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 3 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 3 of 3)

That a blunt instrument, like the small end of a ramrod, should be forced between the loose viscera of the abdomen without wounding any of them, may be easily conceived, but that balls or sharp-pointed swords should do so, is not to be understood so easily. Ambrose Paré, our own Wiseman, Ravaton, Lamotte, Muys, and others, however, have related instances of this kind, in which the patients recovered in an inconceivably short space of time; but these and other recoveries of a similar nature must be considered as exceptions to general rule.

[Footnote 5: He marched with his regiment, in the summer, to Valladolid, and was drowned in the Douro.--G. J. G.]

385. Wounds penetrating the wall of the belly, when made by cutting or lacerating instruments, or by musket-balls, are usually followed, if to any extent, by a protrusion of some portion of the contents of the cavity, generally of the omentum or intestine, if not of both. This may take place at the rounded orifice of entrance of a ball, as well as at the more slit-like opening of exit, which, if the patient should recover, becomes closed by a thin tendinous-like expansion, under the cicatrix formed by the common integuments. These soon yield to the general pressure on the abdominal cavity, and admit of the formation at the part of a ventral rupture, requiring the application of a restraining bandage.

386. When a piece of omentum only protrudes, the direction given by the latest writers on surgery is, that it shall be returned into the cavity of the abdomen whence it came, the finger following to ascertain that it is quite free; after which the wound is to be carefully closed by sutures applied close to the peritoneum, so that the omentum may not again protrude through it. Having objected already to the manner of employing the suture, I now object to the treatment of the omentum, and do not approve of its being so dextrously returned by the finger within the peritoneum to its natural loose situation. I desire, on the contrary, that it may be retained between the cut edges of the peritoneum, but without the slightest pressure or possible strangulation, in order that by its retention it may more readily adhere to these edges, and thus form a more certain barrier against the extension of inflammation than is likely to take place when moving at liberty in the cavity of the abdomen, however closely it may be supposed to be applied to the inner surface of its paries.

It sometimes happens that a portion of omentum is altogether without the cavity of the abdomen, and the opening through which it has protruded seems too small to allow its restoration to the cavity. The latest authors on this subject recommend a blunt director to be introduced between the upper edge of the wound and the protruded part, be it omentum or intestine, or both, upon which a blunt-ended bistoury is to be passed into the cavity as far as the enlargement of the wound seems to require, after which the director and the bistoury are to be withdrawn together. I altogether dissent from this. It is scarcely ever necessary to enlarge the opening in the peritoneum, the obstacle to reduction being situated in the tendinous expansion or aponeurosis of the wall of the belly, a slight division of which will give sufficient space for the restoration of the protruded part in almost every instance. I have unavoidably opened into the cavity of the peritoneum, and have seen it done in other instances, but no inconvenience follows small openings not exceeding a quarter of an inch in length, when they are properly covered over by the healthy parts. It is therefore important in all cases to have as small an opening as possible in the peritoneum, and certainly no addition should be made to the size of a small opening if it can by any possibility be avoided, however indifferent half an inch, more or less, may be in the length of a large one. All protruded parts, whether omentum or intestine, should be gently cleansed with warm water, and the fingers of the surgeon should be wetted in a similar manner, the mesentery being returned first if protruded, then the intestine, and lastly the omentum; the two former under all circumstances; the latter not so, if it be adherent or inflamed, torn or jagged, or in a state of suppuration or gangrene. It should in these cases be left to itself, and treated in the most simple manner; a ligature should never be applied to it, neither should it be spread out and cut off, as was formerly recommended, as it will gradually retract and be withdrawn into the cavity of the abdomen. If suppuration should take place in its substance, and the swelling of the part lead to its constriction, or the formation of matter under the integuments or between the layers of muscular or tendinous fibers, these may be carefully divided.

Evan Thomas, aged seventeen, was admitted into the Westminster Hospital, Sept. 1st, 1828, having been stabbed with a dinner-knife immediately above the umbilicus; the wound was three-quarters of an inch long; the omentum protruded and could not be returned until the skin, cellular membrane, and fascia had been divided; the opening in the peritoneum was then distinctly seen, against the inside of which the omentum was left, the wound in the skin being sewed up by the continuous suture. In the evening he was bled to sixteen ounces, and, as he had thrown up his dinner, an enema only was administered. On the 2d, the belly being tense and slightly painful, although he was not in constant pain, the blood drawn before being buffy, twenty-two ounces more were taken away, a purgative enema administered, and, as the bowel was not believed to be injured, four grains of calomel and six of the compound extract of colocynth were given, with a draught of senna and salts every four hours. 3d. The bowels open; no pain and scarcely any uneasiness on pressure; abdomen soft. No food; barley-water and gruel; pulse 84. On the 6th the sutures were removed, the wound having reunited. He was then made an out-patient, having a comfortable home.

A soldier of the Second Division of Infantry received several stabs from a lance in different parts of the body, at the battle of Albuhera, as the lancers rode past him, while lying on the ground, one only being of any importance: it was on the right side and lower part of the belly, and through it a portion of omentum protruded. On this being reduced, the epigastric artery, which had been divided, bled freely; a ligature was readily applied, and the wound closed by the continuous suture. The patient, after undergoing a very rigorous treatment, recovered.

A Spanish soldier was wounded in a scuffle in Madrid, in 1812, at the gate of the British Hospital, near the Prado, into which he was brought, with a wound on the right side of the abdomen, near and below the umbilicus, through which a portion of omentum protruded about the size of a small orange. As this could not readily be returned, I carefully enlarged the wound at its under part, some three or four hours afterward, by dividing the skin, and then found that it was the aponeurotic or tendinous expansion of the muscles going to form the sheath of the rectus, which prevented the return of the omentum into the belly; on the division of this part it slipped back without difficulty, but as it did not recede further than the peritoneum I left it there, and closed the wound, which was about an inch long, by sewing it up in the manner described. He was bled and starved, and was delivered up to the proper authorities out of danger, with his wound nearly healed, when the army evacuated the place.

A Spanish soldier was wounded at the battle of Toulouse by a musket-ball, which passed in on one side and came out at the other, carrying with it a portion of omentum which gradually became as large as an orange, in which state I saw it four days after the accident. Little had been done; he had not suffered much pain, although the abdomen was tender; he had vomited; passed blood with his motions; was feverish and ill. I visited this man every three or four days; he suffered from privations of every kind, yet each time I found him better. The protruded omentum gradually diminished in size, and was at last drawn into the wound in the abdomen and covered by granulations. He left Toulouse before me, nearly well.

If the omentum be greatly bruised or injured it may be cut off, and the vessels tied if bleeding; but it should not be returned further than the edges of the peritoneum, over which the external wound is to be closed.

Ravaton wrote a hundred years ago: “The views of a surgeon must be very confined who advises the application of a ligature to the omentum when protruding from the cavity of the belly in a healthy state. It is a cruel and deadly maneuver, contrary to reason and experience. To restore it to its place is so simple, just, and reasonable, that I am surprised it does not occur to every one. The reduction is easily effected. It is sometimes difficult to retain the reduced part except by sutures. I admit that when the omentum is strangulated, gorged with blood, black, and about to become gangrenous, the result of its restoration to the cavity may be doubted: yet experience has demonstrated that it is the safest mode of proceeding, taking care not to close the wound entirely, but to leave an opening at the lower part to give vent to any effusion or suppuration that may take place.”

387. When a portion of intestine is protruded without being wounded, it is to be returned, whatever may be its state, unless it be soft and unresisting between the fingers, of a dull blue or black color, and to every surgical eye deprived of life or mortified. At any state previous to this (to Englishmen) almost certainly fatal condition, it should be restored into the cavity of the abdomen. When a portion of intestine is thus returned, three directions are given by most modern surgeons, and especially by Chelius, section 517, on which his English editor makes no comment; and which may therefore be considered to be those which are commonly taught in London, but of which I entirely disapprove. The first is, that the peritoneum is to be divided in cases where an obstacle is interposed to the return of the intestine; this I aver to be less necessary for the intestine than for the omentum. The second is that, “after the reduction, the forefinger must be introduced into the cavity of the belly in order to ascertain that the intestines have not passed into the interspaces of the muscles”--a precaution which is unnecessary, and may do much mischief. The third is, that the patient is then to be placed “in such a posture as that the intestines should least press against the wound,” to which direction I object. The surgeon should certainly take care that the intestine does not pass between the layers of muscle, nor anywhere else than into the cavity of the belly. So far, however, from the intestines being pushed away from the cut peritoneum, the most favorable position for it would be to be applied against the edges of the cut membrane, and even rising up for the least possible distance, without or above it, the great object to be desired being to facilitate adhesion by as perfect an apposition of these parts as possible, while the external wound is accurately closed by the continuous suture, and duly supported by adhesive plaster, compress, and a bandage, provided it be methodically applied. The next best thing which can happen is that, every part being relaxed, and the patient perfectly quiescent, the intestine should press so steadily and yet so gently against the wounded peritoneum that it will be kept in constant apposition with it without protruding through it.

A soldier of the Artillery was stabbed in two places, in 1812, with a long knife, by a townsman, late in the evening, and was carried into the hospital for the sick and wounded French prisoners in Lisbon. The wound in the belly was situated somewhat more than an inch to the right side of the umbilicus, and was about an inch in length from above downward; through it a considerable protrusion of small intestine, without any omentum, had taken place. This was distended by flatus, and of a dark-brown color when I first saw it, some time after the receipt of the injury. The bowel being constricted by the tendinous expansion of the muscular fibers, the latter was carefully divided by a blunt-pointed curved bistoury passed under its upper edge, and resting on the back of the nail of the forefinger, by which the intestine was guarded; the flatus having been pressed out of the intestine, which was gently washed with warm water, it was restored to the cavity of the abdomen. Of the part which had apparently first protruded, the peritoneal coat and a few fibers of the longitudinal layer of muscle were divided to the extent of half an inch, the remaining portion of the gut being unhurt. The skin was then sewed up by a fine continuous suture, and adhesive plaster and a compress duly applied. A good deal of alarm was evinced, the pulse was very small, and the man faint. The other wound was in the back, about half an inch in extent, and near the inferior angle of the right scapula. It appeared to be a penetrating wound, but not giving rise to any peculiar symptoms, he was placed in bed on his back, with his legs raised, and the body slightly bent. Early the next morning, the officer on duty found it necessary to bleed him largely, to forty ounces, according to my directions, on account of pain which had come on in his bowels and in his back, accompanied by difficulty of breathing, the skin being hot and the pulse quick and hard. The cellular membrane around the wound in the back was emphysematous; there was a slight cough, accompanied by an expectoration slightly tinged with blood. The bleeding removed the essential symptoms, but the pain and difficulty of breathing returning next day, it was repeated to eighteen ounces, with an equally good effect. It was necessary to repeat it on the third, fourth, and fifth days, when the pain ceased to return, and the pulse, instead of being small and hard, became softer and fuller. The bowels were open naturally on the third day, and the emphysema had gradually disappeared, no food being allowed, and very little drink for some days, and then only in small quantities of the simplest kind. The threads were removed with scissors on the sixth day, and the man was free from complaint, although very weak, at the end of five weeks.

Madame Doucet was applied to a hundred years ago, by a soldier, who having been struck by a halbert, had a wound made across his abdomen from above the ilium, through which a quantity of intestine protruded, which he carried in his hat, enveloped in his shirt. Having had to walk between three and four miles, in the heat of July, to the old lady, his bowels were as dry as parchment by the time he arrived. She therefore bathed them in warm milk and water until they became soft and natural in appearance, returned them into the cavity of the belly, and sewed up the wound with a well-waxed silken thread--thus setting an example which ought to be followed in 1855. The man recovered.

388. When the protruded intestine is wounded, the case is complicated, and much depends on the size of the wound. A mere puncture, or a very small cut, is often of no consequence, and does not require any treatment; the bowel should merely be returned to the cavity of the belly, and the symptoms of inflammation closely watched, and, if possible, steadily subdued.

It is advisable, in investigating this subject further, to consider the abdomen as devoid of cavity during life and health, the contained parts being so gently pressed upon by the containing and retaining muscular parietes around as to enable them all to carry on their ordinary functions, unless suffering from some derangement, exclusive of that which might arise from a deficiency of the pressure usually exercised upon them; but that this pressure can, or generally will, prevent the effusion of the contents of a bowel when ruptured, if the wound be half an inch in length, or that it will prevent the extravasation of blood from an artery or vein of moderate dimensions, if torn, is contrary to facts now considered indisputable, as I have frequently had occasion to verify. That a mere puncture of the intestine does not allow the effusion of air, much less of the contents of the bowel, is not doubted. When the contents of the bowel have been poured out, without an external opening in the paries through which they might escape, inflammation and death have ensued at no long distance of time. When blood is poured out from the great vessels, as in rupture of the liver or spleen--of which instances will be adduced--the general cavity may be filled; but when the injury is less extensive, or the lesion less important, the blood usually gravitates toward the back or sinks into the pelvis. It is possible that blood may be effused in small quantity, and be then confined, under the general pressure of the wall of the abdomen and the resistance offered by its contents, to a particular spot, whence it may be absorbed after coagulation; or, by commencing decomposition, give rise to irritation, and be discharged through the external wound, if one exist, or through the bowel with which it may happily be in contact.

A soldier, belonging to the Second Division of Infantry, was wounded by the Polish Lancers at the battle of Albuhera, in several places slightly, and in the abdomen severely, a penetrating wound having been made an inch long, between the umbilicus and the crest of the ilium on the left side. Brought to me the day after at Valverde, the edges of the wound were stitched together and dressed simply. He said it had bled freely at first, and was then painful. Treated antiphlogistically and sharply, the inflammatory symptoms gradually subsided. The bowels were relieved by gentle aperients, there being no reason to suppose they had been wounded. A small, oval swelling was soon perceived under the wound, which was tender to the touch, indicating mischief of some kind. The edges of the wound, which did not unite fully, although they were retained in contact, at last separated, and allowed about a wineglassful of bloody matter to pass out, which reduced the swelling and removed the uneasiness and pain of which he complained. After this he gradually recovered, and was discharged to Elvas, and thence to Lisbon.

389. Whenever large effusions of blood have occurred, the sufferers have usually been lost, from the occurrence of peritoneal inflammation. That small ones may be absorbed, cannot be doubted. I have seen instances of their having been discharged by the bowel, although I have never been so fortunate as to see a general formation of matter from effusion, and to have opened the abdomen for the evacuation of its contents with success; nevertheless, I do contemplate that such cases may occur, and surgery may come to their relief with good effect.

The important conclusions to be deduced from the observations of those who have made experiments on the intestines of living animals are--First, that wounds not exceeding four lines in length, (or the third part of an inch,) no matter what their direction may be, are not so apt, as might be supposed, if left to themselves, to be succeeded by extravasation of the contents of the intestinal tube; and that, in the majority of cases, nature, properly aided by art, is fully competent to effect reparation. Secondly, that wounds of the bowels to the extent of six lines, whether transverse, oblique, or longitudinal, are almost always, if not invariably, followed by the escape of the contents of the bowel, and the consequent development of fatal peritonitis. It may, therefore, be concluded, from experiments made on animals, as far as they can be relied upon with reference to man, that every wound in the bowel, of such an extent as shall not admit of its being temporarily filled up by the protrusion and eversion of its internal or mucous coat, which always takes place as an effort of nature to close the wound, ought, if possible, to receive assistance from art, and that can only be given with advantage in the first instance.

Mr. Travers tied a thin ligature firmly round the duodenum of a living dog; the ends were cut off, the parts returned, and the external wound properly closed. On the fifteenth day, the cure being completed, the dog was killed. A portion of omentum, connected with the duodenum, was lying within the wound, and the folds contiguous to the tied part of the intestine adhered to it in several points. A slight depression was observed around the duodenum, the internal or mucous surface of which was more vascular than usual; a transverse fissure marked the seat of the ligature. “The lymph,” Dr. Gross observes, “which is effused upon the external surface of a bowel, consequent upon such an operation, gives the part at first a rough, uneven appearance; but, if the animal survive several months, it is generally no easy matter to determine the seat of the injury from the external appearance of the part. Internally, the cicatrization is almost as complete, the continuity of the mucous membrane being everywhere established, leaving scarcely even a seam at the original seat of constriction. The rapid manner in which the ligature cuts its way from without inward obviates the evils which might arise from the occlusion of the passage. In an experiment, in which the dog was killed upon the eleventh day after the application of the ligature, the canal of the bowel was completely restored, and the bond of connection between the divided parts was firm and organized.”

Similar effects are produced when a small ligature is applied around the edges of a wound from two to three lines in diameter, provided it be drawn with sufficient firmness not to slip off. The process of reparation is not, however, so speedily completed, owing to the breach being much wider than when a ligature is simply placed around the tube. The mucous membrane requires a longer period for its reproduction, and the quantity of lymph deposited around and inclosing the ligature is proportionally greater.

390. The idea of sewing together, and thereby restoring the continuity of a wounded bowel, is attributed to four master surgeons, as they were called, of Paris, in the thirteenth century, who, having united their efforts for the relief of the sick poor in that city, procured, it is said, a portion of the trachea of an animal, one end of which they introduced into the upper part of the divided bowel, and the remaining piece into the lower, and then brought the divided ends into contact, and retained them by as many sutures as appeared to be necessary. Their writings, in which this operation is described, are lost. Peter de Argelata, who lived about the middle of the fifteenth century, says that Jemerius, Roger, and Theodoric supported the intestine by a canula of elder-wood, while Gilbert de Salicetti condemns both the use of the trachea and the elder-wood tube, and recommends, if anything be used, that it should be the dry and hardened bowel of some animal. These ancient surgeons believed that a transverse division of the intestine was necessarily a fatal injury, and only resorted to the methods they recommended when the division was less complete. Duverger de Maubeuge, in the beginning of the eighteenth century, apparently unaware of what had been done before his time, brought forward this method of the four masters as an invention of his own. He cut off a portion of mortified intestine in a case of strangulated hernia, introduced a piece of the trachea of a calf, brought the divided intestine over it, and fastened it by a suture. The trachea was passed on the twenty-first day, and the external wound was closed by the forty-fifth, the patient recovering.

Ramdohr, a German surgeon, who lived in the early part of the last century, seems to have been the first to join the ends of a divided bowel by introducing the upper end within the lower. He removed two feet of mortified intestine in a case of strangulated hernia--performed this operation on the ends of the bowel, retained the parts by stitches, and his patient perfectly recovered. Heister says the mortified parts were in his possession. (Haller, Disputat. Anatom., vol. vi., Observ. Med. Miscel., 18.) Since his time, many of the most eminent surgeons of France, Italy, America, and Great Britain have turned their attention to this subject; but the conclusion at which I have arrived is that the continuous suture is, in all cases of serious injury, the most simple and the best.

391. In making a continuous suture, a fine needle and a waxed silken thread should be introduced through the gut, beginning on the inside close to one end of the cut part, and bringing it out on the peritoneal surface a little more than a line distant from where it entered. The needle is then to be carried to the opposite side through the bowel from without inward, and the sewing thus continued until completed, each stitch being about the sixth part of an inch asunder, and about that distance from the edge of the cut. The threads or stitches should not be drawn close until the whole are inserted, when, on being drawn moderately tight one after another, the cut edge of the intestine should be turned inward by a blunt probe, so that the peritoneal surfaces shall be in contact under the stitches and in the best situation for union, the mucous coat forming a ridge within, the outside being perfectly smooth, the stitches not being too tight, while the end may be secured by a knot made by a turn of the thread over the needle. This done, the intestine should be returned into the cavity of the abdomen, and events awaited. Recoveries more frequently follow wounds of the colon than of the jejunum or ilium; but the result must always be doubtful, being dependent on many causes which the surgeon can neither foresee nor control.

LECTURE XXVIII.

TREATMENT OF INCISED WOUNDS, ETC.

392. When an incised wound in the intestine is not supposed to exceed a third of an inch in length, no interference should take place; for the nature and extent of the injury cannot always be ascertained without the committal of a greater mischief than the injury itself. When the wound in the external parts has been made by an instrument not larger than one-third or from that to half an inch in width, no attempt to probe or to meddle with the wound, for the purpose of examining the intestine, should be permitted. When the external wound has been made by a somewhat broader and longer instrument, it does not necessarily follow that the intestine should be wounded to an equal extent; and unless it protrude, or the contents of the bowel be discharged through the wound, the surgeon will not be warranted in enlarging the wound in the first instance to see what mischief has been done. It may be argued that a wound four inches long has been proved to be oftentimes as little dangerous as a wound one inch in length; yet most people would prefer having the smaller wound, unless it could be believed that the intestine was injured to a considerable extent. Few surgeons, even then, would like to enlarge the wound to ascertain the fact, unless some considerable bleeding or a discharge of fecal matter pointed out the necessity for such an operation. When the wounded bowel protrudes, or the external opening is sufficiently large to enable the surgeon to see or feel the injury by the introduction of his finger, there should be no difficulty as to the mode of proceeding.

393. A puncture or cut which is filled up by the mucous coat so as to be apparently impervious to air does not demand a ligature. An opening which does not appear to be so well filled up as to prevent air and fluids from passing through it cannot usually be less than two lines in length, and should be treated by suture. When the opening is small, a tenaculum may be pushed through both the cut edges, and a small silk ligature passed around, below the tenaculum, so as to include the opening in a circle, a mode of proceeding I have adopted with success in wounds of the internal jugular vein without impairing its continuity; or the opening, if larger, may be closed by two or more continuous stitches made with a very fine needle and silk thread, cut off in both methods close to the bowel, the removal of which from the immediate vicinity of the external wound is little to be apprehended under favorable circumstances. The threads or sutures will be carried into the cavity of the bowel, as has been already stated, if the person survive, and the external part of the wounded bowel will either adhere to the abdominal peritoneum or to one or other of the neighboring parts.

When the intestine is more largely injured in a longitudinal or transverse direction, or is completely divided as far as or beyond the mesentery, the continuous suture is absolutely necessary.

394. When the abdomen has been penetrated, and considerable bleeding takes place, but not from the intestine, it is necessary to look for the wounded vessel. When it comes from one of the mesenteric arteries or from the epigastric, the wound is to be enlarged until the bleeding artery be exposed, when ligatures are to be placed on its divided ends if they both bleed, the external wound being accurately closed. I have seen the epigastric artery tied several times with success.

A Portuguese caçador on picket was wounded at the second siege of Badajos in a sally made by some French cavalry. He had three or four trifling cuts on the head and shoulders, and one across the lower part of the belly on the right side. He bled profusely, and, when brought to me, had lost a considerable quantity of blood which came through a small wound made by the point of a sabre. This wound I enlarged until the wounded but undivided artery became visible; upon this two ligatures were placed, and the external wound was sewed up. The peritoneum was open to a small extent, but the bowel did not protrude; and the patient (not being an Englishman, and therefore not so liable to inflammation) recovered after being sent to Elvas.

A soldier of the same regiment, cut down at the same time, died as soon as he was brought into camp, having been severely wounded in the chest and abdomen. He was said to have died from hemorrhage, from a wound in the belly, two inches in length, made by one of the long-pointed swords of the French dragoons. I had the curiosity to enlarge the wound, and found one of the small intestines had been cut half across, another part injured, and that the blood came from an artery which had been opened by the point of the sword in going through the mesentery, which wound had caused his death.

395. When this operation cannot be done successfully or with advantage to the patient, whose life is in jeopardy from the continued drain, the wound should be closed by suture, and a compress laid over it and retained by a bandage methodically applied for the purpose of aiding the muscular parietes in keeping up that pressure on the viscera which may be useful in arresting the flow of blood from the wounded part. If the bleeding continue, or, having been arrested, should recur, and the belly become in consequence distended, the sutures being evidently so tense as to be likely to cut their way out, or if the blood should ooze out between the stitches, they may be in part removed in order to give immediate relief. When the belly becomes very painful, tense, and manifestly full after a punctured wound, and not tympanitic from the extrication of air or the distention of the bowel by it, the wound should be enlarged to allow the evacuation of the extravasated blood, which cannot be absorbed when in such quantity. The orifice of a small gunshot wound, which is not sufficiently direct to communicate with the cavity and to allow the issue of blood extravasated in the quantity alluded to, should be enlarged to such an extent as to effect that object.

396. Blood effused in moderate quantity, and circumscribed by the pressure exercised upon the contents of the abdomen by its parietes, may readily be evacuated by the wound, provided it be sufficiently open; and the patient may recover, if the inflammation which must necessarily ensue should not be communicated along the peritoneum throughout the cavity, or if it should be subdued in time. If the blood be in small quantity, it coagulates, and may be absorbed; but if in such a quantity as cannot be absorbed, or from any other cause which may prevent its removal by this means, it becomes after a time a source of irritation, and nature sometimes commences early to cut it off from the general cavity by surrounding it with fibrin--a result which, however desirable, can rarely be expected.

When extravasated blood is thus cut off from the general cavity, and cannot be absorbed or be by accident carried off through an opening in the bowel, a change takes place by which it ceases to be bland and harmless, and causes it to excite inflammation and its ordinary consequence, suppuration, if the patient survive so long. This occurs, for the most part, after the first inflammatory symptoms have subsided, from the tenth to the twelfth, or even to a later, day, when the renewal of irritation is accompanied by an increase of the general symptoms, by a more local pain, and by a circumscribed swelling of some part near the wound, in which fluctuation may perhaps be distinguished even during the existence of the general tenderness of the whole abdomen. Under such circumstances, when it is proposed to make an incision into this part, if it should be thought advisable to do such an operation, it may safely be preceded by an exploring needle or a very fine trocar and canula, which will demonstrate the fact of the purulent and sanious depot, without doing in such a case perhaps any mischief, if the expectations of the surgeon should not be realized. If the exploring needle should show that a bloody, purulent, or other fluid is really distending the abdomen, no doubt ought to be entertained about enlarging the original wound and making a depending opening.

Ravaton, in his twenty-fifth observation, relates the case of a soldier who was wounded five days before by the point of a sabre, to the right of the umbilicus. When the man was brought to him, the belly was swollen, hard, and very painful, with vomiting, hiccough, etc., announcing the approach of death. Believing that the abdomen contained a fluid, either effused or secreted, he made an opening into the cavity immediately above Poupart’s ligament or the outside of the internal opening of the ring of the right side, when, finding that nothing came from the cavity, he passed his finger upward along the iliac vessels, and, after tearing up some membranous adhesions, evacuated a pint of coagulated blood and fetid, serous fluid. He then introduced a dossil of lint into the wound to keep it open, fomented and oiled the belly, round which he applied a bandage, and placed the patient on his face. The bad symptoms diminished during the night, and the patient declared himself better in the morning. From the fifth to the tenth day of the wound he was in extreme danger. On the eleventh, the bed was inundated with a purulent matter of an almost insupportable smell. The cavity of the abdomen was injected and cleansed, the ordinary dressings applied, and the greatest cleanliness observed. He was subsequently dressed three times a day in a similar manner; portions of omentum were occasionally drawn away with the forceps. His strength was well supported by every kind of nourishment. The night-sweats continued until the thirty-third day, and on the seventy-second he was discharged from the hospital, cured. The discharge at first was serous, and only became purulent on the sixth day after the operation.

Thomas M’Mahon, 76th Regiment, aged twenty-two, was admitted into the Garrison Hospital, Portsmouth, upon the 13th of June, 1845, with all the symptoms of strangulated inguinal hernia of the left side, of two days’ standing, for which the usual operation was performed. Everything went on favorably till the morning of the fourth day after the operation, when he made a sudden effort to go to the close-stool, which was immediately followed by the descent of a considerable portion of intestine and omentum, accompanied with profuse hemorrhage from a small artery on the surface of the intestine, which was taken up and tied, and the parts returned into the abdominal cavity. The greatest excitement followed, with all the symptoms of acute inflammation. These were treated by general bleeding to the extent of fifty ounces, and sixty leeches to the abdomen, with other antiphlogistic remedies. On the morning of the seventeenth day from the performance of the operation, a piece of intestine came away with the fecal contents of the bowels, after which the patient experienced relief in all his symptoms, and appeared to gain health and strength, and after a time the wound seemed disposed to close, three weeks after the sloughing of the intestine. On the sixth day afterward the evacuations ceased, attended with acute tenderness of the abdomen, which began to swell fast. The means adopted had not the slightest effect, and the patient was considered past relief, unless it could be obtained by an external opening. I accordingly made an incision over the site of the former wound, and carefully opened the intestine, to the extent only to allow the tube of the stomach-pump to be inserted, when there was an immediate discharge of flatus and some feculent matter, and the patient expressed himself relieved. By the further use of the stomach-pump apparatus, I was enabled to extract a quantity of feculent matter by the artificial opening, and after some hours the patient was completely relieved from the dangerous symptoms he was suffering from. The artificial opening was left patent for two months, when the bowels again gave evidence of acting naturally. The artificial wound was not, however, closed till the 22d of August, 1845; a week after the bowels appeared to act freely and naturally.

The patient from this time got well and strong, and was discharged to his duty on the 10th of October, 1845, since which period he continued to perform all the duties of a soldier most efficiently, without experiencing any inconvenience to his general health or constitution, until the 6th of October, 1846, when he died of inflammation of the brain, at Fort George, in Scotland. On dissection, the abdominal viscera, including the intestinal canal, appeared perfectly healthy; but on a minute examination of the portion of small intestine (found to be the ileum) situated in the inguinal region of the side operated upon, directly opposite to the cicatrix of the external wound, it was discovered to be firmly attached to the abdominal parietes, by an adventitious membrane, to the extent of two lines, which then diverged, and formed itself into a canal of a funnel shape for about five inches and a quarter in length, of a homogeneous structure, which united itself with the continuous intestinal tube. By this wonderful provision of nature the healthy functions were uninterruptedly carried on, and permanently continued, without any pain or detriment to the patient’s general health. On appearance, Jan. 23d, 1847.

A. Maclean, M.D., late Surgeon, 76th Regiment.

Cases of extravasation or of effusion, terminating by the formation of a sac, pouch, reservoir, or foyer surrounding it, while the rest of the cavity remains free from inflammation, are so rare in natives of our northern climates that I am indisposed to infer that they do take place, except as very accidental circumstances. The fact that such things do take place should be borne in mind, and surgery should not be wanting in giving its aid, under all well-considered and reasonable circumstances. It is easier to do nothing than to think and to act.

The general treatment to be pursued in the acute period of all these cases of inflammation has been sufficiently marked--antiphlogistic to the utmost extent consistent with propriety, by bleeding, leeching, and cupping; the repeated administration of enemata; the early exhibition of mercury and opium, and subsequently of gentle aperients.

397. Continental surgeons, and by pre-eminence Baron Larrey, who is followed on this point by most French surgeons, inculcate the necessity of enlarging the wounds made by a musket-ball in the wall of the belly, although the Baron is particular in confining it to the muscular parts; M. Baudens, one of the latest writers on the subject, points out the additional tendency this gives to the formation of hernia, and furnishes therefore the soundest reason for not doing it without an especial cause. When a slip of the muscular or tendinous structures interferes with the quiescence of the wound; when it is desirable to introduce a finger to make an examination; when it is necessary to divide a portion to allow the restoration of protruded parts, no one will doubt the propriety of the direction. But when neither these nor any other good or sufficient reason can be given for such an operation as that of enlarging the wound (débridant la plaie) simply because it has been usual so to do, at the risk of making a large hernial protrusion instead of a smaller one, it is unnecessary. It gives rise to some bleeding, but that is really nothing; it makes a cut instead of a hole, by which nothing essential is gained; and as this enlargement of the wound can always be accomplished when it may become necessary from a sufficient cause, such interference, especially on the fore part or the sides of the abdomen, may be safely omitted.

398. When a musket-ball, passing across the abdomen, comes out behind through the thick muscles of the back, with perhaps a slit-like opening in the skin, through which some urine, and perhaps fecal fluid or matter may also pass, such wounds should be enlarged both superficially and deeply. There is here an object to be gained, and the operation is necessary. There is no objection to its being done when it is even supposed that these fluids or matters are likely to be soon or ultimately discharged through it, as it is desirable that any secretions or effusions which cannot be evacuated by the natural passages should have every reasonable opportunity offered of making their escape.

399. When it is obvious, from internal hemorrhage, or from the discharge of fecal matter, or from the introduction of the finger, by which it can be felt, that a large hole or rent has been made in an intestine, the wound should then be enlarged so as to allow its being brought into sight, when the edges should, if required, be smoothed, and the continuous suture applied in the manner directed, Aph. 391.

400. When a musket-ball penetrates the cavity of the belly, it may pass across in any direction without injuring the intestines or solid viscera. It usually does injure one or the other, and it has been known to lodge without doing much mischief. The symptoms are generally indicated by the parts injured, although in all the general depression and anxiety are remarkable; their continuance marks the extent if not the nature of the mischief.

The following cases of the survivors of hundreds who died under similar wounds, during the war beginning with the battle of Roliça in Portugal, in August, 1808, and ending with that of Waterloo, in June, 1815, may be read with a melancholy interest, as showing what sometimes will happen in a few rare instances, and even then as more dependent on the wantonness of nature than on the united efforts of science and of art.

A soldier of the brigade of heavy cavalry, under General Le Marchant, advancing in line to charge the French infantry at Salamanca, on which occasion the general was killed, was struck by a musket-ball, which entered in front, between the umbilicus and the ilium of the left side and came out behind on the opposite side above the right haunch-bone, thus traversing the body. The bowel protruded in front, but was uninjured, and was easily restored to its place. He remained at the field hospital with me for the first three days and was rigorously treated, as well as afterward in the San Domingo Hospital, where he gradually recovered, and was ultimately sent to the rear.

Captain Slayter Smith, of the 13th Dragoons, being engaged at Campo Mayor, on the 25th of March, 1811, was shot by a pistol-ball, which entered at the left hip, three inches and a half from the junction of the ilium with the sacrum, an inch and a half below its crest, and came out about three inches below the navel, and one inch to its right side. He felt a terrible shock, but did not faint or fall from his horse.

“There was a protrusion of bowel from the wound in front of about three inches; but little blood issued from it. The hemorrhage from the wound in my back was very copious. A French officer, with three or four of his men, were so near me that he called out ‘Rendez vous, mon officier,’ to which I replied, ‘Pas encore, monsieur,’ and rode away with my bowel in my hand.

“I reached the field hospital shortly afterward, when the protrusion was returned without enlarging the orifice, and no stitch was put into the wound then or afterward. It was dressed merely with lint and adhesive plaster. I begged earnestly for a glass of Madeira, which, after a little hesitation on the part of the surgeon, was given to me; but they afterward thought it necessary to bleed me; but little blood followed the insertion of the lancet. This was the only time I was bled. In the morning I found the bed saturated with blood, which had trickled through to the floor, and had escaped from the wound behind.

“Before a month had elapsed I and all the wounded were removed to Elvas on bullock-cars, and a desperate journey it was.

“On my arrival, inflammation began in the wound in front, accompanied with great swelling and pain. The swelling was laid open and a quantity of matter was evacuated, followed by an angry-looking protrusion, which was carefully washed with warm water, and poulticed; when the inflammation had subsided, the wound was dressed as before, with lint confined by adhesive plaster. When the protrusion was touched by the hand I experienced a nauseous and disgusting sensation, to which in comparison the application of the knife or lancet was a flea-bite.

“I arrived in England in June, and in September went to Brighton. Soon afterward I felt terrible pains in the right side of my back, in a line with the wound, through the ilium, or rather above it, where a kind of tumor formed. For several days I suffered agony from it; and one night, completely worn out, I fell into a long and deep sleep, and awaking late in the morning I found all pain and excrescence gone, and nothing remaining but a tenderness of the part on pressure with the finger. I underwent much from violent spasms in the stomach, which I never had before I was wounded. I recovered, however, sufficiently to rejoin my regiment the following spring in the Peninsula, and was soon afterward again wounded in a skirmish by a spent shot in the left shoulder, which, however, was of no moment, though I was compelled to return to England on sick leave, in October, 1812, as the spasms increased with greater severity, incapacitating me from doing my duty, and at times rendering me totally helpless.

“I now gradually recovered my health, and in the spring of 1815, accompanied the 10th Hussars to Belgium, and served at Waterloo.

“My health gave way again in 1821, and I certainly was in a precarious state for three or four years, but I gradually recovered, and by dint of great care and attention to diet I am now (1853) in robust health, and can take the strongest exercise with impunity.”

John Richardson, of the 1st Royal Dragoons, was wounded at the battle of Waterloo by a musket-ball, which entered two and a half inches above the umbilicus, and passed out on the left side, close to the lumbar vertebræ. He threw up a considerable quantity of blood, and the stomach was so irritable that nothing would remain on it. He complained of pain, which cut him right across, as he termed it; his eyes were suffused and face flushed; had headache; pulse 130. Thirty ounces of blood were taken from the arm, emollient injections thrown up the rectum, and poultices applied to the wounds.

June 20th.--Some blood came away with the injections during the night; great pain in the right side and shoulder; saline draughts are returned tinged with bile and blood; pulse 130. Bled to sixteen ounces; injections and poultices continued.

21st.--A draught was ejected mixed with blood, and a quantity of bilious fluid; diarrhœa during the night; the feces were mixed with blood; pulse 120; skin hot. Bleeding to twelve ounces; blood sizy.

22d.--Slept a little during the night; had several alvine evacuations of a bilious fluid mixed with blood. The tension of the belly is not so great. He still complains of pain. Tea remains on his stomach. Bleeding to twelve ounces; fomentations and poultices to the belly; chicken and beef broths; injections frequently.

24th.--Feels considerable relief from the tension of the abdomen having subsided; threw up his tea and a quantity of clotted blood this morning.

26th.--Had a bad night; pulse 125, and full. Complains of great pain in the hepatic region, and backward toward the spine. Bleeding to sixteen ounces. ℞.--Hydrarg. chlorid. gr. iv; conf. rosæ. gr. ix; to be made into two pills, one to be taken twice a day.

30th.--Vomiting in the night, mixed with blood; tea, etc. remain on the stomach this morning; pulse 108.

July 5th.--The adnatæ have a yellow tinge; in other respects he is doing well. ℞.--Chlorid. hydrarg. gr. x; extr. colocynth. comp. ʒj: to be made into ten pills, one to be taken three times a day.

20th.--The wound perfectly healed; is cleaning his accoutrements, boots, etc. Was discharged on the 28th of July, perfectly recovered.

Owen M’Caffrey, aged thirty-three, first battalion 95th Regiment, was wounded on the 18th of June at the battle of Waterloo, by a musket-ball, which penetrated the cavity of the abdomen on the right side, about midway between the superior anterior spinous process of the ilium and the linea alba. When admitted into the Minimes General Hospital three days after, he was in the most deplorable state; the whole abdomen was tense and exquisitely tender; the pulse small and wiry; vomiting incessant, with hiccough and ghastly visage. From this period to the 24th, he was thrice largely blooded, and the strictest antiphlogistic plan was laid down and rigidly adhered to. Laxative injections were administered, the whole of the abdomen was frequently fomented, and opiates were administered to allay the irritability of the stomach, and to procure ease and rest. On the 25th the wounded intestine sloughed, and the feces escaped by the external orifice, the adherence of the two surfaces of the peritoneum preventing any, even the smallest portion, getting into the cavity of the abdomen.

26th.--The high inflammatory action having been reduced, milk, rice, and sugar, and the farinaceous part of the potato were allowed.

July 1st.--No very alarming symptom remains. Half a fowl ordered for his dinner, and the greatest attention to personal cleanliness directed to be paid.

7th.--Strength slowly but gradually returning. The action of the large intestines is daily kept up by stimulating injections.

14th.--Progress to recovery satisfactory. The injections are daily repeated, and the discharge by the natural passage increases. The wound contracts and looks healthy. Is enabled to sit up, and has recovered his cheerfulness.

28th.--Still improving; ultimately recovered.

The situation of the ball was never ascertained.

A soldier of la Jeune Garde Imperiale was struck by a ball, which entered to the right and a little below the umbilicus and passed out on the left or opposite side, about two inches above the crest of the ilium. It was supposed to have passed along the canal of the great arch of the colon. Fecal matter, much tinged with bile, passed by both openings. The symptoms of inflammation were severe for the first few days, but gradually yielded to the means employed, when the bowels began to act regularly by the aid of mild injections, and the discharge from the wounds gradually lessened; the man was much reduced, but otherwise in good health, and was sent to France from Brussels, nearly well.

A soldier of the Third Division of Infantry was wounded during the assault of Ciudad Rodrigo, by a ball which entered and lodged in the left side of the back, about midway between the spine and a line drawn to the upper part of the crest of the ilium, from which opening the contents of the bowel were discharged. Left among the dead and those who were supposed to be dying at the field hospital, in the rear of the trenches, I sent him, with all those of different corps who were wounded, to my own hospital at Aldea Gallega, some ten miles off. Here, under a sufficiently vigorous treatment, of which bleeding, starvation, and quietude were the prominent features, he gradually recovered. On the fifth day the ball passed per anum, and on two or three different occasions afterward portions of his coat, flannel shirt, and breeches. Fecal matter passed readily through the wound, while the bowels were gently solicited by common injections for some time; but the wound gradually closed in, and the man regained his health, and was sent to the rear with a slight colored discharge from the wound, not quite free from odor.

Ensign Wright, 61st Regiment, was wounded by a musket-ball, on the morning of the 10th of April, at Toulouse. The ball passed through the abdominal parietes on the right of the linea alba, nearly half way betwixt the umbilicus and the pubes, and lodged. Sense of debility, tremor, nausea, small, feeble pulse, and pain in the lower part of the abdomen were the immediate symptoms.

Peritonitic and enteritic symptoms of considerable violence having begun to manifest themselves on the 11th, copious and repeated evacuations of blood were made by order of Mr. Guthrie, the Deputy Inspector-General in charge of all the wounded. Fomentations were applied to the belly; abstinence in food and drink was strictly enjoined, and the most rigid antiphlogistic regimen followed. The same practice was pursued during the 12th, 13th, and 14th, venesection being performed either two or three times every day, as the augmented state of the local and general inflammatory symptoms seemed to require. The bowels during the above period had continued perfectly free, and the dejections were tolerably natural in color, but rather dark, and extremely fetid. He had been frequently troubled with nausea and vomiting of bilious matter. Two small doses of castor-oil had been exhibited.

Toast and water, tea, boiled milk-and-water, with a little soft bread soaked in it, and mutton and chicken-broth in small quantities at a time, were all that was allowed him for food and drink.

April 15th.--Pulse above 100, weak and small; temperature natural; the tongue clean. Continued affected with a degree of nausea and vomiting, after drinks especially; and some diarrhœa was present.

17th.--Was bled last night to twelve ounces, in consequence of increased pain of abdomen and augmented pyrexia; to-day quiet and easy, and has had several stools.

18th.--Diarrhœa and tenesmus troublesome during the night; ball voided with the feces at six A.M.; it is somewhat flattened, as if from impinging on a stone; has felt easy since. Continue antiphlogistic regimen.

19th.--Diarrhœa abated; but the abdomen is tense and painful on pressure. He is distressed with nausea and vomiting; pulse 100, and sharp; great thirst; tongue dry. Bleeding to sixteen ounces; abdomen fomented.

20th.--Bleeding was repeated last night from persistence of the symptoms of peritonitis. Blood drawn very buffy; has had several loose stools during the night. He is to-day easy; abdomen now scarcely painful. Fomentations continued.

29th.--This morning the abdomen was tense and painful on pressure; he was affected with nausea, and had had vomiting repeatedly during the night; thirst and pyrexia. Fomentations were applied from time to time, and yielded relief. Suspect that he has not observed the prescribed regimen.

May 1st.--Pain of abdomen and bilious vomitings during the night; has had three loose stools. Pulse 110, hard and small; thirst urgent. Blood let to fainting; fomentations continued.

2d.--Last night he was again bled to two ounces, when fainting supervened. He passed a quiet night; had two liquid stools; abdomen not painful, nor is he sick at stomach, nor thirsty. To keep himself warm, particularly the belly.

11th.--Suspect he has been rather irregular in diet. Passed a bad night, partly in delirium; has vomited much; has obviously pain on pressure of the abdomen, but appears studious to conceal it; pulse 112, small and not soft; temperature increased; tongue red; thirsty; three liquid stools. The stomach to be kept warm; ten drops of tincture of digitalis in half an ounce of mist. acaciæ, to be taken three times a day; diet of milk and farinaceous food; for drink, infusion of tea in small quantities. Eight o’clock.--Pulse 120, soft; feels easier, and has not vomited. Ordered a foot-bath.

13th.--Molested by pains, nausea, and vomiting during the night; pulse 110, not soft; skin cool, but is thirsty, and his tongue is of a vermilion color, and arid; confesses that he has hitherto disguised his feelings, as well as other circumstances connected with his case, particularly his manner of living. Digitalis continued; blister to be applied to the epigastric region, and the foot-bath repeated in the evening.

14th.--Bad night; pulse 112; skin hot; pain of abdomen not urgent; no vomiting, but is affected with nausea. Digitalis continued. Four o’clock.--Pulse 100; feels nauseated; no pain of abdomen. Digitalis occasionally.

16th. Eight A.M.--The tendency to vomit continues. One grain and a half of chloride of mercury with a grain and a half of opium, made into a pill, to be taken in the morning; to be bled. Seven P.M.--Vomits whatever he swallows in any quantity; skin hot; thirst great; tongue red; two motions; says abdomen is not painful; pulse 112. A blister to be again applied to the epigastrium; foot-bath in the evening; repeat the mucilaginous mixture for cough.

17th.--Rested ill; blister has not risen; cough has been severe and continues so; two motions; pulse 120, and not soft; cough augmented by deep inspiration, and pain produced. Take blood from the arm to eight ounces; foot-bath in the evening; continue pill.

18th.--Bad night; cough gone; respiration easy; pulse 100; skin cool and moist; no thirst; one motion of a natural kind. Repeat mucilage and the calomel and opium pill.

24th.--Has this morning experienced a severe attack of dyspnœa, attended by cough and pain of chest, both increased by full inspiration. Pulse 120; face flushed; says he caught cold from exposure to the night air. Bled immediately, and as much blood taken as his strength would permit; foot-bath repeated in the evening.

25th.--Six ounces of blood drawn; surface buffy; bad night; cough, pain, and pyrexia abated this morning; in the evening severe dyspnœa; cough and pain of chest have recurred; pulse 120. Six ounces of blood to be drawn, should strength permit; mucilaginous mixture to be continued; another blister to be applied to the chest.

28th.--In a fair way of recovery; was discharged for England in June, with little or no complaint.

John Murray, Surgeon to the Forces.

Sergeant Matthews, of the 28th Regiment, was wounded at Waterloo by a musket-ball, about an inch below the umbilicus, a little to the right side, which lodged. He walked to a village in the rear, where he remained for three days, having been bled each day to fainting, before he was removed to Brussels, where my attention was particularly attracted to him, in consequence of his having passed the ball (a small rifle one) per anum, three days after his arrival, or the sixth from the receipt of the wound. The wound was healed by the end of August; and he felt so well that he marched to Paris with other convalescents, to joint his regiment. After some weeks he got drunk, and suffered from an attack of pain in the bowels, in the situation of the wound, requiring active treatment. On attempting one day to have a motion, he found, after many efforts, that something blocked up the anus, and on taking hold of and drawing it out, he found it was a portion of the waistband of his breeches, including a part of the button-hole--a fact verified by Staff-Surgeon Dease, who wrote to me an account of this peculiar case. After this the man recovered without further difficulty, although, as in all such cases, there was a herniary projection. He was afterward subject to costiveness, to pain in the part after a copious meal, probably from the stretching of the adhesions formed between the intestine and the abdominal peritoneum, which inclined him to bend his body forward to obtain relief.

In all such cases, the extraneous substance having lodged, and mainly injured in all probability the vitality of the part which assists in the lodgment, the ball becomes covered with a layer of coagulable lymph or fiber, capable of retaining it in its new situation, whence it is gradually removed by ulceration, or by the sloughing of the injured parts into the cavity of the bowel; much in the same manner as an abscess in the liver is evacuated into the duodenum or neighboring intestine, to which it may become attached. It is always fortunate when the canal from the external wound is cut off by the deposition of lymph, as it expedites the cure, and renders the injury less formidable; but if this should not take place, the contents of the bowel are discharged through it for a greater or shorter length of time, until the canal between the parts gradually closes, and cicatrization takes place, in default of which an artificial anus may remain in addition to the natural one, the functions of the bowels generally being performed with more or less difficulty.

The two following very interesting cases of abdominal injury having been received while these pages were passing through the press, are here inserted:--

A man in the 19th Regiment was wounded through the abdomen, and survived nineteen hours, the ball entering near to the umbilicus, and passing out close to the sacrum. On the post-mortem examination, the small intestines were found to have been wounded no less than sixteen times by the ball in its passage. When wounded, he was stooping in the act of defecation.

T. Alexander, Deputy Inspector-General.

5th August, 1855.

On the evening after the battle of Alma, as my regiment was halting on the brow of a hill, previous to bivouacking, a wounded Russian officer, apparently in great pain, was perceived on the other side of the ravine. Passing over to where he lay, I found that he had been wounded by a musket-ball, that had entered the lumbar region directly over the spine. As he was enabled in his agony to crawl on his hands and knees, it was evident there was no paralysis, and on passing a probe I found the ball had avoided the spine, but as I could not pass in the instrument more than an inch, I was left in uncertainty as to its further course.

He was removed to my hospital tent, when I tried, but with little success, to remove the excessive pain from which he was suffering. In about two hours after he took my finger and placed it on a hard substance imbedded in the walls of the abdomen, and on cutting down on this I perceived a musket-ball. Previous to extracting it, however, I observed a white, glistening substance oozing from the wound, which, on carefully removing with the probe, proved to be a portion of tape-worm, about a yard and a half in length. I then extracted the ball, and again another portion of the worm presented, which measured about two yards and a half in length. It was now complete, though cut in two evidently by the ball, and the two portions, one containing the head and the other the tail, were soon writhing on the table.

The patient experienced immediate relief; the pain had ceased; he slept well, and on the following morning he was free from thirst, with a tolerably quiet pulse. Unfortunately the order arrived for all prisoners and wounded to be sent to the rear, and I lost sight of the case.

What was the cause of this agony of pain? Evidently the writhing of the worm, or why should it so suddenly cease on the worm’s liberation? The abdomen must have been entered by the ball, or how could the worm’s exit have been effected? Nevertheless, but for its presence, the patient was so free from constitutional symptoms on the following morning that a surmise might really have arisen that the ball had passed round the abdomen without injury to the peritoneum.

Rt. De Lisle, Surgeon, 4th K. O. Regiment.

Camp before Sebastopol, August 8th, 1855.

LECTURE XXIX.

ABNORMAL OR ARTIFICIAL ANUS, ETC.

401. In some cases of wounds of the intestine the continuity of the bowel is not sufficiently re-established; the external wound remains open, and becomes indurated and fistulous, giving passage to the fecal matters, and rendering the sufferers very miserable. These cases are of rare occurrence among the hardy natives of Great Britain and Ireland, and comparatively little has been done or even recommended in this country for the relief of this misfortune.

When an intestine has lost a more or less considerable part of its substance at a particular spot, and an artificial anus is about to be formed, it adheres to the peritoneum around the inside of the external wound, although the adhesion is of little extent or width, and forms but a narrow barrier for the protection of the cavity of the abdomen. The upper end of the bowel is more open than the lower, the caliber of which is contracted in size, and is sometimes even difficult to find; while its opening is partially closed by a sort of septum extending across, or from where the two portions of a divided gut have come irregularly in contact with each other by their sides, without uniting in the first instance in their length; or from the falling in especially of the posterior part of the lower end, to which the upper has become united. The projection thus formed in the tube is called by the French eperon or promontoire, valve or spur, ridge or septum; it directs the fecal matter through the external wound, while it obstructs its passage into the lower part of the bowel. There is generally great difficulty in ascertaining the fact of the existence and exact situation of this valve during life; in distinguishing the upper from the lower end of the intestine, as well as the nature and extent of the adhesions by which the injured intestine is retained in its situation. If the absence of such a valve can be satisfactorily made out--and it is sometimes wanting--the external opening may be successfully closed by compression, or by operation. If the valve should exist, its removal by a preliminary operation is necessary; it has been attempted in France with various but somewhat doubtful success.

402. When a portion of small intestine has been lost by mortification or otherwise, and the patient has recovered with an unnaturally situated or artificial anus, the intestine, although at first in contact with the wall of the abdomen, is gradually, in many cases though not in all, retracted into the cavity--it has been supposed by the dragging of the mesentery upon it at the point of union of the divided extremities outside where the eperon or valve is formed; and it is said that this dragging has even led to the gradual disappearance of the valve, admitting thereby of the contents passing more readily from the upper part of the intestine into the lower, and consequently laying the foundation for a cure. This dragging of the intestine, or its movements under the different motions of the body, in some cases cause an elongation of the membrane formed under the adhesive process, by which the intestine is attached to the inside of the wall of the abdomen in the same manner as adhesions are elongated between the pleuræ, and a sac or pouch is thus formed between the cut ends of the intestine and the fistulous external opening which Scarpa was the first fully to demonstrate and explain, and which he called an entonnoir, infundibulum, or funnel. If, then, in an old case, a small portion of the wall of the abdomen be removed in the form of a V, the internal opening at the apex of the V, if small, would be made into a sort of funnel, while the outer incision would remove all the hardened fistulous parts--an operation which is sometimes required to be done when the external opening is not free, and fecal matters have insinuated themselves between the aponeurotic parts, giving rise to abscesses and other small fistulous openings in different directions. It is necessary to bear the formation of this pouch in mind as well as that of the valve, in order to understand the operations proposed for the relief or cure of this complaint.

If simple compression fail in the first instance to prevent the passage of the feces, which never can be thoroughly controlled from the want of a sphincter and the uncertainty of pressure, the method of Desault may be adopted. This consists in gradually dilating the external wound so as to enable the operator to discover the open ends of the bowel, when a tent is to be introduced into the lower end, and afterward into the upper, being fastened by a thread passed around its middle. A pyramidal-shaped pad is then to be placed over the opening, and compression made by bandage upon it so as to press the whole inward. The size of the tent is to be gradually enlarged until the contents of the gut begin to pass downward with ease, when a well adjusted pressure is to be made on the fistulous opening only, to prevent all oozing from it until the internal parts have had time to close.

403. Dupuytren invented a pair of forceps, consisting of a male and female branch, to be applied separately, one on each side of the valve or eperon, to the extent of an inch or an inch and a half at most, when they were to be closed by a screw until they had compressed the part between them sufficiently to destroy its life. The separation of the valve included within the forceps would take place by the usual processes of ulceration in its immediate proximity, and by adhesion of the parts external to the bowels to those surrounding them. The inflammation, however, did not always stop at the adhesive stage, and death has been the result as well as a successful cure.

404. Mr. Trant has invented an instrument he calls a propeller, for pressing back the eperon, an account of which is given in the Dublin Medical Press, May 14th, 1845. He used this in one case with complete success. The instrument by its formation admits of being passed through the artificial anus, and of being placed on the eperon at the bottom of the wound, where it can be retained for a considerable time without producing the slightest inconvenience. It does not, while in the intestines, offer any obstruction to the passage of the fecal matters flowing along the cavity of the tube. It acts as a forceps in retaining the anterior wall of the intestine in close contact with the posterior surface of the abdominal parietes, while the propeller is pressing back the eperon toward the spine; consequently the danger of separating the delicate adhesions in this situation is prevented, otherwise a fatal extravasation into the cavity of the abdomen might ensue. The instrument was made by Mr. Reed, of Dublin, and merits further trial, being apparently less dangerous than the other methods recommended in similar cases. Whatever may be the method employed for the cure of an artificial anus by operation, it cannot be doubted that the patient must be exposed to all the dangers which may result from inflammation, for which he must be prepared beforehand, and the symptoms of which must be met and subdued as they arise; or, if this cannot be accomplished, the mechanical means, if any be used that can be taken away, must be removed, and quiet, if possible, restored by their abstraction and by the treatment adopted. In successful cases, a small aperture will frequently remain, constituting a fecal fistula instead of an artificial anus. This will sometimes become irritable, inflame, ulcerate, or burst, discharging the solid contents of the bowel, although, on the subsidence of the irritation, the part under pressure usually returns to its former state.

405. Wounds and injuries of the liver, whether incised or penetrating, occurring from blows or from musket-balls, are very serious, although not necessarily fatal. Some few persons recover altogether, some few with more or less of permanent disability. The remainder die during the first or inflammatory stage, or in the secondary one, which follows from the twelfth or fourteenth day after the primary symptoms have in some measure subsided.

The symptoms which ensue after a wound of the liver are those common to inflammation of the cavity of the abdomen, with the addition of those peculiar to the organ--pulse often smaller and less perceptible than in peritonitis; discoloration of the skin, eyes, and urine, amounting even to jaundice, although this is not an immediate symptom, neither is it always present. The pain is not confined to the part, but extends to the umbilicus, while the pain symptomatic of inflammation of the liver--viz., pain in the top of the right shoulder--is felt early, and is often accompanied by cramps of the muscles of the arms and numbness of the fingers. The usual symptoms of anxiety and depression are present, and the stomach shows by its irritability that it has partaken of the shock given to the system. The bowels are usually confined, but I have known blood passed from them when it was not supposed that the stomach or intestines had been wounded; the discharge from the wound is either of blood or bile, or both, mixed with a serous effusion which afterward becomes purulent. Wounds of the gall-bladder are, as far as is known, fatal--the effusion of bile which immediately takes place giving rise to inflammation which, with other causes, destroys the sufferer at the end of a few days. If the gall-bladder be adherent to the peritoneum from any previous inflammation, a wound in it need not prove mortal, as the effusion would be avoided, and there is no reason to believe that an injury to this part would be otherwise more vital than that of any other of the viscera of the abdomen.

The late Lieut.-General Sir S. Barns, when Lieut.-Colonel of the Royals, was wounded at the battle of Salamanca by a musket-ball, which injured the cartilages of the false ribs, a portion of the rib being removed and passed out through the liver. A bilious discharge continued several weeks from the wound, and his life was saved with great difficulty. He returned to his duties, although suffering from a dragging pain and weight in the side, which any exertion increased. In the autumn of 1819 he was attacked by acute inflammation; the pain in the right side, extending over the stomach and umbilicus, was constant and acute, and increased on pressure; the pulse small, indeed scarcely perceptible; the extremities cold; the countenance depressed and anxious; bowels confined; stomach rather irritable. A number of leeches were applied, and other remedies administered. The constant pain, which was increased by pressure, could only be relieved by loss of blood, although every other symptom seemed to forbid depletion. Twenty ounces of blood were taken from the arm, which caused a diminution of the pain, and gave relief for an hour; the pain then returned, and twelve ounces more blood were taken away, with the most beneficial effect; a blister was applied over the part, and a dose of calomel and opium was repeated. Shortly afterward he became tranquil; the extremities lost their coldness; and, although the pain continued in a slight degree for several hours, and much soreness remained for many days, he quickly recovered. Two months afterward he had another and equally severe attack, in consequence of walking about two miles rather hastily; from that he was relieved in a similar manner. Whenever he bent his body, a portion of the rib appeared to press in upon the liver, and often gave him acute, darting pain; and one day, on pulling on his boot in haste with some bodily exertion, a third attack ensued. In order to prevent the bending of the body forward, and to confine the motion of the liver, which seemed liable to injury from the irregular points of bone which could be readily distinguished above it, stays, made with iron plates instead of whalebone, were adapted to his body, and from these he derived great comfort.

Corporal Macdonald, first battalion, 79th Regiment, was wounded on the 16th of June at Quatre Bras, by a musket-ball, which entered the abdomen, splintered the eighth rib on the right side, passed through the liver, and was supposed to have lodged on the opposite side, as he says he felt the ball strike the left side, on which he was not able to lie for a long time. Lost but little blood at the time; was dressed superficially, and arrived in Brussels on the 19th, laboring under considerable fever. Bleeding to thirty-six ounces. For seven successive days the bleeding was repeated, to from twelve to sixteen ounces each day, when a large, bilious, and purulent discharge took place from the wound, on which the inflammatory symptoms appeared to subside, until the 30th of June, when bleeding took place from the wound during the night to the extent of twenty ounces, and then ceased spontaneously. On the 15th of July the hemorrhage recurred with so much fever as to warrant twenty ounces of blood being taken from the arm, and this was repeated the next day. The bilious discharge ceased in the middle of August, and on the 2d of September he was discharged convalescent.

Lieutenant Edward Hooper, first battalion, 38th Regiment, was wounded by a musket-ball on the 9th of December, 1812. It passed through the anterior edge of the liver, and, glancing round the ribs, was cut out about two inches from the spine.

On his being wounded, he could scarcely believe his shoulder was not the part affected. His pulse was intermitting; the breathing hurried and laborious, and in a short time the tunicæ conjunctivæ became yellow. He was very largely bled, and warm fomentations were applied to the abdomen, from which, and the bleeding, he received some temporary relief; but, in consequence of his removal that night to the rear, the symptoms were much aggravated on the morning of the 10th. He complained of acute pain over the whole abdomen, increased on pressure; vomiting; quick, hard, and wiry pulse, (no pain referred to the wound.) The bleeding was repeated ad deliquium, warm fomentations and an enema also repeated, and a saline mixture, with a very few drops of tincture of opium, to allay the irritability of the stomach. On the following evening the vomiting had ceased; his pulse was less frequent and hard; pain less. On the 11th, after passing a very restless night, the pulse again rose; the abdomen became tense but not very painful, and he made ineffectual efforts to stool. He was again bled, a large blister was applied over the abdomen, and an ounce of castor-oil was given immediately. The blister acted well, and the purgative gave him three copious stools of dark and fetid feces. On the 12th he complained of twitching pains, referred to the right shoulder, and was ordered one grain of calomel, with two of antimonial powder, three times a day.

Jan. 13th.--Was free from pain; pulse fuller and less frequent; urine clear; tension of abdomen subsided. The calomel and antimony were continued, and some light nourishment was allowed. From this day a gradual amendment took place. The calomel was continued until his mouth became slightly affected; and, as his bowels were in general torpid, from the deficient secretion of bile, a mild purgative was given every two or three days, as occasion required, and an ounce of the infusion of calumba, with quassia, three or four times daily.

A soldier of the 48th Regiment was struck by a musket-ball at Albuhera, on the upper part of the right hypochondrium, over the liver; it came out behind, at a point immediately corresponding to that in front. Blood and bile were discharged from the wounds in considerable quantity, and his case was considered to be hopeless. Brought to me at Valverde, the next day, he was bled largely several times; the wounds were dressed simply, and he was kept perfectly quiet, and his bowels gently open. The skin became of a yellow color, his strength failed under the treatment, and he became thin, and looked ill. At the end of three weeks he was sent to Elvas, where he gradually improved, and was forwarded thence to Lisbon and to England, with his wounds healed.

An officer was wounded in one of the battles in the Pyrenees, by a musket-ball, which penetrated the outer part of the right hypochondrium, at the edge of the false ribs, and lodged. Blood and bile flowed in considerable quantity; the skin became yellow, the pain and swelling of the abdomen were considerable, and he was given over as lost. Under a vigorous and careful treatment he gradually recovered, so as to be sent to England, with a fistulous opening at the orifice of entrance. I examined the wound in 1817, three years afterward, and found that a large blunt probe passed inward toward the stomach and liver for the distance of five inches, where it ended apparently in a sort of sac. Purulent and bilious matters were constantly discharged from the wound; his countenance was sallow; his digestion bad; he suffered from constant uneasiness, if not pain, and was altogether out of health. I saw him once annually for several years, and found that I could sometimes strike the ball with the probe; that he frequently, after an attack of pain and derangement, passed matter by stool, after which the pain and uneasiness about the wound ceased. I had hopes the ball would some day pass through the opening thus made, and had thoughts of enlarging the external wound, and of endeavoring to extract the ball with a long pair of forceps. He ceased at last to pay his annual visit, and I suspect he died in one of the attacks I have alluded to. This ball must have passed very close to, if it did not penetrate, the gall-bladder.

I have never had an opportunity of extracting a ball from the liver during life, although I have seen persons live many weeks into whose livers balls had penetrated; and I have been acquainted with three persons who had been wounded through the liver, to whom little subsequent inconvenience was occasioned.

406. Portions of the liver have been removed in some instances; in one case, related by Blanchard, a small piece of liver was removed with the forceps. The patient dying of fever three years afterward, a small piece of the liver near the external wound was found wanting. Dieffenbach gives a case in which a small protruded portion was cut off with scissors, without any bad consequence. Dr. Macpherson, in the ‘London Medical Gazette’ for January, 1846, has related the case of a Hindoo, a large piece of whose liver protruded through a wound an inch in length, made by a spear in the right hypochondriac region. A ligature was applied tightly around its base, and the piece cut off, rather than make such an enlargement of the wound as might allow the restoration of the protruded liver. The arteries bled from the cut surface, and required to be tied, and a double ligature was put through the stump of liver and tied on each side. The part was not pushed back into the abdomen, but allowed to remain in the wound. The symptoms were mild, the ligatures came away on the ninth day, and the man returned to his home in three weeks.

These cases may be considered exceptions to the general rule, which directs the return of all protruded parts. The retention of the part from which the piece was cut off within the divided parts of the wound was agreeable to the principles I have inculcated with respect to wounds of all the cavities.

407. Wounds of the stomach are usually fatal, although some persons escape when these injuries are confined to its anterior and upper surface, and do not penetrate both sides, in which case effusion into the cavity of the abdomen, and consequent inflammation, can scarcely fail to ensue. It is fortunate for the patient, when they occur, that the stomach should be empty. If it should not be so, the contents may possibly be ejected shortly after the receipt of the wound, but it is not advisable to excite vomiting by remedies, or by means adapted for that purpose. In a perfectly quiescent state, the general compression of the contents of the abdomen by its walls may prevent effusion under ordinary circumstances, and this state should be maintained as rigidly as possible. The apparent course of the wound indicates the probable mischief, which is especially confirmed by vomiting of blood, great anxiety, depression of countenance, a cold, clammy skin, pain in the part, hiccough, and by the discharge of the contents of the stomach, if the wound be sufficiently open to allow it; pulse low and sometimes intermittent. If effusion of the contents of the stomach should not occur, the external wound, if an incised one, should be closed by suture, and the patient kept in the utmost state of quietude, in a somewhat elevated position, the abdominal muscles being relaxed. Neither food nor drink should enter the stomach, although thirst should be allayed by wetting the tongue and mouth. The bowels should be relieved by enemata, and the belly fomented. Bleeding and leeching, as frequently repeated as the symptoms appear to require, must be carried to the greatest extent that can be permitted with safety.

When the external wound is so large as to enable the wounded stomach to be seen, the cut edges of the wound in it should be brought together by the continuous suture, as in the intestines; and the external wound should be closed in a similar manner, the end of the ligature on the wound of the stomach being cut off close to the viscus, that organ being left perfectly free, with the hope that the thread will be carried into its cavity, while the outside adheres to the peritoneum opposed to it.

When the stomach pours its contents through an external opening, too small to allow its being examined, it is desirable that the wound should be enlarged, if a doubt be entertained of the passage being free. It is a sufficient reason for such an operation to allow the opening in the stomach to be seen. It is very probable that effusion will take place into the cavity of the abdomen if it be not done, and the death of the patient will follow. It is very probable he will die if it be done, and therefore in such cases little has hitherto been attempted. I am of opinion, however, that in the case I have last alluded to, a blunt hook may be sometimes introduced through the wound into the stomach, so as to keep it stationary while the external opening is carefully enlarged, and that it ought to be done in such cases, and the wound in the stomach closed in the manner recommended. I have never had a case under my care in which I could have done this; but I have seen some die in whom it might have been done; and it deserves to be considered when surgeons shall be in sufficient numbers on the field of battle to attend to such recommendations, and to the after-treatment these cases require.

When the stomach is injured by a musket-ball, and its contents are discharged externally, the edges of the wound, not being in a condition to unite, must remain open for several days. The person should be placed in the mean time in the most easy and comfortable position which may enable the contents of the stomach to be readily passed out externally, if they show any disposition to be thus evacuated. The external wound should be dilated as far as the peritoneum, if it should be required, so as to admit of the passage being direct, and symptoms must be awaited and treated as they arise. If the patient should survive the first or inflammatory stage, he should be supported by clysters composed of strong beef-tea or veal broth, given five or six times during the twenty-four hours. When it may be expected that the wound in the stomach has closed, or that the injured portion has adhered to the neighboring parts, warm jellies and light broths may be frequently given in small quantities, but solid food should be forbidden until complete recovery has taken place. I have seen inattention to this precaution in more than one instance prove fatal.

408. Fistulous openings have been known to follow wounds of the stomach, and to continue for years. The case related by Dr. Beaumont of the American army, of St. Martin, who, in 1822, received an extensive wound in the stomach, which became fistulous, admitting of a variety of most interesting inquiries being made into the process of digestion, is remarkable.

Hevin has related some of the most interesting cases of those who had swallowed knives, etc., by design or by accident, and whose stomachs were opened for their removal. The most ridiculous story of the whole is an instructive one, however. Some young students, desirous of punishing a young woman who had offended them, cut short the hair of the tail of a large pig, and when frozen hard, forcibly pushed it up her anus, leaving a couple of inches only hanging out of the small end or tip. The hairs having been cut short caught in the gut when attempts were made to draw out the tail, and gave her inexpressible pain. The most serious symptoms followed during six days, and every attempt having failed, Marchetti was applied to. He prepared a hollow tube two feet long, large enough to receive the thickest part of the pig’s tail, to the end of which he fastened a strong waxed cord, which he drew through the tube. This he carefully introduced into the anus, pushing it over the pig’s tail, until he drew the whole of it into the tube, which he then brought away, including the tail, to the great relief of the sufferer.

409. The necessity for an operation so grave as that of opening the stomach must be shown by the presumed impossibility of the foreign substances being dissolved, or of their passing out of it by any other means, while the continued distress they occasion more than equals the risk which is likely to be incurred. The offending substance ought to be felt through the wall of the abdomen, and the incision for its removal should be made between the recti muscles in the linea alba, unless the foreign body have actually pierced the stomach, and can be felt to the outside of the rectus muscle, at which part the incision ought to be made obliquely in the direction of the fibers of the external oblique muscle, all bleeding vessels being secured before the peritoneum is opened. This having been accomplished, the protruding body should be extracted by such an enlargement of the opening in the stomach as may be actually necessary. When the substance does not protrude, although it can be felt through the wall of the stomach, it will be advisable, if possible, to draw it toward the upper or smaller curvature of the stomach rather than to the lower, avoiding the coronary vessels, and taking a medium distance for the opening from the cardiac orifice, and thereby such advantage as may be derived from gravitation. The wound in the stomach should be united by the continuous suture, and the external wound should be closed in a similar manner. The patient ought to be kept in bed in an easy erect position.

410. Injuries of the spleen have been usually fatal, from hemorrhage filling the general cavity of the abdomen, especially when they have arisen from rupture of that organ, which I have several times seen occur in consequence of falls, or from blows from cannon-shot, which have not opened into the cavity or exposed the viscus. Wounds from musket-balls have for the most part destroyed the sufferers, either from hemorrhage or from inflammation. I have not seen nor heard, during the Peninsular war, of a wound in the abdomen through which the spleen protruded, the patient recovering. Instances have occurred in which this part has been removed in man after its exposure by injury. A case is said to have taken place after the battle of Dettingen, in which the spleen, covered with dirt, was cut off, and the patient recovered. In another case the spleen, found without the wound at the end of twenty-four hours, was cold, black, and mortified. The surgeon placed a ligature above this part, and cut off three inches and a half of the spleen; a large artery was tied, and the remaining portion of the viscus was returned into the cavity of the belly, the ligature hanging to it, and the patient got well.

Wounds from stabs with a bayonet, or a sabre, or long-pointed sword are frequently fatal, either from hemorrhage or from inflammation; but I have seen accidentally, after death, cicatrixes in the spleen corresponding to external marks, indicative of a former wound. The treatment, in all such cases, should be to encourage the discharge of blood from the part, in the first instance; then to close the external wound if an incised one, to place the patient on the injured side, and to subdue all unnecessary inflammation by bleeding, leeching, absolute rest, and starvation. The application of warm fomentations where an oozing of blood may be expected to take place cannot be recommended, and cold should be substituted if agreeable to the feelings of the patient. When the blow or wound does not cause the death of the individual by hemorrhage or acute inflammation, a chronic state of disease may supervene, which, if not duly combated, will ultimately destroy him. The early administration of calomel and opium, and the repeated application of blisters, will, in these cases, as well as in those of wounds of the liver, be of the greatest service. Effusion or suppuration may take place as well as in those cases which have been noticed, when other viscera have been injured; although instances of such terminations are not recorded, it does not follow that they have not taken place.

411. Wounds affecting the kidney have been less fatal than those of the spleen, although they are scarcely less dangerous, from the complications by which they are attended; the successful cases on record are not numerous, and the practice to be pursued can only be general. The results, when not fatal, have been for the most part unknown, from the patients either lingering on or recovering after they have been discharged from the service. I saw two cases of this nature after the battle of Waterloo. In one, the ball had passed through the abdomen, entering a little below and to the left of the umbilicus, and coming out behind nearly opposite and close to the spine. No fecal matter was discharged from the front wound, but some came through the posterior one, accompanied by a small quantity of urine, indicating a lesion of the kidney or of the ureter at its upper part. The symptoms, at first severe, had subsided under proper treatment, and there was every probability that the sufferer would eventually recover, although I was unable to trace the case after the man left Brussels. In the other, pain was principally felt in the testis and the spermatic cord of the side injured.

An officer was wounded on the right side, on the 9th December, 1813, the ball being cut out behind; his case was considered hopeless. An hour afterward, on being moved to the fire, he desired to make water, and then passed what appeared to him to be a quantity of blood. Carried to the rear on a wagon for three leagues, he suffered beyond description, passed bloody water again, and on his arrival in quarters was bled and had an enema administered. He then became delirious, was bled several times, had blisters applied to the abdomen, suffered from pain at the top of the right shoulder, and took no other nourishment but tea for fourteen days. He gradually recovered, and at the end of seven weeks was sent to England. After remaining some time in London, he joined the depot of his regiment. In consequence of this exertion, he suffered an attack of fever and peritoneal inflammation; and a tumor formed in the site of the posterior wound, which was opened, and discharged several ounces of matter of a urinous odor. Another abscess formed, and was opened. During this time he suffered great pain and became greatly emaciated; the urine diminished in quantity with the frequent calls to pass it. He lingered in this state until the end of July. The flow of matter from the wound was great, and had a urinous smell. The desire to make water was incessant; but it passed only by drops, and brought him to a state of frenzy; the discharge from the wounds, which had been lessening for two days before, suddenly stopped; the pain and pressure of urine became intolerable; he remained at last in a state of the greatest torture for about three minutes, when, during an effort, a burst of urine took place, colored with blood, forcing out with it a hard lump, shaped like a short, thick shrimp, three-quarters of an inch long, which proved, when examined next day, to be the cloth which had been driven in by the ball. It must have passed from the pelvis of the kidney or the ureter into the bladder. It was hard, was covered by a black crust, and was thought to be a stone when passed. It could not, however, have been long in the bladder, or it would have been covered by the triple phosphates, and have formed the nucleus of a calculus requiring to be removed by operation.

Le Capitaine Negre, of the French Infantry of the Line, was struck on the left side above the hip, at the battle of Albuhera, by a musket-ball, which went through the upper part of the sigmoid flexure of the colon, and came out behind, injuring apparently the fourth and fifth lumbar vertebræ. As urine came through this opening, the ureter or lower part of the kidney must have been wounded; and, as he had lost the use of one leg and much of that of the other, the spinal marrow must also have been injured. He was left on the field of battle, supposed to be about to die, and was brought to me to the village of Valverde, three days afterward, in a most distressing state. The inflammatory symptoms had been and were severe; the pain he suffered on any attempt to move him was excessive; the discharge of feces from the anterior wound, and of urine from the posterior one and by the usual ways, rendered him miserable, and he at last implored me to allow the box of opium pills, of which one was given at night to each man who stood most in need of them, to be left within his reach, if I would not kindly do the act of a friend and give them to him myself. He died at the end of ten days, after great suffering, constantly regretting that our feelings as Christians caused their prolongation.

412. Wounds of the spermatic cord are of infrequent occurrence, and rarely lead to fatal, although often to inconvenient consequences.

I have removed the bruised and shattered remains of a testis and epididymis to expedite the cure, and I have been obliged to do so at a later period in consequence of the wounded portion becoming enlarged and diseased. These occurrences are rare; the wound in the testis usually heals kindly; but the portion which remains, however, is probably of little use, although the patient does not like to lose it. A gentleman in perfect health was struck accidentally in the right testis by two shot, while out shooting partridges. The shot lodged, and gave rise to uneasiness, and after a time to an enlargement, which could not be distinguished from medullary sarcoma. I removed the testis, and the wound healed kindly. The lumbar glands had, however, taken on the disease, and he died of their great enlargement and the general mischief which ensued within the year. The preparation is in the museum of the College of Surgeons.

I have not had occasion to tie an artery, even when the penis has been as good as amputated. If bleeding should take place in the progress of the cure, a large catheter should be introduced into the urethra, as a point on which pressure may be made laterally; for I am not aware of any other use it can be, unless the urethra be also torn, when a moderate-sized catheter should be kept in it permanently, if it can be borne, to aid in the healing of the surrounding parts with as little contraction as possible of the canal. When the corpus spongiosum has been carried away or sloughs with the urethra, there is usually some injury done at the same time to the corpora cavernosa, and the part becomes contracted and curved when distended. I have not seen any of these cases since the introduction into practice of the methods which have been recommended by Dieffenbach and others for the formation of a new urethra by borrowing from the neighboring parts; but several might certainly have been benefited by such treatment.

A married soldier, of the 29th Regiment, was wounded on the heights of Roliça, in August, 1808, by a small musket-ball, which went through both corpora cavernosa from side to side. The man suffered very little inconvenience, and the wounds healed very well. He seemed to consider the injury as of no importance to himself, but had some idea there might be a difference of opinion in another party. There is usually a deficiency of substance at the part after such wounds, and sometimes on inconvenient curve or twist, such as often takes place when the corpora cavernosa and the corpus spongiosum are injured or ruptured from other causes.

LECTURE XXX.

WOUNDS OF THE PELVIS, ETC.

413. Wounds of the pelvis from musket-balls injuring its contents are of common occurrence, and, although frequently fatal, often permit a considerable length of treatment before they destroy the sufferers or admit of their recovery. In many instances fistulous openings remain for years. The orifices of entrance and of exit of the ball lead to little information. It is only from the absence of paralysis or of hemorrhage, or of those signs which indicate the lesion of any of the organs contained within the pelvis, that the surgeon can form an estimate of the evil which has been committed; even when parts of the greatest importance are injured, such as the bladder or the rectum, the general symptoms are occasionally of little moment.

When paralysis occurs, which it rarely does unless the spinal marrow be injured, the functions of the bladder and of the rectum are implicated, and there is but little pain. When the nerves only are injured, the paralysis is not complete; it usually affects one side more than the other, is a numbness rather than a paralysis, and is accompanied by severe pain, sometimes at the seat of injury, but more usually extending to the thigh and to the extremities of the nerves in the foot. I was consulted in a case of wound from a pistol-shot, in the last dorsal or upper lumbar vertebra, of several years’ standing, in which the paralysis of both limbs was complete. The patient had a great desire to have the cicatrix opened, and the ball followed and extracted, and would willingly have submitted to such an operation, but he could not find any one in London or Paris willing to attempt it.

When a ball appears to cross or pass even from side to side of the pelvis, it is not always easy to say whether it has penetrated the cavity or not, until symptoms indicative of such injury appear; the less done to such wounds the better. When a ball enters, strikes a bone, and lodges, it is very desirable to ascertain its situation, in order that it may be at once removed, if it can possibly be done with but little comparative danger; for balls which lodge in these flat bones may often be removed, and the comfort of the patient assured by a timely operation, instead of proving the source of much torment and misery for many years by their being allowed to remain.

The late Colonel Wade, one of the most distinguished officers of his rank in Spain, was wounded at the battle of Albuhera, in 1811, by a musket-ball on the left side; it passed through the ilium, and was supposed to have narrowly avoided opening into the cavity of the abdomen. It could not be followed beyond the bone. The inflammatory symptoms were subdued in the usual time, and he gradually recovered his health, some pieces of bone coming away from time to time. A small fungous protrusion and discharge continued from the wound for several years, with a certain degree of pain, and of occasional lameness in the leg and thigh. The wound closed sometimes for a few months, and reopened after an attack of pain, with great lameness and swelling of the hip, and a discharge of matter from the original site. An abscess at last formed under the gluteus maximus, and was opened at its anterior and lower edge. This gave great relief and prevented the irritation of the upper and anterior original wound, the matter finding a more ready passage. I often assured him I could distinguish the ball very deeply seated; and in the summer of 1846, thirty-five years after the receipt of the injury, it had descended so far that I passed a probe under it at the distance of two inches and a half from the lower opening. He was to have come to London as early as his duties would possibly permit, in the spring of 1847, to have had it removed, when he was suddenly cut off by apoplexy, to the great regret of all who knew him.

The late General Sir Hercules Packenham, G.C.B., was wounded at the assault of Badajos by a musket-ball, April 6th, 1812, which deprived him of the use of the thumb and little finger, and partially of the hand; and by another which struck him on the right iliac region, passing in just below Poupart’s ligament and outwardly through the ilium. Eight pieces of bone came away at Elvas, and eleven more, in 1813, in London. He went to Baréges in 1814-15-16-17, with the hope that the ball might be loosened and removed, but in vain; it never could be found. A small quantity of inoffensive glutinous matter, sometimes streaked with blood, was discharged occasionally from the seat of the injury. At times the wound became painful and very troublesome for a week or ten days together, after which little inconvenience was felt in the limb.

Colonel Sir J. M. Wilson, now of Chelsea Hospital, was wounded in seven different places by three musket-balls on the left hip, at the Chippewa, near the Falls of Niagara, on the 5th of July, 1814. One, which struck him a little before the trochanter, passed upward through the ilium, (from which several pieces of bone came away on four or five different occasions,) and lodged against or in the spinal column, rendering the left leg quite powerless, and impairing the power of the right. He fell. Shortly after an Indian warrior came up, placed his foot on his neck, drew out his scalping-knife, seized his hair, and was in the act of beginning to scalp him, when a shot passed through his chest and laid him prostrate by the side of his intended victim, who thus happily escaped. The numbness and inability to put the limb to the ground continued from eighteen months to two years, during which time he was on crutches. After this he gradually recovered, always suffering more or less. The pain in the back is often most excruciating, coming on without any apparent cause, except perhaps from change of weather. He limps after walking a couple of miles, and if exercise be continued, pain ensues. He married in 1824, has several children, and is obliged to lead a very regular, quiet life, without which he breaks down. The great suffering he experiences, at the end of near forty years, is, however, from the pain in the back, sense of coldness in the left leg, and numbness accompanied by pain in the course of the nerves. He is equally sensible to heat in a close atmosphere, which he is obliged to avoid. The alvine and urinary secretions, etc. have always been impaired or deranged since the wound was received. He is troubled with painful affections and a train of nervous feelings of the whole system, attributable to the injury. The ball can of late be felt at the bottom of a soft swelling in the loins; but the colonel, since the affair of the Indian, has no predilection for cold steel, and protests as loudly against the scalpel of the surgeon as the scalping-knife of the Indian.

A soldier, of the Fourth Division of Infantry, was wounded at the battle of Salamanca by a musket-ball, which entered immediately above the right ilium, passed across, and made its exit nearly opposite on the left side, going nearer to the back than to the wall of the abdomen. He was supposed to be killed, but had recovered a little life when brought to me at the field hospital some hours afterward. The belly was swollen, generally tympanitic, and some hemorrhage had taken place from the wound of entrance, and he was unable to move the leg of that side. On reaction taking place, he was bled repeatedly, and treated antiphlogistically with the aid of calomel, opium, and antimony. He was removed to the San Domingo Hospital, and on the sixth day the bowels were relieved naturally. A small quantity of fecal matter was passed for several days with the discharge from the wound, but this gradually ceased, and the man ultimately recovered without any particular defect, except weakness and occasional pain and derangement of bowels, on any irregularity.

John Bryan, 1st Light Battalion of the King’s German Legion, was wounded on the 17th of June near Quatre Bras by a musket-ball, which entered at the groin, and made its exit behind. He was transported to Brussels, with his foot and leg in a state of mortification. Wine and other stimulants were freely given, and he rallied a little on the 23d and 24th. On the 25th, the stomach rejected everything except brandy and opium. On the 26th, a line of separation seemed to be about to form between the dead and the living parts, although he was evidently failing. He died on the 28th, eleven days after the receipt of the injury. On examination after death the ball was found to have completely divided the external iliac artery; about a pint of coagulated blood, mixed with some excessively fetid pus, was collected in the pelvis; the ends of the wounded artery had receded considerably from each other, and a coagulum had formed in each, which was easily squeezed out, the orifice of the upper end only being a little contracted. There were signs of some peritoneal inflammation having taken place; the intestines had not been wounded, and the ball, in passing out, had splintered the upper edge of the back part of the ilium.

General Sir Edward Packenham was killed instantaneously at New Orleans, by hemorrhage from a nearly similar wound, in which the common iliac artery was divided.

414. I have removed balls on different occasions which have lodged in the bones of the pelvis, and always with the greatest advantage, when done early. I have seen much evil result from their being allowed to remain, as they caused not only frequent distress, but at last gave rise to disease in the bone, derangement of the general health, and death. When the ball can be felt impacted in the bone, incisions through muscular parts of little consequence should not be spared to expose it. If an error exists at this moment, it is that too little is done, rather than too much. Too great reliance is placed on the efforts of nature, and not enough on the resources of art. The constant meddling with a wound is not recommended; nevertheless, much may be done by careful investigation from time to time, of which La Motte gives a good example in his fifty-first observation.

A grenadier was wounded at the battle of Dettingen, in 1743, by a musket-ball, which entered above Poupart’s ligament, near the opening of the external oblique muscle on the left side, and lodged. Thirteen days after his reception into the hospital at Landau, La Motte felt with the probe what he thought was the ball lying on the outside of the psoas muscle against the bone. He made the patient lie on his face, and touched the foreign body every day in order to loosen it. On the thirty-fifth day he was satisfied it was the ball, and on the forty-fifth, after many attempts, it was at last extracted. His fifty-second observation relates to a case as nearly similar as possible to those of Sir H. Packenham and Colonel Wade. He made several deep and long incisions in search of the ball, which he could not find; the wound became fistulous, and at the end of a year closed, in all probability to reopen from time to time.

The difference in practice between 1743 and 1855 ought to be, that in 1855 the ball should be found first, and the deep and long incisions made afterward for its extraction; which do not preclude any previous external openings that may be necessary to facilitate the first examination.

Captain Campbell was wounded by a pistol-ball, on the 5th of September, 1805; it penetrated the abdomen on the middle of the right side, and was extracted from nearly the same situation on the left; from its irregular denticulated shape, it would appear to have impinged against a vertebra. He complained of violent pain in the loins and belly, with numbness and pain of the left leg and thigh, and suffered also from the greatest oppression, anxiety, and sickness. An enema was administered, and twenty-four ounces of blood were taken from the arm; lower extremities nearly paralyzed; anxiety and oppression great at night. Blood-letting to ten ounces. Cannot pass his urine; hot fomentations; and at twelve at night sixteen more ounces of blood were drawn. At three P.M., had three motions, the two last containing apparently a pint of pure blood. Pain and other symptoms being urgent, eight ounces more blood were taken away. At six P.M., passed urine for the first time, highly tinged with blood; has had two motions, also mixed with blood. Pain continuing, ten ounces of blood were abstracted, although occasionally almost fainting on any movement; belly fomented. At eight at night, sixty drops of laudanum. At ten, being very restless, twenty drops more, which procured some sleep, although he vomited frequently; belly relieved by the fomentation; three stools mixed with blood.

Sept. 6th.--All the symptoms relieved; passes blood with his urine; sickness and vomiting troublesome; pulse 90, rather firm than feeble. One o’clock.--Complains of violent pain in the left leg and thigh, belly, and loins; pulse 116, full and strong. Blood-letting to sixteen ounces. Barley-water with niter for common drink. Six P.M.--Pulse 96; bowels open, with discharge of blood; symptoms generally relieved. Tincture of opium, twelve drops at night.

8th.--Slept better; less pain; paralysis continues. In the evening symptoms aggravated; lost twelve ounces of blood; enema, etc. repeated; pulse 120.

9th, 10th, 11th, 12th.--Pulse 96; bowels open; urine bloody; is generally better.

15th.--Wound of exit healed; urine bloody; bowels open. Chicken-broth for the first time.

20th.--The opening of entrance having nearly closed was enlarged, and a free exit allowed for the matter.

Oct. 20th.--Wounds quite closed; is free from pain, is able to move about the house on crutches; warm, stimulating applications to the limbs seem to have given most relief.

Nov. 20th.--Paralytic affection gone; he can now mount his horse, and has only a feeling of numbness and torpor in the left leg and thigh.

415. The general opinion which formerly prevailed, that wounds of the bladder, by musket-balls, were for the most part mortal, is now known to be erroneous. When the bladder is wounded below, where it is not covered by the peritoneum, persons do sometimes recover by what may be considered the almost unaided efforts of nature. A large number of cases came under my observation at Brussels and at Antwerp, and many had already died. Persons rarely recover in whom urine has found its way into the general cavity of the abdomen. They generally die of inflammation in from three to six days.

When the bladder is wounded where it is covered by the peritoneum, and the opening or openings do not by some accident permit the urine to flow into the cavity of the abdomen, the patient may be free from immediate danger for a short time, although very anxious and greatly depressed in countenance and manner, and even sick to vomiting. The pain is not commonly severe at first, and if he can make water, which in all such cases it is desirable to prevent by having recourse to the catheter, it is more or less colored or mixed with blood. If the urine should not escape into the cavity of the abdomen, the ordinary inflammation which must necessarily ensue takes place and affects the internal surface of the bladder. The desire to pass urine becomes greater, and is frequently insupportable, while it can in some cases be only passed by drops. In others these symptoms are less urgent. Nevertheless, the natural action of the bladder, or, in those severe cases, the additional efforts which are made for its expulsion by the abdominal muscles, may cause the urine to be forced through the wound into the cavity of the abdomen, whence the advantage to be obtained from the early use of the elastic catheter. When the orifices of entrance and of exit are free, and low down in the pelvis, the urine may run out without much immediate mischief ensuing. But as this cannot always be known, an elastic gum catheter should be introduced from the first and fixed in the bladder, in every case where the nature of the injury is doubtful, until the urine ceases to flow through the wounds. It must, however, be recollected that in some cases in which it has caused great irritation, by being introduced too early, while the bladder was very sensitive, the patients have been much relieved by its removal. The principle is nevertheless incontrovertible in all doubtful cases; the urine should be allowed to drop out of the catheter nearly as fast as it passes into the bladder, when this organ is very irritable; great pains should also be taken that the end of the instrument should be within, but not too far within the bladder, so as to excite irritation by rubbing against its sides, or to allow its end rising above the urine which might in this way collect below it, and at last escape through the wounds.

416. The inflammatory actions are to be subdued by general bleeding, the application of leeches, the administration of diluent drinks in moderate quantity, the exhibition of gentle aperients, such as castor-oil, and by enemata. Opium in all these cases is an important remedy, principally in the shape of morphia. Opium in substance, when introduced into the rectum in the shape of a suppository, or dissolved in half an ounce or an ounce of water as an enema, should be repeated in such quantities, beginning with two grains, as will procure ease.

417. The urine, in most cases of injury below the peritoneum, flows readily through the wound of entrance, if not of exit, in the first instance, and care should be taken, by enlarging the posterior wound, that no obstacle within reach shall prevent it; but after inflammation has been established, the parts swell, and as the sloughs begin to separate, its passage is often obstructed; the elastic catheter, if not used before, will then render important service by allowing the sloughs to be separated without the healthy parts being irritated by the urine being retained. After a time the urine may be only drawn off in small quantities through the catheter, as frequently as circumstances may render advisable. The permanent use of the catheter in these cases will often prevent the urine from forming any devious paths as it proceeds outward, ending in abscesses and fistulous openings, causing much discomfort and even misery. It is not common for blood to be poured into the bladder in such a quantity as to cause much inconvenience; it coagulates with equal proportions of urine, and a silver catheter should be used, by which it may be broken up and rendered more easy of solution by injections of warm water. When the neck of the bladder or the prostatic part of the urethra has been divided so that a catheter cannot be efficiently used, surgery must come with more immediate aid to the assistance of the sufferer, by making a clear and free opening from the perineum for the evacuation of the urine and of the discharge from the wound. If a ball lodge in or near the bladder, or in the prostate, it must be removed by an operation in the perineum.

A soldier of the Light Division was wounded on the heights of Vera, in the Pyrenees. A musket-ball had entered behind near the sacrum and lodged. He was bled twice, in consequence of suffering pain in the part, but was not otherwise much disturbed. There was at first a difficulty in passing urine, but this gradually subsided, although he always suffered pain in micturition, which was frequent and distressing. He remained in this state until December, when he passed, with considerable effort and after much difficulty, a hard piece of his jacket about half an inch in length, larger than the orifice of the urethra, through which it was forced. As it was not incased by calcareous matter, it could not have been long in the bladder, but must have been lodged near it before it ulcerated its way in, giving rise to the constant desire and irritation which he had so long experienced. His symptoms then subsided, although they had not entirely disappeared when he left for England.

A French soldier was wounded by a musket-ball on the back part of the right hip, at Almaraz, on the Tagus, was taken prisoner, and sent to Lisbon in the autumn of 1813. The ball had lodged, but gave him little inconvenience at the time beyond some pain in the course of the sciatic nerve, subsequently followed by defect of motion on the right side. Four months after the injury pain came on about the region of the bladder, with great desire to pass urine, which he could not do when standing, but which dribbled away when lying down. When quiet he suffered little, but great pain followed any attempt at continued motion. A catheter could be introduced, but with great difficulty when it reached the prostate gland, which was exceedingly tender to the touch. After a time the instrument could not be passed, and the man was in great agony until something appeared to give way, and a discharge of matter took place, when the urine followed, and he was relieved. An abscess had formed, in all probability from the proximity of the ball, which still could not be felt. The man recovered, retaining, however, his former state of lameness and defect of power, although relieved from the vexatious irritation of the bladder.

A soldier of the Fourth Division of Infantry was wounded at the battle of Toulouse, while entering a redoubt, by a musket-ball, which entered at the left groin, and, crossing the pelvis, came out on the upper part of the opposite hip behind. The urine flowed from both wounds and from the rectum, indicating that the ball had passed between these parts, and a little feces came from the posterior wound for three weeks. The pain and suffering were not great, and principally arose from retention of urine, requiring the use of the catheter, which was left in, and changed from time to time, until the urine flowed by the side of it, instead of through the wounds, which it did occasionally for some weeks in drops, but not in any quantity; after which the wounds gradually closed, and the man was sent to England cured.

A soldier of the Cavalry of the King’s German Legion was struck, at the battle of Salamanca, by a musket-ball, which entered just above the pubes a little to the right side, and came out below on the opposite nates. The urine flowed readily through both wounds for the first three days, and he suffered afterward from great pain and distress about the region of the bladder, from which he could not expel any urine, neither would it pass by either wound. I immediately introduced a catheter, drew off a moderate quantity of urine, and then fixed it in the bladder, desiring him to draw off his urine every hour when awake. This he did, often leaving the stopper out at night. The urine flowed after a few days through the posterior wound, and then ceased. The catheter was washed from time to time, and was at last withdrawn, as the urine began to flow by the side of it, and the wound had finally closed when he left the San Domingo Hospital.

Captain Martin received a wound from a musket-ball at the siege of Ciudad Rodrigo; it entered just above the pubes, passed through the bladder and rectum, and came out behind, splintering the sacrum, the contents of both viscera being freely discharged through this opening. As he suffered but little inconvenience from the urine, very little of which passed by the urethra, that passage was not interfered with in the first instance. Inflammatory symptoms were kept within due bounds, the rectum was carefully washed out by emollient enemata, and his food rendered as light as possible. Under this treatment he gradually improved; the anterior wound first healed, and subsequently the posterior one, leaving him comparatively well when he left me for Lisbon on his way to England.

418. These cases give, however, a brighter view of the nature of these wounds than they frequently justify; extravasation of urine, inflammation, and death are not of infrequent occurrence in cases to which strict attention is not paid; and great misery is often caused from the irritation of the bladder and the discharge which follows, until the constitution is undermined and death ensues.

Captain Sleigh, of the 100th Regiment, was wounded at the battle of Chippewa, on the 5th of July, 1814, by a musket-ball, which entered the left groin immediately over Poupart’s ligament, by the side of the spermatic vessels, injuring in its course the anterior brim of the pelvis. It thence passed through the bladder obliquely across the pelvis, and terminated its course beneath the integuments in the right buttock, whence it was immediately extracted. Blood and urine flowed incessantly from the groin; the quantity of blood lost was considerable. He complained much of pain in the hypogastric region; the abdomen was tense and painful to the touch, and he had an almost continued inclination to micturate; but his attempts, after the most painful efforts, were entirely frustrated. The anxiety was great, the respiration hurried, and the pulse quick and fluttering. He was bled to the extent of thirty ounces; an enema was given; fomentations applied to the belly; and the catheter introduced--all which afforded him some relief. The next day he was removed to the rear, a distance of seventeen miles, in an open wagon, partly during the inclemency of the night, and was quite worn out by so long a journey. He was carried thence on board ship, and landed at York on the morning of the 9th of July, the fourth day after he received his wound.

July 9th.--Abdomen tense and painful to the touch; severe pain in the perineum; great inclination to void urine, but fruitlessly; wound in the groin sloughy, discharges urine and blood mixed with a small quantity of pus; posterior wound healthy, no discharge of urine from it; catheter attempted to be passed without success. Ordered an ounce and a half of castor-oil immediately.

10th.--Passed a restless night; had two copious stools; voided a few drops of urine by the urethra; still great inclination to pass urine. Ordered two grains of extract of opium made into a pill.

11th.--All the painful sensations much relieved; abdomen less tense; a small piece of bone extracted from the urethra about an inch in length, of the thickness of a crow-quill; a little urine followed more freely.

15th.--Complains of severe pain in the spermatic cord; discharge from groin more offensive; wound filled with large maggots; bowels open.

19th.--Wound of groin looks clean; a small piece of bone discharged by the urethra, and a piece of cloth extracted from the groin.

24th.--A small piece of bone extracted from the groin.

August 5th.--Passes a good deal of pus and urine by the urethra.

29th.--Posterior wound much inflamed and very painful upon pressure. A poultice to be frequently applied.

Sept. 1st.--An abscess has burst; a piece of cloth has been extracted; urine and pus are discharged by both wounds.

12th.--Doing well; wounds closing.

16th.--Bladder resuming its power; discharge of matter from groin very trivial.

Oct. 4th.--Posterior wound closed.

30th.--Wound of groin closed; urine, passed by the natural passage, mixed with pus.

At first it was supposed that only the fundus of the bladder was wounded; but when the collection of matter took place in the right buttock, and a piece of cloth was extracted from it, the urine following, it was evident that both sides of the bladder had been transfixed by the ball; and that, probably, the urine from the commencement had been prevented flowing posteriorly by the intervention of this foreign body. An elastic gum catheter could not be passed into the bladder on account of the piece of bone which had forced its way into the urethra, and from its being obstructed afterward by smaller pieces of bone.

When I saw this gentleman some time afterward, it appeared to me that the purulent discharge from the urethra was not from the inner membrane of the bladder, but was probably caused by some dead bone of the pelvis having a communication with the bladder by a fistulous opening.

A soldier, of the King’s German Legion, was struck, at Waterloo, by a musket-ball, which entered a little way above the pubes, and lodged. The symptoms which immediately followed were by no means severe, although he passed a little bloody urine at first; the external wound closed without difficulty. He complained of pain at the neck of the bladder, and had a great desire to pass urine, with other signs of stone in the bladder, which induced me to pass a sound, when I found that the ball was lying loose in that viscus. On his arrival at the York Hospital, at Chelsea, from Brussels, he became, with the French soldier, whose thigh had been amputated at the hip-joint, an object of great attention. I performed the operation for the removal of the ball in the presence of a large concourse of military and medical persons. It was done in less than two minutes; but the calculus, composed of the triple phosphates, which had formed around the ball, yielded, and broke under the forceps. The pieces were removed separately. The ball, being heavy, fell below the neck of the bladder, which, being healthy, yielded to the pressure, and allowed it to sink on the rectum, where it could not be caught by the forceps, until it had been raised by a finger in the bowel. The bladder was then well washed out, so as to remove all the pieces that might remain, and the man was placed in bed. He was bled once in consequence of some apprehension of pain; but he had not a bad symptom, and rapidly recovered.

The symptoms of irritation did not, however, entirely pass away, as could have been wished, and I began to fear that some small pieces of calculus had been overlooked; when, one morning, after considerable effort, he passed a ring of sandy calcareous matter, which had formed around the orifice of the bladder, and which, being dislodged, had fortunately entered the urethra, along which it was forced by the urine. It was evidently formed of the phosphates in minute portions, which had become agglutinated together, around the meatus of the bladder. This he took with him to Hanover, where it, himself, and the cicatrixes of his wound, and of his operation, attracted great notice. The ball, which was flattened on one side, I kept in a small box, together with the pieces of calculus which were extracted, and showed them annually at my lecture on this subject for many years. One evening, however, I unfortunately left my little box on the table after lecture; and when I recollected, and returned for it, I found that some gentleman had borrowed it, and has not yet returned it. At the battle of Chillianwallah a similar wound took place; the ball formed the nucleus of a calculus, and was removed successfully by a gentleman in the service of the East India Company, whose name I have not been able to learn.

The following case, from Baron Percy, is in point: A young man was wounded by a pistol-shot, which entered just above the os pubis, through the linea alba, wounded the bladder, and lodged. The belly swelled; a tumor formed in the perineum; no urine passed; the bowels were confined, and fever ran high, with a tendency to delirium. Believing that the tumor in the perineum, and the fluctuation he thought he perceived, might be caused by extravasated urine, he punctured it with a trocar, and evacuated a large quantity of bloody urine. This induced him to enlarge the opening, and carry it on to the bladder, through which he brought out the ball, some shirt, and several clots of blood. The man was bled nine times in all; the urine after a time passed in the ordinary way, and the patient slowly recovered.

An officer was wounded near Bayonne, by a musket-ball, on the left side; it passed through the ilium across the pubes, and made its exit through the gluteus maximus of the opposite side, but lower down. Urine flowed through both wounds at first very readily, but none of any moment came by the urethra, from which some blood occasionally oozed. The attempt to pass a catheter failed, although the desire to make water was urgent and painful. After a few days the passage of urine by the external wounds became obstructed, apparently by the sloughs; great pain and misery were experienced; fever ran high; rigors and delirium followed extravasation of urine, and death closed the scene. The mischief here arose from the catheter not having been passed into the bladder, which could not be effected, from the prostatic part of the urethra or the neck of the bladder having been injured.

419. Surgery in such, or in nearly similar cases, requires a catheter or staff to be passed down the urethra as far as it will go; an incision should then be made upon it, from the center or across the perineum, and the urethra divided on the staff until the finger rests upon the wounded parts, when, in all probability, a straight catheter, with the aid of the forefinger in the rectum, can be carried through them into the bladder. The urine will then have a direct passage outward, instead of coming indirectly from the bladder by the wounds. If the straight catheter cannot be passed, which can scarcely occur, the central incision is to be continued from the point of obstruction into the bladder, guided by the finger in the rectum. A free opening from the bladder offers the only hope of safety.

420. The rectum may be wounded without any other organ being injured within the pelvis; of this I have seen several instances. Captain Gordon, of the navy, was struck by a rifle-ball toward the lower part of one side of the sacrum, after being knocked down by one he had received on the head, and by another in the neck and back. The ball, which passed into the rectum, made its exit on the opposite side of the sacrum, and stercoraceous matters were evacuated by both wounds. The pain was severe; the limbs were deprived of much of their power of motion, and the next day the bladder was incapable of expelling its contents. This was relieved by the catheter, and the rectum was kept clear by warm, mild enemata, while the inflammatory symptoms were subdued by bleeding, opium, starvation, and rest. At the end of three months he was able to walk, but with some difficulty, on account of defective power in one leg. Some small pieces of bone came away and the wounds closed, although he was subject to an occasional slight opening of the orifice of entrance, from which a little matter was discharged, when it again closed. He remained more or less lame until his death, which took place with the loss of the ship he commanded, in a hurricane, on the coast of North America.

A French soldier was wounded at the battle of Salamanca by a ball, which entered by the side of the sacrum, and lodged. Having been rode over and bruised, he was taken prisoner, and brought to me on the field of battle. From this wound he suffered comparatively little, except from a difficulty of passing urine. On the third day after his arrival at the San Carlos Hospital, or the sixth from the receipt of the injury, he passed the ball per anum. The wound quickly closed, and he aided his comrades as an orderly in the hospital afterward.

CONCLUSIONS.

421.--1. Severe blows on the abdomen give rise to the absorption of the muscular structures, and the formation of ventral hernia, in many instances; this may, in some measure, be prevented during the treatment, by quietude, by the local abstraction of blood, and by the early use of retaining bandages.

2. Abscesses in the muscular wall of the abdomen, from whatever cause they arise, should be opened early; for although the peritoneum is essentially strong by its outer surface, it is but a thin membrane, and should be aided surgically as much as possible.

3. Severe blows, attended by general concussion, frequently give rise to rupture of the solid viscera, such as the liver and the spleen, causing death by hemorrhage. When the hollow viscera are ruptured, such as the intestines or the bladder, death ensues from inflammation.

4. Incised wounds of the wall of the abdomen to any extent rarely unite so perfectly (except, perhaps, in the linea alba) as not to give rise to ventral protrusions of a greater or less extent.

5. As the muscular parts rarely unite in the first instance after being divided, sutures should never be introduced into these structures.

6. Muscular parts are to be brought into apposition, and so retained principally by position, aided by a continuous suture through the integuments only, together with long strips of adhesive plaster, moderate compression, and sometimes a retaining bandage.

7. Sutures should never be inserted through the whole wall of the abdomen, and their use in muscular parts under any circumstances is forbidden; unless the wound, from its very great extent, cannot be otherwise sufficiently approximated to restrain the protrusion of the contents of the cavity. The occurrence of such a case is very rare.

8. Purgatives should be eschewed in the early part of the treatment of penetrating wounds of the abdomen. Enemata are to be preferred.

9. The omentum, when protruded, is to be returned by enlarging the wound through its aponeurotic parts if necessary, but not through the peritoneum, in preference to allowing it to remain protruded, or to be cut off.

10. A punctured intestine requires no immediate treatment. An intestine, when incised to an extent exceeding the third part of an inch, should be sewn up by the continuous suture in the manner recommended, Aph. 391.

11. The position of the patient should be inclined toward the wounded side, to allow the omentum or intestine being closely applied to the cut edges of the peritoneum. Absolute rest, without the slightest motion, should be observed. Food and drink should be restricted, when not entirely forbidden.

12. If the belly swell, and the propriety of allowing extravasated or effused matters to be evacuated seem to be manifest, the continuous suture or stitches should be cut across to a certain extent, for the purpose of giving this relief.

13. If the punctured or incised wound be small, and the extravasation or effusion within the cavity seem to be great, the wound should be carefully enlarged, and the offending matter evacuated.

14. A wound should not be closed until it has ceased to bleed, or until the bleeding vessel has been secured, if it be possible to do so. When it is not possible so to do, the wound should be closed, and the result awaited.

15. A gunshot wound penetrating the cavity can never unite, and must suppurate. If a wounded intestine can be seen or felt, its torn edges may be cut off, and the clean surfaces united by suture. If the wound can neither be seen nor felt, it will be sufficient for the moment to provide for the free discharge of any extravasated or effused matters which may require removal.

16. A dilatation or enlargement of a wound in the abdomen should never take place, unless in connection with something within the cavity rendering it necessary.

17. If the epigastric, circumflexa ilii, or other artery in the wall of the abdomen, be injured and bleed, the wound should be enlarged, and the bleeding vessel secured by ligature. If the main trunk or the external iliac artery be sought for and tied, the patient will in all probability die.

18. When balls lodge in the bones of the pelvis, they should be carefully sought for and removed, if it can be done with propriety and safety.

19. In a wound of the bladder, an elastic gum catheter should be kept in the urethra, frequently without a stopper, until the wound is presumed to be healed--unless its presence should prove injurious, from excess of irritation, not removed by allowing the urine to pass through it by drops as it is brought into the bladder.

20. In all cases in which a catheter cannot be introduced, in consequence of the back part of the urethra or the neck of the bladder being injured, an opening for the discharge of the urine should be made from the perineum into the bladder. It is essential to the preservation of life.

21. The treatment of all these injuries must be eminently antiphlogistic, principally depending on general and local blood-letting, absolute rest, abstinence from food, and in some cases almost even from drink, the frequent administration of enemata, and the early exhibition of mercury, and especially of opium, in the different ways usually recommended, with reference to the part injured.

422. As the operation for opening into the colon may be necessary, after an injury of that part, as well as from disease below it, the following method, recommended by Mr. Hilton, is briefly transcribed from the Reports of Guy’s Hospital. A line drawn parallel to the spinous processes directly downward from the angle of the seventh, eighth, or ninth rib across the costo-iliac space to the crest of the ilium, will correspond with the outer edge of the erector spinæ muscle and the apices of the transverse processes. A measured inch outwardly corresponds with the outer edge of the quadratus lumborum muscle. A vertical incision, two inches long, made at the extremity of the measured inch, should divide the skin, cellular tissue, and the tendon of the internal oblique muscle, and expose the outer edge of the quadratus lumborum muscle. Any bleeding vessels to be secured. The last dorsal nerve, if seen lying across the upper part of the incision, should be divided, to prevent the occurrence of pain from its being engaged in the cicatrix. The transversalis abdominis muscle is then to be divided vertically to nearly the same extent of two inches, parallel to the edge of the quadratus, when a quantity of loose lobulated fat will be seen, which should be partly removed and partly displaced by the blunt end of a director, in the vertical direction of the original incision, when the intestine will be brought into view. Any bleeding vessels should be secured, and pressure made on the abdomen, which will cause the intestine to become more prominent at the bottom of the incision. A silk ligature is now to be passed into the bowel and through the integuments at the upper part, so as to fix the intestine above, when a second ligature is to be applied in a similar manner below. The intestine is then to be opened between them, care being taken to apply another ligature above and below it, if the intestine should not appear to be firmly held in its place. If a vessel in its wall should bleed, it must be tied. Inflammation, pain, and restlessness should be obviated as far as possible by fomentations, opiates, and diaphoretics, and strict attention paid to cleanliness and the comfort of the patient, until the first symptoms have passed away, and he is able to assume the erect position.

423. These commentaries are restricted to those points which constitute, in a great degree, what the French call la haute chirurgie. They are published that every soldier should have the opportunity of knowing how he ought to be treated, when suffering for a country not too grateful for the services rendered by her bravest sons; and I have labored with the hope that some few of them, when they find that their limbs, perhaps their lives, have been saved under the precepts I have laid down, may acknowledge, when I am beyond that bourn whence no traveler returns, that they owe them, under the will of God, to those efforts I, more than any one else, have made, and continue to make, for the adoption of that practice which led to their preservation.

ADDENDA.

Several reports and cases having reached me from various medical officers in the Crimea, too late for publication in their proper places, I have thought it best to notice some generally as to results, others particularly. Chloroform has been freely administered in all the Divisions of the army save the Second, and has been generally approved; one death only, as far as is known, having occurred directly from its administration, of which Staff-Surgeon Gordon, P.M.O. of the Second Division, has favored me with the following report:--

Martin Kennedy, 62d Regiment, aged 32 years, a healthy soldier, having accidentally wounded one of his fingers by his musket going off, and the medical officer in charge considering it necessary to remove it, was brought under the influence of chloroform, but, according to his (the surgeon’s) statement, only about ʒij could have been inhaled. He had commenced the operation, when the patient suddenly expired. On the post-mortem examination, beyond a little fatty deposit on the external surface of the left ventricle, together with a degree of hypertrophy of the same, no morbid appearance existed. The usual restoratives were resorted to, but ineffectually.

The following case, furnished by Assistant-Surgeon Hannan, 49th Regiment, is given as an illustration of the success of amputation without chloroform in the Second Division:--

Patrick Kenny, 49th Regiment, aged 22. This soldier, while on duty in the trenches on the 21st of July, received a compound comminuted fracture of the right humerus, extending from its middle third to the head of the bone. The integuments of the outer and upper part of the shoulder were carried away. There was also a contused and lacerated wound of the left knee, opening into the joint, with comminuted fracture of the patella, these injuries being caused by pieces of shell. He was seen a quarter of an hour after admission by Dr. Gordon, P.M.O., who removed the arm at the shoulder-joint, making a sufficient flap from the integuments of the axilla. The thigh was then amputated in its lower third. These operations were performed in immediate succession without the administration of chloroform. The thigh healed nearly by the first intention--all the ligatures having come away by the fourteenth day. The shoulder healed by granulation--the ligature of the axillary artery coming away on the twenty-first day. During the progress of treatment he had not any constitutional disturbance further than three slight attacks of diarrhœa. He is now up and about, and goes to England by the next opportunity.

In the worst cases of amputation at the hip-joint, or at the upper third of the thigh, chloroform has appeared to cause insensibility to pain without diminishing the powers of the sufferer, when given with due caution or not carried so far as to affect the pulse or respiration. (See Aphor. 51.) The evidence on this point is sufficient to authorize surgeons to administer it in all such cases, with the expectation that it will always prove advantageous, an accidental death, such as has been observed from its use, being independent of the nature of the injury. The amputations performed at the hip-joint, at least six in number, have not been successful as to the result, although the sufferers bore them well in the first instance, offering every prospect of recovery for days and even for weeks.

Deputy Inspector-General Taylor informs me, and his opinion is corroborated by all the medical officers, that the labors the troops had to perform, the privations they suffered, the frequent insufficiency of their food, the want of proper clothing, with other depressing causes, had so deprived them of that power British soldiers generally possess, that all the operations of importance performed on the lower extremities were more or less unsuccessful, while those on the upper were as remarkable for their success. This deprivation of power, it is said, was even more observable in the French army; and he informs me that most of their surgeons had declined performing any of the great operations usually done on the upper third of the thigh, in consequence of their almost certain failure, preferring to let the injuries take their course, even unto the death of the sufferers, rather than hasten their dissolution by any operation usually considered and often found to be conservative; a lamentable state of things from which governments may draw an inference of the utmost importance, viz., that to guard against the effects of disease as well as of injuries, the utmost pains should be taken to preserve the health and maintain the vigor of their soldiers. A matter of expense as well as of arrangement.

This statement is corroborated by Deputy Inspector-General Alexander, who informed me, on the 3d of August, 1855, that “during the whole of this campaign, where we have had ample opportunities of testing the use of chloroform, both after the battles of the Alma and Inkerman, as well as throughout the whole siege operations before Sebastopol, up to the present period, no operations whatever of any consequence (save with one or two exceptions, and then at the patients’ own request,) have been performed in the Light Division, without first placing the patient under the influence of chloroform, and in no single instance have either the medical officers of the Division, or myself, seen any bad results follow, or had to reject its use, but quite the contrary. Of course, in such a campaign, many operations of the most serious character, both on the upper and lower extremities, have been performed in the Division by the different medical officers as well as by myself. At the Alma, I operated upon three patients at the hip-joint, two being our own men and the third a Russian. All the three patients were first placed under chloroform, with the results above stated. In the case of a soldier of the 90th Regiment, whose right arm I removed at the shoulder-joint on the 10th of July, for great destruction of the soft parts and extensive injury to the humerus, the patient was so low when placed on the table that brandy and water was given to him, and he was then immediately afterward placed under chloroform. When I had finished, it was found that his pulse was stronger than before commencing the operation. In Sir T. Trowbridge’s case, in which I had to remove both feet, one at the ankle-joint and the other above it, he was placed under chloroform for both operations, a few minutes having been allowed to elapse before giving it to him again for the second operation, and with the best results. Both feet were much injured by round shot, the bones of both being completely smashed with great destruction of the soft parts, so much so, that in the case at the ankle-joint I had to form the flap from the cushion of the heel. I, however, did not remove the articular surface of the lower end of the tibia, as recommended by Mr. Syme, and the wound healed well. Of the three cases mentioned at the hip-joint, two were performed on the 21st, and the Russian on the 22d of September. At one of the former I was assisted by the late Dr. Mackenzie, from Edinburgh. All three were carried down on the 22d, to be placed on board ships for conveyance to Scutari. It has been reported to me that one of the two operated on, on the 21st, Peter Sullivan, 33d Regiment, died at Scutari General Hospital on the 11th of October, three weeks from the date of the operation, ‘from excessive debility.’ Nothing could be ascertained about Peter Cleary, 23d Fusiliers; it is therefore most likely that he died on the passage.

“The Russian died on the 22d of October, ‘from great debility and extensive sloughing.’

“A shoulder-joint case in the 90th Regiment never had a bad symptom, and the wound is all but healed. The flap in this case was made from the axillary portion of the arm, the deltoid having been all but destroyed.

“The flap operation has been invariably performed in the Light Division, with but two exceptions, viz., one of the arm and the other of the thigh.”

Excision of the head, neck, and trochanter of the femur, with portions of the shaft, has been performed at least six times before Sebastopol. The result has been unfavorable in five, although in all there were well-grounded expectations of success for weeks. In one case by Mr. Blenkins, of the Grenadier Guards, he informs me, it was for the first three or four weeks very favorable. The man, however, sank at the end of the fifth week from deposition of matter in the knee-joint. (See p. 42 et seq.) Of the second case, which occurred in the general hospital in the camp and ended fatally, I have no further notice. The third, in the 68th Regiment, in charge of Mr. O’Leary, the operation performed on the 19th of August, was going on most favorably on the 5th of October.

Private Thomas M’Kenena, aged twenty-five, was struck by a fragment of shell, on the 19th of August, over the great trochanter of the left femur. The wound, nearly an inch in length, extended down to the bone, which was distinctly fractured. Some loose scales could be felt at the bottom of the wound. On examination, the injury appeared to be a transverse fracture of the neck of the thigh-bone, apparently involving the joint.

After a consultation with superior medical officers, it was decided that excision should be performed, which was done without difficulty. No vessels required ligature, although the man lost a considerable quantity of blood.

The excised parts, which are herewith forwarded, show that the nature of the injury was different from what it was supposed to be, and that the head of the bone was intact.

After the wound, about five inches long, had been sewn up, the limb was placed in a sling made of strong canvas, and was swung from a beam over the man’s cot, the bed being raised.

This method of treatment was adopted with a view to encourage approximation of the upper end of the bone to the pelvis, and by pressure on the sides of the limb to prevent the accumulation of matter among the tissues. The man progresses favorably.

Diet was very generous.

J. C. O’LEARY,

Surgeon, 68th Light Infantry.

Camp, 4th Division, Crimea, Sept. 14, 1855.

The bones removed are in the museum of the Royal College of Surgeons.

The fourth case is given at length by Staff-Surgeon Crerar, as follows:--

Private William Smith, First Battalion First Royals, was brought to hospital from the Greenhill trenches, in front of Sebastopol, about twelve P.M., on the 6th of August. On questioning him, I ascertained that an hour or so before he was struck by a fragment of an exploded grenade, which first broke into small pieces a water canteen which was suspended over the left hip, and then made an opening or wound about the size of a shilling nearly a quarter of an inch posterior to the great trochanter. Crepitus was quite distinct on moving the limb; and I easily ascertained, on exploring the wound with my finger, that a fracture through the trochanter had taken place, but was quite unable to ascertain to what extent upward and downward the fracture extended. I accordingly solicited a consultation with Deputy Inspector-General Taylor and Staff-Surgeon Paynter. After a careful examination, (the patient being under the influence of chloroform,) the femur was discovered to be comminuted. Excision at the hip-joint being recommended by these officers, in which opinion I concurred, I proceeded to perform the operation by commencing an incision, nine inches in length, in a line with and two inches posterior to the anterior superior spinous process of the ilium, and carrying it down in a straight line directly over the trochanter major; a second incision about two and a half inches in length was made, commencing immediately below the trochanter backward through the gluteus maximus; by a little easy dissection the seat of fracture was exposed, the trochanter was found broken into several portions, detached and imbedded in the contused muscles around, from which they were at once removed. The fracture was found to extend obliquely inward about an inch and a half along the shaft of the bone. The femur was now protruded through the wound, and I sawed off the whole of the fractured bone, leaving a smooth, clean surface; I then proceeded to disarticulate the head of the femur, which was effected without difficulty. Scarcely three ounces of blood were lost, and little or no shock was induced; only one small bleeding point was secured near the tail of the wound, and the divided parts were brought together by two sutures and bands of adhesive plaster.

At twelve A.M., two hours after the operation on the 7th instant, his pulse being rather feeble, he was ordered some wine and water.

7th, vespere.--Countenance cheerful, voice strong; says he intends keeping up his pluck, and is sure he will get well; has no inclination to take the beef-tea ordered for him, but has had some arrow-root and wine. To have a morphia draught at bedtime.

8th.--Passed a good night; limb in a good position; retracted about two inches; wound looks healthy; pulse 100, soft; has made urine freely; skin moist; bowels were opened freely in the night.

9th.--Slept well at night; says that he feels very comfortable; skin moist; pulse 120; sutures were removed, and the wound allowed to gape; it has a remarkably healthy appearance. To go on with the simple water dressing, chicken-broth, arrow-root, and wine.

Vespere.--Has been very cheerful all day; limb has retracted about another half inch; pulse 112.

10th.--Passed a more restless night, in consequence of not having the morphia draught as early as the previous night; has had several hours’ sleep this morning, and is more refreshed; pulse, on waking, from 114 to 120, skin comfortable; no sign of distress in his aspect; wound suppurating healthily; bowels were opened again once last night.

10th, vespere.--Has been very easy all day; skin cool; tongue normal; pulse 120, soft and regular; has had to-day two eggs, one ounce of arrow-root, two gills of wine, and two pints of chicken-broth, all of which he relished much. To have a grain of acetate of morphia in solution at bedtime.

11th.--Slept soundly all night; when I visited him, at six A.M., he had just awoke; pulse 115, soft; appears contented and comfortable.

Vespere.--Doing well; wound continues to look healthy; position of limb good; has consumed a fair quantity of chicken-broth, beef-tea, arrow-root, and three gills of sherry to-day; pulse 113 at eight P.M.

12th.--Bowels were opened in the night; the introduction of the bed-pan gave him a good deal of annoyance; the air of the hut was rather stagnant last night, and he did not sleep as well as usual; pulse 120, soft; tongue continues clean and moist; there is more discharge from the wound to-day.

Vespere.--The progress of the case is most satisfactory; had a fresh egg, tea, and toast for breakfast, his own selection, which he appeared to relish greatly; at twelve he had two mutton-chops and a glass of wine, and at five P.M., a pint of chicken-broth, with bread, and a second glass of wine. The morphia draught as usual.

13th.--Continues to look happy and contented. Healthy-looking granulations are evident over two-thirds of the wound; swelling of limb subsiding; discharge from wound healthy; pulse 114, regular and soft; all the symptoms are so very favorable that I have every reason to expect a successful issue.

14th.--A small slough at the lower part of the wound, remainder healthy and clean; tongue a little too dry this morning, and he has more thirst than usual; pulse 118. To have effervescing draughts of bicarbonate of potassa and citric acid three times a day; to continue simple water dressing.

Vespere.--Thirst not so urgent; tongue cleaner and moister; has a feeling of fullness in the abdomen. To have his usual morphia draught and an ounce of castor-oil at bedtime.

15th.--Passed three large stools in the night, with great relief; aspect resigned, and his spirits continue good; slough has come away; pulse 118, soft and regular; skin tolerably cool.

Vespere.--Felt a good deal exhausted to-day from the heat, which was very great--ninety-two degrees.

16th.--Looks heavy and out of spirits this morning; discharge has increased, but is of a better quality since the slough separated; tongue dry, inclined to brown; pulse the same, skin rather hot; continue effervescing draughts every third hour.

Vespere.--Tongue more moist, less thirst. When asked how he felt, he replied, with a great deal of life in his countenance, “I am very well, and I feel very comfortable;” asked for a mutton-chop early in the day, which he got, and appeared to like; he had at different times in the day arrow-root, chicken-broth, and wine.

17th.--Wound looks very healthy, and the general symptoms very favorable to-day; tongue clean and moist; less thirst; skin cooler; had him removed to a fresh bed without a great deal of pain or trouble; limb retracted less than three inches; position now good since he was shifted.

18th.--Very much worse this morning; had a rigor about ten A.M. yesterday; features now sharpened and pinched; tongue dry and brown; pulse thready, about 125.

Vespere.--Continues in a very low state; wound has a very healthy appearance; discharge healthy, but not as abundant as it was; has had besides wine, a pint and a half of porter, mutton-broth, and a chop to-day; zinc lotion to the wound.

19th.--When I visited him at six A.M. to-day, I was much pleased to find him looking quite cheerful; pulse soft, 112; skin cool and moist, paler than usual; wound doing well. Continue zinc lotion to the sore, and to have his choice to-day of mutton-broth, beef-tea, or chicken-broth; arrow-root to be given twice, four gills of sherry or port as usual.

Vespere.--No change to report.

20th.--Looking rather pale, and features pinched; pulse better, about 100, soft; skin cool; tongue more coated than usual, inclined to be dry. I fear this case is a bad one, not likely to terminate as we so much desire.

Vespere.--Has been very uneasy all day; skin hot; tongue dry.

21st, six A.M.--Has just awoke, having been asleep since nine last night; says that he feels stronger; aspect certainly improved since the last visit; coating on the tongue thicker, brown; the pulse has more strength than it had yesterday; no feeling of uneasiness; wound looking remarkably well, and discharging laudable pus; asks for cold drinks; to have his choice of iced soda, tamarind, toast or rice water; diet the same as yesterday.--Eleven A.M.: has fallen off very much since the morning, features pinched and blue; pulse irregular, small, and wiry.--Twelve nocte: continues to sink; died at half-past twelve P.M.

Examination of the limb six hours after death.--Cut surfaces of femur perfectly smooth; bone easily denuded of its periosteum; acetabulum smooth; muscles infiltrated with pus; nature had not made the slightest attempt to repair the loss.

What would the result have been if amputation at the hip-joint had been performed? The same. The vis medicatrix naturæ is not sufficient to carry our sick through such formidable operations; it is no fault of the surgeons. A better and a more liberal allowance of animal and vegetable food during health is required, if England expects her soldiers to survive severe operations, disease and wounds. An attempt to save the limb, for the very same reason, would, most undoubtedly, have been a failure. Our Minié rifle-ball fractures of the femur all sink under conservative surgery. Our amputations above the middle of the thigh have a like issue; it is truly disheartening.

J. CRERAR, Surgeon, 68th Regiment.

Camp before Sebastopol, 24th August.

Dr. Crerar was greatly distressed by the loss of this man, and the manner in which he expresses his grief is declaratory of his feelings. The excised bones are in the museum of the Royal College of Surgeons.

The fifth, by Dr. Hyde, ended fatally on the sixth day.

Corporal Benjamin Shehan, 41st Regiment, advanced with his corps, about twelve o’clock, on the 8th of September, to storm the Redan. Having succeeded in getting into the work, the regiment was afterward obliged to retire; in the retreat to our trenches he was wounded, and lay on the field till the following day, when he was brought to the hospital of the Royal Sappers and Miners. On examining the wound, it was found that a grape-shot had entered at the great trochanter, and, passing inward and a little forward, had passed out at the groin of the same side, about an inch below Poupart’s ligament, externally to, and a little in front of, the femoral vessels. The lower fragment of the fracture protruded through the external wound, and the introduction of the finger discovered a comminuted state of the neck of the bone.

Excision of the joint having been decided on, the operation was performed in the presence of Deputy Inspector-General Taylor, Staff-Surgeon Dr. Paynter, and Surgeon Elliot, Ordnance Department.

Operation performed about one P.M. 9th of September.--An incision, about four inches in length, commencing a little above the trochanter, was carried downward along the outer side of the femur. The lower fragment, for about an inch of its extent, was cleared of its attachments. An assistant holding the thigh below, and pushing the bone upward and outward, so as to bring the fragment through the incision, about an inch of the bone was then sawed off. The head of the bone was next dissected from the socket; this part of the operation was considerably facilitated by an assistant catching a firm hold of the neck by means of a pair of tooth forceps, then rotating the head, and using slight force to dislodge it from the cavity, the operator dividing the capsular and round ligaments, the latter of which is more easily and safely divided at the lower and outer side of the articulation. The upper part of the trochanter was next dissected out, and several small spiculæ of bone removed. The edges of the incision were then brought together by sutures, and a bandage applied. It was not found necessary to tie any vessel, and there was very little hemorrhage. The man bore the operation well, and was returned to his bed in good spirits, and with a good pulse.

10th.--Passed a good night; slept pretty well; pulse 106, soft; skin cool; in good spirits.

11th.--Slept some hours; pulse 106, soft; bowels open; tongue furred, but moist. Wound dressed and looking well; some healthy discharge.

13th.--Going on apparently very well; pulse still 106; countenance good. Vespere: Complains of an increase of pain in the hip, but otherwise says he feels much as usual; pulse small and rapid. Ordered wine and arrow-root.

14th.--Died at six this morning.

The autopsy showed a considerable cavity filled with sanies in the situation of the operation, but no other fractured bone was discovered. The articulating surface of the acetabulum was coated by a fetid, pasty substance.

GEO. HYDE, M.D., Staff-Surgeon.

The sixth, by Staff-Surgeon Coombe, also ended fatally.

Private James Nadauld, aged twenty-one, First Battalion Rifle Brigade, was admitted into the Castle Hospital, Balaklava, upon the 16th of July, 1855, five days after the receipt of a gunshot injury of the right shoulder. Upon the 19th of July the head of the humerus was excised, and the ball was found impacted in it. The healing process went on most favorably, and the man was discharged upon the 26th of August, quite well, for the purpose of proceeding to England. The excised bone is in the museum of the Royal College of Surgeons.

W. H. McANDREW, M.D., Surgeon, 57th Regiment.

Camp, Sebastopol, Sept. 14th, 1855.

Private John Purcell, 57th Regiment, aged twenty-one, was wounded upon the 18th of June, in the unsuccessful assault upon the Redan, by a Minié rifle-ball, which passed directly through the head of the humerus, but did not touch the glenoid cavity. Upon the 22d of June, the head of the bone was excised; and upon the 26th of August, the man was discharged from hospital, quite well, for the purpose of proceeding to England. The excised bone is in the museum of the Royal College of Surgeons.

W. H. McANDREW, M. D., Surgeon, 57th Regiment.

Camp, Sebastopol, Sept. 14th, 1855.

The following case of wound of the larynx is instructive:--

Lieutenant Charles H. Evans, 55th Regiment, aged nineteen years, was wounded on the evening of the 5th of August, 1855, about eleven o’clock P.M., while on duty in the trenches. The ball entered the right side of the neck, close to the angle of the jaw, and passed apparently between the hyoid bone and the arytenoid cartilages, and then downward, having its exit below the cricoid cartilage on the left side. The pharynx and larynx were wounded, and the trachea was contused and displaced. Respiration somewhat hurried; a quantity of mucus collects in the trachea, and is expectorated in fits.

About seven o’clock P.M. of the 6th, the respiration becoming more difficult, with a degree of lividity of the lips, indicative of the non-oxygenation of the blood, it was deemed advisable to have recourse to tracheotomy, which, in consequence of the displacement of the parts and the swelling, was effected with considerable difficulty. The usual tubes were found too short for the purpose, and a large silver catheter was inserted, through which the air passed freely. Whenever he attempted to drink, the liquid passed into the trachea through the openings caused by the ball. From the operation no benefit arose, and he continued very restless until within an hour of his decease, which took place about twenty-six hours after the receipt of the wound. The voice was never heard above a whisper.

Post-mortem examination, twelve hours after death. The ball would appear to have passed through the hyo-thyroid membrane, fracturing and shattering the thyroid cartilage. The membrane lining the glottis was torn and destroyed. The vessels escaped without injury, the ball having passed anteriorly.

ARCHD. GORDON. M.D., Staff-Surgeon, 1st Class, in Med. Charge, 2d Division.

Camp before Sebastopol, September 3, 1855.

Deputy Inspector-General Taylor, who was present during the operation, adds: “The want of a longer tracheal tube than is commonly supplied for such operations was obvious, and is a good practical hint. For the first time in my life I found my two forefingers transfixing a man’s neck from side to side. The fingers did not cause any cough or irritation, but those symptoms were occasioned by the least attempt to swallow water. The thyroid cartilage was separated into two pieces.”

The following cases, one of wound of the profunda femoris, the other of the popliteal, deserve attention:--

Late in the afternoon of the 14th of August, Private George Irvine, aged twenty-five, was brought from the trenches, having been struck by a Minié-ball of the largest size, which had penetrated the left thigh, about two inches below Poupart’s ligament, just in the course of the femoral artery. The ball passed slightly outward, fracturing the femur, and was cut out at the back of the limb, completely flattened. As there was considerable hemorrhage, both venous and arterial, no examination with the finger was permitted. Dr. Taylor, superintending the Division, having been informed of the case, a consultation was held.

Amputation at the hip-joint was forbidden by the prostration of the man, who had lost much blood before he was brought to camp. Excision of the head of the femur was also inadmissible, from the evident wound of a large artery, with probably that of a large vein. Search for the wounded artery, for the purpose of applying a ligature, was then determined upon, but before the operation had well proceeded, the hemorrhage was so great that it was found impossible to continue it, and pressure by means of graduated compresses was resorted to, with complete success.

On the following morning an operation was still out of the question. Prostration continued, with great irritability of stomach, and a small, quick pulse. No return of hemorrhage, though the pressure of the tourniquet was but very slight.

On the 16th, the pulse was more quick and irritable, with the same irritability of stomach, and urgent thirst. He had passed a better night, however. At the consultation this morning, the circulation through the posterior tibial artery was so evident that the question of the femoral artery being wounded was set at rest. It was decided, as no return of hemorrhage had occurred, that the case should be left to nature.

On the 17th, he suffered from starting pains in the thigh. There was less irritability of stomach, but the pulse was very small and weak. During the night there was slight hemorrhage, owing to his restlessness, but it was easily arrested by a turn or two of the tourniquet.

On the evening of the 20th, this restlessness increased; delirium set in, and early in the morning of the 22d he died.

The limb was examined after death, when the following appearances presented:--

Femoral artery intact. Femoral vein wounded, with more than half its caliber shot away. At about two inches from its origin there was a wound of the profunda artery, on which an aneurism, nearly the size of a pigeon’s egg, had formed, and passed upward through the wound made by the ball. The profunda vein was intact. The injured vessels having been removed for preservation, the bone was then cut down upon, when a fracture, nearly transverse, and not at all comminuted, was observed below the trochanters. No splitting of bone upward; downward its outer plate was slightly cracked, but nothing more. The preparation is in the museum of the Royal College of Surgeons.

Private James Ross, a lad of eighteen, was brought up from the trenches, on the morning of the 3d inst., having had his right leg blown off below the knee by a round shot. He had lost a very large quantity of blood before the tourniquet was applied, and was consequently so much collapsed that an operation was out of the question. He was therefore dressed and the tourniquets (two had been put on) removed. He never rallied, and died on the 12th, nine days after the receipt of the injury. No hemorrhage ever occurred, though all pressure had been removed from the artery.

R. V. DE LISLE, Surgeon, 4th King’s Own Regiment.

Camp before Sebastopol, Sept. 14, 1855.

The following is worthy of publication, as showing the successful effects of strychnia, when carried to the extreme verge of propriety, in injuries of the spinal cord.

Sergeant William Aldridge, 46th Regiment, aged 39 years, during a sortie from Sebastopol, was knocked down in the trenches, and his back formed a bridge over which Russians and English passed. The result was serious injury to the spine, causing paralysis of the lower extremities and bladder. The pain was excruciating, and the patient could not be moved in bed for several weeks.

On the 4th of March, 1855, he was placed under my charge in the military hospital at Portsmouth, when he complained of great pain and tenderness along the spine, and incontinence of urine, together with wandering day dreams and insomnolency at night. Solution of the muriate of morphia ʒj was prescribed without any effect. (ʒj contains 1 gr.) The dose was gradually increased to ʒij of the solution.

15th March.--Fell out of bed during the night, trying to hide himself. Is wandering, and fancies that he has deserted from the Crimea, and will be shot. The narcotic has been omitted for several days. Strychnia was now ordered, one-sixth of a grain three times a day.

20th.--Continues much the same, with slight twitchings of the face.

25th.--Has been unconscious for three days. Now complains of intense pain in the back and violent cold perspiration.

28th.--Returning consciousness; feels easier, having slept uninterruptedly for forty-eight hours. Expressed a desire to make his will, and send to Dublin for his wife; both wishes were complied with.

30th.--Sensation and motion are gone from the lower extremities, and the urine is still passed involuntarily. One-eighth of a grain of strychnia was ordered twice a day.

31st.--Is powerfully under the influence of the remedy, with convulsive movements of the upper and lower extremities; wild stare and fixed jaws. The lower extremities had not moved for several months previously. This paroxysm lasted for one hour under my own observation, after which the muscles became relaxed, the face bedewed with a gentle perspiration, and resumed its ordinary tranquil appearance.

April 2d.--Feels greatly relieved from pain, and is comparatively comfortable; sleeps calmly. His appearance is entirely changed; looks natural; features calm; is cheerful, and reads the papers. Strychnia was omitted for some days after the last paroxysm, and replaced by the tincture of the sesquichloride of iron with quassia, and a generous diet.

6th.--Continues to improve. Has now and then slight twitchings in the legs and arms. The strychnia was resumed and omitted, as the symptoms indicated, to the end of the month.

May 1.--Is greatly improved; goes about the balcony in a chair. Returning sensation in the right leg. Bladder still not under the control of the will.

20th.--Sensation much improved in both legs, and motion increasing in the right leg.

25th.--Convulsive movements all over the body, resulting from the use of the strychnine. Lower extremities decidedly improved both in motion and sensation.

June 1st.--Maintains his improved condition. Recommenced the strychnine to-day, without any marked effect at the moment.

10th.--Violent tetanic spasms followed the employment of the remedy, producing considerable increase of motion in both extremities. The paroxysms usually continue about fifteen minutes, when the muscular system resumes its ordinary appearance.

20th.--Continues the same. Strychnia not resumed since last entry, as occasional twitchings occur about the head and face, and he is now affected by the smallest dose.

July 1st.--General health excellent.

10th.--Continues to improve daily in regaining the use of his limbs. Is now able to walk on the ramparts with crutches, but is exceedingly sensitive to every change of weather--damp always causing pain in the spine. Continued to improve to the end of the month.

August 1st.--No change worthy of note.

14th.--Discharged to Chatham.

T. H. BURGESS, M.D., Military Hospital, Portsmouth.

The following case of injury of the abdomen, sent to me by Dr. Rooke, civil surgeon with the army in the field, is very remarkable:--

Robert Cousins, aged 20, 77th Regiment, was admitted into the general hospital, camp, June 8th, with severe injuries caused by a round shot, which struck him when he was on duty in the advanced trenches. When the shot struck him he was standing up, half-face toward the enemy, his right arm extended in front of the right hip; he was in the act of reaching his water-can, which rested against the parapet of the trench.

On admission he was in a state of semi-collapse, the integuments of the right hand and forearm greatly lacerated, the wrist-joint laid open, the bones of the carpus comminuted; the radius and ulna were also fractured at the middle third. There was a lacerated wound in the right iliac region, the size of the palm of the hand; over this space the skin and muscles of the abdominal wall were torn away, the peritoneum lining it was also lacerated, and at the bottom of the wound was seen a coil of intestine in situ; there was no tendency to protrusion, nor were its coats at all injured. The crest and body of the ilium were much comminuted, the fracture extending downward between the anterior superior and anterior inferior spinous processes. The anterior superior spinous process was broken off. There was another wound just below the great trochanter; this apophysis was also shattered. The right limb was two inches shorter than its fellow, the foot everted, but, from the great comminution of the pelvis and the extreme pain produced by examination, it was not satisfactorily made out that the neck of the femur was fractured, but the shortening of the limb and eversion of the foot were in favor of that diagnosis. The injuries which the patient had received were considered mortal; it was thought unnecessary cruelty to amputate the forearm. Such pieces of the ilium as were loose were removed; wet lint applied to the wounds; and brandy and water with opiates were ordered. One of his comrades volunteered to watch over him, and he was left, as all thought, to die. The next day (June 9th) he had partially rallied from the state of collapse; had taken liquid nourishment--beef-tea, arrow-root, etc. There was no pain or tenderness of the abdomen; had passed his water without difficulty. The surface of the abdominal wound was sloughy; intestine still visible; complains of pain in the arm. It was not yet considered advisable to perform any operation. He was ordered opium gr. j every four hours; also a dose of morphia at night, arrow-root, beef-tea, and port wine, which he prefers to brandy.

10th.--Has rallied completely; no pain or tenderness of the abdomen; complains greatly of his arm, and is anxious that something should be done. He slept well after taking the morphia; his face is tranquil, breathing natural, pulse weak; no irritability. Deputy Inspector-General Taylor saw the case in consultation with Dr. Mouat, P. M. O. of the hospital. It was decided to amputate the forearm. This was done at the upper third; chloroform was administered, and produced no ill effects. He was ordered any fluid nourishment he might fancy, with port wine, and an opiate at night.

11th.--No symptoms of peritonitis; suffers no pain; tongue clean and moist; pulse quiet; passes his water regularly; the bowels have not acted. The abdomen is quite soft and fallen, not the slightest tenderness on pressure. To continue on the same plan. He could now give some account of the way in which he was wounded. He stated that he thought it must have been a round shot that struck him. It first struck his arm, then entered the right iliac region, emerging at the lower wound. The surface of the wound in the iliac region is in a sloughy state from the severe bruising of the parts. The coil of intestine is still visible at the bottom of the wound.

12th.--No symptoms of peritonitis; bowels have not acted; tenderness down the outside of the thigh, with redness of the skin, and pitting upon pressure. Stump dressed to-day and looking well.

13th.--No unfavorable constitutional symptoms. The outer part of the thigh is tender and the skin red; free incisions were made; the fascia was sloughy. He takes nourishment; has eight ounces of port wine daily, eggs, arrow-root, and essence of beef. Bowels not acted.

21st.--He had no symptoms worthy of remark since the 13th. The bowels have not been moved; he complained to-day of not being able to pass his motions. Two injections of warm water were administered in the course of the day. He passed a large quantity of hardened feces, which relieved him greatly. The sloughs are separating from the incisions in the thigh; the crest and ala of the ilium are exposed; healthy granulations are springing up from the bottom of the wound. Stump healing favorably.

July 26.--The case has progressed without a bad symptom. At first it was thought that the greater part of the ala of the ilium would exfoliate, but some red points appeared on the surface, and the concavity of the bone became covered with granulations. The exfoliation was limited to the anterior part of the crest of the ilium, which separated on the 17th instant. At various times pieces of bone have been removed as they became detached; there are others still left to come away. The granulations on the upper wound are on a level with the skin of the abdomen. The crest of the ilium is covered with granulations; the wound is contracting, but there is a deficiency of skin to cover the projecting portion of the ilium. The lower wound is also open, and has been enlarged to remove pieces of bone; the incisions in the thigh have healed. The bowels have acted regularly without medicines until to-day, when he required a castor-oil injection. The right thigh is more than two inches shorter than the left; union appears to have taken place; he has no pain on motion. The dead bone that still remains alone prevents the wounds from closing, their surfaces being covered with healthy granulations. His general health is good. He has taken at intervals some oleum jecoris aselli, and, for a mild attack of bronchitis under which he suffered at the end of June, expectorants and diaphoretics. There has not been a single symptom of any abdominal complication. He has an opiate at night. The stump has been healed nearly three weeks.

September 14th.--Since the last report no unfavorable symptoms have occurred. The stump of the forearm has been healed some weeks; his health is good; indeed, from first to last, he has not had a single symptom denoting constitutional disturbance. All the dead bone from the crest of the ilium has separated; the wound of the abdomen is skinned over, with the exception of a small spot about the size of a sixpence. This is healthy, and is gradually healing. The bowels act regularly. There are still two sinuses on the outer side of the thigh--one above, the other below, the great trochanter. On probing these, dead bone is felt, which has not yet separated. The right limb is about three inches shorter than the left, is freely movable in any direction without pain. He can raise the knee from the pillow, but cannot lift the heel from the bed; he can, however, turn himself over on to the left side without assistance. The prominence of the crest of the ilium is greatly diminished from loss of bone. The trochanter major is unusually projecting; the natural appearance of the hip-joint is entirely gone. The injuries to the bones have been so severe, it is difficult to say what changes have occurred. The ilium and pubis have been greatly comminuted, the fracture most probably extending through the acetabulum. Immediately below Poupart’s ligament, to the outside of the femoral artery, a hard substance is felt beneath the skin. This, when he was admitted, was at first supposed to have been a piece of a shell, but it is now thought to be a portion of the pubis driven downward upon the thigh.

He may now be said to be convalescent.

* * * * *

John Shehan, aged nineteen, 57th Regiment, was wounded in the left thigh before the Redan, on the 18th of June. He was brought to the general hospital, and placed under the charge of a gentleman of considerable skill and experience. The wound presented two openings, an anterior and a posterior; the latter offered greater facilities for examination than the former; the finger, passed from behind, detected several fragments, which were removed, and as a tolerably uniform surface of bone (vide specimen) was then felt, it was determined, after consultation, to make an attempt to save the limb. The injured extremity was accordingly bound up with a long splint in the most careful manner, and matters promised favorably for a time. He, however, complained of a good deal of suffering in the limb from time to time, gradually wasted, suffered from diarrhœa, and finally sank on the 6th of August. On examination post-mortem, I found the chief organs in a normal condition. There was some congestion of the ilium, and the colon presented a few points of ulceration. The condition of the parts in the left lower extremity was very remarkable. Beneath the integuments, all the muscular and other textures, from the seat of injury to the groin, were converted into a soft, broken-down, black, rotten mass; and I may here observe that this low but intense disorganizing process, extending through the greater part of the limb, has presented itself in several of my examinations of somewhat similar injuries, and appears to me to be connected with a peculiar pathological state in which all the vital organs remain sound, but the vis vitæ is remarkably reduced below par. The fractured bone it is unnecessary to describe. The vertical and cross infraction of the fragments and its almost “arborescent” appearance are most remarkable. I look upon it as a specimen of no ordinary value, conveying more than one most useful lesson. The bones are in the museum of the Royal College of Surgeons.

R. D. LYONS, Pathologist to the Army in the East.

Camp before Sebastopol, August 30, 1855.

Private William Leah, 30th Regiment, aged twenty-one, was brought to me on the 27th of June, while I was on duty in the trenches, with fracture of the external condyle of the humerus of left arm, by a musket-ball, which had entered the joint between it and head of radius, and had made its exit over olecranon process of ulna. Artery uninjured. On being sent to camp, the joint was excised by Mr. Dowse, surgeon of the regiment. The patient progressed favorably, and the wound has been healed for nearly a month. He can use all the muscles of the forearm, except the flexor of the little finger, and is regaining the motion possessed by the elbow-joint.

DAVID MILROY, M.D., Assistant-Surgeon, 30th Regiment.

Camp, Second Division, Heights of Sebastopol, Sept. 5, 1855.

J. Maguire, 31st Regiment, aged twenty, wounded in the advanced trenches.

July 12, five A.M.--Carried into hospital, wounded by a splinter of shell in left elbow and on left hip. The splinter struck him in an oblique direction, from behind, fracturing olecranon process and internal condyle of humerus, lacerating and otherwise injuring the joint, the ulnar nerve being also injured. The splinter continuing its onward course, inflicted a lacerated wound on the hip, with comminuted fracture of about the anterior fifth of the crest of the ilium, several small pieces of bone being driven in on the peritoneum, causing pain on the slightest motion. All the loose portions of bone were removed, and several others separated from the muscles. Abdomen painful, and swollen at that side. Abdomen continued painful during the day; bowels acted; he also passed water freely.

13th.--Pain in abdomen much less; little, if any, constitutional disturbance; elbow extremely painful; the pain accompanied with partial paralysis of the little and ring fingers. Staff-Surgeon Dr. Gordon having seen him, and not apprehending any danger from the wound in the side, the operation for excision of the elbow-joint was determined on, and performed under chloroform, by a single straight incision passing through the original wound, including the upper and lower fourths of the forearm and arm. There was very little hemorrhage. The arm was then put up in an angular splint. It continued to progress favorably, the greater part healing by the first intention. There was some suppuration, but a free exit being given to the matter, it did not retard recovery.

August 19th.--This patient was discharged from the regimental hospital, to general hospital, Balaklava. The wound nearly healed; sensation partially restored to the fingers; slight motion at the bend of the elbow; but he has not power to raise the hand.

THOMAS J. ATKINSON, Assistant-Surgeon, 31st Reg. in Med. Charge.

Camp before Sebastopol, Sept. 1, 1855.

Private Anthony Murray, aged twenty-eight, 41st Regiment, a healthy man, was struck, while on duty in the trenches before Sebastopol, on the night of the 23d of July, 1855, by a portion of a shell, which penetrated the left elbow-joint; the head of the radius and the outer half of the articulating surface of the humerus were comminuted, fragments being impacted in the cancelous structure of the humerus, and driven in between that bone and the ulna. Excision of the joint having been determined on, it was performed in the following manner: a straight incision was made along the posterior surface of the joint, the olecranon cut through, and the extremities of the several bones removed in succession; the parts were then brought together by suture, and the limb placed in a flexed position; about a third of the wound healed by the first intention; no inflammation supervened. On the 3d of August the wound was granulating in a healthy manner; on the 22d, it had almost healed, and the limb was put up permanently, the forearm at right angles to the arm; on the 31st, some union had taken place between the bones; the man can move the thumb and three fingers; he is free from pain; his health is very good, and he appears to be progressing favorably in every respect.

J. E. SCOTT, M.D., Surgeon, 41st Regiment.

August 31st, 1855.

Private Jesse Lockhurst, 31st Regiment, aged twenty-six, was wounded in the advanced trenches, 17th of August, 1855.

August 17th.--Six o’clock A.M., carried into regimental hospital, having received an extensive lacerated wound of right cheek: very little apparent hemorrhage, but the power of deglutition was completely lost, and respiration impeded. On making an examination of the wound, it was ascertained that the right superior maxillary bone was fractured, and a portion of the hard palate with the molar teeth driven in on the tongue; there was a large piece of shell or shot lodged at the bottom of the wound, lying on left palate, and, as far as could be ascertained, on the back of pharynx. Staff-Surgeon Dr. Gordon being present, the ball, after much labor, was extracted, and found to be a grape-shot of seventeen and a half ounces weight. During the operation it was found necessary to dilate the wound by dividing the lip near its external angle--the portions of bone that were removed were the alveolar process, with all the molar teeth, including part of the palate and a portion of the orbital plate and nasal process of the superior maxillary bone, and all the malar bone. There was no serious hemorrhage during the operation, nor immediately after the extraction of the shot. The cheek was then plugged with lint and the wound brought into apposition by sutures. The man experienced immediate relief after the operation, sat up in bed, washed out his mouth, and drank some water; he seemed extremely thankful, and blessed the doctors. During the night and part of the next day there was some oozing from the mouth. No bad symptom occurred until the 20th, when an active hemorrhage came on from the back of the palate. The exact source could not be ascertained. He became very weak and almost pulseless; but the hemorrhage was eventually restrained by means of ice and plugging the wound with lint moistened in tincture of matico. Iced drinks occasionally.

31st.--The man is now doing extremely well, can talk, and takes a pint of jelly daily; the external wound is not yet quite healed, in consequence of the saliva flowing through it. The right eye is uninjured, and sight unaffected.

September 1st.--He has just been discharged to general hospital, Balaklava, from the regimental hospital.

THOS. J. ATKINSON, Assistant-Surgeon, 31st Regiment, in Med. Charge.

Camp before Sebastopol, September 1, 1855.

On the morning of July 24th, Private Francis O’Brien, a lad of eighteen, was brought from the trenches, with a wound from a musket-ball in the right temple. It entered about two inches above the orbit, passed downward, and drove out a large portion of the supra-orbital ridge, which appeared to be imbedded in the upper eyelid, and was cut down upon by the medical officer in the trenches, in mistake for the ball, which it certainly very much resembled. As no ball could be found, it was supposed to have passed out at the opening of entrance.

The finger when passed into the wound could feel the pulsation of the brain, yet from that day to the present no symptom of cerebral disturbance has appeared, unless it be that since his convalescence the muscles of the face work convulsively when he feels faint and weak from remaining too long in the erect posture. About a month after admission, the detached portion of the bone above the orbit was removed from the eyelid, though with considerable difficulty, and on the following morning the ball fell from the wound, much to the poor lad’s horror, who thought his eye had dropped out.

Both wounds have now healed, but he is unable to raise the right eyelid; the eye is perfect, but apparently without power of vision, though sensible to the stimulus of light, for on turning the wounded side to the light, the left pupil contracts. His general health is good.

R. V. DE LISLE, Surgeon, 14th King’s Own Regiment.

Camp, Sept. 10.

Private Joseph Bourke, 17th Regiment, admitted on 9th of September, 1855, with fracture of anterior superior angle of right parietal bone, with depression of about one-third of an inch, for the size of a florin. No attempt was made to elevate the depressed portion. Has not had a bad symptom. Wound of scalp nearly healed.

W. P. WARD, Surgeon, 17th Regiment.

Private Michael Caffrey, 88th Regiment, wounded at the attack upon the Redan on the 8th of September, was brought to the hospital of the 38th Regiment on the morning of the 9th. A round rifle-ball struck him at the anterior part of the left parietal bone, and passed through the brain in a line which brought it out at the vertex, fracturing the parietal bone of the opposite side; the ball at its entrance split, and one-half pushing before it a small piece of bone, both lodged at the entrance; the other half of the ball was found lodged in the brain at the upper and back part, having detached a circular portion of the skull.

A director was passed along the track of the wound, and the scalp laid open; the brain was found to protrude through the fracture. In this condition the patient lived for eleven days, utterly unconscious of everything passing around him, the urine and feces coming away involuntarily. There was paralysis of the opposite side.

A post-mortem examination showed the brain to have been reduced to a pultaceous mass only in the direction of the passage of the missile; the remaining portion of the wounded hemisphere and that of the opposite side were healthy.

The absence of the usual train of head symptoms, and the length of time which so extensive an injury permitted life to remain, render this case worthy of some remark.

FREDERIC WALL, Surgeon, 38th Regiment.

Camp before Sebastopol, Sept. 20, 1855.

Private William Doyle, 19th Regiment, aged nineteen years, was wounded in the head by a rifle-ball, in the advanced trench of the right attack, on August the 30th. The scalp and pericranium were cut about two inches, and a portion of the cranium, a little in advance of the posterior and superior angle of the right parietal bone, close to the sagittal suture, about an inch in length and half an inch in breadth, was depressed. According to statement the man was rendered perfectly senseless and motionless, from the instant of being struck by the bullet. On reaching camp he presented all the usual symptoms indicating compression; pupils dilated and fixed, warm surface, total unconsciousness, complete paralysis, etc. On examination of the depressed portion of bone, no opening whatever could be felt; the edges of the sunk bone and the bone adjoining were in contact, and it was presumed to be an ordinary case of fracture with depression simply. Some very minute portions of cerebral substance were observed to be mixed with the clot of blood about the wound, such as might be squeezed through a fissure. Trephining being determined on, it was performed at once, and the depressed bone raised without difficulty. No relief of symptoms followed. The dura mater bulged slightly upward into the opening. On passing the finger over its surface, a little beyond the space exposed by the trephine, a defined cut edge was felt about an inch in advance of the depressed piece of bone, being the boundary of an opening into the cerebral substance.

Three hours after arrival in camp the patient died. On examination post-mortem, a wedge-like section of the ball was found to have entered and penetrated the cerebral substance; it was discovered in the anterior lobe on the right side, just above the orbitar plate. It had not completely penetrated, but was lying just above the membrane covering the lobe. The ball--a conical rifle-ball with three cannelures--was cut smoothly from apex to base, as if by a sharp knife. This must have been done by the edge of broken bone above the opening made in the parietal bone, one-half of the ball flying off, the other entering the skull. On close examination, several very small points of lead were found to be imbedded along the margin of the bone alluded to. The depressed portion of bone, directly after the piece of ball entered, must have sprung up again by its own resiliency, or been forced up by sudden pressure from within, so that no evidence of an aperture, but merely a fissure and depression remained. The inner table was separated, and nearly detached, for a space rather more extensive than that of the depressed part of the outer table. The superior longitudinal sinus was wounded by the sharp edge of the broken inner table, and a very considerable quantity of blood extravasated upon the surface of the brain.

The portion of bone implicated in this injury has been preserved.

THOMAS LONGMORE, Surgeon, 19th Regiment.

Camp before Sebastopol.

REMARKS.

Six amputations at the hip-joint (if not more) have been performed in the Crimea, and all the sufferers have died, a loss which has not been experienced in civil life under any circumstances, many persons having survived the operation for years. It has been fairly attributed to the depressing causes from which the army suffered, and for which the government has been blamed; although the great functionaries appear to me to have less to account for than their subordinates, as far as regards deficiencies in the treatment of the sick and wounded.

The operation for removing the head of the femur from its connection with the hip, leaving the limb for future use, was first recommended by me as a substitute for amputation at the hip-joint, and has been done in at least six instances, one only surviving. I limited the operation to injuries of the head and neck of the bone, or with little extension beyond these two parts, being cases which hitherto invariably died unless amputation at the hip-joint were performed, and which it was and is hoped the operation of excision might render unnecessary; but it must be done under happier circumstances, and perhaps with greater restriction. The success which has followed the removal of the head of the humerus from the shoulder-joint even with as much as one-third of the shaft, as low as the insertion of the deltoid muscle, has led to the belief that as much may be done in the thigh; and in the hope that it might be so, a considerable portion of the shaft of the femur has been removed with the head and neck in the cases alluded to, so that an approximation of the remainder of the shaft to the cavity of the joint has not been possible. If the operation performed by Surgeon O’Leary, 68th Regiment, (page 564,) which at the end of seven weeks is reported as doing well, although the pulse remained between 80 and 100, should succeed, it is doubtful whether the limb will be of any use or better than an artificial leg, from the extent of the bone removed, which will prevent the formation of a firm joint or union. The sling used in this case has been considered very advantageous by all who have seen the man, and proves how much may be done in all cases of compound fractures by similar appliances, but which has not yet been done. A correct judgment cannot, however, be formed as to the value of this operation until it has been performed on one of those cases in which a ball shall simply lodge in the head or neck of the femur without injuring the shaft of the bone--an accident which has been so frequently observed in the head of the humerus, and of which I have sent two preparations to the museum of the College of Surgeons. (See page 127.)

It has been already stated that the loss of life after amputations performed for gunshot fractures of the upper part of the thigh has been so great, both in the French and English armies, that such operations have been nearly abandoned.

The Russians, at the commencement of the siege of Sebastopol, made use of a conical rifle bullet, flat at the base, weighing nearly one ounce and three-quarters. Latterly they have used a larger conical one, with three grooves around the circumference of the base of the cone, which is hollowed out to receive a cup, and shows a projection on the inside of the hollow. This ball is near two inches long, and weighs somewhat more than one ounce and three-quarters.

The balls formerly used by the French army were twenty to the pound, and by the English, sixteen. The balls alluded to are nine to the pound. When this Russian ball strikes soft parts only, such as the thigh, it merely makes a larger hole than the common bullet, into which the finger passes easily, and the wound heals as readily. Whenever it strikes a bone, it would appear to break it more extensively, and to require more certainly the amputation of the limb; although the smaller French ball used in former days, when it struck a bone, disabled the sufferer as effectually for all future service, yet it might not as certainly lead to his death.

Dr. Lyons not only transmitted to me the case, related page 579, of John Shehan, but has since sent me the broken bones, which confirm everything I have said on this subject, page 321. The sound bone above the fracture has become more solid; the splinters not having been removed are lying across, and prevent the approximation or union of the ends of the old bone, while the effort made by nature to effect this object by the deposition of new ossific matter, adds to the evil by fixing these splinters in so solid a manner that they cannot escape or be removed by any other means than that of forcible abstraction, after painful and perhaps dangerous operations, each splinter possibly requiring a separate one. Shehan’s case was one for amputation from the first, if he had been in a state to undergo it with a prospect of success.

The treatment of gunshot fractures of the leg ought to have been more successful than it has been, even when both bones were broken; the want of success may be in part attributed to the remissness which has taken place in supplying the necessary, nay, the essential appliances, by means of which much suffering might have been alleviated, perhaps prevented, even if cures could not have been effected.

In performing the operation for the excision of portions of the extremities of bones, a chain saw is a most desirable aid on many occasions. There was not one with the British army in the Crimea, and when wanted, they were borrowed from the French ambulances. It was only on the 30th of September last some were ordered to be sent out, and they cannot yet have arrived. In a lecture I delivered on the 14th of April last in the Theater of the College of Surgeons, as its President, by permission of the Council, the proceeding being unusual, I drew attention, for the express purpose, to the necessity which existed for the Crimean army being supplied with a machine capable of being moved from bed to bed, by means of which the unfortunate soldier could be raised in the extended state, and after being washed, his wounds dressed, and his bedclothes changed, he might be again laid down with comparatively little uneasiness. Fifty of them would not cost £300, but there are none in the Crimea, except two, one sent to the Coldstream Guards, by Lord Strafford at his own expense, and one which the makers placed at my disposal. I hear that three have been ordered lately, like the chain saw, when too late, for many are now no more who stood in the greatest need of them, and without which machine they had little chance of being saved.

On the 14th of April, 1855, I published a lecture, in which I gave a sketch of an apparatus for slinging a broken leg, which instrument I declared to be a sine qua non in the successful treatment of a gunshot fracture of the leg. By permission of the Duke of Newcastle, I sent out forty-six sets complete for every part of the body, the year preceding. They were, I am told, left at Varna; and four medical officers, of character and knowledge, who have lately returned from the East, assure me within the last week that no such, or any similarly useful, apparatus was ever seen in the hospitals in front of Sebastopol. Other instances of remissness of equal importance might be adduced, if it were not useless to advert to them; for we delight, I believe, in being admitted by foreigners to be a wonderful people in the mismanagement of our affairs in the first instance, however important or trivial. It is, I believe, an admitted maxim, that the right men should be in the right place--the square ones in the square holes, the round ones in the round holes; but there is another one of equal importance, viz., that the right thing should be in the right place at the right time, without which teaching or practicing surgery becomes of little value.

Amputation at the knee-joint has been done, I hear, in six cases since the taking of Sebastopol; four are dead; one is doing well under Mr. Blenkins, of the Guards, and the other yet survives. Excision of the knee-joint has been performed since the taking of Sebastopol in one case by Staff-Surgeon Lakin, and is doing well.

The excisions performed on the head of the humerus, and on the bones composing the elbow-joint, have been very successful. There is, however, a circumstance to which I am desirous of drawing attention, viz., that the head of the humerus should never be removed in amputations, when it is uninjured, however close the destruction below may have approached it. The round head of bone left in the socket preserves the squareness of the shoulder, and renders the loss of the arm less unseemly. It tends to prevent the inclination the body generally has to the opposite side, and its being left adds nothing to the difficulties of the operation. The excisions of the ankle-joint have been numerous and more successful than might have been expected under the depressing causes alluded to.

For the preparations of the head of the humerus and of the astragalus, referred to at pages 110 and 128, I have since learned I am indebted to Deputy Inspector-General Macgregor; and I am particularly so to Assistant-Surgeon Gregg, of the 17th Regiment, for the great care he has bestowed on several of the specimens of injury sent to me.

Wounds penetrating the cavities of the chest and abdomen have been no less fatal than those of the lower extremities. The same want of power has been exhibited in them; the same inability to bear the means of cure which, under happier circumstances, have proved successful.

I hope to receive reports on wounds of arteries, on secondary hemorrhage, and on injuries of the head, so as to enable me to remove any doubts which may exist on these points; and I beg to assure those officers who will favor me with their opinions and facts, that they shall be duly reported in another “Addenda.”

I cannot conclude these remarks without expressing my sense of the great practical ability displayed by very many of the medical officers in the Crimea, of their devotion, of their self-denial--qualities which ought to obtain for them the special approbation of the nation.

October 18, 1855.

INDEX.

Abdomen, wounds of, 488, 649. causing abscesses in parietes of, 489. penetrating wounds of, 497. protrusion of viscera in, 498. of omentum, 498. of intestine, 501, 509. effusion of blood into, 505, 510. treatment of hemorrhage in penetrating wounds of, 510. suppuration in cavity of, 511. and pelvis, conclusions respecting wounds of, 555. right arm and thigh, extensive injury to, by a round shot, 576.

Abdominal parietes, gunshot wounds of, 489. lodgment of balls in, 489. incised wounds of, 490. followed by ventral rupture, 493. on continuous suture of, 493. severe contusions of, followed by rupture of the hollow or solid viscera, 491.

Abernathy’s mode of tying the external iliac, 257.

Abscess of liver, consequent to injuries of the head, 356. in abdominal parietes, caused by neglected injuries, 489.

Acids, mineral, use of, in sloughing wounds, 70, 168. in hospital gangrene, 70, 168.

Addenda, commentaries on the cases in, 586.

Alexander, Deputy Inspector-General, on amputations, while under the influence of chloroform, 563.

Amaurosis from balls passing behind the eyes, 478.

Amputation, primary, not required in gunshot wounds of the upper extremity, 120. aphorisms on, 73. at the ankle-joint, Mr. Syme’s operation for, 105. of the arm below the tuberosities, 126. by the circular incision, 134. by Mr. Luke’s operation by two flaps, 135. primary, of the arm, 120. at the elbow-joint, 137. place of election for, in local mortification of a limb, 46. of the fingers, 139. of the foot, 114. by Roux’s plan, 108. of the forearm, 137. by the flap operation, 137. by the circular incision, 138. for gunshot wounds of the femur, 145. at the hip-joint, 77, 92, 562, 563, 586. Mr. Guthrie’s mode of operating in, 79, 83. Professor Langenbeck’s, 80. Mr. Brownrigg’s, 82. under chloroform, 564. immediate, question as to, 51. cases for, 150. of the leg, 99. by the circular incision, 99. by Mr. Luke’s flap operation, 101. immediately below the tuberosity of the tibia, 102. of the metacarpal bones, 139. of a metatarsal bone, 118. in cases of mortification from wounded arteries, 228. necessity for, 51. of the phalanges, 140. primary and secondary, 59. secondary, 59, 141. at the shoulder-joint, 122. by two flaps, 124. by one flap, 125. by Lisfranc’s operation, 125. at the tarsus, 112. of the thigh, by the circular incision, 83. by Mr. Luke’s flap operation, 86. at the wrist, 138. under the influence of chloroform, in the Crimea, 561. case of death from, 561. Deputy Inspector-General Taylor on, 562. Deputy Inspector-General Alexander on, 563.

Ankle-joint, excision of, 103. Mr. Syme’s amputation at, 105.

Aneurism of the arch of the aorta, 276. formation of, after wound of artery, 212. Hunterian theory respecting, 188. popliteal, operation for, 263. traumatic, formation of, 214.

Aneurismal swelling after deep wound of an artery, 212.

Anus, artificial, 525. operation for the formation of, in the loins, 558. Desault’s operation for, 527. Dupuytren’s forceps for, 527. Mr. Trant’s forceps for, 528.

Aorta, ligature of, 250, 252, 256. aneurism of the arch of, 276.

Arachnoid and dura mater, wounds of, 345.

Arm, amputation of, below the tuberosities, 126. primary, 120. by the circular incision, 134. by Mr. Luke’s double flap operation, 135. gunshot fracture of, 121, 156. wounds of the arteries of, 238. thigh and abdomen, extensive injury to, 576.

Arsenic, local use of, in hospital gangrene, 169.

Arteries, wounded, the Hunterian theory inapplicable in the treatment of, 189. Mr. Guthrie’s theory respecting, 189. principles of surgery relative to, 191. punctured wounds of, 210. formation of aneurism after, 211. transverse wound of, 212. complete division of, 212. large, mode of arresting hemorrhage from, 234. of arm and forearm, wounds of, 238.

Artery, structure of, 176. deep wound of, forming aneurismal swelling, 213. effects of a ligature on, 203. wounded, not to be operated on, unless it bleed, 215, 241. to be tied at the seat of injury, 191, 219. main, of the lower extremity, mortification caused by a wound of, 45, 226.

Artificial anus, 525. formation of, in the loins, 558. Desault’s operation for, 527. Dupuytren’s forceps for, 527. Mr. Trant’s forceps for, 528. foot, M. de Beaufoy’s, 119.

Astragalus and calcis, Mr. T. Wakley’s operation for the removal of, 115. ball lodged in the, 109, 590. removal of, 109.

Auscultation, value of, in injuries of the chest, 367.

Axillary artery, gunshot wounds of, rarely cause mortification of the hand or fingers, 46, 235. ligature of, 278. wounds of, 235.

Ball, lodging in the abdominal parietes, 489. in the astragalus, 109, 590. in the bladder, 553. calculus formed on, 553. operation for removal of, 554. in bone, 36, 149. in the brain, 283. behind the eye, 478. or other foreign bodies loose in the cavity of the pleura, 448. inclosed in a cyst, 451. lodged in the head of the humerus, 128. in the liver, 532. orifices of entrance and exit, 27, 489. passing behind the eyes, causing amaurosis, 478. lodging in the pelvis, 545. penetrating the brain, 347. rolling on the diaphragm, 451. operation for extraction of, 455. separating the sutures of the skull, 349.

Balls, relative size of those used by the Allies and by the Russians, 588. on cysts inclosing foreign bodies, in gunshot wounds of the chest, 451. operation for empyema, 452. operation for gunshot fracture of the lower jaw, 480.

Baudens, M., on excision of the head of the humerus, 133.

Bayonet, wounds by, 37. wounds, delusion as to, 38.

Bearers for the wounded, 156.

Beaufoy’s, M. de, artificial foot, 119.

Bedsteads for gunshot fractures of the femur, 152.

Bell, Mr. J., on emphysema in gunshot wounds of the chest, 412.

Bennet, Dr. Hughes, on phlebitis, 71.

Blackadder, Mr., on hospital gangrene, 164, 169.

Bladder, wounds of, 546. ball in the, 553. calculus formed on, 553. operation for extraction of, 554.

Blood, effusion of, into the abdomen, 505, 510.

Boggie, Dr., on hospital gangrene, 168, 169.

Bone, lodgment of a ball in, 36, 149. protrusion of, after amputation, 89. exfoliation of, after amputation, 89.

Bones of the face, penetrating wounds of, 479.

Brachial artery, ligature of, 279.

Brain, balls lodging in, 283. balls penetrating into, 347. M. Burdach’s statistics of lesions of, 306. compression of, 302. paralysis caused by, 305. injuries of the head affecting the, 283. concussion of, 287. causing mania, 299. laceration of, by contre-coup, 340. motions of, 303. suppuration of the surface of, 342. wounds of, 347. causing abscess of the liver, 356.

Bronchophony, 372, 376.

Brow and eyelids, wounds of, 477.

Brownrigg’s mode of amputating at the hip-joint, 82.

Brunner, glands of, 486.

Buck, Dr. Gurdon, operation for excision of the knee-joint, 97.

Burdach’s statistics of lesion of the brain, 306.

Calcis and astragalus, operation for the removal of, 115. removal of, 104.

Calculus formed on a ball in the bladder, 553. operation for extraction of, 554.

Cannon-shot, hemorrhage after the carrying away a limb by, 25. wind of, 43. causes mortification of a limb, by destroying its internal textures, 43.

Carotid, common, ligature of, 270. statistics of ligature of, 241. external, ligature of, 272. the common carotid not to be tied for wounds of, 242. internal, ligature of, 272. wounds of, through the mouth, 245. operation for securing, 245, 248, 272. the primitive carotid not to be tied for wounds of, 246. primitive, not to be tied for wounds of external carotid, 541. nor for wounds of the internal carotid, 246.

Cartilages, costal, fracture of, in gunshot wounds of the chest, 429.

Cerebrum, fungus of, (hernia cerebri,) 352.

Chain saw, utility of, 588.

Chelius on suture of incised wounds of abdominal parietes, 493.

Chest, wounds of, 364, 590. effusion into, 371, 378, 420. purulent effusion, etc. into, 378, 390, 420, 435. operation for, 394. non-penetrating wounds of, 364. value of auscultation in wounds of, 367. incised wounds of, 364, 414. wounds of both sides of, 417. large penetrating wounds of, the lung injured, 418. with hemorrhage into the cavity, 421. ecchymosis a sign of internal hemorrhage in penetrating wounds of, 424. conclusions respecting wounds of, 424. gunshot wounds of, 426. statistics of, 426. enlargement of, 427. fracture of the ribs in, 428. of the costal cartilages in, 429. involving the lungs, 429. removal of splinters, etc., 445. the ball loose in the cavity of the pleura, 448. rolling on the diaphragm, 451. inclosed in a cyst, 451. involving the lungs, effusion caused by, 435. formation of a dependent opening, 452. operation for the evacuation of the fluid, 455. anatomy of the parts concerned, 453.

Chloroform, use of, 55. Dr. Snow on, 55. Mr. Syme on the treatment of approaching death from, 58. amputation under the influence of, in the Crimea, 561. case of death from, 561. Deputy Inspector-General Taylor on, 54, 562. Deputy Inspector-General Alexander on, 563.

Circulation, collateral, 184.

Colon, Hilton’s operation for opening into, 558.

Commentaries on the cases in the Addenda, 586.

Compound fractures, 145. splints for, 153.

Compression of the brain, 302. convulsions caused by, 307. paralysis caused by, 305. in hemorrhage from wounds of the hand, 238.

Conclusions respecting wounds of the chest, 424. abdomen and pelvis, 555. hospital gangrene, 173.

Concussion of the brain, 287. causing mania, 299.

Contre-coup, fracture of the skull by, 316. laceration of the brain by, 340.

Contusions, severe, of abdomen, followed by rupture of the hollow or solid viscera, 490.

Convulsions caused by compression of the brain, 307.

Cooper, Sir A., mode of tying the external iliac, 258.

Cranium, fracture of the base of, 317.

Crepitating râle, or rhonchus, 375.

Delpech on hospital gangrene, 165, 166, 167.

Deposits, purulent, 61, 68.

Depression of the skull, 329. of the back of the skull, with fracture, 338.

Desault’s operation for artificial anus, 527.

Diaphragm, ball rolling on the, 451. operation for the extraction of, 455. wounds of, 458. may cause internal hernia, 463.

Dupuytren’s forceps for artificial anus, 527.

Dura mater, incision of, 343. removal of blood from the surface of, 360. suppuration on the surface of, 342. wounds of, 345.

Ecchymosis, a sign of hemorrhage into the chest, 424.

Effusion, purulent, in penetrating wounds of the chest, 420, 435.

Elbow-joint, amputation at, 137. excision of, 135, 580.

Emphysema, 410. Mr. J. Bell on, in gunshot wounds of the chest, 412.

Empyema, 390, 436. operation for, 394, 455. M. Baudens on, 452. necessity for depending opening in, 452. Mr. Quekett’s experiments on the anatomy of the parts engaged in, 452. operation for, by incision, 455.

Endocardial sound of the heart, 466.

Epigastric artery, ligature of, 510.

Erysipelas phlegmonodes, 40. improvement in the treatment of, 41. of the scrotum, 42. of the scalp, 359, 363.

Excision of the ankle-joint, 103. calcis, 104. calcis and astragalus, 115. elbow-joint, 135, 580. with injury to left hip, 581. head of the femur, 90, 150, 564, 587. in gunshot wounds of, 150. of the head, neck, and great trochanter of the femur, 564. of the head of the humerus, 126, 571, 590. Langenbeck’s operation for, 130. M. Baudens on, 133. of the knee-joint, 97. Mr. Jones’s mode of operating, 97, 98. Dr. Gurdon Buck’s operation for, 97. metacarpal bone of thumb, 140. phalangeal joints, Langenbeck’s operation for, 140.

Excito-motory system of Dr. Marshall Hall, 286.

Exfoliation of bone after amputation, 89.

Exocardial sound of the heart, 466.

Expiration, 369.

Extraction of the ball in gunshot wounds, 32.

Extremities, upper, gunshot wounds of, 20.

Eye, ball lodged behind, 478. wounds of, 477.

Eyelids and brow, wounds of, 477.

Face, wounds of, 476. penetrating wounds of the bones of, 479.

Femoral artery, gunshot wound of, a cause of local mortification, 45, 226. laceration of, 208. ligature of, 260. superficial ligature of, 262. and vein, injuries of, may cause gangrene, 45.

Femur, removal of the head of, 90, 150, 564, 587. gunshot wounds of, 145, 579, 587. secondary amputation in, 145. of the head and neck of, 150. bedsteads for, 152.

Fingers, amputation of, 139. mortification of, rarely caused by wound of axillary artery, 46.

Fissure of the skull, 311.

Foot, gunshot wounds of, 107, 112. amputation of, 114. amputation of, by Roux’s plan, 108. at the ankle-joint, Mr. Syme’s operation for, 105. artificial, M. de Beaufoy’s, 119.

Forearm, gunshot wounds of, 137. amputation of, 137. by flap operation, 137. by circular incision, 138. wounds of arteries of, 238.

Forehead, gunshot wounds of, causing loss of sight, 350.

Foreign body, lodgment of in a nerve, 47.

Fowler’s solution of arsenic, in hospital gangrene, 169.

Fractures, compound, 145. splints for, 153.

Fracture, gunshot, of the leg, 154, 588. Mr. Luke’s apparatus for, 154. of the head of the femur, 150. of the upper extremities, 120. of the shoulder-joint, 120. of the elbow-joint, 136. of the arm, 121, 156. of the skull, 311. of the skull by contre-coup, 316. of the base of the cranium, 317. of the inner table of the skull, 321, 324, 328. with depression at the back part of the skull, 338. of the superior maxillary bone, 582. of the ribs in gunshot wounds of the chest, 429. of costal cartilages, ditto, 429.

Frontal sinuses, gunshot wound of, 350.

Fungus, or hernia cerebri, 352.

Gall-bladder, gunshot wounds of, 530.

Gangrene, hospital, 163. Fowler’s solution of arsenic in, 169. mineral acids in the treatment of, 70, 168. sloughing or pulpous form of, 166. conclusions respecting, 173. local and dry, from wound of the main artery of the lower extremity, 44, 226. traumatic, 42.

Glands of Brunner, Grew, and Peyer, 486. solitary, 487.

Gluteal artery, ligature of, 259.

Goyraud’s operation for ligature of the internal mammary, 473.

Grew, glands of, 486.

Gross’s experiments on intestine, 506.

Gunshot fractures of the upper extremities, 120. lower ditto, 154. wounds of axillary artery, rarely cause mortification of hand or fingers, 46, 285. extraction of the ball in, 32. of the foot, 107, 112. knee-joint, 94, 574. shoulder-joint, 120. arm, 121, 156. elbow-joint, 136. forearm, 137. hand, 139. femur, 145, 579, 587. head and neck of, 150. face, 479. leg, 154, 588. lower jaw, 480. skull, 346, 584. frontal sinuses, 350. forehead, causing loss of sight, 353. orbit, 350, 583. superior maxillary bone, etc., 582. chest, 426. statistics of, 426. fracture of the ribs in, 428. costal cartilages in, 429. involving the lungs, 429. heart, 468. abdominal parietes, 489. intestine, 515. liver, 528. gall-bladder, 530. stomach, 535. spleen, 536. kidney, 538. spermatic cord and testicle, 539. penis, 540. pelvis, 541. bladder, 546. rectum, 555. inflammation consequent on, 30.

Guthrie, Mr., mode of amputating at the hip-joint, 79, 83. theory respecting wounded arteries, 189.

Hall, Dr. Marshall, excito-motory system of, 286.

Hand, gunshot wounds of, 139. mortification of, rarely caused by wound of the axillary artery, 46, 235. compression in wounds of, 238.

Head, injuries of, 283. affecting the brain, 283. causing abscess of the liver, 356. mania, 299.

Heart, sounds of, 465. relative position of, 464. wounds of, 464. recovery after, 464, 468. insensibility of, 471. laceration and rupture of, 472.

Hernia cerebri, 352. of the lung, 456. of the stomach or bowels into the chest, after wounds of the diaphragm, 463.

Hevin on the swallowing of knives, 535.

Hilton’s operation for opening into the colon, 558.

Hip-joint, amputation at, 77, 92, 562, 563, 586. Mr. Guthrie’s operation for, 79, 83. Langenbeck’s, 80. Mr. Brownrigg’s, 82. injury to, with excision of elbow-joint, 581.

Hemorrhage after a gunshot wound, 25. secondary, 208. from the intercostal artery, 474. after the carrying away a limb by cannon-shot, 25. from sloughing stumps, 71. means used by nature for the suppression of, 187, 191. from large arteries, mode of arresting, 234. from wounds in the hand, compression in, 288. in penetrating wounds of the chest, 421. in wounds of the heart, 468. in penetrating wounds of the abdomen, 510.

Hospital gangrene, 163. Deputy Inspector-General Taylor on, 171. Dr. Tice on, 165. M. Delpech on, 165, 166, 167. Mr. Blackadder on, 164, 169. Dr. Boggie on, 168, 169. Dr. Walker on, 170. mineral acids in the treatment of, 70, 168. use of Fowler’s solution of arsenic in, 169. sloughing or pulpous form of, 166. conclusions respecting, 173. hospital returns respecting, 175.

Hospital, statistics of operations, 158.

Hughes, Dr., on pneumothorax, 396.

Humerus, amputation of, below the tuberosities, 127. excision of the head of, 126, 571. by Langenbeck’s operation, 130. M. Baudens on, 133. ball lodged in the head of, 128. amputation of, by the circular incision, 134. Mr. Luke’s, by two flaps, 135. gunshot fracture of, 156.

Hunter, John, on inflammation of the veins, 70.

Hunterian theory of aneurism, 188. inapplicable to the treatment of wounded arteries, 189.

Iliac, external, ligature of, 257. internal, ligature of, 256.

Iliacs, common, relative situation of, 251. ligature of, 252.

Immediate amputation, question as to, 51. cases for, 150. tumors of the scalp, 340.

Incisions, use of, in erysipelas phlegmonodes, 40.

Inflammation consequent on gunshot wound, 30. acute idiopathic, of the pleura, 370, 376. of the lungs, 373, 380. typhoid, of the lungs, 388. of the pleura, 390.

Innominata, ligature of, 273.

Inspiration, 368.

Intercostal artery, wounds of, 474.

Internal carotid, wounds of, through the mouth, 245. operation for, 245, 248, 272. mammary artery, wounds of, 473. strangulated hernia, after a wound of the diaphragm, 463.

Intestine, structure of, 482. rupture of, 491. protrusion of, in penetrating wounds of abdomen, 501, 509. wounds of, 504, 508. punctured, 504, 509. Travers and Gross’s experiments on, 506. divided, treatment of, 507. Ramdohr on, 507. wounded, application of continuous suture to, 508. gunshot wounds of, 515.

Jaw, lower, wounds of, 480. Baudens’s operation for, 480. upper, wounds of, 479.

Jones’s mode of excising the knee-joint, 97, 98.

Knee-joint, gunshot wounds of, with fracture of the bones, 94. excision of, 97. Jones’s operation for, 97, 98. Dr. Gurdon Buck’s operation for, 97. loss of, by a round shot, 574.

Kidney, wounds of, 537.

Knives, etc. in the stomach, 535. operation for their removal, 536.

Laceration of the femoral artery, 208. brain by contre-coup, 340. and rupture of the heart, 472.

Langenbeck’s mode of amputating at the hip-joint, 80. excision of the head of the humerus, 130. phalangeal joints, 140. metacarpal bone of thumb, 141.

Larrey’s operation for opening the pericardium, 469. ligature of the femoral artery, prior to amputation at the hip-joint, 79.

Lateral sinus, wounds of, 351.

Larynx, wound of, 571.

Lee, Mr. Henry, on phlebitis, 70.

Leg, gunshot fractures of, 154, 588. amputation of, 99. by the circular incision, 99. by Luke’s flap operation, 101. immediately below the tuberosity of the tibia, 102. apparatus for compound fracture of, 154. for slinging, when broken, 589.

Ligature on an artery, effects of, 203. size of, etc., 207. one, utterly insufficient to control hemorrhage from a wounded artery, 245.

Lisfranc’s amputation at the shoulder-joint, 125.

Liver, abscess of, consequent to injuries of the head, 356. wounds and injuries of, 528. removal of portions of, 533. lodgment of balls in, 532.

Longitudinal sinus, wounds of, 351.

Luke’s flap amputation of the thigh, 86. leg, 101. arm, 135. apparatus for compound fracture of the leg, 154.

Lung, hernia of, 456.

Lungs, acute inflammation of, 373, 380. morbid changes caused by, 380. typhoid inflammation of, 388. gunshot wounds of, 413. removal of splinters from, 445.

Machine for raising wounded soldiers in bed, 589.

Mammary, internal, wounds of, 473. Goyraud’s operation for ligature of, 473.

Mania caused by concussion of the brain, 299.

Maxillary bone, superior, gunshot fracture of, 582.

Membrane, mucous, of the stomach, 485.

Meningeal artery, middle, injury of, 314.

Metacarpal bone of thumb, excision of, 140. bones, amputation of, 139.

Metatarsal bone, amputation of, 118.

Mineral acids, use of, in hospital gangrene, etc., 70, 168.

Mortification, 42. from wind of cannon-shot, not admitted, 43. from extensive injuries from large shot, etc., 44. from gunshot wound of main artery of a limb, 45, 226. of hand and fingers, rarely caused by wound of the axillary artery, 46, 235. from cold, 46.

Motions of the brain, 303.

Mouth, wound of the internal carotid through, 245. operation for, 245, 248, 272.

Mucous membrane of the stomach, 485.

Musket-ball wounds. See gunshot wounds.

Neck, wounds of, 242, 475. Velpeau on wounded arteries of, 246.

Nerve, consequences of the section of, 47. lodgment of a foreign body in, 47. enlargement, of extremity of, after amputation, 89. consequences of incomplete section of, 47.

Nose, wounds of, 477.

Occiput, depression and fracture of, 338.

Œgophony, 373.

Ollivier on lacerations and ruptures of the heart, 472.

Omentum, protrusion of, in penetrating wounds of abdomen, 498.

Operations, hospital statistics of, 158.

Orbit, wounds of, 350, 583.

Os calcis, removal of, 104.

Patella, compound gunshot fractures of, 95.

Paracentesis thoracis, 394, 455.

Paralysis, the result of compression of the brain, 305.

Parotid gland, wounds of, 479. and duct, wounds of, 479.

Pelvis, wounds of, 541. balls lodging in, 545. and abdomen, conclusions respecting wounds of, 555.

Penis, wounds of, 540.

Pericardium, Larrey’s operation for opening, 469. Skielderup’s ditto, 469.

Peroneal artery, ligature of, 266.

Peyer, glands of, 486.

Phagedena gangrenosa, 163.

Phalangeal joints, excision of, 140.

Phalanges, amputation of, 140.

Phlebitis, 60, 62, 63. Mr. Hunter on, 70. Mr. Henry Lee on, 70. Dr. Hughes Bennett on, 71.

Plantar artery, external, ligature of, 267.

Pleura, acute idiopathic inflammation of, 370, 376. typhoid ditto, 390. effusion into the cavity of, 371, 378, 420. purulent ditto, 379, 390. operation for, 393. balls or other foreign bodies loose in the cavity of, 418.

Pneumonia, 373, 379. morbid changes caused by, 380. typhoid, 388.

Pneumothorax, 396, 402. Dr. Hughes on, 396.

Popliteal aneurism, operation for, 263. artery, not to be tied, unless wounded and bleeding, 265. wound of, 573.

Pourriture d’hôpital, 163.

Primary amputation, advantages of, 59. not required in gunshot wounds of the upper extremity, 120.

Profunda femoris, ligature of, 261. wound of, 573.

Protrusion of bone after amputation, 89. of the brain, 352.

Pulpous form of hospital gangrene, 166.

Purulent deposits, 61, 68.

Quekett, Mr., experiments on the anatomy of the parts engaged in empyema, and the operation by incision, 452. on the structure of the agminated glands of Grew and Peyer, 486.

Radial artery, wound of, 238. ligature of, 282. wound of, in the hand, 238. operation for, 282.

Ramdohr on the treatment of divided intestine, 507.

Ravaton on protrusion of omentum in penetrating wounds of abdomen, 501.

Rectum, wounds of, 555.

Removal of the head of the femur, 90. and neck of, in gunshot wounds of, 150. os calcis, 104. astragalus and calcis, 115.

Respiration, the four movements of, 285. distinction of sounds during, 367.

Respiratory murmur, 367.

Rhoncus crepitans, 370, 375.

Ribs, fracture of, in gunshot wounds of the chest, 428. the cartilages of, 429.

Roux’s amputation of the foot, 108.

Rupture of the heart, 472. ventral, 488, 493. of intestine, by violence, 491. of the solid viscera, by violence, 493.

Scalp, immediate and secondary tumors of, 341. wounds of, 361. erysipelas of, 359, 363.

Sciatic artery, ligature of, 259.

Scrotum, erysipelas phlegmonodes of, 42.

Secondary amputations, 59, 141. in gunshot wounds of the femur, 145. hemorrhage, 208. tumors of the scalp, 341.

Shock or constitutional alarm, 26.

Shoulder-joint, gunshot wounds of, 120. amputation at, 122.

Sight, loss of, from a musket-ball traversing the forehead, 350.

Sinuses, frontal, gunshot injury to, 350.

Sinuses, longitudinal and lateral, wounds of, 351.

Skielderup’s operation for opening the pericardium, 469.

Skull, simple fissure or fracture of, 311. fracture of, by contre-coup, 316. the inner table of, 321, 324, 328. depression of, 329. and fracture of back part of, 338. gunshot wounds of, 346, 584. balls separating the sutures of, 349. removal of a large portion of, 359.

Sloughing stumps, hemorrhage from, 71. form of hospital gangrene, 166. ulcer, 164. wounds, use of mineral acids in, 70.

Snow, Dr., on chloroform, 55.

Solitary glands, 487.

Sounds, distinction of, in respiration, 367. of the heart, 465.

Spermatic cord, wounds of, 539.

Sphacelus, dry, from wound of main artery of lower extremity, 45, 226.

Spine, effects of strychnia in injury of, 574.

Spleen, wounds and injuries of, 536. removal of, 538.

Splints for fractures, 153.

Splinters, removal of, from a wounded lung, 445.

Statham’s operation for removal of astragalus, 110.

Statistics, hospital, of operations, 158. Burdach’s, of lesions of the brain, 306. of ligature of common carotid, 241.

Stomach, mucous membrane of, 485. wounds of, 533. gunshot wounds of, 535. fistulous opening in, after gunshot wounds of, 535. knives in, 535. operation for the removal of, 536.

Structure of arteries, 176. of intestine, 482.

Strychnia, effects of, in injury of the spine, 574.

Subclavian, ligature of, 274. above the clavicle, 276.

Suppuration on the surface of the dura mater and brain, 342.

Suture, continuous, for wounded intestine, 508. for incised wounds in abdominal parietes, 493.

Sutures of the skull, separated by a ball, 349.

Syme, Mr., amputation at the ankle-joint, 105. on the treatment of approaching death from chloroform, 58.

Tarsus, amputation at, 112.

Taylor, Deputy Inspector-General, on hospital gangrene, 171. on amputations under chloroform, 54, 562. on wound of the larynx, 572. on the privations endured by the British soldiery in the Crimea, and their effects, 562.

Testicle, removal of, after a wound, 539.

Thigh, amputation of, by the circular incision, 83. by Luke’s flap operation, 86. arm and abdomen, extensive injury to, 576. gunshot fractures of, 579, 587.

Thumb, excision of metacarpal bone of, 140.

Tibia, amputation of the leg below the tuberosity of, 102.

Tibial artery, anterior, ligature of, 268. posterior, ditto, 266.

Tice, Dr., on hospital gangrene, 165.

Tongue, wounds of, 481.

Trant’s forceps for artificial anus, 528.

Traumatic aneurism, formation of, 214. gangrene, 42.

Travers’s experiments on intestine, 506.

Trephine not applicable in simple fracture of the skull, without depression, 312. manner of applying, 358. use of, at different periods, 327. frequent application of, 359.

Trochanter, head and neck of the femur, excision of, 564.

Tumors, immediate and secondary, of the scalp, 341.

Typhoid pleuritis, 390. pneumonia, 388.

Ulnar artery, ligature of, 281. wound of, 238, 281.

Valvulæ conniventes, 483.

Veins, inflammation of, 60, 62. Mr. Hunter on, 70. Mr. Henry Lee on, 70. Dr. Hughes Bennett on, 71.

Velpeau on wounded arteries of the neck, 246.

Ventral rupture, 488, 493.

Vertebral artery, wounds of, 242. ligature of, 248.

Vesicular, or respiratory murmur, 367.

Viscera, rupture of, 491. protrusion of, in penetrating wounds of the abdomen, 498.

Wakley, Mr. T., removal of os calcis and astragalus, 115.

Walker, Dr., on hospital gangrene, 170.

Wounded, bearers for the, 156.

Wound by a musket-ball, 25. shock or alarm after, 26.

Wounds of entrance and exit, made by a musket-ball, 27, 489. from flattened balls, pieces of shell, etc., 28. gunshot, formation of sinuses in, 31. extraction of ball and other foreign substances, 32. gunshot, the bone struck or penetrated, not broken, the ball lodging, 36. of the skull, 346, 584. of the forehead, causing loss of sight, 350. of the frontal sinuses, 350. by a bayonet thrust, 37. of the neck, with hemorrhage, 242, 475. of the larynx, 571. Deputy Inspector-General Taylor on, 572. of the orbit, 350, 583. of the longitudinal or lateral sinus, 351. of the arm, 121, 156. of the forearm, 137. of the profunda femoris, 573. of the popliteal artery, 573. of the abdomen, 488. causing abscess in paries of, 489. gunshot ditto, 489, 515. incised ditto, 490. followed by ventral rupture, 493. penetrating, 497. followed by protrusion of viscera, 498. of omentum, 498. of intestine, 504, 508. punctured ditto, 504, 509. of the chest, 364. non-penetrating, 364. incised, 364, 414. of both sides of the chest, 417. large, penetrating, of the chest, the lung being injured, 418. of the chest, conclusions respecting, 424. gunshot of the chest, 426. statistics of, 426. fracture of the ribs in, 428. costal cartilages in, 429. of the lung, 429. diaphragm, 458. heart, 464. internal mammary and intercostal arteries, 473. face, 476. eyelids and brow, 477. eye, 477. nose and ear, 477. penetrating, of the bones of the face, 479. of the parotid gland and duct, 479. upper jaw, 479. lower jaw, 480. of the head and neck of femur, 150. of the knee-joint, gunshot, 94. of the patella, ditto, 95. of the leg, 154. of the foot, 107. of the tongue, 481. of the liver, 528. of the gall-bladder, 530. of the stomach, 533. of the stomach, gunshot, 535. of the spleen, 536. of the kidney, 538. of the spermatic cord and testicle, 539. of the penis, 540. of the pelvis, 541. gunshot, of the bladder, 546. of the rectum, 555. of the abdomen and pelvis, conclusions respecting, 555.

Wrist, amputation at, 138.

INDEX OF CASES.

A soldier, wounded in the thigh, the ball passing between the femoral artery and vein, 26.

Generals Sir Lowry Cole, Sir E. Packenham, and Colonel Duckworth; injuries to arteries, 26.

Colonel Sir W. Myers and General Sir R. Crawford, illustrating the shock of a severe wound, 26, 27.

Colonel Ross; musket-shot wound of arm: gradual descent of the ball to the elbow, 36.

Erysipelas phlegmonodes of the left arm, treated by incisions, 41.

Local mortification of a leg struck by a cannon-shot, the internal textures being destroyed, 43.

Section of the brachial plexus of nerves by a gunshot wound, causing paralysis, complicated by gunshot wound of the knee-joint, requiring secondary amputation, 47.

Sir James Kempt; injury to a nerve, 48.

Admiral Sir Philip Broke; wound of skull, with paralysis, 48.

Brigade-Major Bissett; gunshot wound, injuring the left great sciatic nerve, perineum, and rectum, 49.

Mr. Wrottesley, of the Engineers; right thigh shattered by a cannon-shot, etc., 53.

An East Indian; severe wound of left thigh from the explosion of his gun; amputation, death, 53.

A soldier of the siege train before Sebastopol; the left thigh nearly carried off by a cannot-shot, 54.

Purulent deposit, after amputation, 61.

Phlebitis, 64.

Jane Strangemore; amputation of limb for white-swelling of the knee-joint; fatal phlebitis, 64.

Endemic fever, after secondary amputation, with subacute pneumonia, 67, 68.

Sloughing of a spear-wound of the arm, 69.

Captain Flack; cannon-shot wound of left thigh, 77.

Excision of the head and neck of the femur, 94.

Colonel Donnellan; musket-shot wound of knee-joint, 96.

Excision of knee-joint, by Dr. Gurdon Buck, 97. by Mr. Jones of Jersey, 97, 98.

Amputation of the foot, by Roux’s operation, 108.

Ball lodged in the astragalus, 110.

Excision of the astragalus and calcis, 115. head of the humerus, a musket-ball having lodged in the bone, 128, 131.

Gunshot wounds of the shoulder-joint, 131, 132.

Lieutenant Timbrell; gunshot fracture of both thighs; recovery without amputation, 149.

Illustrative of the means used by nature for the suppression of hemorrhage, 194.

Illustrative of gunshot wounds of the femoral artery, 196, 208.

Ligature of the right common iliac artery, for supposed gluteal aneurism, 206.

Punctured wounds of arteries, 210.

Colonel Fane; wound of carotid by an arrow; formation of an aneurism, 211.

Scythe wound of the femoral artery, 213.

Wound of femoral artery with a pen-knife; closure of wound; formation of traumatic aneurism, 215.

Gunshot wound of the thigh; severe hemorrhage finally arrested without ligature of the artery, 216.

Don Bernardino Garcia Alvarez; gunshot wound of the thigh; hemorrhage from a deeply-seated vessel; ligature of the common femoral; fatal mortification. The femoral artery quite sound, 218.

Duckshot wound of thigh; closure of wound; aneurismal swelling punctured; hemorrhage; ligature of femoral high up; death, 218.

Captain Seton; gunshot wound of upper part of thigh; hemorrhage from a superficial branch of the femoral; ligature of the external iliac; fatal peritonitis; errors in the treatment, 219.

Dry gangrene, from injury to the main artery of the lower extremity, 227. following an injury to the popliteal space; large incision in the calf, evacuating a quantity of coagulated blood; subsequent separation of the limb, 228.

Gunshot wound of the posterior tibial artery; secondary hemorrhage and traumatic aneurism; ligature of the femoral artery, renewal of the hemorrhage, amputation, death, 230. of the peroneal artery, hemorrhage and formation of an aneurism; ligature of the wounded vessel; recovery, 231.

Axillary aneurism from a bruise; ligature of the subclavian; rupture of the sac; death, 236.

Shell injury; amputation of right leg and arm; secondary hemorrhage; ligature of the subclavian near the seat of the bleeding, 237.

Wounds of the vertebral artery, recorded by Breschet, Chiari, Ramaglia, and Maisonneuve, 242.

Wound of the external carotid during an operation; utter insufficiency of one ligature, 244, 245.

Gunshot wound of head, face, and neck; injury of external carotid and its branches; partial slough of internal carotid; ligature of latter vessel; compression; recovery, 247.

Wound of internal carotid through the mouth; successful ligature of the vessel, 249.

Ligature of the common iliac artery, 252.

Wound of the gluteal artery; ligature of that artery and of the internal iliac; death, 260.

Wound of the popliteal artery by a mortising chisel; secondary hemorrhage; ligature of the femoral unsuccessful; cure by ligature of the popliteal, 265.

Balls lodging in the brain, 284.

Concussion in a child, 289.

Coup-de-soleil, 293.

Concussion of the brain, passing into excitement, etc., 294.

Gouty inflammation, transferred to the brain, 296.

Illustrative of the treatment of concussion, 297.

Concussion, complicated by the symptoms of compression, 298. followed by mania, 300.

Illustrative of the after-effects of concussion, 301.

Fatal paralysis, caused by compression of the brain, 307.

Illustrative of the different forms of paralysis following compression or irritation of the brain, 309.

Fracture of the skull without depression, 311.

Fracture of the skull, with injury to the middle meningeal artery, 315.

Fracture of the base of the cranium, 317.

Fracture of the inner table of the skull, without injury to the outer plate of bone, 322.

Fracture of the inner table of the skull, without injury to the outer; subsequent hemiplegia of the right side; operation with the trephine two years afterward, 323.

Illustrative of a peculiar fracture of the inner table of the skull, with a cutting instrument, 325.

Gunshot wounds of the skull and brain, the ball lodging, 331, 343, 348.

Injury to the head from a fall; large abstraction of blood, 334.

Comminuted fracture of the skull, by a piece of shell, 336.

Injury to the head, the symptoms of concussion and compression being combined, 338.

Gunshot fracture of the left parietal, with suppuration on the surface of, and in the substance of the brain, 343.

Gunshot wound of the skull, the breech-pin of the gun lodging in the brain, 348.

Separation of the sagittal suture by a fall, consequent to a gunshot wound of the body, 349.

Gunshot injury to the frontal sinuses, 350.

Wounds of the orbit, 351.

Fungus cerebri, 353.

Major D.; gunshot wound of the forehead; incomplete recovery, 357.

Loss of a large portion of the skull; reported by Dr. Drummond, 359.

Cannon-shot wound of the head and face, 361.

Wound of scalp and parietal bone, 362.

Non-penetrating wounds of the chest, 365.

Acute pneumonia and pleurisy, 383.

Dr. Wendelstadt; empyema, 398.

Mr. Winter; gunshot wound of the chest, followed by empyema, 399.

Lance and musket-shot wounds of the chest, causing empyema, 399.

Mr. Cornish; pneumothorax and phthisis, 403.

Pistol shot wound of the chest, with pneumothorax and empyema, 404.

Lord Beaumont, 407.

Sword wound of the chest, with emphysema, 412.

Wounds of both sides of the chest, 417.

Penetrating wounds of the chest, the lung being injured, 418.

Sword wounds of the chest, 420.

Penetrating wounds of the chest, with internal hemorrhage, 423.

Fracture of rib, in gunshot wound of chest, 428, 447.

General Sir Lowry Cole; gunshot wound of the lung, 430.

Illustrative of gunshot wounds of the lungs, 431.

General Sir A. Barnard, 431.

Major-General Broke, 432.

The Duke of Richmond, 433.

Mrs. M., 435.

Sir C. B.; effusion, 436.

Gunshot wounds of the lungs, with fracture of ribs, effusion, etc., 436.

Lieut.-Col. Dumaresq, 440.

A two-pound shot passing through the right side of the chest, 441.

Post-mortem appearances in gunshot wounds of the chest, 442.

Mr. Drummond, 443.

Gunshot wound of the lung; extensive enlargement of the wound; removal of splinters and of a piece of cloth, 446.

Gunshot wound of the lung, remaining fistulous; death from pneumonia seven months afterward, 447.

Gunshot wounds of the chest, the ball or other foreign body being loose in the cavity of the pleura, 448.

Major-General Sir R. Crawford, 449.

Gunshot wounds of the chest, the ball or other foreign body being inclosed in a cyst, 451.

Wounds of the diaphragm, 458.

Captain Prevost, 458.

The Duc de Berri, 469.

Lance wound of the heart and diaphragm, 470.

Latour d’Auvergne, premier grenadier de France, 472.

General Sir G. Walker; gunshot wound of the chest; secondary hemorrhage from the intercostal artery, 474.

Gunshot wound of the chest, with rapidly fatal hemorrhage from a wounded intercostal artery, 475.

Gunshot wounds of the neck, 476.

General Sir E. Packenham; twice shot through the neck, on different occasions, 476.

Lieut.-General Sir A. Leith; amaurosis from a sword wound in the forehead, 478.

General Sir Colin Halkett; gunshot wounds of the neck, thigh, and face, 479.

Gunshot fracture of the lower jaw, 480.

Colonel Carleton; gunshot fracture of the lower jaw, 481.

Captain Fritz; bursting of his gun; lodgment of the iron breech in the forehead; its descent through the nares into the mouth, 482.

Ventral rupture, the result of severe bruises or other injuries to the abdominal parietes, 488.

Severe and extensive wound of abdominal parietes from a musket-shot; exposure of the peritoneum, healing by granulations, 489.

General Sir John Elley; sabre wound of abdomen, involving the stomach, and followed by a small hernia, 490.

Rupture of intestine from external injury, 491.

Rupture of kidney and injury to the spine from a cannon-shot, 492.

Fatal inflammation of omentum, intestines, and peritoneum, with effusion, from a severe bruise inflicted by a ricochet cannon-shot, 492.

Penetrating wound of abdomen by a ramrod, 497.

Penetrating wounds of abdomen, with protrusion of omentum, 500. with protrusion of intestine, 502.

Penetrating wound of abdomen, with formation of abscess, 505.

Sabre wounds of the abdomen, with extensive hemorrhage, 510.

Sabre wound of abdomen, with suppuration in the cavity, reported by Ravaton, 512.

Strangulated inguinal hernia; operation; sloughing of the intestine, etc., 512.

Gunshot wounds of abdomen, with protrusion or injury of intestine, 516.

A Russian officer, with a gunshot wound of abdomen, a tape-worm cut in two by the ball, causing intense suffering until it was extracted, 524.

Lieut.-General Sir S. Barns; gunshot wound of the liver, 529.

Gunshot wounds of the liver and gall-bladder, 530.

In which portions of the liver have been removed, 533.

In which a pig’s tail was thrust up the rectum, 535.

In which the spleen was removed, 537.

Wounds of the kidney, 538.

Medullary sarcoma of the right testicle, involving the lumbar glands, ending fatally, caused by a gunshot wound of the testis, 540.

Gunshot wound of the penis, 540.

Pistol-shot wound in the last dorsal or upper lumbar vertebra, causing complete paraplegia, 541.

Gunshot wounds of the pelvis, 542.

The late Colonel Wade; gunshot wound, the ball passing through the ilium; lodgment of the ball for thirty-five years, 542.

The late General Sir Hercules Packenham, G.C.B.; musket-shot wound of the pelvis, lodgment of the ball, 542.

Colonel Sir J. M. Wilson; three musket-shot wounds of the left hip, one passing upward through the ilium, and lodging against or in the spine, causing paralysis of the left lower extremity, etc.; lodgment of the ball, 543.

Gunshot wound of the external and common iliac arteries, 544. of the pelvis, the ball lodging, extracted on the forty-fifth day after the wound; reported by La Motte, 545.

Captain Campbell; pistol-shot wound of abdomen; injury to spine, 545.

Gunshot wounds of the bladder, 549.

Captain Sleigh; gunshot wound of the pelvis, the ball entering the left groin, over Poupart’s ligament, and traversing the bladder obliquely; retention of urine; urethra obstructed by pieces of bone, 551.

Calculus formed around the ball in the bladder, 552.

Pistol shot wound of the bladder; retention of urine; tumor in the perineum containing bloody urine, punctured; the ball, portions of shirt, etc., extracted from the bladder; reported by Baron Percy, 554.

Captain Gordon, R. N.; rifle-shot wound on one side of the sacrum, the ball wounding the rectum, and passing out on the other side of the sacrum; paralysis of the bladder for a time; permanent partial paralysis of the lower limbs, 555.

Gunshot wounds of the rectum, 555.

CASES IN THE ADDENDA.

Amputation of finger; death caused by exhibition of chloroform, 561.

Successful amputation of the arm at the shoulder-joint, and of the thigh in the lowest third, without chloroform, 561.

Amputations while under the influence of chloroform, reported by Deputy Inspector-General Alexander, 563.

Sir T. Trowbridge; amputation of both feet under chloroform, 563.

Amputations at the hip-joint under chloroform, 564.

Excision of the head, neck, and great trochanter of the femur, reported by Mr. O’Leary, 564. reported by Staff-Surgeon Crerar, 565. reported by Dr. Hyde, 570.

Excision of the head of the humerus, reported by Dr. M’Andrew, 571.

Lieut. Evans; fatal case of wound of the larynx; reported by Dr. Gordon, 571.

Wounds of the profunda femoris, and of the popliteal artery, reported by Mr. De Lisle, 573.

Loss of the right leg by a round shot, 574.

The effects of strychnia in injury of the spine, etc., reported by Dr. Burgess, 574.

Extensive injury by a round shot to the abdomen, right arm, and thigh, reported by Dr. Rooke, of the Civil Service, 576.

Gunshot fracture of the left femur, reported by Mr. Lyons, Pathologist to the Army in the East, 579.

Excision of the elbow-joint for a gunshot wound, reported by Dr. Milroy, 580. with lacerated wound of the left hip, and comminuted fracture of the ilium, reported by Mr. Atkinson, 581. for a comminuted fracture of the bones by a piece of shell, reported by Dr. Scott, 582.

Grape-shot wound of the superior maxillary and malar bones, reported by Mr. Atkinson, 582.

Musket-shot wound of the right temple, fracturing the supra-orbital ridge, reported by Mr. De Lisle, 583.

Musket-shot fractures of the skull, reported by Mr. Ward, Mr. Wall, and Mr. Longmore, 584, 585.

THE END

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1. A treatise on Materia Medica, or the natural, commercial, chemical, and medical history of the substances employed in medicine, and recognized by the Pharmacopœias of the United States and Great Britain;

2. A treatise on Pharmacy: Comprising an account of the preparations directed by the American and British Pharmacopœias, and designed especially to illustrate the Pharmacopœia of the United States; and

3. A copious Appendix, embracing an account of all substances not contained in the official catalogues, which are used in medicine, or have any interest for the physician or apothecary. By Geo. B. Wood, M.D., Professor of the Theory and Practice of Medicine in the University of Pennsylvania, etc. etc., and Franklin Bache, M.D., Professor of Chemistry in the Jefferson Medical College of Philadelphia, etc. etc. Eleventh edition, much enlarged. One vol. 8vo. $6.00.

This work has been thoroughly revised, with many alterations and additions, so as to bring it fully up to the level of the present state of materia medica and pharmacy. It embraces the substance of the recently revised United States and British Pharmacopœias, with a commentary on all that is new in those publications. Nothing, indeed, has been omitted in the revision which could render it worthy of the confidence it has enjoyed.

Wood’s Therapeutics.

A Treatise on Therapeutics and Pharmacology, or Materia Medica. By Geo. B. Wood, M.D., Professor of the Theory and Practice of Medicine in the University of Pennsylvania, Senior Physician of the Pennsylvania Hospital, one of the authors of the United States Dispensatory, author of a Treatise on the Practice of Medicine, etc. etc. Two vols. 8vo. $7.00.

In his preface Dr. Wood gives the following account of his opportunities for acquiring knowledge and forming just views on the subjects embraced in this treatise:--

“Almost from the commencement of his professional life the author has given peculiar attention to this branch of medical knowledge. For a period of about thirty years, before 1850, when he was transferred to the professorship which he now occupies, he was engaged in teaching materia medica, first as a private lecturer, and afterwards successively in the Philadelphia College of Pharmacy and the University of Pennsylvania. His position, therefore, rendered constant investigations into the properties, effects, and uses of remedies necessary in order at once to do justice to his pupils and avoid discredit to himself. Most of those whom he now addresses are probably aware that he is one of the authors of the United States Dispensatory. To provide the original materials for his portion of that work, and to gather from time to time the knowledge requisite for its maintenance upon a level with the progressive condition of medical science, unremitting diligence was essential in prosecuting inquiry and investigation in the whole field of pharmacology. In addition to the ordinary professional opportunities, he has for about twenty years held the office of one of the physicians of the Pennsylvania Hospital, which has given him facilities for testing the value of remedies greater than any amount of private practice could afford. Few persons have had greater advantages or stronger inducements than himself for acquiring the knowledge requisite for the production of a work of this kind.”

Wood’s Lectures and Addresses.

Introductory Lectures and Addresses on Medical Subjects. Delivered chiefly before the medical classes of the University of Pennsylvania. By Geo. B. Wood, M.D., LL.D., President of the American Philosophical Society, Professor of the Theory and Practice of Medicine, and of Clinical Medicine, in the University of Pennsylvania, etc. etc. One vol. 8vo. $1.75.

Eberle and Mitchell on Children.

A Treatise on the Diseases and Physical Education of Children. By John Eberle, M.D., late Professor of the Theory and Practice of Medicine in Transylvania University, etc. etc. Fourth edition, with notes and large additions by Thomas D. Mitchell, A.M., M.D., Professor of the Theory and Practice of Medicine in the Philadelphia College of Medicine, late Professor of Materia Medica and Therapeutics in Transylvania University, Lecturer on Obstetrics and the Diseases of Women and Children, etc. etc. One vol. 8vo. $2.50.

Dr. Eberle’s “Treatise” has long been regarded by the medical profession as the best and most comprehensive work on the diseases and physical education of children. Dr. Mitchell has made considerable additions to it, introducing many topics not treated of by Dr. Eberle, every one of which he considers entitled to a place in a work on the diseases of the infant race. The large addition of matter thus made to the work has proved to be both acceptable and useful.

Richardson’s Anatomy.

Elements of Human Anatomy: General, Descriptive, and Practical. With over 400 illustrations. By T. G. Richardson, M.D., Demonstrator of Anatomy in the Medical Department of the University of Louisville, and one of the attending Surgeons to the Louisville Marine Hospital. One vol. 8vo. $3.00.

It is an amply sufficient text-book, and the preceptor may confidently place it in the hands of his pupils as such. The wood-cuts are numerous and elegant, and serve admirably to illustrate the text.--New Jersey Medical Reporter.

Our author claims for his work the improvement of having general, descriptive, and practical anatomy in the same volume; the arrangement of the section devoted to practical anatomy so as to secure the greatest possible economy of material; and lastly, in the substitution of English for Latin terms, wherever it appeared to be practicable and judicious.--N. Y. Medical Times.

Ricord on Venereal Diseases.

A Practical Treatise on Venereal Diseases; or, Critical and Experimental Researches on Inoculation applied to the study of these affections: With a therapeutical summary and special formulary. By Ph. Ricord, M.D., Surgeon of the Venereal Hospital of Paris, Clinical Professor of Special Pathology. Translated from the French by A. Sidney Doane, A.M., M.D. Thirteenth edition. One vol. 8vo. $1.50.

M. Ricord’s reputation as a lecturer and practitioner in Paris is of the highest order. He is distinguished for his sound and philosophical views upon a disease which carries terror wherever it appears, and whose consequences are often felt by the innocent as well as the guilty. The first part of the book partakes of the philosophical spirit of its author, while in the pages devoted to the treatment of syphilis, M. Ricord has spread out the results of thousands of cases coming under his observation.

Thomson’s Domestic Medicine.

A Dictionary of Domestic Medicine and Household Surgery. By Spencer Thomson, M.D., L.B.C.S. Edinb. First American, from the last London edition. Revised, with additions, by Henry H. Smith, M.D., Professor of Surgery in the Pennsylvania University. One vol. 12mo. $1.50.

This work has received the highest encomiums from the critical journals of the day. “Many a useful life,” remarks a British periodical, “might have been spared, and many an insidious disease checked in the bud, had such works as that of Dr. Thomson been earlier in existence. To the traveler by sea or by land, to the settler and the emigrant, far from medical aid, it must prove invaluable.”

The work has been carefully adapted to the American climate and habits by Dr. Henry H. Smith, of Philadelphia, whose contributions to the volume have greatly added to its value. It is the standard book of domestic medicine. The arrangement of the subjects in alphabetical order renders it extremely convenient for prompt reference and consultation.

Agnew’s Practical Anatomy.

A new arrangement of the London Dissector, with numerous modifications and additions; containing a concise description of the Muscles, Nerves, Blood-vessels, Viscera, and Ligaments of the Human Body as they appear on Dissection. With Illustrations. By D. Hayes Agnew, M.D., Lecturer on Anatomy, and Surgeon to the Philadelphia Hospital, (Blockley.) One vol. 12mo. $1.00.

This work has been adapted to the use of the American student by altering the arrangement and changing the nomenclature in many cases; by adding the ligamentous system; by illustrations; by erasing what was unnecessary, and presenting the whole as nearly as possible in the topographical order. The work, as now published in this American edition, has been prepared with a single eye to the faithful economy of the student’s time.

Acton on the Urinary Organs.

A Practical Treatise on Diseases of the Urinary and Generative Organs in both Sexes. Part I.--Non-specific Disease. Part II.--Syphilis. By William Acton, late Surgeon to the Islington Dispensary, and formerly Externe at the Female Venereal Hospital, Paris. From the second London edition. With additional Illustrations and Colored Plates. One vol. 8vo. $4.00.

This work is intended to be used by the student as a complete Text-book on the subjects of which it treats; and, at the same time, to supply data for the surgeon desirous of learning the most modern treatment of the protean forms of Syphilis, as well as materially to assist the practitioner who, in the witness-box, is liable to be cross-examined on many of the most intricate questions of generation, absorption, or contagion.

Transcriber’s Notes:

A number of typographical errors have been corrected silently.

“Remarks” heading added to Table of Contents.

Index, Index of Cases, and Medical Works added to the Table of Contents.

Amputation of arm index to page 156 is deduced, only “ 56” was printed.

Index references page 649 which does not exist.

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