Part 2

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

LECTURE IX.

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

LECTURE X.

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

LECTURE XI.

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

LECTURE XII.

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

LECTURE XIII.

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

LECTURE XIV.

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

LECTURE XV.

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

LECTURE XVI.

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

LECTURE XVII.

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

LECTURE XVIII.

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

LECTURE XIX.

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

LECTURE XX.

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

LECTURE XXI.

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

LECTURE XXII.

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

LECTURE XXIII.

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

LECTURE XXIV.

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

LECTURE XXV.

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

LECTURE XXVI.

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

LECTURE XXVII.

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

LECTURE XXVIII.

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

LECTURE XXIX.

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

LECTURE XXX.

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

ADDENDA.

REPORTS FROM THE CRIMEA.

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

REMARKS.

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

Index. pp. 591-608

Index of Cases. pp. 608-614

Medical Works pp. 615-624

COMMENTARIES ON SURGERY.

LECTURE I.

ON GUNSHOT WOUNDS, ETC.

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

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