribs cannot be felt, and this sign, although not always present, is certainly pathognomonic when it takes place at a late period of the disease. When the effusion is into the left side of the chest, the heart is frequently pushed over with the mediastinum to the right side, and its pulsation can be seen and felt to the right side of the sternum; or it may descend with the diaphragm into the epigastrium--changes which are not so extensive or remarkable when the effusion is into the right side, as the liver materially impedes the descent of the diaphragm, and the heart is already in the left side, in which it is sometimes raised rather than depressed. It is said that if the hand be placed over the affected side, while the patient speaks with a tolerably loud voice, and a strong vibration is felt in the part, the case is not one of empyema; but this is as uncertain a sign and as little to be depended upon as the dullness on percussion which sometimes takes place under the sternum in empyema. The cough and expectoration offer nothing peculiar, unless a communication exist between the lung and the cavity of the chest, when the expectoration in general becomes very fetid and disagreeable. The febrile symptoms depend on the activity of the previous disease, and the rapidity with which the effusion has taken place.

Night-sweats, it has been supposed, never accompany the hectic fever of empyema, unless there be tubercles in the lungs or pleura--a remark which cannot be depended upon.

315. Two symptoms have been insisted upon by older authors as distinctive of effusion in the chest, which more modern ones are disposed to doubt, particularly in the early stages of the disease. One is an edematous swelling of the back, the other a protrusion of the intercostal spaces. A third may be added when the effused fluid is blood, which is that the edematous swelling becomes ecchymosed, or red, or bruised looking, from the effusion of blood into the cellular membrane beneath the skin, over the whole space occupied by the blood within. That the first two symptoms do assuredly indicate the presence of pus, cannot be doubted; and that the third is a sign that the effused fluid is blood, has not been disproved; but it must be borne in mind that they are late, not early symptoms, and the operation should not be delayed until they are present, if other signs should appear to demand its performance. Valentin was the first to notice the ecchymosis of the side and back when the chest was full of blood, a sign which Larrey particularly insists upon, but which certainly does not appear so early as to be distinctive, when other symptoms exist which almost render it certain. The swelling does not arise from transudation of matter through the pleura, but from irritation transmitted through it, as in any other deep-seated abscess. Dilatation of the chest is usually an early symptom, although a considerable effusion may exist without it, or with but a slight elevation of the intercostal spaces. When the complaint is distinct, these spaces are elevated to a level with the ribs, so that the surface becomes perfectly smooth and equal; a farther protrusion is a very rare occurrence. Effusion indeed of serous fluid to a considerable extent, so as to displace the heart, may take place without the intercostal spaces being elevated, which is only believed to occur when the intercostal muscles have become paralyzed. When the matter has been evacuated, the muscles recover their tone, and the intercostal spaces reappear.

In all cases of empyema in which the lung is so bound down by adhesions that it cannot be expanded by the continued process of respiration, a cure can only be accomplished by an alteration of the form of the affected side of the chest, by which its cavity is diminished, and often nearly obliterated. This is an effort of nature. The pleura changes its character, becomes so thick as materially to diminish the cavity, the diaphragm ascends, the heart leans to that side in many instances, the spine curves, the ribs thicken and become flatter, and close in upon each other, abolishing the intercostal spaces.

Treatment.--As long as the febrile symptoms consequent on the inflammation continue to any extent, medicines will be of but little avail, and counter-irritants should be avoided. When they have subsided, purgatives and diaphoretics may be tried, in combination with tonics and a light but good nourishing diet. Blisters applied frequently upon a large surface often do good. When these means fail, the operation must be resorted to.

316. It has not been satisfactorily decided whether the operation for empyema was first performed on Phalereus, Jason, or Prometheus; it is therefore said of all three that, being expected to die of an abscess in the lungs declared to be incurable, they went into battle for the purpose of getting killed; but being only run through the body, they all recovered, in consequence of the escape of the purulent matter through the holes thus made. The operation was performed by Hippocrates and his successors, by the knife, by caustic, and by the hot iron. Ambrose Paré was the first who recommended a trocar and canula, and many instances of success in all ways are recorded. The modern methods are by the trocar and canula, and by incision. Whenever auscultation, percussion, or succussion give reason to believe that a fluid is collected, which medicine has not been nor is able to remove, the simple operation by the trocar and canula should be performed. If fluid should pass through the small canula generally used by way of exploration, a larger one may be introduced in its place if thought advisable. In ordinary cases, the little wound should be closed immediately after the evacuation of the fluid; it usually heals without difficulty, and the operation may be repeated if necessary. Care should be taken that the point of the instrument is perfectly sharp, or it may separate the thickened false membrane from the inside wall of the chest, and, by pushing it before it, prevent the fluid from passing through the canula when the trocar is withdrawn.

317. The place of election, in England, for a puncture, in ordinary cases, is usually between the fifth and sixth ribs, counting from above, and between the sixth and seventh from below, and at one-third the distance from the spinous processes of the vertebræ, or two-thirds from the middle of the sternum. If there should be any protrusion of the intercostal spaces, it may be a rib or two lower down. The point of the instrument should be introduced a little nearer the lower than the upper rib, and pressed on until all resistance has been overcome. It is entered nearer the lower rib to avoid the intercostal artery, and yet not touching the rib lest it should induce a too forcible contraction of the intercostal muscles, by which the operator might be inconvenienced.

If the person should be very fat, or the puffing of the integuments considerable, it may not be easy to feel the ribs, in which case even recourse should not be had to incision. When the arm is placed by the side, and bent forward at a right angle so that the hand rests on the ensiform cartilage, the inferior angle of the scapula will correspond in general, but not always, with the interval between the seventh and eighth ribs at the back part. The attachment, however, of the last of the true ribs, the seventh, to the xyphoid cartilage, can always be ascertained in front, and an error of importance cannot well take place, as the object in making a puncture by measurement is to avoid the diaphragm. Freteau, of Nantes, says that he performed the operation on the left side between the tenth and eleventh ribs, and on the right side between the ninth and tenth in more than thirty dead bodies, and always opened into the cavity of the chest, commencing the incision close to the edge of the latissimus dorsi muscle, or about three inches and a half from the spine--an operation which in this place should be done by incision, and not by the trocar. When there is reason to believe that there is an extraneous body to be extracted, such as a ball, the place of election is of importance, as it is desirable it should be a little above the diaphragm in order to facilitate its extraction; for although, by carefully shifting the position of the patient, a ball or a piece of bone may be brought to rest against the opening, it will not be easily taken hold of unless it lie upon the diaphragm, a point which will be hereafter further elucidated. When an external swelling indicates the presence of matter, and there is reason to believe it communicates with the inside of the chest, the opening should be made into the tumor, and is then called the “operation by necessity,” which is not an uncommon occurrence after gunshot wounds. It is not, however, always done in the most convenient place, and should then be repeated lower down, which will also be sometimes necessary in consequence of the matter collected in this way being cut off by adhesions from the general cavity.

When the operation by incision alone was performed, the success was certainly not great. In modern practice (after the operation by puncture) it has been much greater, which may be attributed to the operation having been had recourse to at an earlier period, or about the end of the third week. After wounds penetrating the chest which do not admit the effused fluid to flow out, it should be done much earlier.

It is possible that both sides of the chest may be affected; but both sides may not be punctured in succession, for an error in puncturing both, or even the sonorous or sound side instead of the dull or affected side, has been almost immediately destructive of life.

318. The admission of atmospheric air into the cavity of the chest during this operation has been much deprecated, and many inventions have been recommended for its prevention, but it is scarcely possible to prevent some air getting in. It is often seen to do so; it has been proved by auscultation to have done so, and is usually absorbed in a few hours. In one case which I saw it gave rise to distressing symptoms from pressure on the lung, but was removed by a common syringe, to the great relief of the patient. In all these cases two things must be considered: Can the compressed lung expand so as to fill the chest when the fluid is withdrawn? The answer must be, in many cases it is so bound down by adhesions that it can dilate but slowly, if at all. If it be asked whether a vacuum is formed in the chest, the answer will be, no; and it will then be admitted, on consideration, that air always finds its way into the chest, and never does harm to persons in health. When mischief does ensue after an operation or an injury, it usually occurs from the irritation caused in a particular state of constitution, and not from the admission of air. A change in the appearance of the discharge has been frequently found to follow, and to depend upon, an accidental derangement of stomach, and to return to its more normal state on the derangement being removed. If the wound into a cavity can be closed and healed, the air will remain with impunity until absorbed. If the wound cannot be healed, unhealthy inflammation may be propagated from it to the whole cavity with which it communicates, but this is not the effect of the admitted air.

Dr. H. M. Hughes has published several cases of pneumothorax in the first part of the of the volume of “Guy’s Hospital Reports” for 1852. In the sixth case, which he calls a genuine example of pneumothorax from rupture of one or more of the vesicles of an emphysematous lung, the patient died speedily; and, on examination, he says: “It is also an interesting fact that no evidence of inflammatory action existed in the pleura, as it indicates that air in a healthy serous membrane does not excite inflammation;”--a Peninsular dogma I have been forty years inculcating, and which I trust is at last admitted as an established fact. How long it may be before it is generally taught, is another matter; for surgeons, like other men, often adhere with tenacity to preconceived opinions, however erroneous, particularly as they advance in life and have ceased to desire to learn more than they already know.

319. In all cases of serous effusion, there can be little doubt that the fluid should be wholly evacuated and the wound closed. When the fluid is purulent, a permanent drain should be early established. It is not, however, common for the operation to be repeated several times without the serous discharge becoming purulent; and, in such cases, it usually becomes necessary at last to allow the wound to remain open until the discharge shall cease of itself. Whenever more than one opening is necessary, and the first is made between the fifth and sixth ribs, the succeeding ones should be made lower down; so that when it is thought right to leave the last puncture to become fistulous, it may be made as near the diaphragm as may be thought consistent with the safety of that part.

When a doubt exists as to the probability of more than one puncture being sufficient, and it seems likely that a third, or even more, will be required, the surgeon may anticipate this necessity by introducing a piece of soft gum-elastic catheter through the canula into the chest to the extent of about three inches, enough being left outside to admit of its being secured by tapes and adhesive plaster; through this a certain quantity of the fluid may be drawn off daily until it ceases to be discharged. The elastic tube bends with the heat, and applies itself to the inside of the ribs. If the lung should rub against it, which can be ascertained by a blunt probe, the elastic tube should be removed, and the external wound kept open by a softer plug. In all these operations, care should be taken to prevent the occurrence of inflammation. The accession of pain in the part, of difficulty of breathing, of fever, should be met by the abstraction of a few ounces of blood by cupping, by dry-cupping, by mercury in small doses, by rest, by diet, etc., and, if a tube have been introduced, by its removal.

The propriety of injecting stimulating or even simple fluids into the cavity of the chest has been often advocated, and as frequently repudiated. Warm water or milk and water is certainly admissible, and has been found very useful, particularly when there is an adventitious cause keeping up the irritation, which may possibly be brought to the opening by the sudden abstraction of the injection. Pieces of cloth and bits of exfoliated bone have been floated out by throwing in an injection of tepid milk and water. The opening, in a case of this kind, should be made between the eleventh and twelfth ribs behind.

Dr. Wendelstadt, of Hersfield, in the year 1810, in the twenty-third year of his age, suffered an attack of pleurisy, which became chronic, and ended in effusion. After severe suffering for six months, he was able to attend to his professional duties. The ribs of the right side protruded, but the intercostal spaces did not; the whole side was motionless on respiration taking place. The circumference of the chest continued to increase, and fluctuation within became evident on succussion. In June, 1819, having undergone another attack of pleurisy, he submitted to the operation for empyema, as offering some hope of preserving life. When a pint of fluid had been discharged, the wound was closed, and he experienced great relief. The next day a third of a quart was taken away twice in the day, and on the third day as much more; but he thought this was too much, as he became greatly exhausted, and feared that suffocation was impending. He was recovered by stimulants. On the fourth day the fluid was thicker in consistence, and fetid, and continued more or less so for a fortnight. It was then allowed to flow as it would at each dressing. Astringent injections were used for six weeks, but were then abandoned, and he gradually recovered his strength. Thirteen years afterward, in 1830, the wound was still open, discharging twice a day, sometimes only half a drachm, sometimes three or four ounces daily. The right side had altogether shrunk, and did not move on inspiration; he had no cough, and was otherwise in good health; a piece of a rib became loose, and was removed at the end of thirteen years, when the report of the case terminated, the patient being in health.

It may be remarked on this case, that the admission of air did no harm; that the lung remained compressed; that the whole side thickened and flattened, as a consequence, so as to obliterate the cavity; but the cure would not have been effected even then, if the piece of carious rib had not been discovered and removed.

Mr. Winter, secretary to Admiral Sir C. Napier, was wounded by two musket-balls, one in the arm, while the other entered between the inferior edge of the left scapula and the thorax, which it penetrated, fracturing a rib in its progress, and lodged. He fell, and spat up some blood, and as symptoms of inflammation supervened in twenty-four hours, he was bled largely; this was repeated frequently until these symptoms were subdued. He was after a time sent to the Marine Hospital, Lisbon, in a miserable plight, suffering from hectic fever, with a flushed face, hot skin, glassy eye, great prostration of strength, cough, restlessness, dyspnœa, and copious night-sweats. The wound discharged a watery, sanious, fetid matter in quantity, and he was unable to do anything but eat, and for food he had a great craving. From this state, under good treatment, he gradually recovered his strength, and on the 18th of June, 1834, a piece of the rib was removed. The wound remained open with a great purulent discharge, which kept him in a reduced state; a little more than one year after the injury, he reached London, and was taken into the Westminster Hospital. The left side of the chest was flattened and contracted, and the lung was doing very little in the respiratory way; the wound discharging a quantity of matter, which he could readily evacuate by making the opening the dependent point, but not otherwise. On enlarging the external wound, so as to make the opening into the chest direct, I found a round-pointed gum-elastic bougie could pass into it for four inches, and, on bending it down, for six inches more, it having to pass over a thickened pleura, and false membrane of an almost cartilaginous nature, for the extent of an inch, before it could be felt to be in a large cavity. As it did not appear that he had any chance of recovery, unless another opening were made lower than the sixth rib, in a more dependent position, I proposed the operation, but he would not submit; and after a time he left the hospital and went into the country, where he died.

A non-commissioned officer, of the 2d Division of cavalry, was wounded at the battle of Albuhera, on the 10th of July, 1811, in several places, by the lances of the Polish cavalry; one of these penetrated the left side of the chest behind, immediately below and in front of the inferior angle of the scapula. He spat and coughed up blood, and lost so much from the wound that he became insensible, the bleeding having been stopped by a part of his shirt being bound upon it tightly by means of his woolen sash. Brought to the village of Valverde, my attention was drawn to him some days afterward, in consequence of the difficulty of breathing having increased so that he was obliged to be raised nearly to an upright position, as well as from his inability to rest on the part wounded, round which a dark-blue inflammatory swelling had taken place, the wound having closed. An incision being made into it, a quantity of bloody purulent matter and clots of blood flowed from it. The incision was then enlarged, so as to allow of a direct opening into the cavity of the chest, which was kept open. The relief was immediate. He was removed to Elvas, apparently doing well, some three weeks afterward.

This case offered the nearest approach I have seen to the ecchymosed edema described by Valentin as accompanying effusions of blood into the cavity of the chest; and, as well as the following, is an instance of operations, not by election, but by necessity.

A French soldier had been wounded at Almaraz by a musket-ball, which went through the right side of the chest, in a line nearly horizontal from a little below and to the outside of the nipple, backward. The first symptoms having subsided, he gradually descended the Tagus to Lisbon, where, after some months of continual discharge, the wounds closed, first the back, and then the front. He did not recover his strength, always looking sickly, and suffering from pain, difficulty of breathing, and other inconveniences, which did not prevent his walking about in the confined space to which he was doomed as a prisoner of war. My attention was drawn to him in consequence of an obvious fullness of the intercostal spaces, of the great difficulty of breathing, and of a puffy inflammatory swelling which was forming around and at the seat of the wound in front. Through this I made an incision into the cavity of the chest, the walls of which, on introducing the finger through the opening, appeared to be very much thicker than usual. A large quantity of pus was discharged, and the man was relieved, but this amelioration was not of long continuance, and he gradually sank and died. On opening the body, the inside of the wall of the chest was found to be half an inch in thickness, in consequence of a firm deposition on the pleura, of a yellowish-ash color, honey-combed or ulcerated, as it were, in plates, particularly where the opening had been made. The lung was shrunk up from the anterior and lower part of the chest, but adhered to the wounded part behind, and was covered by a layer of false membrane of considerable thickness. The wound through the lung could not be distinctly traced, from its being diseased throughout.

At Santander, in October of the same year, 1813, I received some eight hundred wounded in the affairs of Le Saca, Vera, etc. One of the Light Division had been shot through the left side of the chest: the posterior wound had closed, but a sufficiently large quantity of matter was discharged through a small anterior one to show that there must be some depot from which it proceeded. The wound was laid open into the cavity of the chest, and free vent given to a quantity of matter. Some small pieces of rib were discharged, and a bit of something like the cloth of his coat also came away. He could lie on either side, and hopes were entertained of his recovery, until after I left Santander in December, to join the army in France, when he suffered a relapse of inflammation, and died.

A soldier of the German Legion was wounded at Waterloo by a lance between the sixth and seventh ribs of the left side. He spat up much blood for several days, and was carried to Antwerp, where he remained for several months, suffering from great difficulty of breathing and other distress in his chest, which recurred from time to time, although the wound had healed. He was admitted into the York Hospital, Chelsea, in the spring of 1816, in consequence of an attack of inflammation, of which he died. On examining the body, the lung of the right side was found to be greatly inflamed, and full of purulent fluid, which caused his death. The left or wounded side was found to contain a small quantity of pus, the cavity being very much diminished by the great thickening of the pleura and the falling in of the ribs, which were thicker, greatly flattened, and changed in form; the lung, shrunk or collapsed, was covered by a thick adventitious membrane, and bound down against the spine, leaving a long, small space between the pleuræ, which once had doubtlessly been full of matter. The mediastinum and heart appeared to lean toward the left side, aiding in this manner in the obliteration of the cavity, which must take place if a permanent cure be effected in empyema. I have seen two cases in which this obliteration appeared to be complete: one in a soldier, who had been wounded in the chest; the other in a gentleman, the subject of empyema, in private life. In both the spine was also distorted, the side wasted, the nipple lower than the other. The breathing of the opposite side was more marked and developed. It might have been called puerile.

320. Pneumothorax means an effusion of air and of the matter of a tubercular abscess from disease into the cavity of the chest, or from an injury or a wound in the lung. When pneumothorax is the consequence of disease of long standing, the patient may be sensible of a sudden pain, which does not abate, and which is accompanied by an equally sudden increase of the difficulty of breathing, for which he cannot account. He feels relief by lying on his back or on the affected side, rarely on the other, although the difficulty of breathing may increase, so as to render the further continuance of life doubtful, while the prostration of strength is considerable. The muscles of respiration are all in rapid and powerful action; the heart is displaced to the right side when the complaint attacks the left, and it will be displaced somewhat to the left when the right is affected; in some cases it even descends into the epigastrium, or is otherwise removed from its natural situation, even toward the axilla, although the left side is supposed to be more obnoxious to this complaint than the right. The pulse becomes exceedingly quick and small, countenance pale, nights sleepless. The affected side is oftentimes evidently dilated, and the intercostal spaces may be less marked, or partly filled up, when the respiratory motion given to the parts under ordinary circumstances is seen to be deficient. But these differences, as well as that which can be obtained by comparing both sides by measurement, are not so marked as when the cavity is filled with fluid, of which in pneumothorax there is always a small quantity effused.

Percussion, beginning from above, in the erect position, will give, in cases in which it is ascertained that respiration is null, a clear tympanitic sound, as low as the level of the fluid, when it changes abruptly to a dull sound, or that indicating the presence thereof. If the patient be then placed in the recumbent position, the clear sound can be heard above, the dull one below, demonstrating the change in the situation of the air and fluid. Auscultation, in addition to the absence of respiration, when the chest is fully expanded, discovers no respiratory murmur; but a peculiar sound called tintement métallique, or metallic tinkling, is heard at intervals, particularly on the patient’s coughing, speaking, or breathing. It may be imitated by dropping a pin into a large wine-glass, but it more nearly resembles the sound of a jew’s-harp in the hands of a child: once heard it cannot be mistaken. It is a sound distinctive of pneumothorax.

“Mr. Cornish, a medical practitioner, having suffered an attack of pleuritis, nearly expired from suffocation on Monday, the 29th December, 1828. He was lying on his right side, breathing most laboriously; countenance sunk; pulse between 130 and 140; had had no sleep for many nights. The action of all the respiratory muscles was painful to behold; no perceptible difference in the size or shape of the two sides. The right emitted an extremely dull sound; the left sounded hollow throughout. The apex of the heart was beating rather to the right of the right nipple. The respiration was loud and rattling in the right side; metallic tinkling distinct in the left; expectoration muco-purulent, with specks of blood, and many black particles. Mr. Guthrie, who saw him for the first time, made a short incision between the sixth and seventh ribs, and cautiously opened the pleura, when a rush of air issued forth with a hissing noise, strong enough to have extinguished several candles. The patient turned on his back, breathed with comparative freedom, and expressed his gratitude for the operation. No fluid issued from the wound when made a dependent opening. On the 31st, the difficulty of breathing and the metallic tinkling had returned, the wound having closed. The wound was reopened and enlarged; the pulse fell to 120; the metallic tinkling ceased to be heard; the patient took some nourishment and an opiate at night.

“Jan. 1st, 1829.--Has slept several hours; breathing easy; pulse reduced in frequency; appetite good. A canula was placed in the wound, when large quantities of air came through it on each expiration; the heart beat two inches nearer the central line of the thorax than before. During the night he became greatly oppressed, and died next day. On raising the sternum, the heart was found rather to the right of the median line of the chest. The left lung was collapsed to one-fifth of its natural dimensions. The vacant space was filled with air, and about fourteen ounces of turbid serous fluid. The pleuræ costalis and pulmonalis presented marks of inflammation of a few weeks’ standing--viz., some thin false membranes, which were easily separated by scraping with the scalpel. There were no marks of more recent pleurisy. A tube was inserted into the trachea, and air blown into the lungs. The left lung expanded to a certain extent, and air was heard to bubble out, when an aperture was immediately recognized at the division between the two lobes, through which the air rushed forth and extinguished a taper that was held near it. The aperture was circular, fistulous, and capable of admitting a crow-quill, and was found to communicate with a very small excavation, formed by the softening down of some tuberculous matter; into this small excavation a bronchial tube was seen to enter. Thus, the communication between the trachea and the cavity of the chest was distinctly traced. The left lung presented some trifling tuberculation, but was not materially diseased.”

William Griffin, aged eighteen, was admitted into the Westminster Hospital on September 14th. Ten days before his admission into the hospital he discharged a pistol against the left side of his chest, causing a wound corresponding to the middle of the eighth rib, from which a very small quantity of blood escaped. The medical practitioner who was called to him at the time passed a probe to the extent of four inches into the wound. The wound had nearly cicatrized, but he became the subject of acute pain, diffused over the whole of the left side of the chest, accompanied by fever and frequent cough, dyspnœa, and inability of lying on the right side. After the lapse of a week he was transferred by his surgeon to the medical wards under Dr. Roe, at which time he had begun to expectorate purulent matter of an extremely fetid character, occasionally mixed with blood. His respiration was hurried, the right side of the chest expanding much more freely than the left; the lower three-fourths of the affected side were dull on percussion; tubular respiration could be detected at the upper part, but at the lower no air appeared to enter; well-marked modifications of voice existed over the whole of that side of the chest. By measurement no difference in the relative size of the chest was observed, but the intercostal spaces of the left side remained motionless daring expiration. The heart could be felt feebly pulsating at the epigastrium.

October 15th.--He suffered from a violent paroxysm of coughing, during which great dyspnœa suddenly came on. He sat propped up in bed; respiration was almost ineffectual, his face livid and covered by a cold, clammy sweat, pulse scarcely perceptible at the wrist, and his extremities were becoming cold. On examining the chest, the left side, before quite dull, now afforded tympanitic resonance on percussion, which, together with the total loss of respiration and the presence of metallic tinkling, proved the existence of pneumothorax. A trocar was introduced between the sixth and seventh ribs, and was followed by an escape of gas with about five drachms of pus, both of a very fetid character; the canula becoming obstructed, a larger one was then passed through the opening, but not more than half an ounce of pus escaped; it was then withdrawn, and found to be blocked up by what appeared to be disintegrated lung. Being greatly relieved, no further attempts at evacuating the fluid were then made.

At night, during a paroxysm of coughing, six ounces of fetid pus escaped by the opening, after which he felt relieved. A second gush of sanious fluid, to the amount of five ounces, containing small masses of sloughing membrane, subsequently took place. Cavernous respiration at the upper half of the lung, mixed with gurgling and metallic tinkling. Expectoration muco-purulent and offensive.

21st.--Has somewhat improved, but suffers from accessions of fever toward evening, and perspires very profusely during the night; the cough is less frequent, and he expectorates freely, the sputa being of a purulent, fetid character. Scarcely any discharge from the side.

Nov. 5th.--Has remained in nearly the same condition until yesterday, when he ceased to expectorate, and has since become much worse; his skin is now intensely hot; face flushed; tongue brown and coated; pulse jerking, but feeble and frequent; the opening in the chest has quite healed.

A second opening was now made about an inch external to the former one, and a canula introduced, but not more than one ounce of pus escaped, the instrument becoming blocked up by portions of sloughing tissue; during a paroxysm of coughing, which occurred a few hours afterward, several ounces of fetid sanguineous pus were forced through the wound.

16th.--Since the last report he has been slowly sinking--is emaciated to an extreme degree. The wound originally produced by the pistol-ball, as well as those made by the trocar, have become fistulous, so that during respiration the air passes into the chest, and is expelled with as much freedom as that passing by the trocar. Expectoration has continued very copious, about a pint and a half having been passed in every twelve hours; large sloughs have formed upon the nates and hips, his intellect wanders, and he has frequent syncope. Died on the 5th of December.

Sectio cadaveris.--The pleural cavity of the left side contained about ten ounces of purulent matter mixed with blood, and floating in it were numerous masses of white, curd-like matter, at the bottom of which, in the angle formed by the diaphragm with the spine, was found a pistol-ball partly covered by albuminous matter and discolored. Fluid injected into the left bronchus was found to issue freely from an opening at the most depending part of the lung, communicating with a small cavity, the interior of which was lined by the same thick membrane met with in cases of chronic phthisical disease; from the upper part of this cavity two other sinuses were formed, the one passing externally and terminating by an adhesion of the lung with the ribs at the point where the ball had entered; the other was longer and more tortuous, passing deeply in the substance of the lung, and ending in a large abscess capable of containing five or six ounces of pus. The lung was at its lower part firmly attached to the ribs by intervening false membrane, while the upper part was free, and had become compressed toward the spinal column. The substance of that part of the lung not involved in the abscess was infiltrated with pus, and the greater number of the bronchial tubes were filled up by masses of curdy matter similar to those found floating in the effused fluid. The natural division of the lung into lobes was quite destroyed by the pleuritic adhesions of one to the other, while the pleura lining the parietes was covered by rugged layers of false membrane of irregular thickness, but readily detached. No trace of tubercular deposit could be found, and the lung of the opposite side was quite healthy. Since the first publication of these cases the operation has been so frequently and, in many instances, so successfully performed, as to leave no doubt of the advantages to be derived from it.

321. Lord Beaumont was wounded by a pistol-ball on the 13th of February, 1832, when standing sideways. It entered the right side of the chest a little below the nipple, appeared to pass under the lower end of the sternum, just above or about the xyphoid cartilage, and to have lodged in the cartilage of the last of the true ribs of the left side near its junction with the bone, in consequence of a round projection at that part resembling a pistol-ball, but which, on being exposed, showed only a knob of cartilage which might have been a natural formation; no further steps were therefore taken. The injury had been received about four o’clock--it was now five; he could lay flat on his back; had little or no pain or oppression.--Seven o’clock: Breathing became oppressed, and accompanied by pain; vesicular murmur distinct in both lungs; pulse 96; bleeding to thirty-two ounces.--Nine o’clock: Difficulty of breathing; the pain greater; was again bled until the pulse failed, although he did not faint; the relief great.--Half-past ten: Oppressive breathing again returned; pulse very low and quick; thirty-six leeches applied; relief obtained.--Half-past twelve: Thirty-six more leeches.--Half-past two: Thirty leeches were again applied. In all, four pints of blood were taken from the arm, and one hundred and two leeches were applied to the chest, the bleeding being encouraged afterward; during the first ten hours live grains of calomel and four of the compound extract of colocynth had been given, and now forty minims of Battley’s solution of opium were administered.

14th.--Eight o’clock: Slept after four o’clock; on waking took an aperient draught, and is much easier; pulse 120, soft, small, and weak.--Three P.M.: On the dyspnœa returning twenty-one leeches were applied, and the oppression was relieved; an enema given, which acted freely.--Half-past twelve: A returning oppression relieved by eleven leeches; calomel repeated, and thirty minims of solution of opium.

15th.--Eight A.M.: Slept at intervals; little or no expectoration, no blood; thinks he would faint if he sat up in bed; pulse 130, soft, small, and weak; little pain; lies tolerably flat; respiratory murmur distinct on both sides.--Nine P.M.: Oppression returned; twenty-four leeches; repeat calomel and colocynth; an enema, after which the bowels became free.--Evening: Six grains of calomel, and opium draught.

16th.--Eight A.M.: Had forty-eight leeches applied at intervals twice during the night; slept at intervals, and is easier; no pain in the chest; pulse 108.--Evening: An enema; six grains of calomel, and one grain of opium.

17th.--Eight A.M.: Slept during the night, and is better; pulse 108, soft; breathes freely; no pain.--Evening: Has had leeches applied twice during the day, making in all 245, and each time with relief; an enema,--calomel and opium as before.--Twelve at night: More oppression, and, as the pulse was fuller and quicker, a vein in the arm was opened, but only four ounces of blood could be obtained.

18th.--Eight A.M.: Slept at intervals, although very restless; pulse 120, fuller; oppression in breathing returning; bleeding to twenty ounces, which caused him to faint; senna draught.--Evening: Has been much relieved by the bleeding; blood cupped and buffy; twenty leeches; enema; calomel and opium. In the night, at two o’clock, the dyspnœa returning, twenty-two leeches were applied, and thirty minims of solution of opium given.

19th.--Eight A.M.: Easier, quieter, better; pulse 110, soft; can lie quite flat on his back. The wound discharged so little that the external parts were dilated inward toward the sternum, until the pulsation of an artery could be seen, perhaps the internal mammary, which it was not thought advisable to disturb; respiratory murmur not distinct at night; enema; calomel, opium, and twenty leeches.

20th.--At three in the morning, being greatly oppressed, thirty leeches were applied, and at eight o’clock twenty more, which quite relieved him, but left him in a state of great exhaustion, sick, and faint. A little arrow-root relieved the faintness; discharge from the wound free, and accompanied by air; bowels open.--Ten at night: Calomel, and forty minims of the solution of opium.

21st.--Eight A.M.: Has now, for the first time, a hope of life: pulse 112, soft; no pain; can turn on his side, but fears to hurt himself; wound discharges freely; has had a small piece of bread for the first time.--Four P.M.: Restless, but better; senna and sulphate of magnesia mixture.--Eight P.M.: Oppressed; pulse 120; twelve leeches; calomel, and thirty minims of the solution of opium, at night.

23d.--Oppression at night relieved by six leeches; slept afterward; breath slightly affected by the mercury, which was omitted in consequence; ten grains of the compound extract of colocynth given at night, with thirty minims of the solution of opium.

25th.--Free from pain; breathes easily and without difficulty; can turn in bed with ease; slept well; the discharge from the wound is free; takes farinaceous food, oranges, tea, etc. He gradually improved until the 13th of March.--On the previous Friday, the 9th, he removed from Bond Street to Mount Street; and on the 13th, amused himself by washing all over in a small back room without a fire; caught cold, and acquired a troublesome cough, which was quieted on the 14th, at night, by opium.--On the 15th, A.M., it was evident that some mischief had been done; pulse 120; breathing difficult; was bedewed with a cold sweat; respiratory murmur indistinct on both sides; on the left, not heard below the fourth rib; although the whole side sounded sonorously, it evidently contained air, the tintement métallique being very remarkable. The wound having closed very much, and the distance to the left cavity of the pleura under the sternum being considerable, a piece of sponge tied around the eye of a small gum-elastic catheter was introduced, so as to enlarge the track of the ball, and give passage to the air from the left side of the chest. This was done at five o’clock P.M., and at ten, on its being withdrawn, air rushed out in a very manifest manner, to his great relief. The metallic tinkling, which was distinct before the instrument was withdrawn, instantly ceased, but could be reproduced by closing the opening. The small gum catheter was therefore reintroduced with the eye projecting beyond the sponge, and retained, air passing through it; cough very troublesome.

March 17th.--Better; pulse 100; bowels open; cough easier; expectorates freely a rouillée, or reddish muco-purulent matter.

18th.--Easier and better; breathing on the left side not heard below the fourth rib; discharge free; the permanent gum catheter taken out, but passed in daily. After this he slowly recovered, and continued to enjoy good health until the summer of 1854, when he died of what was supposed to be ulceration of the stomach, being an admirable instance of the treatment to be followed in such cases. When there is not an opening to enlarge, one should be made with the trocar.

It has been stated by the latest writers on pneumothorax, that tympanitic resonance on percussion, and the absence of respiration, are not pathognomonic signs of pneumothorax, as these physical signs may exist without it, and pneumothorax may exist without them. The metallic tinkling, in addition to the absence of all appearance of disease in the abdomen, will be conclusive of the presence of this disease.

322. Emphysema, from εν and φυσαω, to inflate; the diffusion of air into a part of or throughout the cellular tissue of the body. It has been said to take place after a wound of the chest, but without an injury of the lung, from the air passing through the wound into the cavity during inspiration; and by accumulation and subsequent compression under the act of expiration, giving rise to all the symptoms of the disease; a complaint more theoretical than real.

Emphysema, as a medical disease, is opposed to the surgical disease, in not being an extravasation of air into the cavity of the chest, but a dilatation of the air-cells formed for its reception. It is of two kinds, Vesicular and Interlobular--vesicular when dependent on the enlargement of one or more air-cells; interlobular when, from the sudden rupture of an air-cell, the air has found its way into the interlobular structure of the lung. A third and very rare kind has been added, in which air, being extravasated under the pleura, has raised it in the form of a pouch. The morbid appearances these diseases afford, and the symptoms they give rise to, do not fall within the range of surgical skill; and are not frequently within the controlling power of medical science and ability.

Emphysema is free from redness, and is distinguished from edema, or the swelling containing a serous fluid which is also colorless, by its not pitting on pressure, or retaining the mark of the finger. It is, on the contrary, elastic; and the displacement of the air, on pressing on the part, gives rise to a peculiar noise, resembling the crackling of a dry bladder partly filled with air on its being compressed, usually called crepitation. This swelling extends as the air introduced increases in quantity until the whole of the areolar tissue of the body may be fully distended.

Emphysema most commonly occurs from fractured ribs, a point from one or more of which abrades the surface of the lung. Through the opening thus made, the air escapes into the sac of the pleura, and thence by the side of the broken part of the ribs into the cellular membrane. The distress in breathing arises from the air being diffused over the surface of the lung, which it gradually causes to collapse under the pressure exercised by the act of expiration; while, at the same time, the mediastinum yielding, the opposite lung suffers in a similar way, although to a less extent, until the aerification of the blood is so greatly obstructed as at last to interfere with life, unless relief be obtained by the equalization of the pressure made on the lung by the compressed air in the cavity of the pleura, with that exercised on the inside of the lung through the glottis.

In ordinary but not severe cases of fractured ribs, a slight degree of emphysema is frequently observed over the injured part, implying that the lung has been wounded; such a case requires the application of a compress, wetted with a little spirit and cold water, retained by a bandage. The great art in the treatment of broken ribs by compress and bandage consists in their proper application, which can only be ascertained by the feelings of the patient. The application of a broad flannel bandage, so as to restrain the motions of the chest, and to cause the sufferer to breathe by the diaphragm, has been recommended from the earliest periods of surgery; but many persons with injured or broken ribs cannot bear the pressure of a bandage, while others derive much ease from its use. A tight bandage generally disagrees when the injury has been sustained at the lower part of the chest, and is more frequently useful when the fracture is above the fifth or sixth rib.

When the emphysematous swelling extends so as to invade a considerable portion of the body, the further diffusion of air should be prevented by punctures made through the skin in such places as may be thought necessary, and in extreme cases even by incisions; but these are things more often spoken of and written about than practiced, or than are even necessary.

323. Mr. J. Bell had so alarmed all military surgeons by stating, in his able discourses on the Nature and Cure of Wounds, that emphysema was “peculiarly frequent in gunshot wounds of the chest, both at the orifice of entrance and of exit of the ball,” that they thought of little else. They could not withstand the brilliant manner in which this remarkable error--for error it is--was expressed. To such of us as had served in the first part of the war in Portugal it was no longer a bugbear; we slept in peace after the battles of Roliça and Vimiera, of Corunna, of Oporto, and Talavera--laughing, perhaps, a little at the credulity of the surgical portion of mankind; for the opening made by a musket-ball rarely admits of emphysema. A slanting wound made by a pistol-ball may sometimes give rise to it. After long and tortuous wounds made by swords or lances it is seen more frequently, but then it takes place shortly after the receipt of the injury.

A soldier, at the battle of Albuhera, was wounded in the right side of the chest by a sword, which had passed slantingly under the shoulder-blade, from which injury he did not suffer much, until the whole side as well as the body and neck began to swell and impede his breathing, which was effected with some difficulty and with any ease only when sitting up. The external wound was enlarged until I could distinctly hear the air rush out and see the part where the weapon had penetrated between the ribs; upon which he declared himself relieved, when the wound was closed by compress and bandage. It did not unite, however; active inflammation of the cavity of the chest ensued, requiring frequent and considerable losses of blood for its suppression. At the end of three weeks the man was sent to Elvas, in a favorable state for recovery.

324. When an opening is made into the cavity of the chest in the dead body, the lung recedes from the pleura lining its wall, for some distance; it is said to collapse; but this does not take place in anything like the same extent in the living body; and if the continued admission of air through the wound be prevented, it scarcely takes place at all; or, should it have done so, the air is usually absorbed and the lung quickly recovers its natural dimensions and functions. Neither does a wound in the chest, when kept open, usually cause this collapse to the extent which it is generally supposed to do in the living body. The lung can be seen in motion and performing its office, although imperfectly, as it does not fill the cavity of the pleura. When the lung has been wounded by a ball actually going through its substance, it does not necessarily collapse; and abrasions or deeper injuries of its surface lead to no such result. To cause the complete collapse of a living lung, its surface must be compressed by a fluid, as in empyema, or by confined air, as in emphysema or in pneumothorax.

In extreme cases, when the patient can no longer lie down, but sits up, supported, in the greatest agony of respiration, approaching to suffocation, the face and lips swollen and blue, the pulse almost imperceptible and countless, an opening should be made into the chest by a small trocar and canula, for the purpose of evacuating the highly compressed and compressing air, and to allow the expansion of the lung after its evacuation. When this compressed air has been drawn off, as in the case of Lord Beaumont, the compressing power being removed, the lung expands in part, if not entirely, in spite of the breach in it, and the mediastinum and heart return to their natural situation, the distress in breathing is removed, the failing circulation is restored, and the opposite lung resumes its functions.

The course then to pursue in such extreme cases is merely to puncture the chest, evacuate the air, withdraw the canula, and close the opening. The life of the patient having been thus saved, time is given for the wound in the lung to heal under the usual inflammatory processes, provided it will do so without a recurrence of the mischief. This, if it should take place, must be met by another puncture, or the opening in the chest should be made permanent in order to equalize the pressure of the air in the cavity.

The incisions (the “taillades” of the French) into the cavity of the chest formerly recommended, should only be resorted to when the means indicated have failed, which they will rarely do when combined in the first instance with an antiphlogistic treatment, aided by sedatives, and if necessary by cordials.

The advantages to be derived from auscultation in these cases are evident. Its value has been sufficiently shown, and the ear or the stethoscope should be resorted to at least three times in every twenty-four hours, in every case, however trifling it may appear to be, until the absence of danger has been ascertained.

LECTURE XXII.

SIMPLE INJURIES OF THE CHEST, ETC.

325. The most simple injury, perforating the wall of the chest, is a stab by a triangular sword, a small knife, or other weapon, which may or may not abrade the surface of the lung, and which is usually attended by little pain, although it often gives rise to considerable alarm. It might be supposed that a very slight wound of the lung would be followed by some expectoration of blood, but this does not always take place; and although its presence may be considered demonstrative of the injury, its absence is no proof of the contrary; for a considerable injury from a stab or from a musket-ball may be inflicted, with scarcely any sign of blood in the matter expectorated. If the pleuræ are in their natural state, a small quantity of air may enter the chest, but the opening will require to be direct and tolerably large before the lung will separate or shrink from the wall on that account; if adhesions should have been previously formed between the pleuræ preventing it, they will be for the advantage of the sufferer.

In a simple incised wound, injuring the lung perhaps extensively, as supposed from the bleeding from the mouth, no examination by probes or other instruments need or ought to be made as a general rule; but the wound should be immediately closed by sutures after the external parts have been sufficiently examined to satisfy the surgeon that no portion of the offending instrument has been broken off, or other extraneous matters are sticking in the part.

The advantages derived from the closure of punctured wounds of the chest in former times led to the practice of sucking them by the mouths of irregular practitioners, generally the drum-major of the regiment, when the patient was a soldier; and the consequences, although in some instances apparently miraculous, were in others quite as unfortunate.

That bleeding may take place from the lung into the cavity of the chest is indisputable, but little or no blood will escape through a small wound; and its continuing to flow from such a wound will be a presumptive if not a conclusive proof that some artery external to the pleura has been wounded. Sucking, under ordinary circumstances, of a small wound, unattended by bleeding, does good by attracting the natural fluids to the parts, and thus causing them to swell so as to be placed in apposition in the most advantageous manner for their reunion. Punctured wounds of small size, therefore, may be sucked chirurgically if any one be willing to do it, after which a bit of gold-beater’s skin, or dry lint, should be placed upon the wound, supported by a compress covered by adhesive plaster; these dressings should not be removed for several days.

326. The patient should lie on the wounded part, as a general rule, if he can conveniently bear it, not for the purpose of allowing any effused blood or fluid to flow out, unless some particular reason require the precaution of keeping the wound open, but to allow the pleura covering the lung to be as closely applied as may be to the pleura lining the wall of the chest, with the hope that the adhesive process may take place between these parts, and by this means cut off the wound from the general cavity of the pleura, a proceeding due to the practice of the Peninsular war, yet so little attended to at the present time by some teachers of surgery, who seem to confound the practice thus recommended in incised wounds penetrating the cavity of the chest with that which should be adopted in gunshot wounds, that few students obtain even a reasonable degree of knowledge on this subject. Teachers are entitled to prefer any mode of treatment they please, but they should be careful not to neglect the opinions of others, whose authority, derived from experience, they are bound at least to notice, even if it should be to disapprove.

327. Incised wounds of even greater extent ought not to be examined by the probe or finger; no disturbance of any kind should be permitted unless the cartilage or bone be injured. The external parts should be brought together as closely as possible, so as to facilitate in every way their union, and the processes which it is desirable should go on within. The external parts or skin and cellular membrane cannot be kept in perfect and continued apposition without sutures, and the proper method of proceeding is to sew up the wound in the skin with a needle and fine silken thread in a continuous manner, including absolutely nothing but so much of the cut edges as will retain the thread; a small piece of gold-beater’s skin or lint should then be laid over the stitches and retained by a compress and adhesive plaster.

In a simple case of this kind little or nothing is effused into the cavity or secreted from the membranes of the chest, which will interfere with the processes which may have happily begun, and which it is desirable should be aided by the absolute quiescence of the patient, to whom no medicine should be given which may render any movement of the body necessary. It was formerly supposed that the greatest object to be attained was the prevention of inflammation, and a man was no sooner stabbed by his opponent than he was blooded and purged by his surgeon, regardless of the necessity which existed for perfect rest and the presence of a certain amount of inflammation, in order to enable nature to carry on those processes which are essential for the restoration of the injured parts. This inflammation should be allowed to commence without interference and to continue in a moderate degree until the object shall have been effected. It should only be interrupted or subdued when it is supposed to be about to exceed that degree which experience has pointed out as likely to be useful.

328. When the most courageous persons are wounded in parts essential to life, there is more or less alarm or shock created by the injury; although it has been gravely argued that a man does not always know when he is actually shot or run through the body. A continued state of anxiety and depression after an accident of this kind is a disagreeable accompaniment of the injury, during which little should be done beyond the giving a little cordial, and quieting the apprehensions of the patient, leaving him to rest, if possible, after the necessary applications have been made. If a gradual improvement take place, if the pulse rise, if the patient resume more of his natural appearance, and that state of commencing excitement which is denominated reaction follow, hope may then be entertained. The general symptoms, as long as they continue within ordinary bounds, are of little importance; the local ones, significative of action commencing in the injured part, are, however, to be carefully watched. They are those of inflammation of the pleura, and it may be of the lung. This inflammation begins slowly, and a day may elapse before it is well marked; for, when persons have died within the first few hours after such injuries, the pleura has often shown but little sign of inflammatory action. Auscultation should always be resorted to from the moment of injury, and constantly used throughout the treatment. Whenever it is concluded that adhesion between the two pleuræ has failed to take place, the direction to lie on the wounded side ceases to be of importance. Until this period no food whatever should be allowed, and thirst should be allayed by small quantities of water.

329. A punctured, incised, or gunshot wound, going fairly through both cavities of the chest, is usually believed to be quickly if not immediately mortal--an opinion generally correct with respect to wounds made by musket-balls, although it is certainly not the case with regard to punctured wounds, and does not always occur in those made by pistol or musket-balls.

Sergeant-Major Richards, of the 29th Regiment, received thirteen sword or bayonet wounds, and other injuries, on the heights of Roliça, on the 17th August, 1808--one particularly through each side of the chest, between the ribs, as if the small-sword had made a wound of larger size than usual. He had distinguished himself greatly in covering the body of his commanding officer, and was beaten down before the British column, which had been repulsed, could rally and recover its ground. He was an object of particular attention to me, for the few minutes he lived after I saw him; he had coughed up a little blood, and died gasping, as if suffocated, the chest laboring on each side to do its work in vain. His commanding officer, Colonel the Hon. George Lake, lay dead by his side, killed instantaneously by a musket-ball, which passed from the upper part of the left through the right side of the chest.

A French gentleman, fencing with his pupil in July, 1834, received a blow under the right axilla in a very violent lunge, whereby the button of the foil was broken off, and the foil itself passed into and through the back part of the thorax, the point coming out between the sixth and seventh ribs on the left side near the angles. There was but little bleeding. The chief symptoms were those of great inflammation of the contents of the cavity, which gave way to full and repeated bleeding from the arm, with perfect rest and almost starvation. He recovered very favorably, and was quite well in about eight weeks. He remains well, and is following his profession as a teacher of fencing.

330. When an incised wound into the chest is large and direct, injuring the lung, two very important points usually demand immediate attention. The first is to relieve the oppressed state of the breathing; the second, to suppress the bleeding.

In large penetrating wounds of the chest, with injury of the lung, it has been observed that the patient has breathed most easily when the external wound has been covered; and has been hardly able to breathe when it was opened, which is attributed to the air getting into that side of the thorax in inspiration, instead of entering the lung by the trachea. If the wound admit of being well closed, the difficulty of breathing diminishes; adhesion may take place, and the inflammatory action within the chest may terminate; but if the inflammatory symptoms continue, adhesion does not take place, and the secretion and effusion of a quantity of serous fluid are the consequence. This secretion of fluid is the natural consequence of inflammation which has passed the stage of adhesion, whether the injury of the chest have occurred from a stab or from a gunshot. It is the leading fact in the treatment of these injuries, hitherto disregarded by writers on this subject, but on the proper management of which, in both instances, a successful result principally depends. If the closure of the wound lead, in the course of a few days, to the re-establishment of the breathing, and the antiphlogistic means employed to the cessation of all urgent inflammatory symptoms, adhesion has most likely taken place, or is about to take place, in the neighborhood of the wound, and the patient will in all probability recover without much further suffering. If this should not occur, and effusion take place, the wound should be reopened, or the fluid otherwise evacuated.

A soldier of the 9th Regiment was wounded at Roliça, in 1808, by the point of a sword in the left side; it penetrated the chest, making a wound somewhat more than an inch long, through which air passed readily, accompanied by a very little frothy blood, which was also spit up on any effort being made to cough, leaving no doubt of the lung having been injured, that viscus appearing to be retained against the wall of the chest. As the edges of the wound could not be accurately kept in apposition by adhesive plaster, two sutures were applied through the skin, and the man was desired to lie on the injured side, with the hope that adhesion might take place, as there appeared to be no effusion of blood into the cavity. He was freely bled on each of the two days following the receipt of the wound, and gradually recovered.

A French soldier was brought into the village after the battle of Vimiera, wounded by a sword in the right side of the chest. He said he had lost a good deal of blood; was very pale; pulse small; extremities cold; breathing hurried and oppressed; had spit up some blood. On removing the handkerchief, a gaping wound presented itself, an inch and a half long, through which the cavity of the chest could be seen, the lung having receded. The wound did not bleed. As adhesive plasters would not keep the edges of the skin in perfect contact if he attempted to move, they were sewn together, and after the application of a compress he was much relieved. The next day all the symptoms were alleviated, and after the supervention of some serious inflammatory symptoms, he was forwarded to Lisbon, for embarkation for France, in a fair state of recovery.

It was the successful results of these cases which led to the closure of all such wounds in the first instance, with the hope of preventing thereby the extension of the inflammation to the whole sac of the pleura, which in many instances it succeeds in doing; and thus that which was done in the first instance from apparent necessity, rather than scientifically adopted, became a rule of practice, which may be laid down as a principle to be followed in similar cases. When persons thus wounded are neglected, the wound remains open, and the cavity of the pleura passes into a state of suppuration, after all the symptoms of acute pleuritis or of pleuro-pneumonia have taken place.

331. If the union of a large incised or other wound by the adhesive process does not take place, a bloody, serous fluid oozes out from under the dressings, if the oppression of breathing should not have led to their removal; the patient is relieved by the discharge, which, after a time, as the case proceeds toward recovery, will become less in quantity and more purulent in quality.

If the union of the divided parts should take place externally, and the general as well as local symptoms become more urgent, there can be little doubt of a collection of some kind having taken place, and then auscultation and percussion, if the latter can be borne, become of the greatest importance. From the moment the wound is closed the ear becomes the most important guide; the only one in fact to be depended upon as to what is going on within the chest. The case is one of pleuritis, perhaps of pleuro-pneumonia, and hence the reason that the symptoms and treatment of these complaints have been more fully noticed than might be considered to appertain to the province of surgery. The effusion of a bloody, serous fluid comes on, after a penetrating injury, from the third until the seventh or ninth day, by which time the cavity of the pleura may be filled; puncturing the chest between the sixth and seventh ribs at the point of election, or reopening the wound, should be early resorted to for its evacuation.

A picket of Portuguese infantry being surprised by a sudden rush of French cavalry from the town, during the first unsuccessful siege of Badajos, were nearly all sabred. The survivors were brought to me. Two had been run through one side of the chest, and one through both sides; the last died a few minutes after I saw him. The other two seemed to be nearly in a similar situation from loss of blood by the mouth and from the wounds. These were immediately closed by stitches, compresses, and adhesive plasters. A little hot brandy and water was given to each, and they were laid aside without hope of recovery. They did not die, however; the breathing became more easy, the distress less, and the pulse more distinct; reaction after a time took place. The next morning, the siege being abandoned, they were removed to Elvas, where I afterward heard they were doing well.

A soldier of the Third Division of Infantry, under the command of Sir James Kempt, was wounded at Waterloo, by a straight sword or sabre, which penetrated the left side of the chest. He fell, and lost a considerable quantity of blood from the mouth as well as from the wound, and was supposed to be dying. On showing some signs of life, the wound was covered by a part of his shirt; and on his arrival at the Elizabeth Hospital in Brussels, four days afterward, it was closed. On the ninth day, when my attention was drawn to him, he was sitting up in great distress, from difficulty of breathing, his hand pressed upon the wounded part, the cicatrix of which was red, swollen, and projecting. I recommended the assistant-surgeon in charge to open this with an abscess lancet, which he did, giving vent to a very large quantity of bloody and purulent matter, to the great relief of the patient for several days, although he did not ultimately recover.

The advantage derived from the closure of the wounds in these cases was manifest. It relieved the breathing, and caused the hemorrhage to cease, aided, in all probability, by the exhausted state of the patients. The relief to the breathing was at the moment the most essential point, the wounds of entrance being nearly two inches long, and the free admission of air quite unopposed; the lung had receded from the opening.

332. The important question of hemorrhage, in cases of incised wounds admitting of being accurately closed, remains for consideration. In many instances, the quantity of blood effused is trifling, and in others, although greater, it is absorbed without being productive of evil. In a third class, the quantity extravasated is larger than can be absorbed, although it does not flow in an inconvenient or dangerous manner through the wound, and may ultimately become coagulated and adherent to the diaphragm and spine in the angle between them, when the patient lies long on his back. In the worst or most alarming cases, the loss of blood is and has been so great that its suppression offers the only chance for the continuance of life. It is between these two last cases only that a difference of opinion exists as to the treatment to be pursued: one party desiring that the effused blood, if moderate in quantity, should be allowed to discharge itself, the wound being kept open; the other, that under all circumstances, whether the quantity of blood poured out be small or great, the wound should be closed, and the result awaited. The right course is, I apprehend, to remove all the blood which can be evacuated by position, provided it can be done without danger to the patient, rather than to allow it to fill the chest; but as the bleeding vessel in the lung cannot readily be got at, if seen, nor be secured by ligature with advantage, it is advisable, if the bleeding continue, to close the wound, and allow the cavity of the pleura to be filled, until the lung shall be sufficiently compressed to cause the hemorrhage to cease, if the person survive so long. The first object is to save life; after that, if time be given, the next will be to relieve the loaded cavity. After the wound has been closed, and the patient has so far recovered that reaction has begun to take place, it may be concluded that the bleeding has ceased. The chest should then be most carefully auscultated from day to day, so that its respiratory state may be known, particularly with regard to the increase of effusion, which will then be serous. This will not take place until after the third, and not perhaps before the fifth or sixth day, in any considerable quantity; when, if it should have occurred, the wound should be reopened, or another opening made at the most convenient place for the evacuation of the effused blood and serum. It is probable that the wound of the vessel in the lung which furnished the blood will be closed in five or six days: while it is of great importance that the lung should be early relieved from pressure, that it should be allowed to expand, and not be bound down by false membranes; which will be the case if the compressing fluid be not removed, and the inflammatory symptoms subdued. There is no object to be gained but the suppression of the hemorrhage by retaining the blood and serum within the chest; while the probability of a return of the bleeding is not great after an opening has been made, and the blood and serum have been evacuated, although much mischief will inevitably follow the effused fluids remaining too long.

Repeated observation has shown that in sabre-wounds penetrating the chest and lung, which have not united, and from which no excessive hemorrhage has occurred, a great discharge of serous fluid usually takes place from the cavity, which, gradually diminishing, becomes purulent, and at last ceases, without the function of the lung being destroyed; while, if the wound had been early closed, and the fluid collected too long retained, the functions of the lung would be impaired, and a counter-opening, for the relief of the resulting empyema, may be unavailing. Whenever, therefore, the adhesive process between the pleuræ has failed, and great effusion has taken place, the sooner it is discharged the better.

In addition to the closure of the wound, it is desirable to arrest the hemorrhage by other means, if possible, such as the abstraction of blood from the arm to such an extent as it may be considered the patient can bear, the administration of the acetate of lead with opium, turpentine, matico, or the mineral acids; and the external and internal use of cold or iced water, if it can be borne. If there be reason to believe that a rib or ribs have been injured--that any extraneous body is inclosed in the wound--or, from its appearance, that it will certainly reopen, an incision should be made in the part injured, for the purpose of giving the necessary assistance. The cure, however, will not only be assisted, but mainly effected, by procuring a depending opening by means of the small trocar and canula introduced as low down as auscultation will authorize; the introduction of this instrument will give the desired information on the one hand, and do little or no harm on the other.

A soldier of the 3d Regiment of Infantry was wounded by a lance at the battle of Albuhera, in the left side, between the fifth and sixth ribs; and was thrown down, bleeding from the mouth and from the wound, which was afterward closed by his comrades, by confining upon it a piece of his shirt folded up for the purpose. Brought to the hospital, at the village of Valverde, he appeared ten days afterward to be dying from difficulty of breathing. On enlarging the opening in the integuments, a quantity of blood, partly fluid, partly coagulated, issued from the cavity of the chest. The wound was kept open to allow the discharge of this, and of a reddish, watery fluid, which, after a few days, became purulent. At the end of three weeks I sent him to Elvas, doing well, and with but little discharge from the wound.

A heavy dragoon, of the German Legion, was wounded at the battle of Salamanca by a sword, which penetrated the cavity of the right side of the chest, between the sixth and seventh ribs. He fell from his horse, and lost a considerable quantity of blood from the mouth and from the wound. On examining the wound next day, a black coagulum was seen filling up the orifice, the cellular membrane around being considerably ecchymosed, and little doubt existed that the oppression in breathing under which he labored was caused by blood effused into the cavity. On separating the edges of the wound with a director, several ounces of blood, half fluid, half coagulated, were evacuated by making the external opening, which was enlarged, quite dependent. The lung was then seen in contact with the external opening of the wound, having expanded as the pressure of the blood was removed from it. The wound was closed simply by lint, compress, and adhesive plaster, without bandage; the man was largely bled, and placed upon his wounded side on the ground, being the most comfortable position, in some degree relieved from the oppression in breathing. Two days after, the wound discharged freely a reddish-colored watery fluid, evidently from the cavity of the chest, the exit of which was aided by keeping the wound generally dependent. This continued for several days, the fluid gradually becoming less in quantity, and purulent; under careful management he was able to go to the rear, nearly well, by the end of October.

333. On the subject of the ecchymosis, which Valentin considers to be a pathognomonic sign of effusion of blood within the chest, he says: “It is very dissimilar to that which occurs after a blow or wound, and which takes place shortly after the accident, beginning around the wound, if there be one, and extending from it. The patient also complains of pain when the bruised part is pressed by the fingers. These characters are not observed in the ecchymosis, the sign of effusion, which always takes place near the angles of the lower or false ribs descending toward the loins. Its color is identical with that which appears on the abdomen of persons some time after death, a bright violet, (violet très éclairci.) It appears about ten days after the receipt of the injury, sometimes later.” The same sort of thing, he thinks, takes place when the cavity of the chest is filled with pus, but that edematous swelling is without discoloration.

334. In order to be explicit on points so important as those of which I have treated, I have thought it right to lay down certain general conclusions, subject to occasional deviations:--

a. All incised or punctured wounds of the chest should be closed as quickly as possible by a continuous suture through the skin only and a compress supported by adhesive plasters, the patient being afterward placed on the wounded side--a precept which is absolute only with respect to incised wounds capable of being united by suture in the manner directed.

b. As soon as the presence of even a serous fluid in the chest is ascertained to be in sufficient quantity to compress the lung, a counter-opening should be made in the place of election for its evacuation by the trocar and canula, which may be afterward enlarged; unless the reopening of the wound should be thought preferable, which will not be the case unless it should be low in the chest.

c. If blood flow freely from a small opening, the wound should be enlarged so as to show whether it does or does not flow from within the cavity. If it evidently proceed from a vessel external to the cavity, that vessel must be secured by torsion or by a ligature applied on it, all the other methods recommended being simply surgical absurdities.

d. If blood flow from within the chest in a manner likely to endanger life, the wound should be instantly closed; but as the loss of a reasonable quantity of blood in such cases, say from two to three pounds, will be beneficial rather than otherwise, this closure may be delayed until syncope takes place or until a further loss of blood appears unadvisable.

e. If the wound in the chest have ceased to bleed, although a quantity of blood is manifestly effused into the cavity of the pleura, the wound may be left open, although lightly covered, for a few hours, if the effused or extravasated blood should seem likely to be evacuated from it when aided by position; but as soon as this evacuation appears to have been effected, or cannot be accomplished, the wound should be closed. It must be borne in mind that the extravasation which does take place is usually less than is generally supposed--a point which auscultation will in all probability disclose.

f. If the cavity of the pleura be full of blood, and the oppression of breathing and the distress so great as to place the life of the patient in immediate danger from suffocation, the wound should be reopened, if it have been closed, or freely enlarged, if small, to such an extent as will allow a clear evacuation of the effused blood. It has been supposed that in such a case the lung does not sufficiently collapse, and the bleeding is therefore continued because the vessel cannot contract; but the lung will usually collapse under pressure of the air, unless prevented by previously-formed adhesions, when the hemorrhage may possibly cease--instances of which are said to have taken place, and the practice should therefore be borne in mind.

LECTURE XXIII.

WOUNDS OF THE CHEST, ETC.

335. Gunshot wounds of the chest, penetrating the cavity, are always exceedingly dangerous. After the battle of Toulouse, on the 10th of April, 1814, one hundred and six cases of wounds in the chest in officers and soldiers, in all of whom the cavities were not penetrated, were received into hospital. Between the 12th of April and the 28th of June thirty-five died, fourteen were discharged to duty, and fifty-seven were transferred to Bordeaux to proceed to England, some to die, some to be pensioned, but few in all probability to return to the service--being an ultimate loss of nearly one-half, if the fifty-seven cases sent to England could be traced. M. Menière, in giving an account of the wounded carried to the Hôtel-Dieu of Paris, in the three remarkable days of July, 1830, where every case was immediately taken care of, says forty cases were received into the hospital; of these twenty died; he states the case of ten more, seriously wounded, who recovered; and he gives the names of seven more, in six of whom the cavity of the chest was not perforated, and alludes to three wounded by small-swords, who recovered--the loss being thus one-half, even if the rest happily and perfectly recovered, which may be doubted, thus showing that with the ablest assistance the Hôtel-Dieu of Paris could afford the loss was one-half. After the battle of Waterloo the loss was much greater; with the army on the Sutlej the loss was deplorable, in consequence of the want of a sufficient number of medical officers and of means--a state of destitution to which I have drawn the attention of the directors of the East India Company in the strongest possible terms, but which they will not rectify, but which will some day, I hope, become the subject of Parliamentary discussion, and, I doubt not, of public reprobation. That the wounds of the chest with the army in the Crimea will afford a more satisfactory result, cannot, I fear, be expected, and for similar reasons.

336. When a musket-ball fairly passes through the cavity of the chest, the orifice of entrance is round, depressed, dark colored, and more or less bloody in the first instance; the orifice of exit is generally more of a rugged slit or tear than a hole. The alarm is great, and the powers of life are much depressed. The wounds may or may not bleed; the sufferer may spit up more or less blood; respiration may be difficult, countenance pale, extremities cold, pulse variable--symptoms dependent on particular constitutions and circumstances connected with the extent of the injury.

It has been said that balls are apt to run round the body, coming out at a point opposite to that at which they entered, without penetrating the cavity of the chest; this, whenever it does take place, is a rare exception to a general rule, dependent on the ball being reflected from something solid which it cannot penetrate, such as a button, a piece of money, a rib, etc. If the ball run under the integuments exterior to the fascia covering the intercostal muscles, it is usually marked by a tenderness in its course on touching the part and a discoloration of the skin. A ball may, however, run between two ribs for some distance, injuring the muscular structures between them without penetrating the cavity, in which case, after the first moments of alarm have passed away, the symptoms indicative of a penetrating wound either cease or do not occur, although those of inflammation of the pleura or lung may and often do follow to a considerable extent.

When the ball cannot be traced, the absence of symptoms, after the first period of alarm has subsided, will enable the surgeon to form the surest prognosis; their absence, however, cannot too certainly be relied on.

A ball will occasionally rebound from the sternum, leaving merely a black mark; from the spongy nature of that bone in which they frequently lodge, they require the application of the trephine. If a ball should be felt through a wound in the sternum, the broken portions of bone should be removed by the small saw or by the trephine, and the ball extracted.

337. An enlargement of the wound, the “debridement” of the French, does no harm beyond the pain it occasions, unless there be something to be removed, when an incision becomes necessary, in many instances, for the removal of extraneous bodies or for the evacuation of blood, etc. When a wound from a musket-ball appears likely to have penetrated the cavity of the chest, and is too small to admit the end of the finger, the opening ought to be enlarged so as to allow its introduction as far as the ribs, in order to ascertain whether those bones have sustained any injury, or whether anything is lodged exterior to or within them. It is not necessary that a man should be cut simply because he has been shot; and an enlargement of the wound should be of no greater extent than is absolutely necessary for the purpose intended. When pieces of shell, or of a sword or lance, are broken off and partly lodged in the cavity of the thorax, which is more likely to happen when they enter through the large muscles of the back, they will require larger incisions to give room for their removal. Great praise was given of old to Gerard, surgeon-in-chief of La Charité in Paris, who, having perceived that a small sword, after going through a rib, was broken off close to it, thought it advisable to make an incision through the intercostal muscles into the chest, and then to introduce his forefinger, armed at the end with a thimble, with which he pressed back the point of the broken blade. In a case of this kind, the surface and outer edge of the bone should be removed, until the piece of steel can be firmly seized and withdrawn by a fine pair of pincers or pliers.

When a ball sticks firmly between two ribs, it requires some care to remove it, as the rib both above and below may be more or less interested, although not actually fractured. The attempt should be made during inspiration, when the lower rib should be depressed, and some thin but not sharp-pointed instrument like an elevator should be gently pressed around and under the looser edge of the ball, in order to extricate it.

When a musket-ball fractures a rib, there ought to be no hesitation about the propriety of enlarging the wound, to allow the splintered portions of bone to be removed. It is possible that in doing this some pieces of cloth or other matters may be extracted, which might else glide into the cavity of the thorax, or stick in the lung itself.

A soldier of one of the regiments on the left of the position of Talavera was brought to me, wounded by a ball in the left side of the breast; it had struck the sixth rib, and passed out about four inches nearer the back. As the point of the finger indicated the presence of broken bone, I enlarged the anterior wound, and then found that the ball had driven some spiculæ of bone into the surface of the lung, which appeared to have been previously attached to the pleura costalis at that part. These having been removed, together with a piece of coat which had been carried in with the ball, a small, clean wound was left, which gradually healed up, the man accompanying me on the retreat over the bridge of Arzobispo.

338. When a ball impinges with force on the center of one of the ribs, and passes into or through the chest, the bone is usually broken into several splinters of different lengths, some of which frequently accompany the ball in the commencement of its course, or are even carried into the substance of the lung, together with a part of the wadding of the gun, or of the clothes of the patient. These should if possible be extracted if they can be seen, and the sharp ends of the rib rounded off. When the ball fractures a rib on passing out of the chest, the splinters are driven outwardly, and should be removed by incision.

339. When a ball strikes a cartilage of one of the ribs, it does not punch out a piece as it were, but merely divides and passes through it, bending it inward, rarely tearing away a portion. The parts of the cartilage thus bent and turned inward are to be drawn outward, and replaced by the end of the finger, a bent probe, or other curved instrument.

A ball, when striking obliquely but with force on the chest, will frequently penetrate, and then run round, between the lung and the pleura lining the wall of the chest, for a considerable distance, before it makes its exit. In this case the lung may be only slightly bruised, without the pleura pulmonalis or costalis being more than ruffled. In others the lung shows a distinct track or hollow made by the ball. A shade deeper, and the ball penetrates, and forms not a hollow, but a canal. The patient in all these cases spits blood, and the first symptoms are severe; they frequently, however, subside, and are not always followed, under proper treatment, by effusion, although it may always be expected.

340. When a ball fairly passes through the lung, it leaves a track more or less bruised, which continues for a time to bleed according to the size of the vessels which are injured, thus making a wound more dangerous as it approaches the root of the lung where the vessels are largest. More or less blood is spit up, or, if effused, it gravitates in the chest, until it rests on the diaphragm or other most depending part, according to the position of the patient. If it should be in quantity, the filling up of the chest may be ascertained by auscultation, if the wound be closed. As the quantity of effused blood increases, the lung becomes more and more compressed, until at last the hemorrhage ceases under pressure, if the wound be covered; and the patient is saved for the moment, unless he should die of asphyxia, from the lung on the other side being also compressed through the bulging of the mediastinum on it; to prevent which, if possible, the wound should be reopened or enlarged, so as to take off the pressure of the effused and perhaps coagulated blood. If the person wounded shall have suffered formerly from inflammation, and the lung has adhered in consequence to the wall of the thorax, at the parts where the ball enters and goes out, the cavity of the chest will not be opened, and the track only of the ball will communicate with the external parts, unless the ball shall have perforated some of the large vessels, when he will continue to bleed by the mouth. The pressure of the blood effused into the track of the ball, which may become coagulated, will sometimes suffice, under even these circumstances, to effect the suppression of the hemorrhage which the loss of blood, the faintness of the patient, and the weakness of the circulation, under proper treatment, will materially assist in rendering permanent.

General Sir G. Lowry Cole, G.C.B., was struck at the battle of Salamanca, on the 22d of July, 1812, by a musket-ball, which entered immediately below the clavicle, fractured the first rib, and, inclining inward, came out through the scapula behind; as he spat blood for three days, the upper part of the lung was shown to have been injured. The ball appeared to have passed so close to the under part of the subclavian artery that the greatest fears were entertained for his safety; more particularly as a marked difference in the size of the pulse was perceived in the left arm, which did not exist before. He remained three days on the field of battle, in a Portuguese officer’s tent I always carried with me. Under repeated bleedings, and the strictest antiphlogistic treatment, several splinters having come away, and a large piece of the rib and of the scapula having exfoliated, he gradually recovered, so as to be able to resume the command of the Fourth Division in October at Madrid. The subclavian artery never resumed its power, and the radial always beat less forcibly on the left side. He perfectly recovered his health, the respiratory murmur of the lung being natural. He died suddenly in 1844, from rupture, I believe, of an aneurism of the abdominal aorta.

A dragoon of the King’s German Legion, shot in a nearly similar manner on the same occasion, suffered more severely: the clavicle and first rib were splintered to a greater extent, and he lost a large quantity of blood by the mouth. The splinters having been removed, after enlarging both wounds for that purpose, and the inflammatory symptoms subdued, he appeared to be going on favorably for three weeks; when, having eaten some meat obtained irregularly, he suffered what seemed to be a bilious attack of vomiting and purging, attended by fever and oppression in the chest; an ipecacuanha emetic having been given with full effect, relieved him much. During the efforts to vomit, the wounds discharged a quantity of sero-purulent fluid, a piece of the cloth of his coat, and another of bone, which had gone in with the ball, and in all likelihood had been lying with the matter at the bottom of the chest. After this he slowly recovered. This case is peculiarly instructive.

General Sir Andrew Barnard, G.C.B., was wounded when in command of the Rifle Brigade, at the passage of the Nivelle, on the 10th November, 1813, by a musket-ball, which entered between the second and third ribs, in front of the right side of the chest, passed directly through the cavity and through the shoulder-blade, from under the integuments covering which it was removed. He not only felt but heard the sound of the ball as it struck him, and he fell from his horse. Blood gushed from his mouth, and continued to do so until after he was completely exhausted by bleeding from the arm to the amount of two quarts. He was again bled at night, and the subsequent morning, which relieved all the material symptoms. During six weeks he suffered from difficulty of breathing and cough, and from night-sweats. Some pieces of bone and cloth came away from the wounds, with a free discharge in the first instance, which gradually diminished until the wound closed. In eight weeks he was able to resume his command.

More than forty years afterward I found the lung pervious; the vesicular murmur could be freely heard even up to the situation of the wounds, to the internal parts of which it may be concluded the lung adhered, from the sound conveyed to the ear on auscultation. He suffered little or no subsequent inconvenience from the injury, and died in January, 1855, aged 82.

Case of Major-General Broke, by himself.--Toward the close of the battle of Orthez, on the 27th of February, 1814, a musket-shot struck me between the second and third ribs on the right side, near the breast-bone. I was then on horseback, being aid-de-camp to Lieutenant-General Sir Henry Clinton, commanding the Sixth Division. The sensation was precisely as if I had been struck a violent blow with the point of a cane, but it did not unhorse me. I was attended in a very short time by the surgeon of the 61st Regiment, when, on removing my clothes, the air and blood bubbled out from the wound as I drew my breath. The surgeon, turning me on my face, discovered the ball to be lodged under the thin part of the blade-bone. This he cut through and extracted the ball, and with it pieces of my coat, waistcoat, and shirt, which were lodged between the ribs and the blade-bone. This occurred about four P.M. I was then removed to the town of Orthez, a distance of about three miles, and in the course of the afternoon the veins of both arms were opened in at least seven different places, but scarcely any blood came away; breathing became exceedingly painful in a day or two, and I felt nearly suffocated, when, in the evening, my brother, Sir Charles Broke Vere, arrived with my friend, Mr. Guthrie, who examined me carefully. The agony of drawing breath was such that I could scarcely endure it. He opened one of the temporal arteries, and desired that it might be allowed to bleed without interruption. He afterward left me to visit some other wounded men, and returned in about three hours, when I told him that I felt relieved, and had much less of the suffocating pain in breathing. He then opened the other temporal artery, directing as before that its bleeding should not be checked. I shortly after that dropped asleep, and on waking could breathe freely; my recovery was progressive from that time, the wound in front, where the ball entered, being the first closed; but both were healed at the end of about eight weeks, and in about ten I was able to rejoin the army at Bordeaux.

H. G. Broke, Major-General.

He is now, in 1855, in perfect health, the respiratory murmur being free all over the chest.

The Duke of Richmond, then Earl of March, was wounded by a musket-ball at the battle of Orthez, while at the head of his company in the 52d Light Infantry. He was standing at the moment with his right face toward the enemy. The ball entered that side of the chest, between the fourth and fifth ribs, nearly in a line with the lower edge of the scapula. He fell to the ground with great violence, and was speechless for some time. He stated to me at a subsequent period that the sensation he felt at the moment was as if he had been “cut in two.”

On immediate examination there was no other opening to be found but the one where the ball had entered; nor were the medical officers able to feel the ball anywhere under the skin or under the muscles.

The wound having been dressed he was laid on a door and removed to Orthez, about three miles from the scene of action, during which he complained of excruciating pain, extending from the wound to the top of the os ilii on the same side, the pain being much aggravated by frequent and severe cough, with copious expectoration of frothy mucus, and much florid blood; respiration hurried; countenance pale.

The moving him to Orthez occupied nearly three hours; a great part of the ground being very rough and broken, the men could not well step together, and the consequent unavoidable shaking and jolting caused him much pain. On his arrival at Orthez, he was extremely languid, with a tendency to syncope. Pulse feeble; extremities rather cold.

Seven in the evening: After having been faint for an hour, he became hot and restless; pulse 108, and full; skin more hot, and the respiration short and more hurried. After he was placed in bed hemorrhage from the wound took place to a very considerable extent. Eight ounces of blood were taken from the arm. (Could bear no more.)

15th inst., nine A.M.: After the bleeding he became more quiet, and had less pain; but he has since become very restless, and the pain returned, with a full, hard, and frequent pulse. The wound has again discharged a very considerable quantity of blood. Bleeding repeated as before.

Nine P.M.: Deputy-Inspector Thomson and Staff-Surgeon Maling examined the wound. Mr. Maling introduced his finger (the whole length) between the ribs into the wound without any interruption to its progress, and without being able to reach the termination of the passage of the ball; and Dr. Thomson then passed a probe (its whole length) straight into the chest, with a similar result; thus leaving no doubt on the minds of all present that the ball had passed directly into the posterior part of the chest.

Midnight: The blood last taken is very buffy; and there has again been an immense discharge of blood, etc. from the wound; the sheets, mattresses, etc. are saturated with it; and on the floor, under the bed, there is a large pool of blood which had soaked through the bedding. Pulse 114, low and frequent; cough and expectoration as before; pain violent, and great restlessness. Repeat the bleeding.

Mem.--Perhaps enough has now been stated to show the nature of the wound; and any further detailed statement of his lordship’s sufferings, or the treatment of his case, would be unnecessary. On the latter point, however, it may be mentioned that, exclusive of the general treatment, he was bled seven times between the evening of the 27th of February and the morning of the 2d of March, the cough, expectoration, breathing, pain, etc. being much relieved by each bleeding.

A. Hair, M.D.

Mr. Guthrie saw the Earl of March on the same day as Colonel Broke, and suggested that no further efforts should be made to find the ball, while the treatment adopted should be steadily pursued; and in 1846, he pointed it out lying under the edge of the base of the scapula. His grace is now, 1855, in good health, and the chest, well formed, sounds clearly and healthily in every part, even at the point injured.

341. The ball in passing through the lung, in these cases, destroyed the life of that part only which it touched; and although air would pass out at the time, this would not be of long continuance. The wounds being kept covered, the lung did not and does not usually, in similar instances, collapse or recede from the wall of the chest, but quickly recovers its state of expansion, however impaired it may be at the moment by the injury. The track made by the ball gradually suppurates and heals, leaving merely a depression or cicatrix on the surface attached around or in part to the wall of the chest by adhesion. The track through the lung may be readily seen in such cases after death; although during life it interferes so little with the respiratory murmur as not to be observable, unless by its greater distinctness, from the thinness of the intervening parts.

Mrs. M. was wounded by a small pistol-ball, which entered on the right side from behind, between the seventh and eighth ribs, just under the arm when hanging down, and passed out in front over the cartilage of the sixth rib, more than an inch from the pit of the stomach. She had not spit blood, and the ear declared the lung to be pervious to air at the wounded part, which raised a hope that the ball might not have penetrated the cavity, although it might have injured the pleura. As she suffered great pain twenty-four hours after the injury, the breathing being oppressed, Mr. Adams bled her into a hand-basin, until about to faint. She lost nearly thirty ounces of blood, but her symptoms were quite relieved, so as to render any other bleeding during her treatment unnecessary. At the end of the third day she spat a very little blood after removal in a carriage to another lodging, and then gradually recovered. After four different stethoscopic investigations, I came to the conclusion that the ball had not struck the lung in the first instance, although the lung adhered to the pleura costalis, and suffered from some abrasion or ulceration at that point, which gave rise to the expectorated blood.

These cases are instances of wounds of the upper part of the lung, which are in general more dangerous than those of the lower, from the vessels being larger, and from the greater difficulty with which any extravasated blood or fluids can escape. They also prove that when blood is poured out in small quantity, it may be absorbed, but what that quantity may amount to is doubtful.

342. In cases in which the external opening or wound does not communicate freely with the cavity of the chest, the principal danger arises from the inflammation of the pleura ending in effusion, which, if not evacuated, leads to the loss of the individual. It is the great fact to be attended to in the treatment of pistol wounds of the chest, or those made by small balls which do not pass out. All the persons I have seen die from small balls have died with the affected cavity more or less full of fluid. The post-mortem reports of all persons killed in England in duels by wounds through the chest, unwittingly attest this fact, as well as the insufficiency of the surgical treatment they received; and the necessity, for the future, for its amendment. It is in these cases that the stethoscope is most valuable--its frequent use indispensable. When the respiratory murmur ceases to be heard except at what is the upper part of the chest, whatever the position of the patient may be, it is full time to enlarge the original opening, or to draw off the fluid by the trocar and canula.

Laennec thought that when a considerable effusion took place in pleuro-pneumonia, filling the posterior part of the chest when the patient lay on his back, it nevertheless diffused itself over the whole surface of the lung; but dissection has shown, in cases of wounds, that the fore part of the lung may be applied to the anterior part and sides of the ribs, while a serous effusion fills the hollow behind, the respiratory murmur being distinctly heard above it. It is the most important fact to ascertain, particularly in pistol or small penetrating wounds of the chest, in which the opening is not sufficiently large to allow any fluid effused to run out.

Sir C. B. was wounded by a pistol-ball in the back, which passed into the chest through the lower part of the lung of the right side, and lodged on the inside of the wall of the chest in front of the same side, sticking in and against a rib, but giving rise to no external marks or signs of mischief at that part, so as to admit of an operation for its removal. The inflammatory symptoms having been restrained, it was nevertheless obvious that the cavity of the chest was full of fluid, and that the oppression in breathing arose from it, and not from the injury done to the lung. The stethoscope was then unknown, the ear was not in use; my older colleagues were obstinate; they would not hear of an operation for enlarging the wound into the chest; and as our patient was, unfortunately for him, shot in London, instead of at the pass of Roncesvalles, or on the bridge over the Bidassoa at Irun, we let him die on the eighth or ninth day, without all the aid which surgery might have given him. It is possible he would not have recovered under any circumstances, from the ball having lodged, and from his advanced age.

A soldier of the Fifth Division of Infantry was wounded at Toulouse by a musket-ball, which entered between the fourth and fifth ribs of the right side, near the sternum, and came out behind nearly opposite, fracturing the ribs, the splinters of which were removed. The first symptoms of inflammation, having been in some degree subdued by the sixth day, were followed by those more immediately indicating effusion; such, particularly, as great oppression, difficulty of breathing, and inability to lie in the recumbent position, which induced me to introduce, after a little pressure, a gum-elastic catheter into the posterior wound, through which a quantity of red, serous fluid was withdrawn, exceeding, perhaps, three pints by measure. On the removal of the catheter the discharge of fluid ceased, and, under a strict antiphlogistic treatment, the man gradually recovered, so as to be sent to England in the following June. If the symptoms of oppression had returned, I should have repeated the operation perhaps lower down. Auscultation, if it had been then known, would have smoothed away many doubts and difficulties.

A soldier of the 40th Regiment was wounded at Toulouse on the 10th of April by a musket-ball, which entered about two inches below the nipple of the right breast, passed through the cavity and the lung, and came out behind at a nearly opposite point, injuring the ribs above and below, without entirely destroying their continuity. He was bled largely on the morning of the 11th, and again at night. On the 12th the bleeding was repeated; some small pieces of ribs were extracted from both orifices, and some part of his dress from the anterior one. He spat blood when he coughed, and respiration was difficult. Calomel, opium, and antimony were given in pills every six hours, and the bleedings were repeated daily, and sometimes oftener, for the first eight days, during which time a free discharge, at first serous, afterward purulent, took place from the wound, after which the inflammatory symptoms subsided; the cough became easier, the expectoration less, and free from blood; breathing easy. The calomel was omitted; a mild farinaceous diet was allowed instead of a little gruel, and a very little bread and milk. In a fortnight the wounds began to heal. On the 1st of May, some small pieces of rib were removed from the anterior wound, after which both gradually closed, and he was forwarded to Bordeaux on his way to England in the beginning of June, cured.

Corporal Dunleary, of the 69th Regiment, was wounded on the 16th of June, 1815, at Quatre Bras, by a musket-ball, which entered the thorax, fracturing the seventh rib on the fore part of the right side, and lodged. He said he had lost a large quantity of blood from the mouth, and some from the wound, between that and the 19th, when he was brought to the hospital in Brussels. The pulse was then quick and hard, respiration difficult and anxious, and a bloody discharge issued from the wound on every respiration; bowels confined since the accident; was bled to forty-four ounces; saline purgatives, with calomel, antimony, and opium, were given until the 29th of June, when the wound discharged good pus. From this time, at different periods for six weeks, he lost ninety-two ounces more blood, being strictly placed on milk diet. Several pieces of rib exfoliated. He was sent home on the 31st of August, declaring himself quite as well as ever he had been in his life; the ball remaining undiscovered.

A soldier of the Fusilier Brigade was struck by a musket-ball on the right side of the front of the chest, at the battle of Albuhera; it entered between the fifth and sixth ribs, passed through the lungs, and lodged. Three days afterward, when the first symptoms were in part subdued, he complained of pain in a particular spot, nearly opposite to where the ball had entered, at which part something could be felt deeply seated. An incision being made, the ball was found lodged in the intercostal muscles between the ribs, whence it was easily removed. A considerable discharge of reddish-colored serum followed, with great mitigation of the symptoms, after which, under strict treatment, the man recovered, and was sent to Elvas with every prospect of a cure.

Lieutenant-Colonel Harcourt and Major Gillies, of the 40th Regiment, were both shot through the chest, at the head of the regiment, at the successful assault of Badajos; the wounds were as nearly similar as possible, from before directly backward. They were taken to the same tent, and treated alike with the same care by the late Mr. Boutflower, the surgeon of the regiment, with whom I saw them daily. The inflammatory symptoms ran high in both. In Major Gillies, a tough old Scotchman, they could not be subdued, and he died, at the end of a few days, of pleuro-pneumonia. Colonel Harcourt slowly recovered, and died Marquis d’Harcourt, near Windsor, more than twenty-five years afterward, suffering little or no inconvenience from his chest, when I last saw him.

Captain Cane, 23d Fusiliers, was wounded at the affair of Saca Parte, in front of Alfaiates, in 1812, by a musket-ball, which struck him below and a little to the outside of the left nipple, fractured the rib, and entered the chest, giving rise to the sensation as if the ball had passed diagonally downward and backward to the loins of the same side. He spat blood, and was very faint. The next day he could scarcely breathe, was in great pain, continued flushed and anxious; pulse 100. He was bled into a washhand-basin until he fainted, and every day afterward, some days twice, to a less extent, for ten days, and once again until syncope was induced, on an accession of symptoms after an imprudence in taking a little wine, which nearly smothered him, he said. Some pieces of flannel shirt, of braces, coat, etc. were removed from the wound, and several portions of bone gradually followed, together with a quantity of matter, which continued to flow from May until the end of the following September, when the wound healed.

On the 23d Jan., 1821, I had an opportunity of examining this gentleman. My report says, he is never free from a little pain in the loins, where the ball is supposed to be, and cannot take a full inspiration without pain in the chest; expectorates more or less constantly, and occasionally a little blood about once in three or four months in half congealed lumps. Cannot ride or take any exercise because it brings on the pain. The cicatrix shows a large, deep hole, and the deficiency of the rib is well marked. The side of the chest is altogether contracted and flatter; the heart has been moved behind the sternum; the beat of the apex being on the other side of the xiphoid cartilage, and that of the heart, as a whole, is more indistinct than usual. In other ways in good health. It is possible that the ball may be lodged in or be retained by layers of coagulable lymph in the angle formed between the diaphragm, the ribs, and the spine.

William Downes, of the 11th Regiment of infantry, aged thirty-three, was wounded by a musket-ball, on the 31st of August, 1813, in the Pyrenees; it fractured the fourth rib of the left side, passed through the chest, and came out behind through the scapula. He spat a good deal of blood, although little flowed from the wound. The next day he was bled largely twice, to relieve the bleeding from the lung, and was sent to Passages, where he was bled daily; and thence, a ship being ready, to Santander, where he arrived on the 14th of September. A free, bloody, purulent discharge took place from the anterior wound, but little from the posterior, and he expectorated a bloody, purulent matter, and occasionally a little blood. Toward the end of September the sanguineous expectoration ceased; but the soft parts of the chest had sloughed and separated under an attack of hospital gangrene, from which he had a narrow escape during the month of October. The wound in the chest gradually closed during the month of November; and on the 14th of December he was discharged convalescent, his health tolerably good, but his breathing by no means free; no expectoration. The left arm was impaired in power, in consequence of the mischief done to the muscles of the fore part of the chest and shoulder by the hospital gangrene. The chest was altogether somewhat flattened and shrunk, but there did not seem to be any diseased action going on within.

Case of Lieutenant-Colonel Dumaresq, aid-de-camp to Lord Strafford, by himself.--While turning round, after a successful charge of infantry, at Hougomont, on the 18th of June, 1815, I was wounded by a musket-ball, which passed through the right scapula, penetrated the chest, and lodged in the middle of the rib in the axilla, which was supposed to be broken. When desired to cough by the medical officer who first saw me, almost immediately after receiving the wound, some blood was intermixed with the saliva. I became extremely faint, and remained so about an hour and a half, after which I rode four or five miles to the village of Waterloo, where I was bled, which relieved me from the great difficulty I had in breathing; this difficulty was accompanied by a severe pain down my neck, chest, and right side. I was much easier until the evening of the 19th; but in the course of the night, the difficulty of breathing becoming much greater, and the spasmodic affection having very much increased, I was bled seven times, until the middle of the next day.--20th. I continued better, but was then seized with the most violent spasms imaginable in my neck, chest, and stomach. I could scarcely breathe at all, and was in the greatest possible pain; I was again bled twice very largely, and my stomach and chest fomented for a length of time with warm water and flannels. I passed a very tolerable night, and continued pretty well until two o’clock the following day, when I was again very largely bled, by which I was very much relieved. I continued pretty well, and free from much pain; but my pulse having very much increased, and having a good deal of fever, on the 23d I was bled again; after this I continued free from much pain or difficulty of respiration, and on the 26th was removed into Bruxelles, when I came under your care. I forgot to mention that when I was so violently attacked I had two lavements most vigorously applied; salts, etc. proving of no avail, took digitalis, commencing with ten drops every four hours, increasing to fifteen from the second day.

N.B.--Up to this period, the 2d of July, the devil a bit have I eaten.

While with fat mutton-chops, and nice loins of veal, You stuff your d--d guts, your hearts are all steel. Oh! ye doctors and potecaries, you’ll all go to hell, For cheating our poor tripes of their daily meal. H. Dumaresq.

The ball in this case was lodged in the rib, which ultimately became thickened around it. He recovered with good health, but with occasional spasms in the chest; and died of apoplexy, in Australia, twenty-five years afterward. His doggerel lines show the buoyant and unconquerable spirit of a soldier, who knew that his chance of recovery was small. It was a most gallant, a most friendly spirit. Peace to his manes.

If the ball had caused a greater degree of irritation, I was prepared to cut down upon the rib, and remove a part of it, if necessary; for I have seen balls so situated slip from their lodgment, roll on the diaphragm, and cause general inflammation, suppuration of the cavity, and death, which must almost always ensue in such cases, unless the ball can be removed, and the matter evacuated by an operation to be hereafter described.

General Macdonald, of the Royal Artillery, was present at Buenos Ayres, when a bombarder of that corps received a wound from a two-pound shot, which went completely through the right side, so that when led up to the general, who was lying on the ground, he saw the light quite through him, and supposed he was of course lost. This, however, did not follow, and some months afterward the man walked into General (then Captain) Macdonald’s room, so far recovered from the injury as to be able to undertake several parts of his duty before he was invalided; thus proving the advantage of a shot, however large, going through rather than remaining in the chest.

LECTURE XXIV.

Appearances After Death, Etc.

343. The appearances after death differ materially even in apparently similar wounds.

A French soldier, shot through the right side of the chest at the siege of Badajos, died in December, 1812, in Lisbon, apparently of consecutive phthisis. The ball had gone through the chest from before directly backward; the posterior wound was closed; the anterior one was fistulous, and discharged a small quantity of matter, of which he spat up daily a large quantity until he died. The lung was diseased throughout, and contained several vomicæ or small abscesses, from which the matter expectorated was secreted. The track of the ball was nearly filled up, although the part immediately around was harder than usual. The lung adhered in many places to the wall of the chest, which was much flattened.

In other cases, portions of wadding, of leather belts, of splinters of different lengths, pieces of buttons, and even balls, have been found loose in the chest, showing the necessity for an especial and decided treatment.

A French soldier was wounded by a musket-ball at the battle of Waterloo; it penetrated the chest, fracturing the second rib, then passed through the lung, and went out behind in nearly a straight line, close to the spine. Left on the field of battle for five days before he was brought to Brussels, he was nearly dead with difficulty of breathing and other symptoms of inflammation, from which he recovered in the course of the next ten days, under repeated bleedings and the strictest antiphlogistic regimen. At the end of this time, when apparently doing well, an accession of inflammation and of all his bad symptoms took place, destroying him at the end of four weeks from the receipt of the injury. On dissection, the lung was found adherent to the chest by false membranes of some thickness, with a quantity of purulent fluid in the cavity. The track of the ball was in a suppurating state, and two pieces of rib were found in the center of its course. The whole of the lung appeared to be filled with a sero-purulent fluid, which could be readily squeezed out.

John Roth, of the 5th battalion of the 60th Regiment, aged twenty-nine, had been wounded by two balls, one on the 10th of April, 1814, at the battle of Toulouse, which grazed the left temporal bone; the other had gone through the upper part of the right chest, in the Pyrenees, the autumn before. Both wounds had healed. He was seized on the 8th of May, after a little intemperance, with pains in his body and joints, pain in the chest, and cough, with bloody expectoration; skin hot, tongue foul, and bowels confined. On the 9th he was bled, and purged by calomel, antimony, and salts. On the 10th symptoms augmented, pulse 120, small, and wandering, but no pain in the head. Repeat the medicines. Head shaved and cold applied; bleeding to ten ounces. 11th. Every symptom increased; great pain on touching the chest; pulse 126; skin hot. On the 12th passed his urine and feces involuntarily; and on the 13th he died, his body being covered by petechiæ.

The head, on examination, showed pus under the dura mater, at and behind the situation of the wound he had received. The right lung adhered to the walls of the chest where the ball had entered and passed out, the track made by it being very visible, indurated, and inflamed, from the last attack: the parts otherwise sound; no fluid in the cavity.

Mr. Drummond was wounded by a pistol-ball in the back, low down, about two inches from the spine, and three inches from the inferior angle of the scapula; it was afterward found to have entered between the eleventh and twelfth ribs, and to have passed between the base of the lung and the diaphragm, abrading the former, and passing through the latter into the abdomen, ultimately lodging in the fat under the skin, over the cartilage of the eighth rib of the left side, nearly at an opposite point in front. From the absence of all symptoms of shock and alarm, it was hoped by some that the ball might have run round, but on the removal of the little ball its course could not be traced. This occurred on Friday. On Saturday morning at five o’clock he suffered great uneasiness and difficulty of breathing, accompanied by a particular catch or jerk in respiration, indicating a wound of the diaphragm. The stethoscope and the ear attested the clearness of the respiratory murmur in every part of the chest, which sounded well, and I was satisfied the lung was not materially injured; twelve ounces of blood were drawn with difficulty from both arms. At ten o’clock, the jerk and difficulty of breathing being greater, the left temporal artery was opened, as no blood could be drawn from the veins; five ounces only could be obtained; a dose of calomel and a senna draught had been followed by the discharge of a teaspoonful or two of blood, leaving no doubt on my mind that the ball had penetrated the cavity of the abdomen, as well as of the chest, and that a bowel had been injured. With a constitution apparently unequal to bear an inflammation of the most dangerous character, or the remedies necessary to subdue it, the prospect was but melancholy. Thirty-six leeches were applied around the wound in front, but they drew little blood. Pulse from 108 to 112. Dr. Hume, Mr. B. Cooper, and Mr. Jackson were added in consultation on Monday at twelve, when the jerk became worse, the oppression in breathing greater. Muriate of morphia, half a grain; at two, bled to twelve ounces; blood very buffy; calomel, two grains, opium, half a grain, every two hours. In the evening, bleeding, repeated to fourteen ounces; no more would flow. Tuesday morning, at five, bled again to twelve ounces. The ear now indicated effusion for the first time. It was not, however, in sufficient quantity to render the evacuation of the fluid necessary. After this he gradually sank, and died on Wednesday morning. He lost on the whole fifty-six ounces of blood. On examination after death, it was found that the ball, after entering the cavity of the chest, had slightly abraded the left lung at its lower and inferior edge, which was covered by recent lymph, the lung being internally sound. The left side of the chest contained nearly a pint of red-colored serum. The ball had perforated the diaphragm, grazed the fat of the left kidney, passed through the great omentum below the stomach, to the part where it was extracted, injuring apparently no important organ in the abdomen in its transit, but giving rise to an effusion of blood from some small vessel which had sloughed, the blood being partly coagulated and partly diffused to the amount of many ounces; its loss appeared to have been the immediate cause of death.

A gamekeeper’s gun burst at the Red House, Battersea, and a small part of the lock entered the middle of the left arm, and passed upward into the axilla, where it could not be traced by Mr. Keate, who saw him within an hour after the accident. The symptoms which followed were those of inflammation of the chest, and were subdued by active treatment; the wound healed, and he returned to his occupation in Wiltshire. Having exposed himself to the night air some weeks afterward, the inflammation of the chest returned, and he died. On opening the thorax, one edge of the bit of iron was found impacted in the surface of the lung, the other edge was rubbing against the inside of the sixth rib, which was nearly worn through by the constant friction it underwent during respiration; there was also a mark on the pericardium as of a cicatrix, and of a graze on the surface of the heart.

Among the French prisoners in Lisbon, in the spring of 1813, I saw a man in whose chest a ball had entered midway between the fifth and sixth ribs, and lodged; from this a constant and considerable discharge of purulent matter took place. The ball was found after death lying between the diaphragm and the spine, surrounded by coagulable lymph, and adhering by its envelope to the spine and diaphragm at the angle formed between them; there was a very thickened pleura costalis; the lung was shrunk and attached by membrane almost equally thickened across the chest, the lower part of which was filled in the upright position by the discharge, which was only evacuated in quantity when the opening of the wound was made dependent.

A case was met with after the battle of Waterloo, among the French wounded, which was somewhat similar. A portion of rib had been driven in, and the assistant-surgeon was aware that the ball could occasionally be felt. The man died at the end of a fortnight, the cavity containing a quantity of sero-purulent bloody matter. The lung had been injured by the ball, which had fallen loose into the cavity of the chest.

344. The removal of splinters of bone, or of other foreign bodies from the lung, has occupied the attention of surgeons from the earliest periods, and some of them proposed to draw a piece of cambric or other things through the chest, for the purpose of removing them. These extreme measures have been abandoned; but there can be no doubt of the propriety of removing as many of these causes of irritation as can be either seen or felt. If the ball have broken a rib, the orifice of entrance especially should be enlarged as early and as carefully as possible, so as to give an opportunity for the removal of the splinters and of all angular points of bone which may be turned inward. A little addition to the original opening can do no harm, and if the lung should not collapse, or should it be adherent, it will enable the surgeon to see whether any splinters are impacted in it, and to remove them. It is possible that the end of the finger even may be introduced, and the lung felt, if it should not have receded too far; as it is insensible to such an operation, no evil will ensue; but all probings with small, sharp-pointed instruments should be avoided. That wadding, buttons, pieces of cloth, and of bone have been frequently coughed up, I have had experience; but although it is said that even balls have been thus brought up, I have not had an opportunity of seeing them.

An officer was wounded by a musket-ball on the 9th of July, 1745; it passed through the chest, entering in front, fracturing the seventh rib near its junction with the cartilage attaching it to the sternum, and passing out behind near the angle of the same rib, which it again broke, together with the one immediately below it. M. Guerin enlarged the openings of entrance and of exit to the extent of nearly two inches, by dividing the pleura, the intercostal muscles, and the integuments from within outward. Several splinters of the rib injuring the lung were removed, the smallest of which might be half an inch or six lines long, by two wide. A tent was then passed through the wound. The patient suffered much, and spat a great deal of blood; pulse feeble, extremities cold. He was bled three times the first night, and twenty-six times during the first fifteen days, the seton being retained in the chest the whole time. On the twenty-second day, a piece of cloth was felt by the finger, after removing the seton, and was extracted; a splinter was also felt, but so deeply that it could not be removed without enlarging the incision. As the inflammatory symptoms were re-excited, he was bled for the twenty-ninth time. On the thirtieth day these symptoms had so much increased that the seton was withdrawn, under the impression that it was doing more harm than good, and the thirty-first bleeding was effected. The next morning the patient complained of something pricking him within, and the parts left between the two original wounds, after the incisions which had already been made, were divided. The chest was now open from the articulation of the head of the rib with the sixth and seventh vertebræ behind, nearly to the cartilage in front; and the whole course of the ball was seen; it had made a groove in the surface of the lung, in the substance of which a splinter was sticking. This was extracted, and the wound dressed simply, after which the patient gradually improved, and was quite cured in four months.

The two first incisions for the removal of the splinters were necessary. The tent or seton drawn through the chest was an error; and although the fortunate result of the case depended probably on the removal of the splinters of bone sticking in the lung, few would survive the formidable operation performed for their removal. The case is suggestive and instructive.

345. When the lung can be seen through the opening made by the ball, or after some moderate enlargement for the purpose of removing any splintered pieces of rib or any spiculæ which can be felt or seen, the object is attained. I have not had experience of the utility of large incisions for the purpose of making the lung more visible, although the importance of extracting foreign substances in the first instance is inculcated, provided their situation can be ascertained.

A Spanish soldier, wounded at the battle of Toulouse, was brought to me the same evening, shot through the right side of the chest, between the fifth and sixth ribs, one of which was fractured, the ball passing out nearly opposite behind. On removing the splinters by the aid of an incision, I found that the lung was adherent to the inside of the chest, and was enabled to withdraw from within the lung some splinters of bone and a part of his coat. He left Toulouse apparently doing well; but natives of warm climates rarely suffer from such severe attacks of inflammation as those of northern habits and constitutions.

A soldier of the German Legion was wounded at the battle of Waterloo, the 13th of June, 1815, by a musket-ball, which entered between the seventh and eighth ribs in front, about two inches from the sternum on the right side, passing out behind. He died in York Hospital, Chelsea, in the month of January following, where he was taken after some drunken fits, which induced an attack of pneumonia. A fistulous opening existed, and had discharged a little matter, which was gradually diminishing; the sinus was from six to seven inches long, extending into and nearly through the base of the lung, and was lined by a mucous membrane, the lung around being thickened to the extent of from a quarter to half an inch. There was but little fluid in the cavity, although the lung on both sides showed signs of recent inflammation, without which he would in all probability have recovered. The orifices of entrance and of exit through the lung adhered to the walls of the chest, thus separating the track of the ball from the general cavity of the pleura, which would in all probability have led to his ultimate recovery, if it had not been for his intemperance.

346. When a ball, or portion of bone, leather, cloth, wadding, or other foreign substance is driven into the cavity of the pleura, it usually gives rise to fatal results, constituting, therefore, cases of the greatest importance, to which attention has not been sufficiently given, but on which too much cannot be bestowed, if life is to be preserved by the art of surgery. The neglect of these cases has probably arisen from the insufficiency of the means of ascertaining their nature--an insufficiency which auscultation has in some measure removed, and which the science of surgery may still further diminish. The presence of a ball, a piece of bone, or of any other substance, lying upon or rolling about on the pleura covering the diaphragm, must give rise to more or less irritation and inflammation, and consequently to suppuration, or the formation of matter upon the surface of that membrane in its thickened state, until, in all probability, the foreign substance has been removed or the person has wasted away and perished.

A dragoon of the King’s German Legion was wounded between the eighth and ninth ribs at the battle of Salamanca. The ball had entered and lodged; the symptoms were severe; the breathing laborious. As the discharge from the wound was not free, I enlarged the opening, removed some scales of bone, a bit of cloth which stuck between the ribs, the lower of which was broken, and evacuated a great quantity of bloody-colored fluid, not purulent. After a few days the discharge became purulent, and, as he felt something, as he thought, roll within him, which he supposed might be the ball, I contemplated again enlarging the wound, so as to be able to see whether anything were loose in the cavity; but a sudden relapse of inflammation, from drinking some brandy, carried him off. On examination, the ball was found lying loose on the diaphragm in the chest, and might, with some enlargement of the wound, have been extracted.

A French prisoner of war, who had been wounded near Almaraz by a musket-ball, which had lodged in the left side of the chest, was sent to Lisbon in 1812, with a considerable discharge through the wound, and died there. The ball was found in the angle formed between the diaphragm and the spine, enveloped in coagulable lymph, by which it was attached to the spine; there were some splinters of bone inclosed with it.

A soldier of the 29th Regiment was wounded at Talavera by a musket-ball, which penetrated the right side of the chest, between the fourth and fifth ribs, and lodged. He died the day after, and on opening the body, I found that the ball had passed through the lung, and was lying loose on the ribs behind, near the union of the diaphragm with the spine.

Major-General Sir Robert Crawford was wounded at the foot of the smaller breach at the storming of Ciudad Rodrigo, by a musket-ball, which passed through the posterior fold of the armpit and entered the side of the chest in the axilla by a small opening or slit, apparently too small to allow a ball to pass through. I saw him a few minutes afterward with Dr. Robb, under whose care he remained, when, from the general anxiety manifested, I was satisfied as to the severity of the injury. The symptoms were not at first urgent, but their continuance and augmentation, in spite of the most rigorous antiphlogistic treatment, led, in a few days, to his death. On examination of the body, the ball was found lying on the diaphragm; the cavity of the chest contained a large quantity of very turbid serum; false membranes had formed on the lung, which was compressed toward the spine, and at the upper part retained the mark of an injury as from a ball which had not had force enough to penetrate and lodge.

Baron Larrey has had the good fortune to meet with some remarkable cases of this kind. In the first he did not see the man for some weeks after the wound had been inflicted, the ball entering at the upper edge of the fourth rib, about an inch from its junction with the cartilage. By means of a bent and flexible sound introduced through the wound, he distinguished a hard, metallic substance at the bottom of the cavity of the chest, which he supposed to be the ball, nearly in the situation of the place where the operation for empyema is usually performed. This operation having been done, about twelve ounces of pus escaped, and the ball was discovered rather flattened. It was easily removed with the aid of a pair of polypus forceps. After this there was every prospect of recovery, until the patient, having unfortunately one day drank too much brandy, was attacked by enteritis, and died.

William Barrett, of the Life Guards, a middle aged, muscular man, of full habit, was wounded by a musket-ball at the battle of Waterloo; it fractured the third and fourth ribs behind on the left side, and broke the left arm. He was brought to Brussels, where the inflammatory symptoms were subdued by repeated general and local bleedings, and the other ordinary but strictly antiphlogistic means, during the first six weeks, by which time the external wound had nearly closed, and no trace of the ball could be perceived. At the end of this time, Staff-Surgeon Collier, now Inspector-General of Hospitals, under whose care he was, and who furnished me with these particulars of the case, which I saw in Brussels, finding that his symptoms became worse, that he had rigors and evening exacerbations, and that the difficulty of breathing had increased almost to suffocation, decided on opening into the cavity of the chest and following the course of the ball. This he did by a deep incision, which enabled him to remove some pieces of the ribs, which were denuded but not detached. A bag-like protrusion was then felt between the ribs near their angles, which was opened, and nearly two pints of thick, fetid pus escaped, the relief which followed being as complete as sudden. The wound was dressed from the bottom, and every means adopted, except introducing a tent, to prevent its closing, but in vain; the opening closed, and matter again collected, requiring a second incision for its removal. Between these two operations small bleedings were resorted to most beneficially. A short gum-elastic catheter was introduced into the cavity of the chest after the second incision; very little matter, however, was secreted. From this time he gradually recovered, and was sent to England, cured, in November.

347. The presence of a ball, rolling about on the diaphragm, can now be ascertained by means of the stethoscope at an early period, so as to admit of an operation being undertaken with confidence for its removal; while the knowledge acquired by auscultation or percussion, of the filling of the chest by fluid, whether serous, bloody, or purulent, is at the same time incontestibly demonstrated. The presence of a ball, or of any other foreign body, decides the question as to the place where the opening into the chest should be made. On this point the information derived from the practice of the French surgeons in Algeria is valuable.

M. Baudens, whose labors I again refer to with great pleasure, says that he has also seen splinters of bone and even a ball, surrounded by a cyst formed by the pseudo-membranes of inflammation, cut off from the general cavity, and confined in the angular space formed behind between the rib, the diaphragm, and the spine. In one case, M. Baudens introduced a sonde à dard, such as is used in the high operation for the stone, between the second and third ribs, and made it project behind between the eleventh and twelfth. He then cut down upon it, and extracted a ball and some splinters of the rib. The wound thus made was then closed, the upper one being sucked dry daily by a pump. The patient recovered in forty days.

A., 54th Regiment, was brought to the hospital at Algiers, on the 22d of October, 1833, wounded eleven days before by a ball, which, having broken the right clavicles was lost in the chest, without any sign of effusion having taken place; he appeared to be going on well, until suddenly he complained of pain about the middle of the sixth rib, which could not be removed by the means employed, and was accompanied by a great discharge from the wound. On the 10th of November he died. The clavicle and the first rib had been fractured, and an abscess had formed behind them, the size of a hen’s egg, containing several splinters of bone, which had stuck in and afterward separated from the lung. The ball had passed from above downward and outward, forming a sinus, which terminated at the middle of the sixth rib, to which this part of the lung was attached; the posterior three-fourths of this canal were closed; the anterior fourth contained two splinters of bone, one of which was about to fall into the abscess in front. The sixth rib was broken, although it had not been perceived during life; and a small digital cavity was formed at this part in it by the ball, surrounded by portions of lymph, floating loosely from its edges; from this the ball had been detached, and had given rise to the inflammation which destroyed him. The ball had fallen on the diaphragm, where it was lying loose, surrounded by a quantity of purulent matter.

M. Baudens says himself, and rightly, that the operation of opening into the chest should have been performed in the eleventh intercostal space, and that the wound in front should have been enlarged.

M. Baudens relates another case, in which the posterior wound, situated near the angle of the tenth rib, had healed, the anterior one, half an inch below the clavicle, giving issue to an abundant and weakening suppuration. The lung above this was permeable to air, but the respiratory murmur could not be heard below it. To draw off this offensive fluid, he adapted an empty caoutchouc bag to a gum-elastic canula, which he affixed against the orifice of the wound, and thus sucked out six pints in five days. Some days later the wound behind reopened, and a piece of bone was discharged from it, which saved the man’s life. Two years afterward he was seen in good health.

The desire to have as dependent an opening in the chest as possible in these injuries has been manifested by all surgeons of experience; and the interspaces between the ninth and tenth, and between the tenth and eleventh ribs, have been often selected for this purpose; but as the operation was formerly done with the trocar, the abdomen was as often opened as the thorax, and death was frequently thus caused, even if it would not have been occasioned by the disease. To prevent, or to avoid this evil, M. Baudens advises its being performed at three fingers’ distance from the spine, by incision, and he says he has frequently done it with success, although he does not give any circumstantial directions as to the operative method to be pursued. I therefore caused several experiments and dissections to be made in the workroom of the College of Surgeons by Mr. Quekett, with the following results:--

348.--1. That a trocar and canula pushed in between the eleventh and twelfth ribs, in a diagonal direction upward, on a line with the angle of the ribs generally, will in the dead body invariably enter the cavity of the chest without injuring the diaphragm.

2. That the same operation performed on the living body would, in all probability, if done at the moment of expiration, first enter the thorax, then pierce the diaphragm, and thus open into the cavity of the abdomen,--a difference in result to be explained by reference to the anatomy and physiology of the parts concerned; showing that this operation, when required on man, should always be done cautiously by incision, and not by puncture with the trocar and canula.

On examining the lower part of the chest from within, after removing the pleura, the diaphragm is seen forming the boundary between the thorax and the abdomen, commencing from the transverse process of the first lumbar vertebra, and forming an arch under which the upper part of the psoas muscle passes, (the ligamentum arcuatum proprium.) From this part extends another aponeurotic arch along the lower border, to the end of the last rib, called the false ligamentum arcuatum, (ligament cintré du diaphragme of Cruveilhier,) which is nothing more than the upper edge of the anterior layer of the aponeurosis of the transversalis muscle, folded upon itself in all its extent. The diaphragm is afterward attached to the lower border of the twelfth, and in succession to the eleventh, tenth, ninth, eighth, seventh, and sometimes to the sixth, ribs, counting from below upward. The external intercostal muscles are distinctly seen between the ribs, extending from the spine until they meet and are concealed by the fibers of the internal intercostal muscles, near the angles of the ribs. The vessels and nerves, after passing on the external intercostal muscles, subsequently run between them and the internal ones.

The lower intercostal arteries arise from the aorta on each side, and before they enter the space between the ribs give off a branch passing backward to the vertebral canal and the posterior muscles of the spine. The eleventh and twelfth intercostal arteries, covered at first by the pillar of the diaphragm, ascend on leaving the vertebræ to reach the under edges of the ribs, and are accompanied by a vein and nerve. The tenth intercostal artery, and those immediately above it, run almost horizontally, and nearly in the mid-spaces of the ribs, as far as their angles, at which part a small artery is commonly given off, which descends from the main trunk at an acute angle to the rib below, and may be injured in opening into the chest, and be perhaps mistaken, in operating, for the intercostal artery itself. From the angles each artery runs in a groove in the under edge of the rib as far as the anterior third, when they all become very much diminished in size, and, leaving the grooves, run in the middle of the intercostal spaces, until lost in their different anastomoses with the branches of the epigastric, phrenic, lumbar, and circumflexa ilii arteries.

In making an opening into the chest between the tenth and eleventh, or between the eleventh and twelfth ribs, the artery will not be injured, provided the opening be made below the middle of the intercostal space, which is wider between the eleventh and twelve ribs than between those above it. The vein is situated above the artery, and proceeds to the vena azygos major on the right, and to the smaller azygos vein on the left side.

The intercostal nerves are the anterior branches of the dorsal nerves, and lie below the arteries under the pleura upon the external intercostal muscles, until they approach the angles of the ribs, where they enter between the layers of the intercostal muscles.

It is worthy of observation that the pleura is necessarily continued over the inside of the twelfth rib to line the different attachments of the diaphragm, and that an incision may always be made into the chest above this point, if done carefully.

On removing the integuments of the back, covering the muscles and the lower ribs, the broad expanse of the latissimus dorsi muscle is brought into view, extending from the ilium and spine upward and outward, and covering all the parts of importance beneath in the operation to be described. On the removal of the lower part of this muscle the serratus posticus inferior is seen, of a somewhat quadrilateral form, arising by a thin aponeurosis common to it and to the latissimus dorsi, from the spinous processes of the three superior lumbar vertebræ and the two inferior dorsal, and proceeding upward and outward to be inserted by four flat, tendinous digitations into the four lower ribs.

If this muscle be separated from its origins and turned outward, or divided in the middle, and its two portions reflected, the posterior spinal or long muscles running in and filling up the groove or hollow of the side of the spine will now be distinctly seen, composed chiefly of the sacro-lumbalis and the longissimus dorsi muscles, sometimes called as a whole the erector spinæ or the sacro-spinal muscle. This, which forms a thick mass over the beginning of the tenth, eleventh, and twelfth ribs, is not to be divided or interfered with beyond a very few at most of its external fibers; the opening into the chest about to be made should begin at its external edge and go through the external intercostal muscle, which is now exposed on a plane below it.

The eleventh and twelfth ribs, unlike all those which precede them, except the first, have only one surface of articulation with the corresponding vertebræ, to which they are attached, instead of two facettes articulating--one with the body of the vertebra above, the other with that below. They form, particularly the twelfth, a more acute angle with the spine than the other, which gives to them their greater degree of obliquity, while the freedom of their cartilaginous extremities enables the twelfth, particularly, to be depressed or separated by a moderate force from the rib above to a greater extent than at any other part, by which means a foreign body of larger size may be removed from between them more readily than elsewhere.

349. Operation.--The eleventh and twelfth ribs having been distinctly traced, and the obliquity of their descent from the spine having been clearly made out, the patient ought, if possible, to be placed on a stool, with the upper part of the chest supported by a pillow on a table before him. An incision should then be made over the intercostal space between these ribs, three inches long and slightly curved, through the integuments down to the latissimus dorsi muscle, and as the mass of long spinal muscles is usually three inches in width, and can in general be seen, the incision should commence two inches from but between the spinous processes of the eleventh and twelfth vertebræ, and be continued obliquely or diagonally downward in the course of the interspace between these ribs. The latissimus dorsi and the serratus posticus inferior muscles having been divided at the upper part where they cover the longissimus dorsi or the long spinal muscular mass alluded to, its edge becomes apparent; from this point the latissimus and the serratus are to be further divided downward. The external intercostal muscle being thus exposed, its fibers should be scratched through or separated in the middle of the interspace between the ribs, which can now be seen as well as felt. A director should be introduced below the muscle, on which it may be carefully cut through, as well as any fibers of the internal intercostal muscle which may extend as far as the wound thus made. The pleura will then be exposed, and if the cavity of the chest contain fluid in any quantity, it can scarcely fail to project in such a manner as to convey to the finger the assurance of its being beneath. An opening may then be carefully made into it at the upper part of the incision close to the external vertical fibers of the spinal mass of muscles, at the moment of inspiration, and on the existence of fluid being ascertained by its discharge, the opening should be enlarged by a director previously introduced under the pleura, the patient being desired to draw a full breath at the time, in order that the diaphragm may descend as low as possible. If there should not be any fluid in the chest, the diaphragm, in ascending during expiration, may be applied to the inside of the pleura lining the chest as high even as the fifth rib, counting from above, and might easily be divided with the pleura, if great care were not taken to make the opening during the process of inspiration.

In all cases of wounds of the chest, in which auscultation points out the presence of a ball rolling loose on the diaphragm, this operation should be performed for its removal, and may save the life of the sufferer. It would, perhaps, have done so in the case of Sir Robert Crawford. At a later period the presence of a foreign body, perhaps, can only be known by the sounds or defect of sounds which may be observed at the back part of the chest, in which the ball or other foreign bodies lodge or become enveloped by matters confining them in that situation.

LECTURE XXV.

HERNIA OF THE LUNG, ETC.

350. Hernia of the lung, as a consequence of a wound in the chest which has healed, is a complaint of rare occurrence. It appears to take place when the intercostal muscles have been much injured and are deficient, the opening through them being merely covered by the common integuments which have yielded to the pressure exerted from within. It has been supposed that it might be mistaken for the thinning of parts from the formation of matter within, or empyema. The early occurrence of the abscess after the receipt of the injury forbids the supposition, while the ear, applied to the protruded part which is most prominent during EXPIRATION or coughing, perceives not only a crepitation, felt equally by the touch, but the natural respiratory murmur stronger, softer, but less vailed and more like the sound given out by a pulmonary lobule inflated close to the ear, but without enlargement of the part.

A portion of lung will sometimes protrude during the efforts made by the sufferer to breathe, particularly in expiration, when the wound is left open and the lung is sufficiently free to admit of it. When protruded, it sometimes happens that the efforts of nature are not sufficient for its retraction, and it remains filling up the opening into the thorax. A large portion of lung is rarely protruded, except through an opening which readily admits of its return; but when the wound is small, the return of a portion of protruded lung, when it is not positively strangulated, should not be interfered with. The surface of the lung is but little sensible; touching it causes no apparent pain, and its adhesion to the edges of the cut pleura is more advantageous than its separation from it. It should, therefore, be allowed to remain or be only so far returned, if it can be so managed, as to rest within the edges of the divided pleura and fill up the gap made by the incision, over which the integuments should be accurately drawn and retained. The adhesion of the lung to the pleura costalis arrests the inflammation, and may prevent its progress to other parts of the cavity. That the inflammation may extend farther into the substance of the lung, is possible, but when the sufferers are otherwise healthy, the chance of evil from pneumonia is less than from inflammation of the general cavity. Whenever the protruded lung has been completely returned, more inflammation has followed than where it has been allowed to remain under the precautions recommended. Three cases were brought under my notice at Brussels, after the battle of Waterloo, which were not interfered with, greatly to the advantage of the patients. It is rare, however, to see a protrusion of the lung after a gunshot wound.

The protruded lung, when left uncovered and unprotected, soon loses its natural brilliancy, dies quickly, shrinks, and becomes livid, without being gangrenous. In such cases the protruded part may be removed, but it should never be separated at its base from its attachment to the pleura costalis by which it is surrounded.

351. Wounds of the diaphragm were known to the older surgeons from the time of Paré; they were aware that these wounds were not immediately, although generally, mortal. They knew that the viscera of the abdomen did sometimes pass through such wounds into the cavity of the chest, but they did not know that a wound of the diaphragm never closes, except under rare and particular circumstances; that it remains an opening during the rest of the life of the sufferer, ready at all times to give rise to a hernia which may become strangulated and destroy the patient, unless relieved by an operation as yet unperformed, but to which attention is especially directed--a fact first pointed out by me early in the war in the Peninsula.

A soldier of the 29th Regiment was wounded at the battle of Talavera, and died in four days after the receipt of the ball, which went through the chest into the liver. I found, on examining the body, an opening in the central part of the diaphragm of an oval shape, the edges smoothing off as if they were inclined to become round; this opening was nearly two inches long, evidently ready to allow either the stomach or the intestines to pass through it on any exertion.

Captain Prevost, aid-de-camp to Sir E. Packenham, was wounded by a musket-ball, on the 27th September, 1811, on the heights of Saca Parte. It penetrated the chest from behind, splintering the ninth and tenth ribs of the left side, and made its exit a little below and to the right of the xiphoid cartilage. A good deal of blood was lost from the posterior wound, but he did not spit up any. He was carried to Alfaiates, and there he threw up a small quantity of bloody matter by vomiting. The posterior wound was enlarged and continued to discharge some blood, the intercostal artery being in all probability wounded. Sixteen ounces of blood were taken from the arm, giving great relief, and the bowels were opened by the sulphate of magnesia.

Sept. 29th.--Bleeding to eighteen ounces; on the 30th he was bled again to thirty-two ounces, from which great relief was obtained; he fainted, however, on making a trifling exertion to relieve his bowels.

Oct. 1st.--Accession of symptoms as yesterday, relieved by bleeding in a similar manner; bowels open.

3d.--The inflammatory symptoms recurred this morning, and were again removed by the abstraction of sixteen ounces of blood. Beef-tea.

5th.--Passed a sleepless night, and was evidently suffering from considerable internal mischief; wandered occasionally; pulse quick, 120, and small; felt very weak and desponding. A little light, red wine given, with beef-tea and bread; opium night and morning.

6th and 7th.--Much the same; pulse always quick, with much general irritability.

15th.--The wounds discharged considerably, particularly the posterior one; has a little cough; pulse continues very quick; spasms of the diaphragm troubled him for the first time, and caused great pain and uneasiness; they were relieved by opium in large and repeated doses.

On the 18th the spasmodic affection of the diaphragm and the pain returned with great violence, so as to threaten his dissolution, which took place on the 20th.

On examination, I found that the ball had passed through the under part of the inferior lobe of the left lung, and through the pericardium under the heart, through the tendinous part of the diaphragm, and into the liver, before it made its exit. The wound in the lung was suppurating; the matter and fluid from the cavity of the chest had a free discharge by the shot-hole; the edges of the wound in the diaphragm were smooth as if cicatrized, leaving between them an elliptical opening an inch long. The injury to the liver was through the substance of the anterior part of its right lobe; the matter having a free discharge, and generally slightly yellow, as if tinged with bile in small quantity. The skin did not show a yellowish tinge, neither were the conjunctivæ discolored.

A soldier of the 23d Regiment was wounded at the same affair, by a musket-ball, on the right side; it fractured the sixth rib, from three to four inches from the sternum, and passed out behind, between the ninth and tenth ribs, near the spine. The rib being fractured, the splinters were removed after an enlargement of the wound by incision, when the opening into the cavity of the chest was manifest, air being discharged freely from it. The shock in the first instance was great; but after a time reaction took place, and he lost a considerable quantity of blood in six bleedings during the first sixty hours. The discharge, at first serous and bloody, gradually became purulent, and the occurrence of jaundice showed that the diaphragm and liver had in all probability been injured. Under the administration of calomel, antimony, and opium, this symptom was gradually disappearing, when I left him to rejoin the army. He was sent to the rear at the end of ten weeks nearly well.

On the day preceding the battle of Fuentes d’Onor, in 1811, Sergeant Barry was wounded in the chest. The ball entered close to the nipple of the left breast, and passed out at the back, between the eighth and ninth ribs. The anterior opening of the wound soon healed, but the posterior one did not do so for a considerable period, when he became affected by such severe cough, with expectoration, that his medical attendant deemed it proper to reopen it. The symptoms were relieved, and portions of his shirt and jacket were discharged. After this his health improved so rapidly as to enable him soon to rejoin his corps. The wound in the back repeatedly opened and healed--generally at intervals of twelve or fourteen months; but for five or six years it ceased to do so. His appetite was small and delicate; flatulence was much complained of; and if the stomach at any time happened to be overloaded, vomiting occurred. He died of mortification of the left leg, January 4th, 1833.

On examination, the whole of the stomach and the greater part of the transverse arch of the colon were found in the left cavity of the chest, having passed through an opening in the diaphragm extending about three inches in a transverse direction, near the center of the dorsal attachments of that muscle. The peritoneum lining the diaphragm was firmly attached to the parts passing through it.

The wound in this instance was through muscular, not tendinous parts. The preparation is in the museum at Chatham, No. 63, Class 6.

A French soldier was admitted into the Gensd’armerie Hospital at Brussels, in consequence of a wound from a musket-ball, at the battle of Waterloo, which entered behind between the eighth and ninth ribs, near the spine, and lodged internally. After many severe symptoms and much suffering, he died on the 1st of December, worn out by the discharge, which often amounted to a pint daily, for the free exit of which the external wound had been early enlarged. On examination, the lung was slightly ulcerated on its surface, opposite to where the ball had entered, and a little matter contained in a sac had formed between it and the wall of the chest. That the ball had gone on was proved by the fact of there being an opening in the tendinous part of the diaphragm, through which a portion of the stomach had passed into the chest, from which it was easily withdrawn. The ball could not be found in the abdomen; in all probability, it had passed into the intestine and had been discharged per anum, as has happened in other instances.

James Wilkie, 12th Light Dragoons, aged thirty-four, was suddenly attacked, at four P.M. of the 6th September, 1815, with violent pain in the umbilical and epigastric regions, accompanied with nausea and great irritability of stomach; pulse small, rapid, and regular. Assistant-Surgeon Egan visited him half an hour after the attack, bled him freely, and caused the abdomen to be fomented with hot water; a large blister was applied to the seat of pain, an ounce of castor-oil was given, and emollient and laxative clysters were occasionally administered. At night the symptoms abated, and he slept about three hours. The next morning his countenance exhibited that appearance of haggardness and anxiety which have always been alarming indications; pulse feeble and rapid; the pain severe; at noon he vomited from two to three ounces of black, fetid blood in a fluid state; the pulse became very feeble. At four P.M. the pain increased, he ejected from his stomach from four to six ounces of dark, fluid blood that had less fetor; and at six the same evening he expired in pain.

This man, on the 18th of June, at Waterloo, received a punctured wound from a sword, which entered about an inch below the inferior angle of the scapula on the left side, penetrated the thorax, appeared to have passed through the diaphragm, the point of the weapon coming out on the opposite side of the chest between the first and second false ribs. The wounds were quite healed, and he apparently enjoyed good health, when he arrived from Brussels in August.

Appearances on dissection.--On opening the abdomen, the whole of the intestines, with the exception of the duodenum, were in a high state of inflammation. On tracing the duodenum upward a very small portion of the stomach was found in its natural situation; while, on opening the thorax, a large spherical tumor was seen in its left cavity, containing two quarts or upwards of black, fluid, fetid blood. This sac was soon seen to be the stomach, which had protruded through the aperture in the diaphragm, by which it was so firmly embraced as to render the communication between the portion of the stomach in the thorax and that in the abdomen impervious to each other. The hernial sac and its contents were supported by the diaphragm. The left lung exhibited a shriveled, contracted appearance, as if its function had been impeded by the pressure of the sac and its contained fluid. The cicatrix and the course of the sword were well marked. The cardiac and pyloric orifices of the stomach were in the natural cavity.

S. Fletcher, 31st Regiment, wounded at Sobraon on the 10th of February, 1846; died at Chatham, February, 1847. On opening the thorax, the greater part of the stomach, and a foot and a half of the transverse arch of the colon, with the omentum attached, were found in the left pleural cavity. There was an opening in the diaphragm with a rounded margin two inches and a half in diameter, two inches to the left of the œsophagus. The stomach, colon, and omentum adhered firmly, at one part, to the pleura covering the diaphragm and lining the ribs to the extent of a few inches, although otherwise loose and free in the cavity. The parts in the aperture of the diaphragm were free from adhesions, and the finger passed easily through the opening from below upward. Two cicatrixes were to be seen on the left side of the chest--one between the eleventh and twelfth ribs, close to the transverse processes of the vertebræ; the other between the eighth and ninth ribs, three inches and a half from the cartilages. The preparation is in the museum at Chatham.

352. These cases confirm the fact that wounds of the diaphragm, whether in the muscular or the tendinous part, never unite, but remain with their edges separated, ready for the transmission between them of any of the loose viscera of the abdomen which may receive an impulse in that direction. That parts of these viscera do pass upward and back again, cannot be doubted; and it is probable that incarceration may take place for a length of time before strangulation occurs from some sudden and distending impulse giving rise to it.

When the solid viscera of the abdomen are injured, as well as the diaphragm against which they are applied in their natural situation, the wound may sometimes be considered a fortunate one; for the liver or spleen may adhere to the opening in the diaphragm and fill up the space between its edges.

A wound of the diaphragm may be suspected from the course of the ball, particularly when it passes across the chest below the true ribs. It is necessarily accompanied by an opening into the cavity of the abdomen, and is by so much the more dangerous. The symptoms will partake of an injury to both, although they are principally referable to that of the chest, and are those of intense inflammation, accompanied by a difficulty of breathing, which in the case of Mr. Drummond was a peculiar sort of jerk; in that of Captain Prevost it was more spasmodic. The risus sardonicus, hiccough, pain on the top of the shoulder, and loss of power of the arm, which were all more or less present, in all probability depended on some larger fibrils of the phrenic nerve being wounded. The treatment should be antiphlogistic, with a free external opening for the discharge of matter. The accession of jaundice shows an injury to the liver; vomiting of blood or its passage per anum indicates a wound of the stomach or intestines.

353. When the patient recovers, the probability of a hernia taking place into the chest through the diaphragm should be explained to him. If any reason should exist for the belief that it had occurred, he should be doubly cautious as to eating and drinking in small quantities only, and remaining in the erect position for some time after each meal; he should carefully avoid a stooping posture and all muscular exertion or straining. If symptoms of strangulation should come on, an opening made into the abdomen would appear to offer the only chance for life. The hernia may perhaps be drawn back into its place in the abdomen; but if firm adhesions have formed between the protruded parts and the edges of the opening in the diaphragm, the case must be treated as one of adherent strangulated rupture in any other part, by a simple division of the stricture in the most convenient situation. The opening should be a straight incision through the wall of the abdomen, large enough to admit the hand, immediately over the part where the diaphragm is supposed to be injured. It should be closed by a continuous suture through the skin. This operation, now for the first time recommended, although apparently formidable, cannot be compared as to danger with the incisions of twelve and fourteen inches long through the wall of the abdomen, which have been in some instances successfully made for the removal of diseased ovaria.

354. Wounds of the heart are for the most part immediately fatal. Many persons have, however, been known to live for hours, nay days, and even weeks, with wounds which could scarcely be otherwise than destructive; and several cases are recorded in which the cicatrixes discovered after death, in persons known to have been wounded in the vicinity of the heart, have shown that even severe wounds of that most important organ are not necessarily fatal. As our knowledge of the nature of the injury inflicted can never be distinct, it follows that every wound should be considered as curable until it is unfortunately proved to be the contrary.

355. Auscultation and percussion, and principally auscultation of the whole precordial region, have afforded means of judging of injuries of the heart which were not formerly known. A vertical line, coinciding with the left margin of the sternum, has about one-third of the heart, consisting of the upper portion of the right ventricle, and the whole of the left, on the left. The apex of the heart beats between the cartilages of the fifth and sixth left ribs, at a point about two inches below the nipple and an inch on its external side; or, if one leg of a compass be fixed at a point midway between the junction of the cartilage of the fifth rib on the left side with the rib and sternum, and a circle of two inches in diameter be drawn around, it will define as nearly as possible the space of the precordial region occupied by the heart while uncovered, except by the pericardium and some loose cellular texture. In the rest of the precordial region it is covered, and separated from the walls of the chest by the intervening lung.

If the chest of the dead subject be transfixed with long needles, it will be found that the center of the first bone of the sternum corresponds with the lower edge of the left subclavian vein and to the arch of the aorta crossing the trachea, the center of the second bone to the upper edge of the appendix of the right ventricle, and the center of the third bone to the right side of the right auricle, the right ventricle being lower down. A needle penetrating the chest at the costal extremity of the fifth rib, close to the upper edge of its cartilage, will touch the septum of the ventricle. The apex of the heart is an inch and a half below this, and inclined to the left side.

The semilunar valves of the pulmonary artery correspond to a spot a little below the center of the third bone of the sternum. The aortic valves are a few lines below and behind the pulmonary. The mitral valves are a little lower, and still more deeply seated. The pulmonary artery, after touching the sternum, inclines to the left, and is found close to the sternum between the second and third ribs. The aorta ascends to the first bone, and crosses it to form the arch.

One-third of the heart, consisting of the upper part of the right ventricle and of the whole of the right auricle, is beneath the sternum; the remainder of the right, with the left ventricle and auricle, are to the left side of that bone.

356. On applying the ear to the precordial region, the patient being in the erect position, two sounds are distinguishable in a healthy heart--one duller and more prolonged, the other clearer and shorter; between these there is scarcely an appreciable interval. The period of repose is sufficiently marked before the first or duller sound returns. Of the time thus occupied, one-half is filled up by the first or dull sound, one-quarter by the second or sharp sound, one-quarter by the pause or period of repose.

Twenty-nine theories have been proposed, each accounting for the sounds of the heart. The theory of Dr. Billing appears to prevail at present, which supposes that the sounds thus heard “are caused by the valves, which, being membranous, each time they resist the reflux of the blood are thrown into a state of sudden tension, which produces sound.”

The impulse of the heart, as far as it can be felt by the touch, depends much on the position in which the body is placed. In the erect position, it is heard between the fifth and sixth ribs. In the recumbent posture, the impulse is almost imperceptible. It is perhaps more observable when the body is turned on the right side, but decidedly more so when it is turned on the left. A clearer sound proceeds from a thin, and a duller sound from a thick heart; a sound of greater extent from a large heart, and a sound of less extent from a small one. A more forcible impulse is given by a thick heart, and one more feeble by a thin one; the impulse is conveyed to a longer distance from a small heart.

From a clearer sound we believe in the probability of an attenuated heart, but we argue its certainty from a clearer sound joined with a weaker impulse. A stronger impulse denotes the probability of a hypertrophied heart, but we argue its certainty from a stronger impulse with a diminished sound.

The terms endocardial and exocardial are used to designate the alterations which take place in the sounds of the heart under disease--endocardial when they occur within the heart, and exocardial when they take place upon its surface. The endocardial murmur of disease, or bellows-sound, takes the place of and is substituted in certain cases for the first or second, or even for both the healthy or normal sounds. The exocardial murmur of disease is heard with the normal sounds, but confusing and overpowering, sometimes overwhelming, them by its rubbing or crumpling noise. The natural sounds exist, although rendered imperceptible by the greater distinctness and nearer approach of the unnatural or unhealthy ones.

The heart apart from the pericardium never moves without a sound; the pericardium apart from the heart never gives out one. Under disease the heart gives out the natural sound, diminished, exaggerated, or modified, or it may be totally altered. The sounds given out by a diseased pericardium must always be new, (there being no old ones,) and are described as rubbing, or to-and-fro sounds. The pleura, when diseased, being a serous structure, like the inner membrane of the pericardium, gives out less marked but somewhat similar sounds (the “frottement” of the French) in particular stages of disease.

The alterations in the ordinary sounds constituting the endocardial murmurs of the heart under disease depend principally on the altered state of the endocardium, or membrane lining its cavities; the sounds given off, and called exocardial, on an altered state of the serous membrane of the pericardium, reflected over the outer surface of the heart. The endocardial or bellows-sound, when it accompanies the normal sounds of the heart, may result from any kind of derangement affecting the internal membrane of that organ, particularly rheumatic inflammation, or from any force which may compress its cavities; or it may depend on the altered quality of the blood, from anemia. It should be present after excessive hemorrhages have greatly reduced the powers of the sufferer. When this murmur or sound occurs after injury in the vicinity of the heart, and is accompanied by fever, it indicates inflammation of the lining membrane, although no local pain, no palpitations, no irregular movements of the heart be present.

When a murmur or sound is heard of a different kind, possessing the character of friction, of surfaces moving backward and forward on each other, or to and fro, it is the sign of inflammation of the membrane covering the heart, as well as of that lining the fibrous external tissue of the pericardium. The signs of both external and internal inflammation may be present at the same time, and they frequently are in cases of acute rheumatism.

357. When the heart is supposed to be wounded, even without much loss of blood, there is fainting; palpitation; irregular movement or total cessation of its action; coldness of the extremities; ghastliness of countenance, succeeded by great anxiety; a sense of anguish; an intermission or cessation of pulse, followed, if the patient should survive, by reaction, which renders it very frequent and sometimes increases its impulse; while the anxiety is increased by pain, sometimes intolerable, referred to the part. These symptoms imply a serious injury, although they may not all be present, and many of them differ in intensity. If the patient should survive, the ordinary sounds of the heart will return, with more or less irregularity, accompanied after a few hours by the endocardial murmur, although something like it may perhaps be observed from the first period of injury. The friction or attrition sound, indicating the presence of inflammation of the pericardium, may be absent; it will not be discernible, if a layer of blood be effused into the cavity of that membrane; while the natural sounds of the heart are rendered more indistinct as the heart is separated from the walls of the chest by the effusion which distends the pericardium, and impedes the regular action of the heart, but cannot compress it, as an empyema does the lung. If inflammation take place without an effusion of blood, the friction sound will be heard, and will usually continue even after some effusion of serum and of lymph has occurred, as the quantity of serum secreted is rarely sufficient to prevent the effused and attached portions of lymph from rolling against each other.

The presence of a larger quantity of fluid may be more distinctly known by percussion, if it can be borne in cases of injury, the degree and extent of the dullness being the measure of its existence and accumulation. It may extend over a part or over the whole of the precordial region, reaching as high as the second, or even the first rib, beneath the sternum, and even under the cartilages of the ribs of the right side.

358. That the heart when wounded is capable of recovery by the permanent closure of the wound, in a few rare instances, is indisputable; and it would seem, from a consideration of the different cases which have been recorded, that such recovery takes place in consequence of there being but little blood discharged through the wound, or into the cavity of the pericardium, or into that of the pleura. The absence or the cessation of the hemorrhage by the contraction of the wound, or the formation of a coagulum, is the first step toward a cure, and it was to one or other of these circumstances that most of those who survived the injury for several days or weeks owed their existence for the time, although they usually died from the effects of inflammation, more of the inner lining and outer covering than of the substance of the heart itself.

If the wound be inflicted by a musket or pistol-ball, it cannot be closed, although pressure may be made upon it for a time, so as to suppress the external flow of blood. If this should succeed, it is more than probable that the hemorrhage will continue internally, and that the patient may die after much suffering, principally from oppression, caused by the escape of blood into the cavity of the chest.

If the wound be a stab, the external opening may be accurately closed, and the escape of blood prevented; but as the pressure of the blood in the pericardium is unequal to restrain the action of the heart, blood forced out through the opening fills the cavity of the pleura, and causes suffocation, unless from some accidental circumstance the opening in the heart becomes obstructed, and the bleeding ceases.

If all the circumstances be considered, there can be no doubt of the propriety of closing the wound in the first instance, if the flow of blood be excessive and appear likely to endanger life. It seems to be as little doubtful that the wound should be reopened after a time, if the danger from suffocation be imminent. The relief obtained by the escape of a little blood may be efficacious, while it does not necessarily follow, although it is more than probable it will be so, that its place will be occupied by a further extravasation of blood, which will prove fatal. It is a choice of difficulties, and death from hemorrhage is easier than death from suffocation.

In the case of the Duc de Berri, whose right ventricle was wounded, and who died from loss of blood, Steifensand reprehends Dupuytren for having opened the external wound every two hours, to prevent suffocation; but if death were actually impending from the filling of the cavity of the chest being about to cause suffocation, there was nothing to be done but to give relief at all hazards.

359. When the sufferer has recovered from the imminent danger attendant on the infliction of the injury, and the pericardium is believed to be so full of blood or of serum as to prevent in a great measure the movements of the heart, it has been proposed by Baron Larrey to open the pericardium by the following operation--equally, as he thinks, applicable in an ordinary case of hydrops pericardii:--

“An oblique incision is to be made from over the edge of the ensiform cartilage, to the united extremities of the cartilages of the seventh and eighth ribs. The cellular tissue being divided with some fibers of the rectus and external oblique muscles, there remains only a portion of the peritoneum called its false layer, above the pericardium, which can be seen after the division of all the intervening cellular tissue, projecting between the first and second digitations of the diaphragm. Into this the bistoury is to be entered, with the precaution of doing it with the edge turned upward, and directed a little from right to left, to avoid the peritoneum. The smallest portion possible of the anterior border of the diaphragm is next to be divided, where it is attached to the inner part of the cartilage of the seventh rib. The internal mammary artery is to the outside. The patient should be placed perpendicularly, and supported on his bed, which inclines the anterior part and base of the pericardium to the fore part of the chest.”

Skielderup recommends this operation to be done by first trepanning the sternum a little below the spot where the cartilage of the fifth rib is united to that bone, at which part the periosteum lining it offers considerable resistance, and should not be divided by the trephine. Below this there is a triangular space formed by the separation of the layers of the mediastinum, free from cellular tissue, and tending a little more to the left than to the right. The apex of this triangle is opposite the fifth rib; its base touches the diaphragm. The bone having been removed, the patient is made to lean forward, when the projection of the pericardium will enable the operator to feel that a quantity of fluid is within, and to open it with safety.

360. J. Dierking, a stout, muscular man of the 3d Regiment of German Hussars, was wounded at the battle of Waterloo by a lance, which penetrated the chest between the fifth and sixth ribs, and was then withdrawn. He fell from his horse, lost a good deal of blood by the mouth, and some by the wound, and was carried to Brussels without any particular attention being drawn to the injury. His strength not being restored, while he suffered from palpitations of the heart, and other uneasy sensations in the chest, he was sent to England to be invalided; and in November, 1815, was admitted into the York Hospital, Chelsea, in consequence of an attack of pneumonia, of which he died in two days, without attention being particularly drawn to the cicatrix of the wound.

On examining the body, I found that the lance, having injured the edge of the cartilage of the rib, passed through the inferior lobe of the left lung, the track being marked by a depressed, narrow cicatrix. It then perforated the pericardium under the heart, and sliced a piece of the outer edge of the right ventricle, which, being attached below, turned over and hung down from the heart to the extent of two inches, when in the fresh state, the part of the ventricle from which it had been sliced being puckered and covered by a serous membrane like the heart itself. The lance then penetrated the central tendon of the diaphragm, making an oval opening, easily admitting the finger, the edges being smooth and well defined. It then entered the liver, on the surface of which there was a small, irregular mark or cicatrix. The heart in front was attached to the pericardium by some strong bands, the result of adhesive inflammation, but the general appearance of the serous membrane showed that this had not been either great or extensive. The pericardium was not thickened.

If this man had lived long enough, he might have furnished an instance of hernia of the stomach or of intestine into the pericardium. The preparation is in the military museum at Chatham, Class 1, Div. 1, Sect. 7, No. 156.

That the heart, when exposed, is insensible, or nearly so, to the touch, was known to Galen and to Harvey. Galen is said to have removed a part of the sternum and pericardium, and to have laid his finger on the heart. Harvey did the same to the son of Lord Montgomery, who was wounded in the chest. Professor J. K. Jung not only introduced needles into the hearts of animals, but also galvanized them without disadvantage, although Admiral Villeneuve is supposed to have died suddenly from running a long pin into his heart, which scarcely left the mark of its entrance.

That persons may die from the shock of a blow on the heart, need not be doubted, and that they do die when little blood is lost, is admitted. History preserves the fact that Latour d’Auvergne, Captain of the 46th demi-brigade, who had obtained the honorable title of “Premier Grenadier de France,” fell and died immediately after receiving a wound from a lance at Neustadt, in the month of July of the sixth year of the Republic; it struck the left ventricle of the heart near its apex, but did not penetrate its cavity. He was, however, sixty-eight years of age.

361. In wounds of the heart, all extraneous matters should be removed, if possible, and all inflammatory symptoms should be subdued by general bleeding, by leeches, by calomel, antimony, opium, etc. The chest should be examined daily by auscultation. If the cavity of the pleura should fill with blood, it ought to be evacuated to give a chance for life, and if the pericardium should become permanently distended by fluid, it should be evacuated.

Lacerations and ruptures of the heart have frequently taken place from blows or other serious contusions.

Ollivier, who devoted much time to reading and collecting the observations made by different writers on the injuries of the heart, says: “That of forty-nine cases of spontaneous rupture of the heart, thirty-four were of the left ventricle, eight only of the right, two of the left auricle, three of the right, and that in two cases both ventricles were torn in several places; and that these results were in an inverse proportion to those which occurred after blows or contusions; the right ventricle being ruptured in eight out of eleven cases, the left ventricle three times; the auricles being also torn in six of these eleven cases; the ruptures not being confined to one spot, but taking place occasionally in several different parts, or even in the same ventricle.” In eight of these cases he had noticed, the heart was ruptured in several places. That a spontaneous rupture may be cured as well as a wound, seems likely, from a case reported by Rostan, of a woman who died after fourteen years’ suffering with pain about the heart, and was found to have the ventricle ruptured. A cicatrix was observed to the left side of the recent rupture, half an inch in extent in every direction, in which the new matter was evidently different from the natural structure of the heart.

LECTURE XXVI.

WOUNDS OF THE INTERNAL MAMMARY ARTERY, ETC.

362. Wounds of the internal mammary and intercostal arteries have so much occupied the attention of theoretical surgeons, and so many inventions have been broached for the suppression of hemorrhage, particularly from the latter, that it becomes consolatory to know that bleeding from these vessels rarely takes place; that the inventions are more numerous than the case requiring them, and that no notice need be taken of them, they being as unnecessary as they are useless. I have never had occasion to see a distinct case of hemorrhage from an internal mammary artery, but if bleeding should take place from a wound in its neighborhood, of a nature to lead to the belief that it came from this vessel, the wound should be enlarged until the part whence the blood flows can be ascertained, when, if it be from that artery, the vessel should be twisted or secured by ligatures, and if these methods should be impracticable, the wound should be closed and the result awaited.

The following method of operating for the application of a ligature on this vessel has been proposed by M. Goyraud. It may be done with ease in the three first intercostal spaces, it offers some difficulties in the fourth, is very difficult in the fifth, and is scarcely to be done lower down. An incision two inches in length is to be made near the side of the sternum from without inward, at an angle of forty-five degrees with the axis of the body. The middle of this incision should be three or four lines distant (a quarter of an inch) from the bone, and in the center of the intercostal space, within which the vessel is to be found. The skin, cellular substance, and the great pectoral muscle having been divided, the aponeurosis of the external intercostal muscle with the muscular fibers of the inner intercostal muscle are to be separated and torn through with a director, until the artery and its two venæ comites are laid bare at the distance of three lines from the edge of the sternum, lying before the fibers of the triangularis sterni muscle, which separates these vessels from the pleura. A bent probe, or other proper instrument, can then be readily passed under the artery. The vessel can only be secured in this way when injured at the upper part of the chest; below this it must bleed into the cavity, unless there be an open wound.

363. The intercostal artery, although often injured, rarely gives rise to hemorrhage so as to require a special operation for its suppression; but whenever it does so happen, the wound should be enlarged so as to show the bleeding orifice, which should be secured by one ligature if distinctly open, and by two if the vessel should only be partially divided. The vessel is sometimes so small as to be easily twisted, or its end sufficiently bruised as well as twisted, to arrest the hemorrhage. It lies between the two layers of intercostal muscles, and in the middle of the ribs it runs in a groove in the under part of each.

I have had occasion to twist and bruise the end of an artery bleeding in an intercostal space, and I have tied the vessel under the edge of the rib; but I have not met with any of the great difficulties usually said to be experienced in suppressing a hemorrhage from this artery, when the wound was recent, and the parts were sound; no reliance should be placed on the hypotheses often entertained on this subject.

When the parts are unsound, and the hemorrhage is secondary, greater difficulty is sometimes experienced in arresting it, because the ligature easily cuts its way through the softened parts, and styptics are liable to fall into the cavity of the chest.

The late General Sir G. Walker, G.C.B., after scaling the wall of Badajos, with the fifth division, was wounded by a musket-ball, which struck the cartilages of the lower ribs of the right side, broke the bones, penetrated the chest, and then passed outward. He remained in Badajos under my care during the first three weeks, with many of the other principal officers who were wounded; and overcame the first inflammatory symptoms in a satisfactory manner. After I left him the wound sloughed, some part of the cartilages separated, and one of the intercostal arteries bled, although the bleeding was arrested once by ligature, and afterward, on its return, by different contrivances; each time it reappeared his life was placed in considerable jeopardy from it and the discharge from the cavity of the chest, which was profuse. The bleeding was ultimately arrested by the oil of turpentine, applied on a dossil of lint, and pressed on the bleeding spot by the fingers of assistants until the hemorrhage ceased. He recovered after a very tedious treatment, with a considerable flattening of the chest, and a deep hollow at the lower part of the side, whence portions of the rib, and of the cartilages had been removed.

A young man, aged fifteen, was wounded by small shot in the chest, between the first and second ribs, and near the sternum, at the distance of about forty-eight paces. He ran about six hundred paces, fell, and died thirty-eight hours afterward. On opening the injured cavity of the thorax, it was found to contain twenty-eight ounces of blood, the lung having collapsed to one-fourth its natural size. An opening on its upper part corresponded to the external one in the paries; but the track of the shot could not be traced into its substance for more than two inches and three-quarters; a lacerated spot was, however, perceived at the lower edge of the sixth rib, about two inches from its head, at which part the intercostal artery was found to be torn through; the shot could not be found, and there was no opening in the skin behind.

The discussions which took place on this case led to the statement of an anatomical fact--that when a man is standing erect, a line drawn horizontally from the upper border of the second rib in front would touch the upper edge of the fifth rib behind, and that very little inclination, viz., an inch and a half, was necessary to make the shot wound the intercostal artery of the sixth. Auscultation would have made known the extravasation, and relief might have been given by an incision over the spot where uneasiness was felt; for the loss of blood was not sufficient of itself to destroy life, unless some other injury had been sustained, which was not perceived.

364. Wounds of the neck which are made with swords, or by knives or razors, by persons attempting to destroy themselves, are to be treated on two great principles. The first is, not to place the parts in contact until all hemorrhage has ceased, lest the patient be suffocated. In the mean time, while any oozing continues, a soft sponge should be placed between the edges of the cut. When the larynx or trachea is obstructed by a quantity of blood, it may be sucked out, or drawn up by an exhausting pump, and it may be advisable in some cases to introduce a tube. If the trachea be cut across, a stitch will be necessary to keep the ends in contact. The second is, to keep the divided parts in contact afterward, by position and bandage, but not by suture. If the œsophagus be wounded, nourishment should be administered by a gum-elastic tube introduced through the nares into the stomach. It is almost unnecessary to add that the artery, if wounded, should be secured by ligature. A hole in the internal jugular vein may be closed by a thread passed around it when raised by a tenaculum.

Captain Hall, of the 43d Regiment, was wounded by a ball which passed between the upper part of the back of the larynx and the termination of the pharynx, without causing much further inconvenience than the loss of voice. In this instance it must have been the superior laryngeal nerve that was injured, and not the recurrent, yet the voice could only be heard in a whisper, and was not completely recovered for years. If a ball should lodge in the trachea, it must be removed by the operation of laryngotomy or tracheotomy, if the original wound cannot be enlarged; although Birch, says Christopher Wren, hung up a man wounded in this way by the heels, when the ball dropped out through the glottis and mouth. General Sir E. Packenham, who was killed at New Orleans by a ball which went through the common iliac artery, had been twice shot through the neck in earlier life. The first shot, which went through high up from right to left, turned his head a little to the right. The second shot, from left to right, brought it straight. My kind and excellent friend had ever afterward a great respect and regard for the doctors and a strong feeling for the wounded. The recollection of that regard, and the advantages derived from it, have made me sometimes think it might be advantageous for the unfortunate as well as for the doctors if every general could be at least shot once through the neck or the body, before he was raised to the command of an army in the field; for there is nothing like actual experience of suffering to make men feel for their fellow-creatures in distress. A Minister at War would not perhaps be the worse for a little personal experience in this matter.

365. Wounds of the face made by swords or sharp-cutting instruments should be always retained in contact by sutures. When the cut is of small extent, and not deep, the skin only should be included by the thread, and that in the slightest possible manner, and the part supported by adhesive plaster and bandage. When the cheek is divided into the mouth, one, two, or more sutures may require to be inserted more deeply, but the deformity of a broad cicatrix will in general be avoided, by carefully sewing up the whole line, taking the very edge of skin only; and a cut in the bone or bones of the cheek should not prevent the attempt being made to unite the external wound over it.

Incised or even lacerated wounds of the eyelids and brows should be united by suture, as far as can possibly be done in the first instance, by which a subsequent painful operation may be avoided; great care should be taken in doing this; the suture must be inserted through the eyelid, and a leaden thread is often the best, the first being introduced at the very edge of the lid, and two, or as many more afterward as may be necessary. They may remain for three or more days, as circumstances seem to require. If the eye be wounded, any part protruding beyond the sclerotic coat should be cut off with scissors; but the eye, however injured, should not be removed unless the ball be detached in every direction, or destroyed. The treatment should be strictly antiphlogistic, in order to prevent suppuration of the eyeball, which may in general be effected, if too much injury have not been done to it, and if the treatment be sufficiently decided and well continued. These observations apply to the nose and ears, and all parts not actually separated--or, if separated, for a short time only--should be replaced in the manner directed, and every attempt made to procure reunion. If this should fail, surgery may yet be able to yield assistance by replacing the loss by a piece of integument dislodged from the neighboring parts--a proceeding requiring a separate consideration. Injuries from musket-balls are often attended by considerable laceration, particularly when near the eyelids. Whenever this occurs, the parts likely to adhere should be brought together by suture, after any splinters of bone which may present themselves, or can be seen or felt, have been removed from the holes made by the ball. If the bones should be broken, and not splintered, they will frequently reunite under proper management.

366. Wounds of the eye from small shot are remediable when these small bodies lodge in the cornea or sclerotica, whence they may be removed by any sharp-pointed instrument. When a shot or piece of a copper cap is driven through the cornea, into the iris, or lies in the anterior chamber, it should be removed by an incision to the extent of about one-fourth or one-fifth of the cornea, near its junction with the sclerotica, but in these cases a cataract, if not amaurosis, frequently results. When the shot passes through all the coats of the eye, it can neither be seen nor removed with safety; vision will be lost, much pain may be endured, and the eye will frequently be destroyed by suppuration, or by a gradual softening, and ultimate diminution in size. A contused wound from a large shot which only injures the coats of the eye, but does not perforate them, will oftentimes be cured by a proper antiphlogistic treatment, which in all cases should be most strictly enforced, although loss of sight is a frequent consequence after such injuries.

When a ball lodges behind the eye, it usually causes protrusion, inflammation, and suppuration of that organ. If it be not discovered by the usual means, its lodgment may be suspected from the gradual protrusion and inflammation of the eye itself. If it be discovered, it should be removed together with the eye, if such proceeding be necessary for its exposure. If suppuration have commenced in the eye, a deep incision into the organ will arrest, if not prevent, the horrible sufferings about to take place, and allow of the removal of the offending cause. If the eye remain in a state of chronic disease and suffering, a similar incision will give the desired relief. If the chronic state of irritation affect the other eye, the incision and sinking of the ball of the one first affected or injured is urgently demanded, and should not be delayed. If the back part of the eye be left with the muscles attached to it, a stump remains, against which an artificial eye may be fitted, so as sometimes to render the loss of the natural one almost unobservable.

367. I have several times seen both eyes destroyed and sunk by one ball, with little other inconvenience to the patient; one eye sunk, the other amaurotic, and both even amaurotic, almost without a sign of injury, by balls which had passed from side to side through both orbits, but behind the eyes. When the eye becomes amaurotic from a lesion of the first branch of the fifth pair of nerves, the pupil does not become dilated; the iris retains its usual action, although the retina may be insensible and vision destroyed. This was well shown in the case of the late Major-General Sir A. Leith, who was wounded by a sword in the forehead, this nerve being divided. It has so often occurred as to leave no doubt of the fact, and of the error formerly existing on this point.

368. Penetrating wounds implicating the bones of the face are always distressing. When the bones of the nose are carried away, there must always be some deformity remaining, although there is oftentimes but little suffering. When these bones are merely splintered and depressed, great pains should be taken to keep them properly elevated. If the duct of the parotid gland be implicated by an incised wound, care should be taken to divide the cheek into the mouth, if it should not have been already done, and to keep the incised wound open until the external one is closed. If a salivary fistula have formed externally, from inattention or otherwise, it must be treated according to the ordinary methods adopted in such cases. When a wound of the gland itself becomes fistulous, and weeps, which is a rare occurrence, it will be best treated by actual or potential cauterization, if moderate pressure should fail. When these wounds are of some extent, they are often followed by partial paralysis, in consequence of the seventh pair of nerves being injured, when the mouth is drawn somewhat to the other side. When the lachrymal bones or sac are injured by balls or swords, the tears usually continue through life to run over, and give inconvenience, although much good may be done by early attention to the injuries of this part. Wounds injuring the upper jaw are oftentimes followed by much suffering, and by permanent inconvenience.

General Sir Colin Halkett, G.C.B., was wounded on the 18th of June, at Waterloo, when in front of his brigade, which was formed in squares for the reception of the French cavalry, by a pistol-ball, fired by the officer commanding them, which struck him in the neck, and gave him great pain, but without doing much mischief. A second shot shortly afterward wounded him in the thigh, and he was obliged to leave the field toward the close of the day, by a third musket-ball, which struck him on the face, when standing sideways toward the enemy. It entered a little below the outer part of the cheek-bone on the left side, and, taking an oblique direction downward and forward, shattered and destroyed in its course several of the double teeth in the upper jaw, fracturing the palate from its posterior part, forward to the front teeth. The ball then took a direction obliquely upward, destroying the teeth of the opposite side of the upper jaw, which bone it also broke, and lodged under the fleshy part of the cheek. These wounds gave great pain, and until the ball was removed, the left ear was totally insensible to sound and all external impressions, although the general suffered much from distressing noises in his ear. These subsided on the removal of the ball some days afterward.

The treatment of this wound, however, was most painful; the extraction of several pieces of bone was necessary at different times, during the three following years, before the wounds were finally closed. Considerable derangement of health followed, the deafness remains; and the general has ever since been subjected to attacks in the head of an increasing and most distressing nature.

369. Wounds of the lower jaw are perhaps more common, and are certainly more troublesome than those of the upper; they are more difficult of management, and, for the most part, end in greater deformity, unless particular care be taken to prevent it, and then only in very severe cases, by operations which were formerly not in use, but which the intrepidity of the surgeons of the present day have deprived of all their terrors. I mean the methodical division of the soft parts, the sawing off and removal of the broken pieces of bone, and the rounding off of those parts of the jaw which may remain irregular and pointed. M. Baudens has given two good examples of the success of this proceeding during his campaigns in Algeria. In the first case, the ball entered at the middle of the left cheek, and came out by the side of the spinous process of the seventh cervical vertebra. The ascending ramus of the lower jaw was broken into numerous splinters. M. Baudens divided the soft parts down to the bone, entering the straight bistoury four lines, or the third of an inch, below the articulation of the jaw with the temporal bone. He then carried it downward, and a little obliquely forward, so as to terminate it in the fibers of the masseter muscle, about half an inch below the base of the bone. This incision was begun below the seventh pair of nerves, and exposed the parotid gland divided vertically at its middle part. The splinters were removed, a part of the pterygoideus internus muscle was divided, and a projecting point of bone attached to it sawn off. He then separated the attachments of the buccinator, temporal, and pterygoideus externus muscles, divided the ligaments, and removed the coronoid and articulating processes, taking care to avoid the fifth and seventh pairs of nerves. The bleeding from two arteries was suppressed by twisting their ends; and the parts were afterward brought together by sutures, which remained for eight days. A month after the operation the patient ate solid food, and in six weeks was cured. In the second case, the ball entered near the left commissure of the lip, and came out behind on the side of the middle of the neck; three inches of the jaw were splintered, the ends of the bone being sharp and angular. In order to remove the splinters, and to prevent the evils anticipated, M. Baudens divided the lip from the angle downward and outward, below the base of the bone, as far back as the edge of the masseter muscle. He then separated the flaps, and sawed the jaw across, first near the symphysis, and then behind, outside the attachment of the masseter. The facial artery was twisted, four sutures were inserted, and the jaw duly supported. The patient was bled twice, and in six weeks was cured; at the end of that time he could eat solid food. After the healing of such wounds, mechanical means are often necessary to enable the sufferer to eat and to live without causing disgust to his neighbors and his friends.

It is said there are fifteen men in the Hôtel des Invalides, in Paris, wearing silver masks on the lower part of their faces, in consequence of injuries of this kind.

Colonel Carleton was an instance of a ball fracturing the jaw directly through its body, near where the masseter muscle is attached on both sides; the jaw was broken into three pieces, besides splinters; several teeth were knocked out, and the tongue very much hurt. By sawing off the splinters both from within and without, and by cleansing and supporting the parts with great care, he recovered after a length of time, the deformity after such a wound being much less than might be expected.

370. Incised wounds of the tongue do sometimes give rise to hemorrhage somewhat difficult to restrain, particularly if it occur a few days after the receipt of the injury, when the tongue is swollen and painful. It does not so frequently occur after gunshot wounds. As the vessels of one side do not communicate with those of the other, any bleeding which continues after the artery of one side has been properly secured, can only take place from a wound of the artery of the other, which must then also be tied. This should be done by drawing the tongue as far as possible out of the mouth by a flat pair of forceps, which may be easily effected at an early period, when it is not tender and painful. At a later date, and under difficult circumstances, various styptics, such as the mineral acids, nitrate of silver, etc., will be useful. The actual cautery has been recommended, but I have never seen it used in such cases.

371. One of the most curious instances of the lodgment of a foreign body in the face occurred in the person of Captain Fritz, at Ceylon; his gun burst in his hand, and drove the iron breech into the forehead, whence it descended into the nares, and, at the end of a year, part of it made its appearance in the mouth, through the palate. He died eight years afterward, having suffered much inconvenience from the offensive discharge it occasioned. When the iron was removed, it had obviously injured no part of any material importance to life. I have seen balls descend in this way into the throat and soft palate, and have removed them from both places with success, and from the hard palate with equal surprise and advantage to the patient. I have known a ball lodge in the superior maxillary sinus for months, and even for years, before it was removed, or the death of the patient proved the fact.

LECTURE XXVII.

STRUCTURE OF AN INTESTINE, ETC.

372. If an intestine be divided circularly in any part, its walls will be found to be composed of three principal coats or tunics, which are--commencing from the inside--the mucous, the muscular, and the serous or peritoneal, each being separated from the other by a layer of areolar tissue. A diagram thus made would show a transverse division of the intestine, and eight distinct if not all different parts. Beginning from without, viz., serous or peritoneal, areolar or sub-serous; longitudinal muscular, areolar; transverse muscular, areolar or sub-mucous, and epithelial. The mucous coat in man has a peculiarity not observable in animals, of ledges or shelves projecting into its cavity.

When the mucous coat of the duodenum is examined with the naked eye, the first part of its course presents a tolerably smooth appearance, gradually, however, becoming irregular in transverse folds, which are so numerous, marked, and regular in the jejunum and ileum as to have obtained from the earliest times the name of valvulæ conniventes. They are most strongly marked in the jejunum, and gradually disappear toward the lower part of the ileum, the inner surface of the large intestines being still smoother than any part of the small, although large pouches or cells are formed in the colon by a peculiar arrangement of the muscular coat. These valves never extend completely round the inside of the intestine, and rarely more than half or two-thirds, although they sometimes bifurcate. They have a velvety appearance, which has obtained for this coat the name of villous as well as that of mucous.

Valvulæ conniventes are peculiar to man; none exist in the ourang-outang or chimpanzee. In the frog there are valvular folds, appearing, at first sight, like the valvulæ conniventes of the human subject; but, on a careful examination, they are found to be mere elevations, without villi. In the tortoise there are similar folds, running however in a longitudinal or opposite direction. In the rhinoceros the mucous membrane is raised up into villiform processes, somewhat like the valvulæ conniventes, or large villi; but they are not villi, as each process is covered with other projections which really are villi. A valvula connivens consists of two layers of mucous membrane and sub-mucous tissue, but the muscular coat is not continued into it.

373. When examined microscopically, the velvety appearance is found to consist of innumerable small processes which have been called villi, each villus being composed principally of a very thin, transparent basement or germinal membrane, forming a sheath or case, inclosing within it an artery, a vein, a capillary plexus, and an absorbent vessel termed lacteal. A nerve has not been discovered, although it is presumed to exist. These villi are longest in the duodenum, and gradually diminish in number and in size from 1/25 to 1/50 of an inch. Between these villi or projections, holes or openings are observable, termed the follicles of Lieberkühn, who first described them; they resemble inverted villi, being in some instances as deep as the villi are long. Unlike the villi, they are found throughout the intestines. The villi in every part in common with all mucous membranes are covered, and the follicles are lined by epithelium, which in this instance is the columnar, situated on the basement membrane, each column being attached by its pointed extremity. A layer of this epithelium extends between the villi, down to the lower part of each follicle, each column being, generally speaking, shorter and rounder than when covering the villi.

The office of the epithelium of the villi has been stated to be protective, that of the follicles to be secretive. A villus, when duly magnified, is seen to have a bulbous extremity without an opening, and to be covered by epithelium when the intestine is in a state of quiescence, uncalled upon for any purpose of digestion. When digestion commences, the epithelium, according to the researches of Mr. Goodsir, is separated and thrown off. As the chyme begins to pass along the small intestine, an increased quantity of blood circulates in the capillaries of the gut. In consequence of this increased flow of blood, or from some other cause, the internal surface of the gut throws off the epithelium of both villi and follicles, which is intermixed with the chyme in the cavity of the gut. The cast-off epithelium, forming 19/20ths of the covering of the villus, is of two kinds, that which covers the villi, and which from the duty it performs may be termed protective, and that which lines the follicles and may be termed secretive, each column having a nucleus situated at some part of it, and bulging out that part.

The villi being now turgid with blood, erected and naked, and covered by the chyme mingled with the cast-off epithelia, commence their functions. The summit of the villus becomes at first somewhat flattened and crowded under the basement membrane with a number of newly-formed and perfectly spherical vesicles, varying from 1000 to less than 2000 of an inch in size. Toward the body of the villus or the inner edge of the vesicular mass, minute granular or oily particles are situated in great numbers, and gradually pass into the granular texture of the substance of the villus. As the process advances lacteal vessels are shown passing up from the root of the villus, subdividing and looping as they approach the spherical mass, which in this stage has become more distinctly vesicular, although no distinct communication can be detected between them. The blood-vessels and capillaries shown in injected preparations are now seen colored red with their own blood, and running up to the basement membrane, looping with each other immediately beneath it, and ending in one or more venous trunks. The vesicles, quite distended and grouped in masses, push forward the membrane, and give to it by these inequalities an appearance resembling that of a mulberry.

The minute vesicles above noticed fulfill the important office of absorption, by drawing into their cavities through their walls, by a process called endosmosis, that portion of the chyme necessary to form chyle; when filled with it they burst or dissolve, their contents being thus discharged into the texture or substance of the villus, fit to be taken up by the granular vesicles interspersed among the terminal loops of the lacteals, and communicating with their trunks, running up from the root of the villus in their center. Absorption is thus shown to be effected by closed vesicles, and not by vessels opening on the surface of the villus.

The débris and the contents of the dissolved chyle cells, etc. pass into the looped net-work of lacteals, as in other lymphatics. When the gut contains no more chyme, the flow of blood to the mucous membrane diminishes, the development of new vesicles ceases, the lacteals empty themselves, the villi become flaccid, and the cast-off epithelium is reproduced, apparently from the nuclei in the basement membrane, in the intervals of digestion, showing that this function should only be induced at regular periods, the presumed special use of the epithelium being to prevent, in a measure, the absorption of any effete or other matters which might exert a deleterious influence oh the system, the epithelium of the follicles now secreting a mucus which may be considered protective.

In the large intestines there are no villi, but the whole surface is covered with follicles which must be capable of absorbing as well as of secreting, as it is ascertained that persons can be nourished and kept alive for many weeks by nutritious enemata which do not pass into the small intestines.

374. On examining the mucous membrane of the stomach, its follicular structure is immediately seen, the follicles resembling much in appearance those of the intestine; but in the stomach minute tubes are found opening into the bottom of each follicle, fulfilling in all probability a different office, the follicles being lined by columnar epithelium, the tubes by spheroidal or glandular epithelium; it is therefore presumed that the gastric juice is secreted by the tubes, the mucus by the follicles. The tubes differ in the middle and lower parts of the stomach, by being longer or more deeply seated, and more numerous as they approach the pylorus, showing in all probability a difference of function between the upper and middle, and the pyloric or lower extremity of the organ.

The intestines are supplied with glands, not apparently for the purposes of absorption, but of secretion; these require attention. They are the duodenal of Brunner, the agminated of our countryman, Nehemiah Grew, and of Peyer, and the solitary, which are found in the lower part of the small and in the whole course of the large intestines.

The glands of Brunner are situated at the commencement of the duodenum, within an inch of the pylorus, and are not visible until the serous and muscular coats have been removed from without. They appear to the naked eye like the little white eggs of an insect. Under the microscope each little gland is found to be lobulated, very much resembling a small portion of a salivary gland or pancreas, each lobule having an excretory duct, which unites with those from other lobules to form one larger one opening on the mucous surface of the bowel. The lobules themselves are made up of vesicles, within which the secretory cells are discernible.

The agminated glands of Grew and Peyer, by the latter of whom they were more minutely described, occur in oval patches at irregular distances throughout the jejunum and ileum, and are situated on the side immediately opposite the part where the mesentery is united to the bowel. Each gland resembles somewhat a Florence oil-flask in shape, the small end or mouth, which is more or less pointed, projecting through among the villi or the follicles. They are composed of cells, supplied by capillary vessels, which Mr. Quekett says have the peculiarity of being unsupported by areolar tissue, and are termed by him, in consequence, naked. These are the glands which are found more or less diseased after phthisis and fevers which have terminated fatally. The oval form of the patches is retained, although considerably raised above the general surface of the mucous membrane, and when injected the parts around are more vascular, the ulcerated portion being less so than usual.

The solitary glands are best seen in the cœcum and appendix vermiformis. They are well developed in the fœtus, projecting slightly above the mucous membrane. Each gland may be considered as one of the agminated form much enlarged, and when the free surface is very flat, an opening may be easily seen in the center. These glands also are frequently the seat of ulceration in fever and dysentery, and particularly in phthisis. The follicles partake of this disease, and the whole mucous coat may be destroyed. In some cases there is an attempt at healing, and the edges of the ulcers become more vascular and even villous.

The sub-mucous areolar tissue--the tunica nervosa of Haller, the fibrous lamella of Cruveilhier--separating yet connecting the mucous with the muscular coat of the intestine, is composed of the yellow elastic and of the white or non-elastic fibers, the latter of which predominate. It is more firmly connected with the mucous than with the muscular coat, and in it the blood-vessels and nerves are supported prior to their distribution in the mucous membrane. This sub-mucous tissue or structure prevails also in the stomach, and is often much altered by disease, becoming thicker, and assuming a more dense and sometimes an almost gristly hardness. It is an important part in the surgical treatment of wounds of the intestines, being firmer, stronger, and more elastic in reptiles, and more distinct in carnivorous than in herbivorous animals or in man.

375. The muscular coat of the intestines is in two layers, the internal being composed of fibers running transversely, the outer fibers running longitudinally; they are thickest in the duodenum and rectum. They are of the involuntary or unstriped kind, as opposed to the voluntary or striped, which are of large size, and characterized by striæ running transversely and longitudinally.

The involuntary fibers, on the contrary, are much smaller in size, are always more or less flattened, and present no trace of striæ or stripes, although the interior appears granular, with an occasional nucleus. The heart is a remarkable exception to this rule, being an involuntary organ, with striped fibers differing in size, resembling in this respect those of a voluntary muscle.

The peritoneal coat is formed of the white fibers, under a structureless or basement membrane, covered by tesselated epithelium, constituting a serous and secreting membrane.

376. Wounds and injuries of the abdomen are essentially of three kinds--1. Affecting the paries or wall. 2. Opening or extending into its cavity. 3. Wounding or injuring its contents.

The wall of the belly is, when severely hurt, liable to a permanent defect, as the ordinary result of a severe bruise. It is the formation of a ventral rupture. A division of the wall to any extent by a sharp-cutting instrument is usually followed by a similar consequence; and it never fails to occur in the openings made by a musket-ball penetrating into or passing through the cavity.

Captain Tarleton, of the 7th or Royal Fusiliers, was struck on the left iliac region by a large, flat piece of shell, at the battle of Albuhera, in 1811. The surface was not abraded, although the iron caused a very severe and painful bruise; the whole of that side of the belly became quite black, and the remaining part much discolored. Some months afterward he drew my attention to the part, and I then found that the whole of the muscular portion of the wall had been removed by absorption to the extent of the immediate injury from the piece of shell, the tendinous parts alone remaining under the integuments. These protruded on any effort, constituting a circular-shaped ventral rupture, with a large base, which required the application of a pad and bandage for its repression.

Mr. Smith, a deputy-purveyor, received a blow on the side of the fore part of the belly from the end of a spanker-boom, which knocked him down, and gave rise for some time to much inconvenience. He showed the part to me in Lisbon, in 1813, in consequence of the formation of a ventral hernia to the extent of the spot originally injured. In neither of these cases was such a result expected; no rupture of the fibers of the muscles was distinguished at the time, and it was supposed that the sufferers would recover without any permanent defect. The absorption of the muscular fibers was therefore a subsequent process; whether this result may or may not be prevented in similar cases by a more active or a longer-continued treatment, with the early application of a retaining bandage, is yet to be ascertained. It may be that some muscular fibers were actually ruptured and others bruised in these cases; but the extent of the absorption was greater than the apparent injury would seem to have warranted.

Abscesses form from neglected injuries of this kind, and give rise to the most serious apprehensions of their bursting into the cavity of the abdomen, which, however, they very rarely do. The safety of the peritoneum and its capability of affording sufficient resistance to the progress of the matter through it seem to depend upon the strength of the fibrous structure on its outer or muscular side; the inner or really serous surface being very delicate, and offering but little resistance to the application of any moderate degree of force.

An officer, whose name I forget, was wounded at the assault of Ciudad Rodrigo, in 1812, by a musket-ball, on the left side and fore part of the abdomen, near the crest of the ilium: it made a wound about four inches in length, cutting away the muscles of the abdominal wall so deeply as to lead to the exposure, and, as I feared, to the ulceration of the peritoneum, when the sloughs should separate. Under these circumstances, although not belonging to my division, I took him with me from the field to the divisional hospital at Aldea Gallega, some ten miles from the battlefield. Granulations sprang up, however, from the bottom and sides of the wound, which gradually closed in and healed without further difficulty.

377. It has been supposed theoretically, to be a matter of importance to discriminate between the orifice of entrance of a ball passing through the abdomen or its wall, and that of its exit. Practically speaking, it is a matter of indifference; the part on which the ball impinges is usually distinguished by a more circular and depressed appearance, while the opening of exit more frequently resembles a tear or slit, the edges of which are rather disposed to protrude.

A ball striking obliquely against the wall of the abdomen has been said to run sometimes nearly round under the skin, or between the muscles and the peritoneum, a proceeding upon the recurrence of which little expectation need be placed. It may, however, do something of the kind for a considerable distance, passing even over or between the spinous processes of the vertebra behind. In such cases, when they actually occur, the course of the ball will usually be marked by a line on the skin, more or less of a reddish-blue color; and the constitutional alarm, if it should occur at all, will subside early. A ball may, however, pass under and between the muscular layers of the wall of the belly, (or run nearer to the peritoneum for several inches,) giving rise to great anxiety, until the sloughs have separated from the openings of entrance and of exit, at which parts they prevail to a greater extent than in the middle of the track of the projectile. In some few instances an opening will require to be made in the middle of this track or course of the ball, for the evacuation of pus or of other extraneous matters which may be detained in it.

When a ball lodges in the wall of the abdomen and is deeply situated, it sometimes escapes notice, and when found is often better left alone unless it prove troublesome. When it approaches the surface, it may be removed if it cause inconvenience. When removed after the lapse of twenty or more years, I have found some dense cellular membrane forming a sac around and adhering to the ball, which is usually more or less flattened and irregular.

378. Injuries of the wall of the abdomen from cuts or stabs affecting the muscular and tendinous parts are said to be frequently troublesome, and even dangerous, from their giving rise to pain, vomiting, and severe general derangement. This only occurs when suppuration takes place, and, from some accidental circumstance, the matter does not find a ready exit, but collects between the muscles, or within or under their aponeurotic sheaths. This is indicated by the pain and swelling of the part, proceeding sometimes to the formation of an abscess, which ought to be prevented, if possible, by an early enlargement of the wound, so as to remove the cause of irritation, and the obstacle to the free discharge of the secreted matter. If the swelling should become prominent in a more convenient situation than the spot of injury, it should be opened at that part.

In these and in all other serious injuries of the abdomen, the recumbent position, with a relaxed state of the muscles, should be observed for several days at least. The antiphlogistic plan of treatment should be fully enforced, especially by leeching, bleeding, and spare diet, and in due time the part should be supported by a proper bandage.

The late General Sir John Elley was wounded in the last charge of heavy cavalry at Waterloo, by the point of a sabre, which entered nearer the extremity of the ensiform cartilage than the umbilicus, causing a wound about two inches in length, penetrating the stomach. From this he recovered in due time without any severe symptoms, but with a small hernia of that organ, which remained until his death, giving rise occasionally to some gastric inconvenience when he did not keep a gentle pressure on it by a retaining bandage.

379. Severe blows, or contusions from falls or from the concussion of foreign bodies, may give rise not only to injury of the internal parts of the abdomen, followed by inflammation, but to rupture of the hollow as well as of the more solid and fixed viscera, and death.

William Fletcher, of the 18th Hussars, a healthy man, thirty-seven years of age, received a kick from a horse, immediately above the os pubis, on the 15th of April, 1810, (about a league from Cartaxo, on the Tagus;) great tension of the belly soon followed, with excessive pain and vomiting. The pulse rose rapidly. He was bled to syncope twice during the day, to the extent of sixteen ounces each time. In the evening he was removed to Cartaxo, and taken into hospital; the pain continued, accompanied by retching, without much vomiting; the abdomen was constantly fomented with hot water, and injection was thrown up, and two ounces of infusion of senna with salts were given every two hours. In spite, however, of the most active treatment, he died on the 17th. On dissection, the peritoneum was found to contain a large collection of fluid, partaking of a fecal character; the bowels appeared to have suffered to the greatest extent, and a laceration was discovered in the ileum.

A child, just able to walk, was placed under my care in the Westminster Hospital, in consequence of its having received some injury on the side of the belly, from having been tossed up into the air by its father with his right hand, and caught in its descent in the crutch formed by the thumb and fingers of the left, on the thumb of which it unfortunately at last fell; this caused the child great pain, which was soon followed by considerable swelling and inflammation of the belly, of which it died. On examination after death, the small intestine was discovered to have been ruptured by the end of the thumb, from which extravasation of its contents into the abdomen had ensued.

The first effect of a rupture of the intestine must be the extravasation of such gas as may be contained in or secreted from it, giving rise to the sudden swelling, as well as to the sudden effusion, of part of its contents, but which, from the support of continuity, and of the general pressure of the abdominal parietes, is perhaps more gradually poured out. The rapid swelling and tension of the belly is perhaps then a distinguishing symptom of a rupture of the intestines.

A Spanish soldier was brought to me, near the conclusion of the battle of Toulouse, in consequence of having been struck obliquely by a cannon-shot on the right side of the abdomen and back, which appeared to be badly braised, although no abrasion of the skin had taken place. The shock was great, however; he was unable to move his limbs, and appeared likely to die, which he did in fact, in the course of the night, having passed bloody urine, but without any reaction having taken place. On making an incision through the skin, which was then quite a blue black, although not torn, all the soft parts were found reduced to a state approaching to the appearance of jelly; the spine was injured, the right kidney ruptured, and the cavity of the abdomen full of blood.

A soldier of the 40th Regiment was struck by a ricochet cannon-shot, on the last day of the siege of Ciudad Rodrigo. He saw the ball, which destroyed his left forearm so as to render amputation necessary, strike the ground a little distance from him, before he was himself injured. He thought, from the sort of shock he received, that it had also struck his belly; but this I should not have credited, if it had not been for a bruise across the umbilical region without actual abrasion of the integuments, on which account my attention was drawn to him on the fourth day after the injury, at the hospital of Aldea Gallega. He had been bled in consequence of complaining of pain, and because of the quickness of pulse and the fever which had ensued, and which were attributed to irritation after amputation. The belly was swollen and tender under pressure. Calomel, antimony, and opium were given: he was bled again, and blisters were applied. The stump took on unhealthy action, and he died a fortnight after the receipt of the injury. The abdomen, when opened, was found to contain a quantity of opaque serous fluid, mixed with shreds of coagulable lymph. The omentum and intestines were of a dark color, and loaded with blood, distinctly indicating the chronic state of inflammation which had taken place.

If the injury should not destroy the patient, but prove sufficient to give rise, after several weeks, to effusion into the cavity, the fluid should be evacuated by the trocar.

When the fixed viscera are ruptured by severe blows, such as those received by falls or from cannon-shot, the sufferers usually die from hemorrhage and not from inflammation. The arm has been carried away, and the liver ruptured without almost a sign of injury to the skin of the abdomen, death ensuing from hemorrhage.

380. When an incised wound is made through the wall of the abdomen to any extent, except perhaps in the linea alba, the muscular parts are rarely found to unite in a more perfect manner than when they are ruptured and bruised. In those cases in which I have tied the common iliac artery by an incision on the face of the lateral part of the abdomen, the patients recovering afterward, the incision through the muscular wall did not remain united, although union appeared to have taken place in the first instance, and a herniary protrusion formed in the course of the greater part of the line of the wound.

The constant occurrence of this non-union, except by skin and cellular membrane, led me to repudiate the introduction of ligatures through other parts for the purpose of keeping them in apposition, as it does not lead to the permanent cohesion of the parts, while it exposes the sufferers to all the dangers which the irritation of sutures commonly occasions, thus offering another instance of the improvement surgery owes to the war in the Peninsula.

Chelius recommends “several flat ligatures to be introduced through the skin and muscles, the needle being placed close to the muscular surface of the peritoneum.” Graëfe (section 514) is declared to be of the same opinion, he recommending, however, that a soft tape should be substituted for a ligature. Reference is made to Weber in support of this practice, to which Mr. South, the translator, does not raise any objection.

381. In all simple wounds of the wall of the belly of moderate extent, the edges of the wound should be brought together by means of a small needle and a fine silk thread passed through the skin and the loose cellular membrane only which is in contact with it, by a continuous suture without puckering, in the manner a tailor would fine-draw a hole in a coat. This gives a certain degree of support to the parts beneath; and if proper attention be paid to maintain a well-regulated, relaxed position of the muscles, no great separation takes place in wounds of a reasonable extent, and little or none in a wound of smaller dimensions. An effective support should be also given by strips of adhesive plaster extending to some distance around the body; a bandage rarely does good, and will assuredly do mischief, unless it be very carefully applied and watched, so as only to give support and not to make undue pressure. The position of the patient is of the greatest importance; its essential object is to bring the edges of the incision, and especially of that in the peritoneum, as nearly as possible in apposition, so that the space between them may be more easily filled up by the opposing peritoneum forming the anterior layer of the omentum, or by the outer covering of the intestine if the omentum should not intervene. This is to be effected by the gentlest inclination of the body toward the wound which may be supposed capable of keeping these parts in apposition; for although the omentum and intestines are often capable of undergoing a considerable degree of motion from side to side, independently of that peculiar wormlike movement on themselves which in the intestines is called peristaltic, they very frequently do not wander from place to place in the manner which has been sometimes attributed to them, but remain, under proper care, so far stationary as to admit of the cut edges of the wounded peritoneum adhering to the healthy peritoneum opposed to them, when they will be retained in contact with it. The serous surfaces of the peritoneum which are in contact with each other soon offer on one part, and accept on the other, the process of adhesion through the medium of lymph or fibrin deposited between them. If this adhesion take place, it extends for some little distance from the wounded part, which it thus closes up and cuts off from all communication with the general cavity of the belly; the previous admission of air--the bugbear of surgeons of the olden times--being of no sort of consequence. The adhesive process is the effect of inflammation extending to a certain point, and ending in the deposition of fibrin. When it exceeds this, the secretion of a quantity of serous fluid, together with threads of flocculent matter, marks the excess of inflammation; it is diffused over more or less of the peritoneum lining the wall of the belly, covers its contained viscera, and prevents that adhesion from taking place which is the safeguard of the patient.

382. Absolute quietude is no less to be observed. It must, however, be steadfastly continued; the slightest alteration of position should be forbidden. Motion should not on any account, nor for any reason whatever, be allowed, if it can by any possibility be avoided. In the position in which the patient is placed he should be rigorously maintained until adhesion has been effected or all hope of it has passed away. The practice of the older surgeons was to purge such persons vigorously, in order to remove from their bowels any peccant matters that might be in them; in the same manner they recommended persons should be purged who had undergone the operation for strangulated hernia--both which proceedings the experience of the war enabled me to condemn, as being not only contrary to the right medical treatment of such cases, but to the physiological and surgical principles on which it ought to be founded, a condemnation the accuracy of which is now universally admitted, although the source from which it is derived is not so universally acknowledged. No purgative medicine whatever should be given to a person with a penetrating wound of the abdomen. No food should enter his mouth; and no more water even should be allowed than may be found requisite to moisten the lips and allay any intolerable thirst which may ensue. This precaution need not be carried out so strictly if it could be readily ascertained that an intestine was not wounded; but as this knowledge, however satisfactory it would be, cannot always be obtained, and ought not in the generality of instances to be sought for, the restriction should be fully observed if possible. In all cases of injury of the belly there is more or less shock, alarm, and anxiety. It is sometimes remarkably great, even when the mischief has not been considerable. When little or no injury has been inflicted on the intestines, the natural and usual action of expelling the contents is generally delayed beyond the time at which in health it would in all probability have occurred. When nature shall point out by the sensations of the patient an inclination to perform this function, it may be assisted by an injection of warm water or of any mild laxative which may facilitate the process and prevent any unnecessary action of the abdominal muscles, against which the patient should be cautioned. The attendants should be forewarned that the position of the patient is not to be interfered with under any circumstances, the necessary arrangements being made by bedsteads of a proper construction, or by other simple means which are sufficiently well known.

383. The custom of directing a man to be bled forthwith, as well as purged, because he has been stabbed, was another error much in esteem by the older surgeons, but which experience did not sanction, and it could not therefore be approved. The abstraction of blood before reaction has taken place delays its occurrence as well as the commencement of that inflammatory stage which is to be so salutary in its result in favorable cases. It tends to prevent the agglutinative process from taking place, and thus aids the diffusion of inflammation over the whole surface of the peritoneum. The general abstraction of blood is to be ordered, and regulated as to quantity by the symptoms of inflammation which may accompany or follow reaction. The quantity of blood required to be taken away in these cases is usually large, particularly at an early period. With the army in the Crimea, the abstraction of large quantities could not in general be borne and has not been found serviceable, nor has it been found so necessary to repeat the bleedings as in persons more favorably situated. It is, however, often a nice point to determine when blood enough has been abstracted with advantage, as too much may be taken away as well as too little--the former being marked, after death, by the general diffusion of a slight degree of inflammation, without the concomitant sign of effusion of serum. Leeches applied in considerable number will often be found more beneficial, particularly at a late period, when the sufferer may not be able to bear a general abstraction of blood. The patient, after leeches have been once applied and their good effect has been ascertained, will often ask for them himself on the recurrence of pain or on its increase; and from twenty to sixty, or even eighty, may be applied in some instances of great danger with advantage.

The pulse is by no means a guide in the management of these cases; a small, low, and sometimes not even a hard pulse being more strongly indicative of an overpowering state of inflammation than is a quick and full pulse; much more depends on the pain, the anxiety, and the general oppression than on the apparent state of the circulation. Before general and local bleeding cease to be employed with advantage, calomel, antimony, and opium will render essential, nay, most important, service.

The extensive incisions made of late years into the abdomen for the removal of ovarian tumors, with fair success, confirm what I have constantly repeated in my lectures for the last thirty-five years, that penetrating wounds of the abdomen, without injury to the viscera, when properly treated, are not so dangerous as they were generally supposed to be.

384. In penetrating wounds of the belly, the offending instrument frequently passes in for a considerable distance, sometimes separating or pushing the viscera aside without injuring them, at others inflicting upon them wounds more or less severe. In fatal cases of stabs from knives and sharp instruments, the intestines have been usually injured by the point, although when the lapse of three or four days before death takes place, the small wound is not readily perceived.

W. Carpenter, private, 1st battalion, 43d Regiment, was accidentally wounded, March 19th, 1812, by a comrade, the small end of a ramrod entering about two inches below the navel, passing in a direction upward, penetrating the second lumbar vertebra, and protruding an inch and a half on the opposite side.

On examining the wound, the ramrod was found firmly fixed in the bone. It was endeavored at first to extract it by a gentle turn, making extension at the same time, but this failed. Force was then applied on the opposite side, by fixing the broad end of a ramrod on the point of the protruding one, which was laid bare by an incision, when by a smart stroke with a stone it was driven back and removed. Bleeding to twenty ounces.

March 20th.--Has slept several hours during the night; passed urine two or three times; suffers slight pain occasionally on turning himself in bed; has the perfect use of his lower extremities; pulse rather full; skin cool; repeat bleeding to twenty ounces.

22d.--No evacuation since the 20th; pulse rather full; bleeding to twenty-two ounces; sulphate of magnesia, one ounce. Seven o’clock A.M.: Medicine operated three or four times; feels no pain in passing water.

23d.--Has passed a good night; wounds dressed; is allowed a small proportion of bread with his tea.

28th.--So far recovered as to be able to be removed to Elvas.[5]

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