Part 4
20. In making incisions for the removal of balls in the vicinity of large vessels, particularly in the neck, the hand should always be unsupported, in order to prevent an accident from any sudden movement of the patient. This caution is the more necessary on the field of battle, where many things may give rise to sudden alarm. At the affair of Saca Parte, near Alfaiates, in Portugal, I stationed myself behind a small watch-tower, and the wounded were first brought to this spot for assistance. A howitzer had also been placed upon it, being rising ground, and at the moment I was extracting a ball situated immediately over the carotid artery, the gun was fired, to the inexpressible alarm of surgeon, patient, and orderly, who bolted in all directions. From my hand being unsupported, no mischief ensued, and the operation was completed as soon as all had recovered their usual serenity. When a ball is discovered on the opposite side of a limb, through which it has nearly penetrated, but has not had sufficient power to overcome the resistance and elasticity of the skin, it should be removed by incision. An opening is thus obtained for the evacuation of any matter which may be formed in the long track of such a wound, and any other extraneous bodies are more readily extracted. When a ball has penetrated half through the thick part of the thigh, in such a direction that it cannot readily be removed by the opening at which it entered; or, from the vicinity of the great vessels, it may be considered unadvisable to cut for it in that direction; or if the ball cannot be distinctly felt by the finger through the soft parts, it ought not to be sought for at the moment, for an incision of considerable extent will be required to enable the surgeon to extract it. Much pain will be caused, and higher inflammation may follow than would ensue if the wound were left to the efforts of nature alone, by which, in time, the ball would in all probability be brought much nearer to the surface, and might be more safely extracted. It frequently happens, that after a few days or weeks, a ball will be distinctly felt in a spot where the surgeon had before searched for it in vain. A wound will frequently close without further trouble, the ball remaining without inconvenience in its new situation; and the patient not being annoyed by it, does not feel disposed to submit to pain or inconvenience for its removal. A very strong reason for the extraction of balls during the first period of treatment, if it can be safely accomplished, is, that they do not always remain harmless, but frequently give rise to distressing or harassing pains in or about the part, which often oblige the sufferer to submit to their extraction at a later period, when their removal is infinitely more difficult; and may be more distressing than at the moment of injury.
Nothing appears more simple than to cut out a ball which can be felt at the distance of an inch, or even half an inch below the skin, but the young surgeon often finds it more difficult than he expected, because he makes his incision too small; and cannot at all times oppose sufficient resistance to prevent the ball from retreating before the effort he makes for its expulsion with the forceps or other instrument. The ball also requires to be cleared from the surrounding cellular substance, to a greater extent than might at first be imagined; for all that seems to be required is, that a simple incision be made down to the surface of it, when it will slip out, which is not usually the case. When a ball has been lodged for years, a membranous kind of sac is formed around it, which shuts it in as it were from all communication with the surrounding parts. If it should become necessary to extract a ball which has been lodged in this manner, the membranous sac will often be found to adhere so strongly to the ball that it cannot be got out without great difficulty, and sometimes not without cutting out a portion of the adhering sac.
It often occurs that a ball lodges and cannot be found, especially where it has struck against a bone, and slanted off in a different direction. If the ball should lodge in the cellular tissue between two muscles, it often descends by its gravity to a considerable distance, and excites a low degree of irritation, which slowly brings it to the surface, or terminates in abscess. Colonel Ross, of the Rifle Brigade, was wounded at the battle of Waterloo by a musket-ball, which entered at the upper part of the arm and injured the bone. More than one surgeon had pointed out the way by which it had passed under the scapula and lodged itself in some of the muscles of the back. About a year afterward I extracted it close to the elbow, the ball lying at the bottom of an abscess, which was only brought near the surface by time, by the use of flannel, and by desisting from all emollient applications.[1]
[Footnote 1: Various instruments have been invented for the removal of balls which have been deeply lodged in soft parts; but little assistance has been derived from them hitherto, although many of them are very ingenious.]
21. A ball will frequently strike a bone, and lodge, without causing a fracture, although it will a fissure. It will even go through the lower part of the thigh-bone, between or a little above the condyles, merely splitting without separating it, and some balls have lodged in bones for years, with little inconvenience. It should nevertheless be a general rule not to allow a ball to remain in a bone, if it can be removed by any reasonable operation. The rule is not entirely devoid of exception. Lieutenant-Colonel Dumaresq, aid-de-camp to the present Lord Strafford, was wounded at Waterloo by a ball which penetrated the right scapula, and lodged in a rib in the axilla. The thoracic inflammation nearly cost him his life, but he ultimately quite recovered, and died many years afterward of apoplexy, the ball remaining enveloped in bone.
22. When a bayonet is thrust into the body it is a punctured wound made by direct pressure; when of little depth, much inconvenience rarely ensues, and the part heals slowly, but surely, under the precaution of daily pressure. A punctured wound, extending to considerable depth, labors under disadvantages in proportion to the smallness of the instrument, and the differences of texture through which it passes. When the instrument is large, the opening made is in proportion, and does not afford so great an obstacle to the discharge of the fluids poured out or secreted as when the opening is small. Lance wounds are therefore less dangerous than those inflicted by the bayonet. When a small instrument passes deep through a fascia, it makes an opening in it which is not increased by the natural retraction of parts, inasmuch as it is not sufficiently large to admit of it; and which opening, small as it is, may be filled or closed up by the soft cellular tissue below, which rises into it, and forms a barrier to the discharge of any matter which may be secreted beneath. If the instrument should have passed into a muscle, it is evident that if that muscle were in a state of contraction at the moment of injury, the punctured part must be removed to a certain distance from the direct line of the wound when in a state of relaxation, and vice versa. The matter, secreted, and more or less in almost every instance will be secreted, cannot in either case make its escape, and all the symptoms occur of a spontaneous abscess deeply seated below a fascia. That inflammation should spread in a continuous texture is not uncommon; that matter, when confined, should give rise to great constitutional disturbance is, if possible, less so; but that this disturbance takes place without the occurrence of inflammation, or the formation of matter, may be doubted; and it may be concluded that there is no peculiarity in punctured wounds that may not be accounted for in a satisfactory manner. Serious effects have been attributed to injuries of nerves, but without sufficient reason; nevertheless, those who have seen locked-jaw follow a very simple scratch of the leg from a musket-ball, more frequently than from a greater injury, are not surprised at any symptoms of nervous agitation that may occur after punctured wounds. As many bayonet wounds through muscular parts heal with little trouble, it is time enough to dilate them when assistance seems to be required. Cold water should be used at first; care should be taken not to apply a roller or compress of any kind over the wound; matter, when formed, should be frequently pressed out, and, if necessary, a free exit should be made for it.
23. A great delusion is cherished in Great Britain on the subject of the bayonet--a sort of monomania very gratifying to the national vanity, but not quite in accordance with matter of fact. Opposing regiments, when formed in line, and charging with fixed bayonets, never meet and struggle hand to hand and foot to foot, and this for the very best possible reason, that one side turns round and runs away as soon as the other comes close enough to do mischief; doubtless considering that discretion is the better part of valor. Small parties of men may have personal conflicts after an affair has been decided, or in the subsequent scuffle if they cannot get out of the way fast enough. The battle of Maida is usually referred to as a remarkable instance of a bayonet fight; nevertheless, the sufferers, whether killed or wounded, French or English, suffered from bullets, not bayonets. The late Sir James Kempt commanded the brigade supposed to have done this feat, but he has assured me that no charge with the bayonet took place, the French being killed in line by the fire of musketry; a fact which has of late received a remarkable confirmation in the published correspondence of King Joseph Bonaparte, in which General Regnier, writing to him on the subject, says: “The 1st and 42d Regiments charged with the bayonet until they came within fifteen paces of the enemy, when they turned, _et prirent la fuite_. The second line, composed of Polish troops, had already done the same.” Wounds from bayonets were not less rare in the Peninsular war. It may be that all those who were bayoneted were killed, yet their bodies were seldom found. A certain fighting regiment had the misfortune one very misty morning to have a large number of men carried off by a charge of Polish lancers, many being also killed. The commanding officer concluded they must be all killed, for his men possessed exactly the same spirit as a part of the French Imperial guard at Waterloo. “They might be killed, but they could not by any possibility be taken prisoners.” He returned them all dead accordingly. A few days afterward they reappeared, to the astonishment of everybody, having been swept off by the cavalry, and had made their escape in the retreat of the French army through the woods. The regiment from that day obtained the ludicrous name of the “Resurrection men.”
The siege of Sebastopol has furnished many opportunities for partial hand to hand bayonet contests, in which many have been killed and wounded on all sides, but I do not learn that in any engagements which have taken place regiments advanced against each other in line and really crossed bayonets as a body; although the individual bravery of smaller parties was frequently manifested there, as well as in the war in the Peninsula.
LECTURE II.
ON INFLAMMATION, MORTIFICATION, ETC.
24. In some very rare cases, an intense, deep-seated inflammation supervenes after some days, almost suddenly and without any obvious cause. The skin is scarcely affected, although the limb--and this complaint has hitherto been observed only in the thigh--is swollen, and exceedingly painful. If relief be not given, these persons die soon, and the parts beneath the fascia lata appear after death softened, stuffed, and gorged with blood, indicating the occurrence of an intense degree of inflammation, only to be overcome by general blood-letting; and especially by incisions made through the fascia from the wound, deep into the parts, so as to relieve them by a considerable loss of blood, and by the removal of any pressure which the fascia might cause on the swollen parts beneath.
25. Erysipelatous inflammation is marked by a rose or yellowish redness, tending in bad constitutions to brown or even to purple, but in all cases terminating by a defined edge on the white surrounding skin. It frequently spreads with great rapidity, so that the limb, and even the whole skin of the body, may be in time affected by it, the redness subsiding and even disappearing in one part, while it extends in another direction. When this inflammation attacks young and otherwise healthful persons of apparently good constitution, it should be treated by emetics, purgatives, and diaphoretics, in the first instance, with, perhaps, in some cases, bleeding. When the habit of body is not supposed to be healthy, bleeding is inadmissible, and stimulating diaphoretics, combined with camphor and ammonia, will be found more beneficial after emetics and purgatives; these remedies may in turn be followed by quinine and the mineral acids, with the infusion and tincture of bark. Little reliance can be placed on large doses of cinchona in powder; they nauseate and therefore distress.
When the inflammation extends deeper than the skin, into the areolar or cellular tissue, it partakes more of the nature of the healthy suppurative inflammation, commonly called phlegmonous, is accompanied by the formation of matter, and tends to the sloughing or death of this tissue at an early period. The redness in this case is of a brighter color, although equally diffuse, and with a determined edge; the limb is more swollen and tense, and soon becomes quagmiry to the touch. The skin is then undermined, and soon loses its life, becomes ash colored and gangrenous in spots, and separates, giving exit to the slough and matter which now pervade the whole extremity affected. If the patient survive, it will probably be with the loss of the whole of the skin and the cellular substance of the limb.
As soon as the inflamed part communicates the springy, fluctuating sensation approaching, but not yet arrived at the quagmiry feel alluded to, an incision should be made into it, when the areolæ or cells of the cellular tissue will be seen of a bright leaden color, and of a gelatinous appearance, arising from the fluid secreted into them, being now nearly in the act of being converted into pus. The septa, dividing the tissue into cells, have not at this period lost their life, and the fluid hardly exudes, as it will be found to do a few hours later, when the matter deposited has become purulent. When this change has taken place, the patient is in danger, and if relief be not given, he will often sink under the most marked symptoms of irritative fever of a typhoid type. Nature herself sometimes gives the required relief by the destruction of the superincumbent skin; but this part is tough, offers considerable resistance, and does not readily yield until the deep-seated fascia is implicated, and the muscular parts are about to be laid bare.
An incision made into the inflamed part through the cellular tissue, down to the deep-seated fascia, which should not be divided in the first instance, gives relief. One of four inches in length usually admits of a separation of its edges to the amount of two inches, by which the tension of the skin, which principally causes the mischief which follows the inflammation, is removed. As many incisions are required as will relieve this tension, according to the extent of the inflammation, which is also relieved by the flow of blood, but that requires attention, as it is often considerable, particularly if the deep fascia be divided on which the larger vessels are found to lie. If the necessary incisions be delayed until the quagmiry feeling is fully established, the skin above it is generally undermined and dies. The following case is given as the first known in London, in which long incisions were made for the cure of this disease, and their effect in relieving the constitutional irritation is so strongly marked as to need no further explanation:--
Thomas Key, aged forty, a hard drinker, was admitted into the Westminster Hospital, under my care, on the 21st of October, 1823, having fallen and injured his left arm against a stool, four days previously. On the 30th, the skin being very tense, the part springy, and yielding the boggy feel described, pulse 120, mind wandering, I proposed, in consultation with my colleagues, to make incisions into the part, but which were considered to be unusual and improper. On the 31st, the pulse being 140, and everything indicating a fatal termination, I refrained from any further consultation, although directed by the rules of the hospital; and, after my old Peninsular fashion, made an incision eight inches long into the back of the arm, and another of five on the under edge, in the line of the ulna, down to the fascia, which was in part divided; one vessel bled freely. The next day, November 1, the pulse was 90; the man had slept, and said he had had a good night. The incision on the back of the arm was augmented to eleven inches; and from that time he gradually recovered, being snatched as it were from the jaws of death.
This case, published at the time, has been the exemplar on which this most successful practice has been followed throughout the civilized world--a practice entirely due to the war in the Peninsula.
When this kind of inflammation attacks the scrotum, which it sometimes, although rarely, does, as a sporadic disease, independent of any urinary affection, incisions into it should be made with great caution, not extending beyond the discolored spots, in consequence of the loss of blood which would ensue from the great vascularity of the part. They should be confined to, and not extend beyond, the parts obviously falling into a state of slough or of mortification.
26. Mortification is the last and most fatal result of inflammation, although it may occur as a precursor of it in the neighboring parts, and not as a consequence. The essential distinction is, between that which is _idiopathic_ or _constitutional_ and that which is _local_; and has not existed long enough to implicate the system at large, or to become _constitutional_. Idiopathic or constitutional mortification, sphacelus or gangrene, may be _humid_ or _dry_. _Humid_, when the death of the part has been preceded by inflammation and a great deposition of fluid in it, followed by putrefaction and decomposition, as after an attack of erysipelas following an injury. It may then be said to be acute. Dry, when preceded by little or no deposition of fluid in it, and followed by a drying, shriveling, and hardening of the part, nearly in its natural form and shape, unless exposed to external causes usually leading to putrefaction. The most remarkable instances have occurred in persons suffering from typhus fever, and exposed to cold, without sufficient covering or care. When it occurs in old persons, or in those who have lived on diseased rye or other food, it may be called chronic. The gangrene which follows wounds has been termed _traumatic_, which explains nothing but the fact of its following an injury.
_Local_ mortification may be the effect of great injury applied direct to the part, or of an injury to the great vessels of the limb. It may occur from intense cold freezing the part, or from intense heat burning or destroying it.
27. It sometimes happens that a cannon-ball strikes a limb, and without apparently doing much injury to the skin, so completely destroys the internal textures that gangrene takes place almost without an effort on the part of nature to prevent it. This kind of injury was formerly attributed to the wind of a ball; but no one who has seen noses, ears, etc. injured or carried away, and all parts of the body grazed, without such mischief following, can believe that either the wind, or the electricity collected by it, can produce such effect.
The patient is aware of having received a severe blow on the part affected, which does not show much external sign of injury, the skin being often apparently unhurt or only grazed; the power of moving the part is lost, and it is insensible. The bone or bones may or may not be broken, but in either case the sufferer, if the injury be in the leg, is incapable of putting it to the ground. After a short time the limb changes color in the same manner as when severely bruised, and the necessary changes rapidly go on to gangrene. The limb swells, but not to any extent, and more from extravasation between the muscles and the bones than from inflammation, which, although it is attempted to be set up, never attains to any height. The mortification which ensues tends to a state between the humid and the dry, and rather more to the latter than the former. These cases are not of frequent occurrence, and are not commonly observed until after the blackness of the skin, and the want of sensibility and motion attract attention; for the patient is generally stupefied at first by the blow, and the part or parts about the injury feel benumbed. I made these cases an object of particular research after the battle of Waterloo, but could find only one among the British wounded. The man stated that he had received a blow on the back part of the leg, he believed from a cannon-shot, which brought him to the ground, and stunned him considerably. On endeavoring to move, he found himself incapable of stirring, and the sensibility and power of motion in the limb were lost. The leg gradually changed to a black color, in which state he was carried to Brussels. When I saw it, the limb was black, apparently mortified, and cold to the touch; the skin was not abraded; the leg was not so much swollen as in cases of humid gangrene; the mortification had extended nearly as high as the knee; there was no appearance of a line of separation; and the signs of inflammation were so slight that amputation was performed immediately above the knee. On dissecting the limb, I found that a considerable extravasation of bloody fluid had taken place below the calf of the leg, and in the cavity thus formed some ineffectual attempts at suppuration had commenced. The periosteum was separated from the tibia and fibula; the popliteal artery was, on examination, found closed in the lower part of the ham by coagulated lymph, proceeding from a rupture of the internal coat of the vessel. Two inches below this the posterior tibial and fibular arteries were completely torn across, and gave rise, in all probability, to the extravasation. The operation was successful. The proper surgical practice in such cases is to amputate as soon as the extent of the injury can be ascertained, in order that a joint may not be lost, as the knee was in this instance. It is hardly necessary to give a caution not to mistake a simple bruise or ecchymosis for mortification. To prevent such an error leading to amputation, Baron Larrey has directed an incision to be previously made into the part, and to this there can be no objection.