UNIVERSITY OF CALIFORNIA. SAN DIEGO

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JNrVG SiTY OP
CALlFORMIA

UNIVERSITY OF CALIFORNIA, SAN DIEGO

3 1822 01835 2492

University of California, San Diego

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CI 39a (4/91)

UCSD Lib.

PRINCIPLES

MILITARY SURGERY.

" Je vais, dans les loisirs d'une paix, helas ! trop incertaiiie, preparer, si je
puis, de nouveaux secours aux guprriers." Percy.

" Heec habui, candide Lector, quae de nostro curandi modo tibi proponerem, ex-
cogitata quidem non temere, sed rationis ductu, comprobata non casu, sed usu."

Magatus.

PRINCIPLES

MILITARY SURGERY,

COMPRISING

OBSERVATIONS ON THE ARRANGEMENT, POLICE,
AND PRACTICE OF HOSPITALS,

AND ON THE

HISTORY, TREATMENT, AND ANOMALIES

VARIOLA AND SYPHILIS.

ILLUSTRATED WITH CASES AND DISSECTIONS.

By JOHN HENNEN, M. D. F. R. S. E.

INSPECTOR OF MILITARY HOSPITALS.

THIRD EDITION.

WITH LIFE OF THE AUTHOR,

BY HIS SON, DR. JOHN HENNEN.

LONDON :

JOHN WILSON, PRINCES STREET, SOHO ;
AND ADAM BLACK, EDINBURGH.

1829.

LU.SuU.N . — J. UA\ >, IKI.MER,
OCEKN STRF.ET, SEVEN DIALS.

SIR JAMES M'GRIGOR, Kxt. K.C.T.S. M.D.
F.R.S. LoxD. AND Edix.

FELLOW OF THE ROTAL COLLEGES OF PHYSICIANS OP LONDON AND

EDINBURGH, HONORARY FELLOW OF THE ROYAL COLLEGE OF SURGEONS OF

IRELAND, AND DIRECTOR-GENERAL OF THE ARMY MEDICAL DEPARTMENT,

&C. &C. &C.

Sir,

Numerous obstacles hitherto preve?ited
the completion of the following pages, I for some time
hesitated whether I should ever obtrude them on the
public; but, from the moment that I had resolved to
publish them, it was no longer a matter of doubt to
whom I should inscribe the work.

You, Sir, in your various Official
capacities, have uniformly presented to the JMedical
Officers of the British Army, an invaluable example of
zeal tempered by judgment, and of energy combined with
prudence, ichile sciejice has guided both; and to the
elevated station which you 7iow fill, you have added the

VI DEDICATION.

stUl higher distinction, of being looked up to as the
fathe)' and friend of your department.

To you, therefore, I offer, as a 7?iemorial
of grateful estimation, for public excellence and private
worth, these " Principles of Military Surgery,'" which
have been chiefly suggested from materials collected while
employed wider your orders, and supported by your
encouragement.

I remain.

Sir,

with gi^atitude and respect,

ITour faithful and devoted Servant,

JOHN HENNEN.

Edinburgh, ist January, 1818.

LIFE

THE AUTHOR,

BY HIS SON,

DOCTOR JOHN HENNEN.

The lamented Author of the ** Principles of -Military-
Surgery," was born on the 2 1st of April, 1779, at
Castlebar, County Mayo, Ireland, and after a career
of nearly thirty-one years, spent in active employ-
ment and entirely devoted to the public service, died
at Gibraltar, of the yellow fever, on the 3rd of
November, 1828, aged forty-nine years and six
months.

Dr. Hennen received the first rudiments of his
education in his native town, and at an early age com-
menced the study of medicine under his father, a
medical practitioner, eminent for his general as well
as professional attainments.

Vm LIFE OF THE AUTHOR.

During his apprenticeship he regularly attended the
County Infirmary, where he acted as Dresser, and saw
most of the principal operations in surgery.

In 1796 he was sent to prosecute his studies at
Edinburgh, under the second Monro, Dr. Black, and
the other distinguished teachers of that period.

In March 1798, he received a diploma from the
College of Surgeons of Edinburgh ; and in June, the
same year, accepted the appointment of Assistant
Surgeon to the Shropshire Militia, then quartered in
Edinburgh Castle. Being desirous of obtaining more
active employment, he was, in March 1800, appointed
Hospital Mate by warrant, and the following month pro-
moted to the Assistant Suroreoncv of the 40th Resriment
of Foot ; on the day of his appointment he embarked
with his corps for the Mediterranean, and forthwith
sailed with the expedition under the command of
Sir Ralph Abercromby, destined to Egypt. The 40th
Regiment was, however, detained at Malta, at which
island and at Minorca he continued until 1802, when
he returned to England, having been appointed Assis-
tant Surgeon to the 3rd Dragoons; with this regiment
he served in Scotland and Ireland until the end of the
following year, when he was promoted to the Sur-
geoncy of the 3rd Battalion of the Irish Light Bri-
gade ; with this corps and the 7th Garrison Battalion
he continued to do duty in Ireland for about four

LIFE OF THE AUTHOR. IX

years, when he was removed to the 2nd Battalion of
the 30th Regiment which, in 1809, he accompanied to
Cadiz and Gibraltar, and ultimately to Portugal,
where a wide field presented itself to his industry ;
and his uncommon zeal, activity, and professional at-
tainments soon attracted the notice of Sir James, then
Dr. M'Grigor, the head of the Medical Department
in the Peninsula.

On the retreat of the French from Portugal in ISll,
being the Senior Surgeon of the 5th Division of the
British Army, he performed the duties of Acting Staff
Surgeon, and after the action of Fuentos d'Onor was
publicly thanked, on the field of battle, for his ex-
ertions, by Major General Dunlop, commanding the
Division. He continued to serve as Acting Principal
Medical Officer with the 5th Division, in its various
advances, retreats, skirmishes and actions, until Oc-
tober, 1811, when he was promoted to the rank of
Surgeon to the Forces. From Dr. M'Grigor's inti-
mate knowledge of Mr. Hennen's great abilities, his
dexterity as an operator, and his incessant zeal in the
cause of suffering humanity, the charge of some of
the most important Surgical Hospitals in the Penin-
sula was from this period allotted to his special care.

Upon the peace in 1814, he returned with the army
to England, and was placed for a short time upon half
pay, during which period he retired to Dumfries, in

■JX. LIFE OF THE AUTHOR.

Scotland, and entered into private practice. During
this short respite from active employment, he began
to arrange the materials which he had collected whilst
engaged in his arduous duties with the troops in the
Peninsula, and planned his work on Military Surgery ;
he at this period also published, in the London
Medical Repository, a practical paper on Hospital
Gangrene.

On the return of Napoleon from Elba in 1815, he
was again called into active service, and ordered to
Belgium, being placed in charge of the Jesuits' Hos-
pital at Brussels. After the Battle of Waterloo, he
had the sole superintendance of the wounded general
staff, and performed many important operations on
that occasion. He continued to direct the duties of
the Jesuits' Hospital until September 1815, when he
was promoted, by his friend Sir James M'Grigor, who
had now become the Director General of the Depart-
ment, to the rank of Deputy Inspector of Hospitals.
Early in ISIG, on the breaking up of the Hospital
establishments in the Netherlands, Mr. Hennen was
ordered to Portsmouth, and placed in charge of the
South Western District. He now began seriously to
prepare for j)iil)licati()n the result of his ])rofessional
experience, and during the eighteen months he was
stationed at Portsmouth, studied with extraordinary
diligence every point connected with his subject.

LIFE OF THE AUTHOR. XI

In September 1817, he was removed to Edinburgh,
where he, shortly after his arrival, published the first
edition of his work on Military Surgery. During
his stay there (a period of three years and a half,)
he continued to prosecute his studies with no or-
dinary zeal ; he became intimately connected with
the Editors of the "Edinburgh Medical and Surgical
Journal," the entire management of which, during
the latter part of his stay in the " intellectual city,"
almost entirely devolved upon him.* After having
defended a thesis entitled, " De Sanitate Militum
Tuenda," Dr. Hennen received, in August 1819, a
degree in medicine from the University of Edinburgh.
In the winter of J 820 he delivered a course of Lec-
tures on Military Surgery, and, in conjunction with
Professor Thomson, gave weekly clinical reports on
the cases in the Military Hospitals. In Edinburgh
he became acquainted with the first literary and pro-
fessional characters of that celebrated school, and we
learn from the preface to the second edition of his
"Principles," (which was published in 1820,) what
material assistance and support he received from them.

* The original papers to which Dr. Hennen affixed his name, and published in
the Edinburgh Medical and Surgical Journal were, two on the Non-Mercurial
Treatment of Syphilis ; an Historical and Experimental Enquiry into the Nature
of Small Pox ; and an Essay, entitled Sketch of a Plan for Memoirs on Me-
dical Topography. The greater part of his labours, however, while connected
with this journal, were anon5Tnous.

Xn LIFE OF THE AUTHOR.

This work acquired for its author a high reputation
as an army surgeon, and in addition to the many
literary distinctions conferred upon him, he latterly
received from the Emperor of Russia, a magnificent
diamond ring, ** as a mark of his high approbation of
Dr. Hennen's work on Military Surgery."*

In August 1821, Dr. Hennen embarked with part
of his family for Malta, and upon his arrival there took
charge of the medical department of the Mediter-
ranean army. He resided at Malta three years and
a half, and at Corfu nine months, paying during that
period frequent visits to all the islands within the
command. Immediately upon his arrival at Malta
he circulated amongst the medical officers in the
Mediterranean, a paper which he had published in
the sixty-seventh number of the Edinburgh Medical
and Surgical Journal, on " Medical Topography,"
and requested answers to a series of queries connected
with the topography of the Mediterranean ; and from
the information thus furnished, in addition to the
results of his own laborious investigations, he soon
collected a vast body of interesting and useful matter,
subsequently arranged by him, and prepared for pub-
lication, under the title of " Sketches of the Medical

• I'riiire Leiven, Ihe Russian Ambassador's letter to Dr. Hennun.

LIFE OF THE AUTHOR. Xlll

Topography of the Mediterranean Islands occupied
by the British Forces."*

The Director General, in 1823, as an additional
proof of his estimation of the Author's services, re-
commended him for promotion to the rank of Brevet
Inspector of Hospitals. In the beginning of 1826 he
was removed from the command in the Mediterranean,
and placed in charge of the Medical Department at
Gibraltar, where he had no sooner arrived than he
commenced his topographical researches, and before
the close of the year, transmitted to the Director
General the most complete body of information con-
nected with the medical history of that celebrated
fortress that was, perhaps, ever collected by one in-
dividual.

From Dr. Hennen's long previous study of the
subject, and the peculiarly ardent, yet candid, manner
in which he pursued every professional object, no one
was, perhaps, ever better qualified to investigate the
nature of the late fatal epidemic of Gibraltar ; and,
as an instance of that cool and unbiassed search after
truth which characterized all his enquiries, I shall here
quote a passage from the report alluded to, where
treating on the subject of the endemic and epidemic

* This work, together with the Medical Topography of Gibraltar, the author
of this sketch is now preparing for the press.

XIV LIFE OF THK AUTHOR.

diseases of Gibraltar, he thus concludes: ** It cannot
be supposed that, in making a report upon the diseases
of Gibraltar, I am called upon to identify myself with
either party, or to descend into the arena of disputa-
tion in defence of one or other of their opinions ; I
have, therefore, determined to become the partizan of
neither class of those controversialists, whose reports
have agitated the medical world, on the endemic or
imported nature, the contagious or non-contagious
properties of the fevers which prevailed in the unfor-
tunate seras of 1804, 1810, 1813, and 1814. The
professional characters of the supporters of the oppo-
site theories stand high, and I neither question the
fidelity of their reports, (to the best of their know-
ledge,) nor the uprightness of their intentions; but it
has long been allowed by the more dispassionate part
of the profession, that much is assumed on defective
evidence, that much special pleading has been entered
into, and that there is often room to suppose that the
opposite parties have contended more for victory than
truth."

Nearly two years after the above was written, in
August 1828, a fever of a suspicious nature made its
appearance in Gibraltar, which soon assumed the
character of former epidemics. Dr llennen imme-
diately put in force every means which human fore-
sight could devise to stay its course, and enjoying the
unbounded confidence of tlie Lieutenant Governor,

LIFE OF THE AUTHOR, XV

Sir George Don, all his suggestions were, in the
promptest manner, carried into execution, '* Our
present situation" (says he, in a letter, dated the 25th
October, 1828, to his Excellency the Lieutenant
Governor,) ''will be a matter of history, and every
measure which may have spread or checked contagion
will be rigidly enquired into by the public."

His exertions were prodigious, — night and day he
laboured, and still seemed, except at times, equal to
the task ; but on the 28th of October he was seized
with symptoms of the prevailing fever. He could not
be prevailed upon to give up his public duties, and
until within a few hours of his death he continued to
dictate letters and to sign the usual official papers.
** Public men cannot always transfer their cares to
satisfactory hands ; and if they could, the strong in-
terest with which they are gradually blended in the
mind, and the continual hopes that to-morrow will be
better with them than to-day, irresistibly persuade
them, that to quit their post is as unnecessary as it
would be dishonourable."* — So it was with my ho-
noured father : on himself he could hardly be per-
suaded to bestow a thought; he clung to nothing but
his duty, and to that he held fast until he could hold
no longer.

* Life of Dr. Bateinan, (anonymous,) p. 118.

XVI LIFE OF THE AUTHOR.

The attack commenced with sickness and vomit-
ing, the skin soon became yellow, and on the third
day an almost fatal symptom supervened, viz. sup-
pression of urine ; this, however, was removed on the
following day, and strong hopes were entertained of
his recovery ; — these were illusory, for at six in the
morning of the 3rd November he expired.

The announcement of his death excited universal
regret, but at Gibraltar his loss was looked upon as an
additional public calamity ; for after the necessity of
his first measures became obvious, he endeared himself
to all classes by his indefatigable exertions and atten-
tion to the wants of the meanest in the garrison ; and
it has been acknowledged by every one capable of
judging, that, fatal as the disease was, but for his
exertions it would have been incalculably more so.

A subscription was immediately entered into by all
classes at Gibraltar, at the head of which was his
Excellency the Lieutenant Governor, Sir George Don ;
and also in London, Edinburgh and Dublin, for the
purpose of erecting a monument to his memory ; and
this brief sketch cannot, I think, be better concluded
than by transcribing the public testimonial which has
been engraved thereon :

LIFE OF THE AUTIIOK. XVll

THE MEMORY OF

JOHN HENNEN, M.D. F.R.S.E.

INSPECTOR OF MILITARY HOSPITALS,

AND

AUTHOR OF THE PRINCIPLES OF MILITARY SURGERY,

AND VARIOUS OTHER WORKS,

HE FELL A VICTIM TO THE EPIDEMIC FEVER, ON THE
THIRD OF NOVEMBER, 1828, AGED FORTY-NINE YEARS;
AND WHILE ARDUOUSLY ENGAGED, EVEN TO THE DAY
PRECEDING HIS DEATH, IN THE ABLE DISCHARGE OF
THE THEN URGENT DUTIES OF

PRINCIPAL MEDICAL OFFICER

OF THIS GARRISON,

THIS TABLET

IS ERECTED BY HIS PERSONAL FRIENDS, NOT WITH

A VIEW OF PERPETUATING HIS NAME, FOR THAT
LIVES IN THE MORE IMPERISHABLE MEMORIALS OF

HIS OWN GENIUS, BUT AS A TESTIMONY OF REGARD

FOR A MAN WHOSE ZEAL WAS INDEFATIGABLE, AND
WHO, IN THE DAY OF GENERAL CALAMITY, SACRI-
FICED ALL CONSIDERATIONS OF HIS OWN SAFETY

FOR THE

PUBLIC WEAL.

THE THIRD EDITION.

A SHORT time before my father was attacked with
that fatal malady which deprived his country of his
valuable services, he had prepared for publication
this third edition of the " Principles of Military
Surgery." The work has undergone a few, but not
any material alterations ; the plates, which added to
the expense of the second edition, without conferring
any practical benefit, have in this been cancelled, and
in lieu of them a short Biographical Sketch of the
Author has been prefixed, which, I think, may prove
generally interesting.

Some additional observations, and many references,
to works published both before and since the publi-
cation of the last edition, appear throughout the
work ; the greater number of these were inserted by
the author himself, in his interleaved copy now before

XX ADVERTISEMENT.

me; I have added a few additional references, but I
have not deemed it necessary to distinguish them
from the others.

The chapter on '* Miscellaneous Points connected
with Military Surgery " has been divided, and the
subject of ** Feigned Diseases " now forms a separate
chapter; these are the only alterations which have
been made in the work.

JOHN HENNEN, M.D.

Assistant Surgeon^

Royal Military Asylum,
Southampton,

October, 1849^

PREFACE

THE SECOND EDITION.

FrOxM the favourable reception which the first
edition of the following work met with, both among
surgeons in civil life, and those for whom it was more
particularly designed, I have been induced to offer a
second to their attention. My respectable publishers
originally intended to print the book in two volumes;
but the desire of making it more portable, and less
expensive, afterwards led them to adopt a compressed
and comprehensive page.

The \vant of Engravings having been much com-
plained, of, I have introduced a selection from the
numerous original drawings, plates, and preparations
within my reach or in my possession. These have
been executed by an artist already known by his
excellent anatomical delineations.

In the preface to the first edition, which was
published under the title of ** Observations on some

XXll PREFACE.

Important Points in the Practice of Military Sur-
gery," &c. I acknowledged my obligations to several
friends, and I here most willingly repeat them. Mr.
Vance, one of the surgeons of Haslar Royal Naval
Hospital, allowed me constant access to his excellent
specimens of Morbid Bones; and he rendered the
permission still more valuable, by his numerous
communications in illustration of every point on
which I consulted him, during the period of my
superintendence of the Portsmouth district; but as
this experienced surgeon may on some future occa-
sion favour the world with descriptions of his pre-
parations, and with his professional opinions, 1 have
expunged from this edition the very cursory allusions
which I made to them in the former. To Dr.
Denmark, Physician to the Fleet, I owe the use of
many beautiful preparations during my residence at
Portsmouth; and from him I readily received per-
mission to make drawings, some of which illustrate
the following pages. Mr. Hammick, Surgeon of the
Royal Naval Hospital of Plymouth, allowed me to
examine the whole of his collection, and politely
offered me permission to make drawings from any
part of it. To these gentlemen, and to Drs. Dickson
and Johnson, of the same service, my sincere thanks
are offered; but much as I am indebted to the naval
surgeons, 1 could not presume to hold out in my title-
page, a promise of information upon a branch of

PREFACE. XXIU

service with which I was only acquainted through
the medium of others.

To some of my military friends it will be seen,
that I owe considerable obligations ; and I take the
present opportunity to offer my acknowledgments
particularly to the junior classes, who have served
with me on various occasions, and whose zeal and
personal exertions have amply repaid me for my en-
deavours to acquire their friendship and confidence.
To Dr. Thomson, Surgeon to the Forces, and Regius
Professor of Military Surgery in the University of
Edinburgh, I am under great literary obligations, for
the unreserved use of his preparations and his books,
and for the numerous sources of information (not
hitherto generally accessible to officers of the army)
to which he has directed my inquiries. The peculiar
opportunities, however, which military surgeons now
enjoy, facilitated as they are by the Director-General,
open a very wide field for improvement, and afford
the promise of much future benefit. Under these
circumstances, therefore, I have oftener referred to
the works of the older surgeons, and of foreigners,
than I otherwise should have done ; for while I
deprecate the literary dishonesty of quoting without
acknowledgment, I think the fastidiousness of never
availing ourselves of the labours of others, is often as
injurious to science; and in many cases, while an

XXIV PREFACE.

author labours to secure for himself an acquittal from
the charge of pedantry, he may entail on his readers
the penalties of ignorance.

It now remains for me to mention what I have
done towards rendering the present work more worthy
of notice. To the Cases, Observations, and Illus-
trations, I have made several important additions.
If I may be considered as somewhat diffuse on many
preliminary points regarding the police and establish-
ment of hospitals, it is because I conceive these
details to be of the greatest practical importance ;
and I have enlarged my historical notices, under the
impression that much has always been learned in
every department of science from a knowledge of its
history, and an acquaintance with what has already
been done on the subject. I have added three
entirely new Chapters, comprising Remarks on the
Examination of Recruits ; on the Detection of Feigned
Diseases; on Medical Topography; on Vaccination;
and on Syphilis. This last chapter, I trust, will be
found an useful, as I can conscientiously say it is a
faithful statement of facts. I could with much
greater case to myself have dilated it into a volume,
than compressed it as I have done into a few pages.
The materials are from sources inaccessible to the
majority of practitioners, and my intention in collect-
ing them has neither been to support, nor to contro-

PREFACE. XXV

vert, the opinions of any particular set of men, but
to advance the purposes of science and of humanity,
and thus to lay the surest basis for promoting the real
interest of the profession at large.

Upon the whole, I can assert, that I have spared
neither time, labour, nor expence, to enhance the
value of every part of this work, by re-considering
all the cases which have occurred in my own prac-
tice, or in the hospitals under my superintendence,
and by comparing them with the communications of
living practitioners, and the details of preceding
writers. These improvements will, I trust, justify
the change which I have been induced to make in
the Title of the present volume.

In one part of my task, I have been most essentially
assisted by the free access which my excellent and
learned friend Dr. Duncan junior. Professor of the
Institutes of Medicine in the University of Edinburgh,
has allowed me to the Library of the College, for
which my warmest gratitude is due. To other Pro-
fessors in the University I am also greatly indebted.
Dr. Monro opened his Museum unreservedly to me.
Dr. Home communicated his numerous collections
upon the history of Mercury; and Dr. Hope pointed
out and explained to me those useful contrivances in
the domestic arrangement of hospitals which he has

XXVI PREFACE.

introduced into the Royal Infirmary, and which have
so essentially contributed to the utility of that noble
charity, that nothing seems now wanting of which its
original structure will admit. To these eminent indi-
viduals, and to many other medical and surgical
friends in the ** intellectual city," I owe much for
their uniform kindness, and I feel more than I can
here express.

I have only further to remark, that, whatever doc-
trinal errors or omissions may be found in the follow-
ing pages, they are to be charged solely upon the
author; for in neither the plan nor the execution has
he received any assistance (beyond the mechanical
helps aftbrded by some of his literary iriends) which
he has not acknowledged, either in these prefatory
lines or in the body of the work.

Edinburgh, 15/ June, 1820.

CONTENTS.

PAGE

Introductory Remarks 1

Preparatory Steps on taking the Field 22

General Nature and First Treatment of Wounds 30

Preparation, Arrangement, and Selection of Hospitals 52

Dressings, and General Medical Treatment 65

Extraction of Foreign Bodies - 76

Contusions and other Serious Injuries 92

Injuries of the Bones 104

Injuries of the Joints 145

Contracted Extremities c I61

Injuries of the Blood-vessels 167

Injuries of the Nerves ig2

GeBeral Affections of the System 199

Hospital Gangrene, and Ordinary Mortification 213

Tetanus 248

Amputation 255

Wounds of the Head 281

Injuries of the Eye, Ear, Face, and Neck 344

Wounds of the Thorax 37 1

Wounds of the Abdomen 405

Miscellaneous Remarks on the Examination of Recruits, and

Medical Topography 454

Feigned Diseases 463

Variola and Vaccination 483

Syphilis , 496

Appendix, containing Diet Tables, &c 569

PRINCIPLES

MILITARY SURGERY,

S^C. SfC.

INTRODUCTORY REMARKS.

A VERY few years have elapsed, since Military Surgery was
at so low an ebb in England, that one of the most able and
enthusiastic medical philosophers which the country ever pro-
duced, made the following observations on the subject:

*' Practice, not precept, seemed to be the guide of all who
studied in this branch; and, if we observe the practice hitherto
pursued, we shall find it very confined, being hardly re-
duced to the common rules of surgery, and therefore it was
hardly necessary for a man to be a surgeon to practise in the
army." This opinion of Mr. Hunter, who was himself an
army surgeon, little as it flatters his predecessors, was, to a
great extent founded on truth ; but if we come to investigate
the cause of this deficiency in practice, and this scantiness
of precept, we shall be able easily to trace it to one of the
most powerful springs of action implanted in the human
mind. He must have been indeed possessed of a most glow-
ing enthusiasm, and an utter contempt for self-interest, who
would have buried his talents and his industry in a situation

2 INTRODUCTORY REMARKS.

where obscurity, poverty, and neglect, spread all their miseries
before him. These were, for years, the portion of the army-
surgeons ; their situation was looked upon as the lowest step
of professional drudgery and degradation ; and if a man of
superior merit by chance sprang up in the service, or entered
it for temporary purposes, he soon abandoned the employ-
ment for the more lucrative, the more respectable, and the
less ser\ile walk of private practice. — The school was good,
but the best and most natural feelings of the human heart
were too deeply lacerated to permit any independent man long
to continue a pupil.

A brighter day has, however, dawned on Military Surgery;
encouragement has been held out to the active, the respect-
able, and the well educated; and the country has been repaid
for its judicious liberality, (tardy as it has been,) by the
acceptance of its offers. It is to be hoped, that no petty jea-
lousies, nor ill-judged economy, may sap this fair foundation,
and that a recollection of what has happened at the commence-
ment of former wars may influence our future statesmen.

Ingenious and speculative men of almost every profession
bave afl'ected to find traces of their favourite art in the oldest
and most venerable of books; and where written records have
failed, they have plunged into the unrecorded depths of anti-
quity, and supplied, by bold and plausible conjecture, the
deficiencies of fact. In imitation of this example, I might show
that man, in his earliest state, was subjected to disease; —
whether proceeding from internal causes or from mechani-
cal inflictions, it is not necessary to investigate, since it is
certain that mankind early congregated together for the
purp<jses of mutual aggression and mutual defence ; and
although we cannot trace the actual existence of surgeons
among the armies of those barbarous hordes, we may be
assured that experience would teach many of them the more
simple and obvious means of relieving themselves from the
injuries inflicted by the teeth or llic clubs of their enemies.

INTRODLKJTORY REMARKS. 8

Some traces of humaoity would probably induce these indi-
viduals to offer assistance to others, while self-interest and
nascent ambition would soon contribute to spread their fame.
The fortunate tribe who possessed our aboriginal surgeons
would be distinguished among its fellow savages, while these
gifted men became the object of love, terror, and, by a very
natural transition, of adoration also. Upon the whole, without
wandering farther into the regions of conjecture, we may
conclude, that military surgery, rude and imperfect though it
was, if not the very first, was at least among the earliest of
the arts which the follies and the infirmities of mankind forced
them to cultivate.

From the writings of the first of the Greek poets, we find
that the army-surgeons of antiquity united in their own
persons the soldier, the physician, and not unfrequently the
prince, and that honours almost divine were paid them. From
historical testimony we are informed, that Cyrus provided
the most able physicians and surgeons to attend his army
both in the field and at sieges, and that, after he got pos-
session of Babylon, he formed in that city a depot of medi-
cines and surgical instruments for their use. We also know
that Alexander the Great was equally attentive to the health
of his troops; but whether these commanders had any re-
gular hospital establishments for the cure of their sick and
wounded, we are entirely ignorant. From the Commentaries
of Cfesar, however, we learn that the Romans were in the habit
of sending off their sick and wounded to the nearest towns
whenever their armies moved : — while stationary, a separate
part of the camp, or " Valetudinarium," was appropriated for
their accommodation, under the immediate eye of the prefect
of the camp, or quarter-master-general; and in the event of
great battles in the neighbourhood of cities, they were distri-
buted in the houses of the nobility. Of the discipline observed
among their wounded we know nothing; we find, indeed, that
the invalids who were rendered incapable of further service

B 2

4 INTRODUCTORY REMARKS.

were provided for at the public e-spence; but whether hospi-
tals were erected for them or not, is altogether a matter of
conjecture.

From the best authorities it appears, that one of the first,
if not the very first, hospital establishment, was erected at
Rome in the sixth century, by Fabiola, a Christian lady, the
friend of St. Jerome. Paula, another of his disciples, bailt
several hospitals on the road to Bethlem, and others were
soon spread over many of the wild and uncultivated districts
of Europe, for the accommodation of pilgrims to the Holy
Land ; originally they were not intended solely for the pur-
poses of the sick, but were rather a species of inns, bnilt
close to the churches and monasteries, and under the super-
intendence of the clergy. How they were furnished with
medical oflicers is very dubious; but certain brotherhoods
were busily occupied in their concerns, and appear to have
given what assistance they could to the sick, as well as to
each other. From this period hospitals multiplied throughout
Europe; and, from being made places of mixed accommoda-
tion for the religious, the aged, the destitute orphan, and the
sick, they gradually assumed their present form.

The learned Beckman, in whose work much curious matter
upon the subject of hospitals is to be found, has been able
to collect but little satisfactory upon the subject of those
destined for military purposes, or indeed upon military surgery
in general, in the early ages of the Christian era.* The term
" exercitus medicus," he has not been able to trace to any
higher antiquity than the third century, and the institution of
flying hospitals he fixes in the sixth. In that century the
Emperor Mauritius carried along with his army, Despotati,
or AuiroTUToi, (Drink-givers, in the barbarous Greek of the
middle ages,) whose duty it was to carry off the wounded in
battle; for which purpose, they were distrii)uted among the

• History of Inventions and Discoveries.

INTRODUCTORY REMARKS. 5

cavalry, and were equipped with two stirrups on the left side
of their saddles, to take up the wounded behind them with
the greater ease, and were obliged to carry with them water
for the refreshment of the sufferers. In the ninth century
the Emperor Leo. VI. mentions them expressly in his Tactics,
as a necessary appendage to an army, furnished with their
field medicines and materials. In the fifteenth century the
field surgeons came into some note ; they were principally at-
tached to the general ofiicers ; and although not obliged to act
as combatants, received a certain portion of booty and prisoners.
The field-surgeon of Henry V. of England (Nicholas Colnet)
received a yearly sum of forty marks, in addition to his
share of plunder; but Nicholas had to furnish three archers ;
and if his booty exceeded twenty pounds, he was to give up
one-third to his majesty. Colnet was engaged for one year
only, and was obliged constantly to follow the king. Morstede
also was employed as his chief army-surgeon, with twelve
other surgeons, and three archers ; his pay was twelve pounds
per quarter, and twelve pennies a-day subsistence. What
improvements may have been made in field surgery in the
days of Henry's immediate successors, I have not been able
to trace ; but the following passage, in a letter written by a
military officer * in the reign of Queen Elizabeth, may tend
to show the estimation in which army surgeons were held in
the days of that sovereign : — " Every captain of one hundred
footmen doth receive weekly, upon every Saturday, his
full entertainment of twenty-eight shillings. In like case, every
lieutenant fourteen, an ensign seven, our serjeant, surgeon,
drum, and fife, five shillings pay, by way of imprest, and
every common soldier three shillings, delivered to all by the
poll weekly. To the four last lower officers, two shillings

* Sir John Harrington in NugcR Antique, 8to. London, 1779, toI. i. p. 17.
See Grose's Military Amiquilies, vol. i. pp. 272, 277, for some curious details ou
this subject.

6 INTRODUCTORY REMARKS.

weekly, and for every common soldier twenty pence weekly
is to be answered, to the full value thereof in good apparel of
different kinds." How long- the British army surgeons may
have continued to receive this " entertainment," or how long
they continued to take rank with the Serjeants and drummers,
I know not ; the amelioration was most probably progressive ;
but I apprehend we need search for no further explanation of
the low state of the profession, than what the above expose of
their comparative rank and pay so strikingly furnishes.

The institution of the more permanent establishments for
invalids took place at Constantinople in the end of the eleventh
century ; the learned Anna Comnena has given an account of
this institution of her father, the Emperor Alexius.* In those
times the knights attended the sick and wounded themselves,
compounding- balsams and vulnerary drinks for them with
great spirit and perseverance, although with no pretensions to
scientific accuracy; for, according to Guy de Chauliac, they
trusted to exorcisms, beverages, oil, wool, and cabbage leaves !
The regular physicians and surgeons took the duties of the
hospitals upon themselves in the early part of the fifteenth
century, and were guided by a code of written regulations, and
it is to be hoped, by more scientific principles ; army surgery,
however, remained in a very rude and neglected state for many
years after this period.

The invention of gunpowder, while it certainly tended to
the saving of many lives in battle, yet must have produced
great individual misery. In the practice of the surgeons of
that day, charms, prayers, and incantations, formed the chief
part of the treatment in the new species of wounds presented
to their view ; and the poisonous nature of the ingredients
which formed the powder, or of the balls projected by it, were
the principal subjects of their theoretical discjuisitions ; hence,
iKithiiig can be injagined more unprolitable llian a perusal of

• Amnc Coiiiiiieiiic Altxiado-. Lib. xv. JmI. \ iiict. p. 303.

INTRODUCTORY REMARKS. 7

their works. The wounded in tiiose early days, if rich, wer^
attended at their own expence in the most commodious places
of reception they could find : the poorer class (for whose sur-
gical treatment an allowance was generally made to their
commanders) were often left to shift for themselves, or were
dragged to the nearest hovels, or quartered on the houses of
religious communities, where they were treated as the whims
or the experience of their hosts, or of casual visitors, might
suggest.

The illustrious " Henri Quatre " first established field hos-
pitals in France, at the siege of Amiens in 1597. — a boon so
grateful to the soldiers, that, by way of pre-eminence, they
distinguished the campaign in which they were instituted by
the title of " The velvet campaign." His son, Louis XIII.
erected the first fixed hospital, in that counti-y, at Pignerol,
but in what precise year I know not. Humanity to the
wounded had, however, been a trait in the character of the
French monarchs previous to these days; and St. Louis him-
self, the ninth king of that name, personally assisted in the
cure of the soldiers, whose wounds were the consequences
of the wars undertaken for the purpose of expelling the
infidels from the Holy Land, or of his contests with our
Henry III. To his lineal descendant, the hero of Na-
varre, was due a triumph of humanity greater than any
achieved by his arms; he laid the first plan of an hospital for
decayed and wounded soldiers, which the magnificence of
Louis XIV. perfected into the present Hotel des Invalides,
the same year in which the hospital for invalids at Chelsea
was commenced by our James II. Louis also founded mili-
tary hospitals in all the fortified towns of his dominions and
his conquests, and these establishments were much attended
to by succeeding monarchs. In 1747 they were all new mo-
delled, and schools of military surgery and medicine were
instituted at the hospitals of Brest, Toulon, Metz, Strasburgh,
and Lille. It is singular that in England we still want

8 INTRODUCTORY REMARKS.

establishments of the kind, nor have we any hospital for mili-
tary purposes worthy of the national name.

Ambrose Pare, the surgeon and counsellor of Henry IV.
was one of the earliest and best of army-surgeons. He
followed the French armies, which he first joined at Turin in
1536, in all their operations, down to the Battle of Moncon-
tour in 15G9, which is the latest date I can find in his
account of his campaigns. The state in which he found mili-
tary surgery at his first entrance on its practice, may be
guessed at by the very interesting account he gives of it in
his 11th and 29lh books; in what condition he left it, his in-
valuable works testify in every page ; these were all collected
and published together, by Guillemeau at Paris, in 1582. His
" Maniere de traiter les Playes d'Arquebusades et Fleches "
had already appeared in a separate form in 1551.*

Maggius published a work, " De Vulnerum Bombardarum
et Sclopetorum Curatione," at Bologna, in 1552, and Alphonsus
Ferrius followed on the same subject, the ensuing year at
Lyons. Rota, a public lecturer at Bologna, published at that
place a book entitled " De Tormentariorum Vulnerum Curatione
et Natura," in the year 1555; and Lconardus Botallus, by far
the best author of the Italian school, produced his work,
" De Curandis Vulneribus Sclopetorum," at Lyons, in 15()0.
These authors, together with De Vigo, Hieronymus a Bruns-
wich, and Gersdorf, who flourished prior to Pare; — and J.
Baptist. Carcanus, the director of the Military Hospital at
Milan, who published his excellent, original, but little known
work, " De Vulneribus Capitis," in 1583, — are among the
principal early continental surgeons who have professedly
written on, or incidentally treated of, military surgery; a
catalogue, the furllur extension of which would be of very

• Percy gives different dates; he says that I'ar»- published in 1545, in which
date Portal agrees with him, and that Maggius published in 151S. I have followed
ilallcr (Uihiiolli. Chirurg.) in every date where my researches after the original
works have failed.

AUTHORS. y

doubtful utility, and which, indeed, embraces but a very few
more names, and scarcely one of celebrity.

The earliest English military author, of whose work I have
any knowledge, is Thomas Gale, who served as a surgeon in
the army of Henry VI II. at Montruil in 1544, and also in
that of King Philip at St. Quintin in 1557. He published the
•' Institution of a Chirurgeon," and, together with it and other
tracts, a Treatise on Gunshot Wounds, London, 1563, Svo.
He refutes the opinion entertained by Hieronymus a Bruns-
wich, De Vigo, Ferrius, and others, concerning the poisonous
nature of gunpowder, and the actual " ustion" produced by the
ball. ThB general state of military surgery, however, was most
deplorable in his day ; tinkers, cobblers, and the most humble
practitioners of the veterinary art, forming a part of the surgical
attendants on the army in the field.*

William Clowes, a naval surgeon, who afterwards served
in the army, published in 1591 " A Proved Practice for all
Young Chirurgeons, concerning Burnings with Gunpowder,
and Woundes made with Gunshot, Sword, Halberd, Pike,
Launce, or such other." This work was twice reprinted, with
some variation in the title-page ; its principal merit consists in
recommending mild dressings. Quercetan's " Sclopetarius "
was translated and published about this time at London (1590)
by John Hester. -f-

Peter Lowe may also be reckoned a military writer; he
served for many years in France and Flanders in the wars of
Henry IV. and published at London, in 1597, " A Discourse
on the whole Art of Chirurgery," which went through several
editions, in which he treats of gunshot and other wounds.

* See some curious extracts from his works in Aikin's Biographical Memoirs
of Medicine in Great Britain, Svo. London, 1780.

+ Quercetan or Duchesne wrote in 1576. There is also an English translation
of Brunswich's book extant, published at London iu 1525, entitled " The Noble
Experience of the virtues llandworke of Surgery," folio.

10 INTRODUCTORY REMARKS.

John Woudall, who accompanied the troops sent by Queen
Elizabeth to France, in L589, and who also served in the navy
in the East Indies, and became Surgeon-General to the Com-
pany, published his " Surgeons' Mate, or Military and Do-
mestique Surgery," after the queen's death, but in what year
I have not been able to ascertain. His " Viaticum, or Path-
way to the Surgeon's Chest," an appendix, to the former work,
was published in 1628. Both contain many useful practical
facts, and evince considerable learning, and great humanity.
Fare's book on gunshot wounds appears to have been previously
translated into our language by Hammond, in 1617.

Richard Wisemen published his " Eight Chirurgical Trea-
tises," in 1676, one of which is expressly on gunshot wounds.
His book abounds in valuable facts, collected from his prac-
tice both in the military and naval service of his country,
as a reward for which services, he was appointed Sergeant-
Chirurgeon to King Charles II.

John Brown, sworn Chirurgeon in Ordinary to Charles II.,
published " A com|)lete Discourse of Wounds, both in gene-
ral and particular, as also a treatise of Gunshot Wounds in
general," at London, in 1678, a very learned work, deduced
from his practice in the navy in the Dutch war of 1665, in
which he was severely wounded. 1 am not acquainted with
any other practical work published in England during the
remainder of the seventeenth century, nor for the early part
of the eighteenth, until at length, in 1734, a small volume by
Atkins, under the title of " Tlie Navy Surgeon," made its
appearance, in which, among other subjects, the author gives
the result of his practice in gunshot wounds.

John llanby, who filled the situation of Principal Sergeant-
Surgeon to his ^Majesty King George II., and who attended
that prince in his < anipaigns on the Continent, and particidarly
at the battle of Dcttingon, published a small treatise in
1744, entitled " The Method of Treating Gunshot Wounds."
His |)rofess(d object in this work was, to recommend plentiful

AUTHORS. 11

and early bleeding, together with light easy dressings; to
banish from the republic of surgery the extravagant use of
instruments, " and, above all, to introduce the signal use of the
bark."

Dr. Francis Home, late Professor of Materia Medica in the
University of Edinburgh, published in 1759 a volume of Me-
dical Facts and Observations, in which he has introduced a
short but valuable chapter on gunshot wounds, the result of a
long military experience in Germany and the Low Countries,
in the war of 1742, and the following years.

Almost the whole of the systematic writers on surgery in
general, have introduced into their works observations and
remarks, in some degree connected with military surgery, the
value of which is in a great measure proportioned to the ex-
perience they have had in that branch of practice ; the majority
have merely copied each other, and where they have attempted
to be original, it has been more on theoretical than practical
grounds ; thus we find one of them seriously recommending the
surgeon to be much upon his guard against glass halls, and the
dreadful effects of the splintering of these articles is insisted
on at some length.*

Foreign authors have, in general, evinced much more prac-
tical acquaintances with the subject than those of our own
country; indeed, their surgical education was not considered
as complete until they had served a campaign or two. My
limits will only admit of my naming at present a few of those
of modern date.

In the year 1718, Heister published at Nuremburgh his
" General System of Surgery," in German, which soon after
appeared in an English translation. The first book of this
work is dedicated entirely to wounds ; and his third chapter
treats exclusively of those by gunshot. He had qualified him-
self for the task, by serving in the war of 1707, between the

* Latla's System of Surgery.

12 INTRODUCTORY REMARKS.

French and Dutch in Flanders. Theden, Mursinna, Hemman,
Richter, and Schmucker, are the best practical German
authors who have followed him upon the subject of JMilitary
Surgery, and are of high and deserved celebrity.

The French authors Le Dran, Faudacq, and Le Cat, had,
early in the eighteenth century, published their works " ex
professo" on gunshot wounds, and Poissonier, Desport, Rava-
ton, and Thomassin, followed them in a few years afterwards.
To enumerate all the other writers that have treated on mili-
tary surgery in France would be more the subject of a trea-
tise than a sketch ; but it would be unpardonable not to men-
tion the various papers on the subject which have appeared in
that splendid monument of science, the " Memoirs of the
French Academy of Surgery," through which most valuable
facts and observations are profusely scattered.

Neither should the collections formed under the auspices
of the old French government be passed over in silence, afford-
ing as they do many excellent papers, and ofl'ering a plan
highly worthy of imitation in our own armies. One of these
was published at Paris in 1766 and 1772, in two volumes
quarto, under the title of " Recueil d'Observations de Medi-
cine des Hopitaux Militaires," edited by M. Richard de Hau-
tesierck ; another, and a very valuable one, the " Journal de
Medicine Militaire," was edited by De Home, and published
in several volumes octavo, at the same place, in 1782, and
following years. They contain ample notices of the medical
topography of a number of the permanent garrisons in France,
with an account of the hospitals, and the practice pursued in
them, together with histories of their prevalent diseases, illus-
trated with cases and dissections. These works, and the insti-
tution of hospitals of instruction lor the young army-surgeons,
which I have already mentioned, tended much to improve
military surgery in France.

The Revolution produced some able practitioners and excel-
lent writers on military surgery ; among them J3urou Percy,

AUTHORS. 13

who published, in 1792, his little book, which he modestly styles
a " Manuel," but which is conspicuous for learning and solid
judgment; and Baron Larrey, who published his " Relation
Chirurgicale" in 1803, and his " Memoires " in 1812, works,
the product of extensive military experience, and great pro-
fessional enthusiasm. Assalini in Italy has also furnished us
with an ingenious little volume published at Milan in 1812,
his " Manuale di Chirurgia," for the use of army-surgeons;
and M. Paroisse, surgeon to Jerome Napoleon, late king of
Westphalia, has given some interesting observations on military
surgery in his " Opuscules de Chirurgie," which appeared at
Paris in 1806.

The American revolutionary war gave rise to only one
work, as far as I know, in which military surgery was touch-
ed on by a native writer of that country ; it is the very short
account of the result of observations made upon the diseases
which occurred in the Military Hospitals of the United
States during the contest with Great Britain, by the late Dr.
Rush, and his account of the influence of the military
events of the revolution upon the human body, to be seen
in the first volume of the Philadelphia edition of his works.
The only important facts which he mentions, connected
with surgery, are the successful adoption of Ranby's plan
of amputation in wounds of the joints, and the superior
fortitude with which operations were borne immediately after
a battle ; but his papers contain some sagacious observations
upon military hospitals, and the effects of a military life. A
later American writer, Mr. Barton, has published a work on
naval hospitals; and since the late war, Mr. Mann has given
us some sketches of the campaign of 1812, and the following
years.

In England, within the period of the French Revolution,
few practical surgeons have written exclusively on military
surgery. One towering genius has touched upon it, as a
part of that immortal monument which he has raised to

14 INTRODUCTORY RKMARKS.

his own and his country's fame, in the " Treatise on the
Blood, Inflammation, and Gunshot Wounds." This great
woric of Mr. John Hunter was published in 1794, after
his death. The materials were collected during a period of
active service abroad, whither he went as senior Staff-surgeon
in the year 1760, a rank which he held in Belleisle and in
Portugal for the remainder of the war. In the year 1790, he
was appointed to the joint offices of Surgeon-General to the
Army, and Inspector of Regimental Infirmaries ; and in con-
junction with the Physician-General, Sir Clifton Wintringham,
held the superintendence of the department. Staff-surgeons,
as well as Physicians, were, at that period, and antecedently,
selected from civil life on the spur of any expedition, and
very rarely from the Regimental Surgeons.

The names of Pringle, Brocklesby, and Monro, survive in
their works, but, previous to the time of Mr. Hunter, no pub-
lication with which I am acquainted was produced by the
Staff or Regimental Surgeons ; although the appointment of
the latter was coeval with their corps, and many of them,
consequently, had ample opportunities for observation. On the
lamented death of Mr. Hunter, a board was formed, which
dates from his late Majesty's order, issued through the Secre-
tary at War, in October 1793. This consisted of a Physician-
General, a Surgeon-General, and an Inspector of Regimental
Infirmaries, who were invested with distinct but jarring powers,
and continued to act until 1808, when it was dissolved, and
new modelled, upon the basis of responsibility as a body,
constituted of a Director-General and two Principal Inspectors.
On the peace establishment of 1817, one of the latter officers
ceased to be borne on the returns of the staff of the army.
A Board appears to have been established early in 175G,
by order of the Duke of Cumberland, consisting of the
Physicians belonging to the hospitals of his Majesty's forces,
the Surgeon-General, and Principal Surgeon, and Purveyor
to the Hospitals, who had it given them in charge conjointly

AUTHORS. 15

•

to digest certain rules for regulating all hospital matters.
This Board, however, seems gradually to have been dissolved,
and its power merged in the appointment of the Principal
Hospital Surgeon to the new situation of Inspector of Regi-
mental Infirmaries.* The precise dates of the appointments
of the Surgeon-General, and of the Physicians, &c. I have
not been able to ascertain.

The circumstance of a long war gave rise to many divi-
sions of rank among the officers of the medical staff; but se-
veral of these were abolished by the King's warrant of 1804,
while the situation of those who were left was seriously im-
proved. The Staff is now composed of a certain number of
Inspectors and Deputies, Physicians, Surgeons, Apothecaries,
Assistant-Surgeons, and Hospital- Assistants, with commissions,
and of some Hospital Mates and Dispensers, who hold their
situations by warrant.

During these liumerous changes in the department, which,
it must be confessed were loudly called for by the circum-
stances of the times, very little indeed was done for the sci-
ences of Army Medicine and Surgery ; and those who were
best qualified by experience to write on these subjects, were
the last to employ their talents in publishing the fruit of their
observations. The natural consequence of this was, that
when young men entered the service of their country, they
had no practical guides to point out to them the peculiarities
of the situation and the habits, constitutions, and accidents,
of that class of men, whose health and lives were entrust-
ed to their care. The demand for medical officers for the
armies naturally stimulated the public lecturers, and the pro-
fessed writers, to turn their attention to those points which
more peculiarly concerned that class of their hearers and read-
ers; many ponderous "tomes" were therefore dragged from

* Vide " Economical and Medical Observations tending to the Improvement of
Military Hospitals," &c. by Richard Brocklesby, London, 1764, p. 30.

16 INTRODUCTORY REMARKS.

their dusty abodes, and, with the aid of a few cases which au
accident, a duel, or a vohuiteer 6ekl-day occasionally sup-
plied, systems were formed. This was quite sufficient for the
men of established character in settled practice; but it became
necessary to do something' more, to satisfy the increasing de-
mands of the war, and the practice of the great naval hos-
pitals at home, afforded the public teachers a source of se-
condary information on these points ; while few, if any, of
them, had ever been in the service, or had treated a se-
ries of military accidents from their infliction to their termi-
nation. In place of practical facts, therefore, the ingenuity
of conjecture and the poignancy of wit were occasionally called
into action ; the army-surgeons, many of whom were able,
although their multifarious employments did not permit them
to write, were hinted at as ignorant " rouliniers ;" while they
were acquiring knowledge in the volume of nature, the lecture-
room and the press poured forth, in many instances, the fa-
brications of imagination ; the modesty and forbearance of
those who were really qualified to instruct, were construed
into inability ; and some teachers and writers, without taking
time to deliberate, or even without having data to deliberate
on, were they so inclined, essayed to involve in promiscuous
reprehension the whole body of army practitioners, and held
them up to derision and contempt ; imitating the example of
those critics, who, to use the language of a celebrated author,*
" by long digressions unsought for, and universal censures
unprovoked, have forced into the light, with much pains and
dexterity, their own excellencies, and other men's faults, with
great justice to themselves, and candour to those they criti-
cise." On this subject I shall not dwell ; the " lites chirur-
gica;" have been already too numerous, and it has been too
long the practice of the members of the liberal professions to
allow differences of this kind to degenerate into personal illi-
beralities, while the taste of the age seems to strengthen the

• Swift's Ta\c of a TiiM.

AUTHORS. 17

tendenc\'. How melancholy, that the professors of a science,
whose legitimate objects are the happiness and comfort of
mankind, should be foremost in this race of ribaldry !

The various periodical works with which the present day
abounds, furnish numerous detached papers and cases con-
nected wilh military surgery ; but Mr. John Bell is the first,
in point of time, among the living authors, who has paid par-
ticular attention to it, iu his well known "Discourses upon
Wounds." (Edinburgh, 1795.) He was followed by Mr. Che-
valier, who published a small volume on " Gunshot Wounds ; "
which, in the form of an essay, gained the prize given by the
Royal College of Surgeons of London for the year 1803.

In 1804 a work appeared under the title of " Chirurgical
Institutes on Gunshot Wounds," by St. John Neale, the author
of which refers to his experience as an army-surgeon in the
American war, although his book seems principally to be a
compilation and translation from Le Dran.

3Ir, Charles Bell, in his " System of Operative Surgery,"
has enlarged upon many points of military surgery ; and, in his
second edition, (London, 1814,) has incorporated a Treatise
on Gunshot Wounds, which is also published in a separate
form. In his " Quarterly Reports" also, which have appeared
occasionally since that period, he has continued his remarks
upon the subject.

Mr. Guthrie, Deputy-Inspector of Hospitals, from his exten-
sive practice in the Peninsular war, has added a valuable
work to military surgery, in his book " On Gunshot Wounds
of the Extremities requiring Amputation, &c". (London, 1815;)
and Dr. Thomson, Surgeon to the Forces, and Regius Pro-
fessor of Military Surgery in the University of Edinburgh,
has furnished us with a faithful " Report of the State of the
Wounded in Belgium after the Battle of Waterloo;" (Edin-
burgh, 1816.)*

* Second and third editions (with many valuable additions) of Mr. Guthrie's
work was published in 1S20 and lS-27. Mr. Hutchison also has published a second
edition of his Observations, 1S26. C

18 INTRODUCTORY REMARKS.

Mr. Hutchison, in his " Practical Observations in Sarg^ery,"
(London, 1816.) and in his " Farther Observations on the
Subject of the proper Period for Amputating in Gunshot
Wounds," (1817,) has given us some valuable remarks, and a
series of reports on the surgical results of the great naval action
at Algiers, well worthy of attention.

Mr. Allan, in his System of Surgery, (Edinburgh, 1819,)
has given a very good practical chapter on Wounds, drawn
from his own experience in the naval service.

In the works published by Sir Gilbert Blano and Dr. Trot-
ter on the diseases of seamen, much important matter con-
nected with military surgery is also to be found. Indeed, we
owe much to the naval surgeons in general for many improve-
ments in the treatment of wounds, and it is only to bo
lamented that they have not favoured us with more observa-
tions on a subject in which they are so well qualified to in-
struct.

In the last edition of his Surgical Dictionary, (1825,) and
in the la.st edition of his First Lines, (182fi,) Mr. Samuel
Cooper, Surgeon to the Forces, has incorporated many very
valuable observations and cases, derived from the best foreign
and domestic sources, as well as from his own personal expe-
rience in the Held, and in the military hospitals of Holland,
Belgium, and France.

Dr. Millingen, Surgeon to the Forces, published in the year
1819, a Manual for the use of Army Medical Ollicers on Active
Service, in which he has proposed some very important
improvements in the arrangement of our Held equipments,
which, if adopted, cannot fail to add to the comforts of our
wounded soldiers, and to the ease and convenience of their
medical attendants.

The following observations, which insensibly grew upon me
to their present bulk, are the results of an active military life
during the eventful period of the last twenty years, a very small
portion only of which, has been nnoccupi<(l by the study and

AUTHORS. \@

the actual practice of military surgery, — in the MecUterra-
uean ; throughout the whole of the Peninsular campaigns •
in the hospitals of France; and, lastly, from the very com-
mencement to the termination of that short but bloody cam-
paign, (1815,) which has for a time settled the fate of Europe,
during which the charge of a very large hospital establishment,
and the general superintendence of the wounded staff and re-
gimental officers, were specially entrusted to me.

To collect, or even to enumerate, all the different injuries
inflicted in war would occupy a lifetime ; their direction and
their importance vary from a number of causes dependent on
the circumstances or the situation of tbe contending parties ;
and it is much to be questioned, whether the most elaborate
description of individual cases, where they are not distin-
guished by some illustrative peculiarities, do not tend rather
to confound than instruct the reader. To these, therefore, I
have confined myself; and it is but reasonable to suppose,
that, with a knowledge of the more important species of in-
juries, little difficulty will be experienced in treating any of
the lesser that may occur. A system, it is true, would not
have been complete without a special enumeration ; but, in
what is here offered to the profession, I state principally what
1 have seen, without pretending to embrace all tbat has been
seen by others ,• although I trust little of importance will be
found to have escaped me.

At the termination of a series of wars, which, for a large
portion of a century, have desolated the fairest regions of the
European world, and drenched their fields in blood, the medi-
cal philanthropist will naturally ask, what results have accrued
from such ample sources of experience t What progress
has been made in softening the miseries of pain and dis-
ease, and in extracting from such multitudes of victims,
antidotes to the waste of human life? The younger practi-
tioner also, who may enter the service of his country, will in-
quire, where am I to collect the fruit of that experience, with

20 INTRODUCTORY REMARKS.

which so many campaigns have enriched my predecessors i
and how, if the opportunities come within my reach, am I
best to avail myself of them ? It is in some degree to answer
these interrogatories, that I have ventured to make the fol-
lowing observations. In arranging them, I have carefully
availed myself of the written and oral remarks of the best
army surgeons, both domestic and foreign, to whose works or
conversation I have had access, or who have had more expe-
rience than myself. I have studiously avoided controversial
discussions, where they could lead to no practical results ;
and theory, unsupported by experience, I have altogether re-
jected ; well knowing how much the young practitioner has
to unlearn at the patient's bed-side, when he comes there
fraught with opinions acquired from books or lectures only.
With this in view, I have given the accompanying cases,
nearly as they were taken down in large hospitals, or private
practice, without, however, embarassing them with trivial
diurnal occurrences, which would only have enlarged the nar-
rative, without adding to its value.

The system of subordination and progressive responsibility,
which is of such vital consequence in all military establish-
ments, is in none of greater importance than in military hos-
pitals. While it throws up the most secure barrier against
disease, by the enforcement of well-digested regulations, it
ensures the prompt and vigorous treatment of the sick soldier,
and affords facilities to his professional attendant, which no
other situation possibly can, of adding to the general stock of
knowledge. The surgeon is indeed, from the very nature of
his profession less fettered by the letter of military law, but
by no means less amenable to its spirit, than other classes of
officers; and while the desire of investigation is kept alive,
by the frecjucnt opportunities of indulging it, the rashness of
inexperience and the crudcness uf theory are restrained, by
the gradations of rank and seniority.

It i? not, however, by a cold and servile performance of his
duties, that llu- military surgeon will acquit himself with in-

AUTHORS. 21

dividual credit or public benefit; he must, to the habits of
subordination, add professional enthusiasm : — not that ungo-
verned impulse which catches at the ephemeral proposals of
empty theorists, or self-dubbed reformers, but that regulated
and chastened zeal which has real and useful acquirement for
its object, and which, while it strengthens and increases his
own powers and resources, gives him confidence in his prin-
ciples, and an honest independence in their application. Thus
constituted, the mind will soon adapt itself to the peculiarities
of any situation, however difiicult or novel, in which its pos-
sessor may be placed : and if his professional duties are less
splendid, and the termination of his labours more distant,
than those of his purely military associates, in the scale of
general good, he will stand on grounds fully as high and ho-
nourable.

As the entrance of a young man into the service presup-
poses, and indeed ensures, an acquaintance with the theoretical
part of medicine and surgery, as taught in the Schools, I have,
in the following sketches, introduced him at once to the field
of battle, and thence to the patient's bed-side, in the fixed
hospital; but I must previously remind him, that many opera-
tions become indispensable in these situations, which may well
be deferred, if not altogether avoided, in private life, or in
military patients placed under difl"erent circumstances. This
will sutficiently account for many discordant opinions, particu-
larly upon the subject of amputation.

CHAPTER I.

PREPARATORY STEPS ON TAKING THE FIELD.

To enable the young army surg-eon the more effectually
to apply his professional talents to the relief of the suffering
soldier, it will be necessary to direct his attention to some pre-
liminary points, a knowledge of which can be derived from field
practice alone; without a due observation of these, his best re-
gulated plans, and most zealous endeavours to do good, will
often end in severe and sometimes fatal disappointment.
Were he always under the eye of his more experienced se-
niors, it would be superfluous to dwell on these points; but
the exigencies or the casualties of actual service will often
throw him at a distance from all professional aid, and leave
him totally dependent on the resources of his own mind, and
on the scanty supplies to which original deficiency or subse-
(juent expenditure may frequently reduce him. In this point
the military surgeon is far less favourably circumstanced than
his naval brethren. Their hospitals, their medical stores,
their provisions, and all their little comforts, are as perfectly
within their reach, after the most protracted engagement, as
if no such event had taken place; their patients suffer none
of the heart-rending privations of a soldier, lying wounded on
the field of battle, without bedding, food, or shelter; and,
when he is removed, torn from his comrades, and sent to dis-
tant hospitals by a precarious and uncomfortable conveyance
over broken-up roads, nr intricate moiuitain passes. In short,
the sailor fights at home. Could a general fix upon his own
ground, the medical officer, at the head of his staff, could

PREPARATORY MEASURES. 23

easily determine on the necessary buildings for the sick and
the wounded : but their shelter and their convenience are in-
separably connected with the movements of their command-
ers, and with the facilities of transport which the seat of war
may afford, and the commissariat can procure, in addition to
the unemployed cavalry and waggons of the army.

The supply of hospital stores, which should accompany
an expedition, rests in the hands of those who immedi-
ately communicate with the government; and has seldom
heretofore been, and it is to be hoped and believed never will
hereafter be, deficient, either in its quantity or its selection.
In apportioning it off, however, to the various divisions or
corps of an army, or to the different stationary hospitals,
great attention and discrimination are necessary ; and the skill
and experience of a medical officer are in few particulars more
strongly evinced than in making his requisitions on the great
depots, for his field and hospital supplies, with judgment and
selection. With this in his view, the first and peculiar care
of the medical officer, on commencing a campaign, should be
carefully and minutely to examine his Medical and Purvey-
or's stores, with a view to their completion in every respect.
Whether in charge of a corps of the army, of a regiment, or
of a detachment, so much of the success of the Surgical
Campaign depends upon this, that too great pains cannot be
bestowed upon it. He should therefore, however circumstan-
ced, calculate his mode and quantity of transport, as well as
the comparative necessity or utility of different articles of me-
dicines, instruments, surgical materials, bedding, utensils and
medical comforts, necessary for his situation. If the articles
are to be supplied on a large scale, the estimate will be best
made by a board of intelligent and experienced Medical Offi-
cers ; and by no means should it be left at the discretion of
an Apothecary or Purveyor, who cannot be supposed to be
adequate judges of what are necessary on such occasions. For
want of this precaution, I have more than once seen whole

24 PREPARATORY MEASURES.

cart-loads of useless rubbish put in requisition to be forwarded
to the army, while the most necessary articles for the field
abounded at the stores of the depots.

Indisputably, the best mode of packing stores for the field
will be, either in wicker baskets covered with skins or leather,
fitted for carriag^e on horses' or mules' backs, and commonly
called Ji eld- panniers ; or in wooden boxes, of such a size as
may easily be adapted to a similar mode of conveyance ; and
instead of filling several of these with duplicates of the same
articles, a small proportion of each of the most indispensable
medicines and materials ought to be placed in each pair of pan-
niers, or boxes, and an invoice of the contents of each should
be pasted within the lids. Inconsiderable as this precaution may
appear, the additional trouble it gives to the packer is amply
compensated by the convenience and utility to the medical
ofiicers in the field.

Each Regimental or Staff Surgeon is allowed by the go-
vernment a horse or mule, or its full price, with a pair of
field panniers and pack saddle, for the carriage of his field
stores. The articles of the latter description generally served
to the army, from their weight, clumsiness, and bad finish,
completely defeat the purpose for which they are designed ;
and no animal can carry the necessary load for the short-
est march without injury to his back, sometimes so irre-
trievable as to render him utterly useless for the remainder
of a campaign. No pains should therefore be spared to
render the pack-saddle as light, pliable, and easy to the ani-
mal as possible; and, when in movement, every precaution
should be taken accurately to balance the panniers, and reduce
the load within a moderate bulk. To these ordinary articles
of equipment, a few bearers, a camp kettle, a camp stool, and
a water bucket, will be found most useful additions.

Foreign armies often allow carts and waggons for the car-
riage of what they denominate their Field Hospital : but the im-
proved plan of British equipment does not recognize them on

PREPARATORY MEASURES. 25

the line of march, and only a proportion of spring waggons,
for the use of each division, is allowed to accompany the ar-
my; and that solely for carrying the sick and wounded. It
does not enter into my plan, at present, to enlarge upon the
ambulance volante of the French armies, described at such
length by M, Larrey, and found so useful; although an estab-
lishment of that kind, duly modelled, would no doubt be of
important service in our field arrangement. I shall therefore
confine myself to some hints on the purpose of the trans-
ports, and the selection of the stores usually allowed by the
British regulations.*

Lint, surgeon's tow, sponges, linen both loose and in rol-
lers, silk and wax for ligatures, pins, tape, thread, needles, ad-
hesive plaster ready spread and also in rolls, opium both solid
and in tincture, submuriate of mercury, antimonials, sulphate
of magnesia, volatile alkali, oil of turpentine, &c. &c. are
among the articles of indispensable necessity in the panniers;
and, perhaps, as useful an article of convenience as the sur-
geon can possess, is a supply of wax candles, with phosphoric
matches, or some other contrivance for procuring instant light ;
for want of which I have known some very distressing acci-
dents occur ; in one case in particular, several months of the
patient's life were rendered uncomfortable in consequence of
a large plexus of nerves having been included in the liga-
ture. Every surgeon will naturally have the best instru-
ments he can procure ; but it may not be amiss to remind
him that his knives will often loosen, and his scalpels,
more particularly, break from their handles, if not firmly
riveted through at least the half of their length ; an indispen-
sable addition to his case will be a good strop to touch them

* See Larrey's Memoires de Chirurgie Militaire, passim. Beckman's History
of Inventions, by Johnson, vol. iv. 2d edit. London, 1814. Article, Infirmaries
&c. p. 467. The article " Despotat," in the " Dictionnaire de Sciences Medi-
cales," and MiUingen's Army Medical Officer's Manual," for full information on
the history and practical details of this subject.

26 PREPARATORY MEASURES.

on when blunted. The hone sometimes put into surgical in-
strument-cases is of but little use, as it requires an acquaint-
ance with the peculiar mode of using it, without which the in-
struments are often totally spoiled : he should have one or
two spare blades to his saws, and a set of Hey's saws, which
are now usually put in by the instrument-makers ; and if the
chain-saw, invented by Professor Jeffray, of Glasgow, were
substituted for, or added to, the metacarpal saw, I conceive it
would be an addition of serious importance.* The straps of
the screw tourniquet, usually put in instrument-cases, are
often defective, and their buckles unsafe ; they should be
carefully proved before using, lest they should give way at a
critical period of an operation. The clumsy pieces of leather
added to some are entirely useless ; but a neat small pad, se-
cured with a bit of tape, may be retained ; and if the handles
are rounded, and properly padded, as recommended by one of
the most experienced field surgeons of our day, Mr. Guthrie,
nothing else will be wanting to command the arteries in the
shoulder-joint operations, for the very few seconds that they
require pressure. The tenaculum of Assalini, and the artery-
forceps with a slide, will be found very useful. The bullet-
forceps in general use might be much improved, by being
rendered less bulky, and its blades made to separate occasion-
ally, or join, as in the midwifery forceps ; or the very use-
ful forceps of M. Percy substituted in its stead, f Some flex-
ible catheters, and some flexible tubes for conveying food
«r medicine into the stomach, in case of injuries of the blad-
der and of the oesophagus, may be advantageously added to
the Hold o<|ui|)nient, as tlu'y arc light and portable, and the
distance from the field to the fixed hospitals, where they are

• See Cases ot'llie Excision oT Carious Joints, by II. Park and P. F. Alorcau ;
vthU OI)Scrvali«ns by James Jtflray, Rl.D. Glasgow, \H)0.
t Manuel ciu Cliirurgien d'Armee, par M. Percy, Paris, 1792.

PREPARATORY MEASURES. 27

usually kept in abundance, is in some cases considerable: they
are not, however, articles of immediate or urgent necessity.*

To keep his instruments in perfecl and serviceable order,
must be the wish of every surgeon. Some wrap them in lint,
or bibulous paper ; some dust them with absorbent powders,
as starch or magnesia ; others smear them with mercurial
ointment ; and some with simple oil, as fresh as they can pro-
cure it. The latter carefully applied, and afterwards gently
rubbed off, I prefer to all other modes; but whatever
precaution is adopted, the instruments should be frequently
examined, and the case covered with patent leather, or some
other water-proof substance, and the whole loading of the
baggage animal carefully secured with painted canvass.

About his own person each medical man, of course, carries
a pocket case of instruments ; and I would strenuously re-
commend that he never omits a canteen of good wine, or spi-
rits diluted. Many men sink beyond recovery for want of a
timely cordial before, during, and after operations ; and many
of the primary operations would be rendered much more fa-
vourable in their results, by the administration of a single
glass of wine.

It is usual also to issue a certain number of what are called
field tourniquets to the officers, and to some of the non-com-
missioned officers, drummers, and other non-combatants. Tn
many instances life has been preserved by these instruments ;
but too great caution cannot be employed in guarding against
superfluous and long-continued pressure ; and the attendants,
as well as the wounded individuals, should be warned to ap-
ply as soon as possible to the medical assistants, in order that
they may examine the state of the parts in which the circula-
tion is confined.

* An instiument of late invention, and of pre-eminent utility, the patent sy-
ringe of Mr. Read, will be an addition of the most serious importance, and will not
occupy more room than tlie clumsy pewter syringe, usually put in the field
panniers.

28 PREPARATORY MEASURES.

As the staff and regimental pannier mules or horses should
never be overloaded, and as there is often a necessity for tak-
ing on forage for the use of the animals, the supply of mate-
rials must be limited to a certain weight : two hundred pounds,
including instruments, panniers, and barley, &c. &c. should
be, in general, the maximum. The duty of having in readi-
ness a reserve supply is one of the most serious importance ;
this, however, as always devolving on the head of the medical
staff, who must be supposed perfectly prepared for all contin-
gencies, it is unnecessary to enlarge upon here. The most
portable articles of medicines, and materials ; of medical com-
forts, as tea, sugar, wine, chocolate, portable soup, lemon juice,
&c.; the least cumbersome cooking apparatus, and some neces-
sary articles of bedding, must, of course, constitute the store.
The distribution also of the various ranks of medical offi-
cers to the different corps, divisions, and brigades of the ar-
my, rests with the same authority ; and however superfluous
the number of professional men may appear before a battle or
a series of movements, it will very seldom be a source of com-
plaint after these operations. In the selection of field neces-
saries, and of Staff-Officers, circumstances of course must very
materially influence every arrangement.

We shall suppose, however, that the army has taken the
field, or opened the trenches; each of its divisions furnished
with a due proportion of the general Hospital Staff with their
stores ; the field-panniers of the regiments and of the Staff-sur-
geons complete; their surgeons and assistants present; and an
arrangement made with the Commissariat for the transport of
the wounded to tiie fixed hospitals in the rear; The usual
and most rational plan for providing against the casualties that
will naturally succeed to the opening of the fire in the field,
is that laid down by Ranby;* viz. to form in small parties,
at a convenient distance in the rear, out of the immediate

* Mclhoil uf treating Gun«shol Wounds, London, p. 174-1.

PREPARATORY MEASURES. ^

reach of shot and shells, where the field-panniers are fixed as
a sort of table, and where some of the regimental non-com-
batants, the drummers, band, &c. are prepared to act as or-
derlies. Where, however, it can be conveniently done, espe-
cially at a siege two, three, or more points of rendezvous, at
a house, farm, church, or marquee, ought to be appointed to
carry the wounded to in the first instance. In either of these
situations the first dressings ought to be applied, and the pri-
mary operations performed ; here, also, the wounded should
be selected for conveyance to the receiving hospitals in the
rear; those who can walk selected from those who require
mules, horses, or waggons, and the whole sent off under a
proper escort, with a careful assistant, and with a due sup-
ply of rations, in such proportions as the nature of circum-
stances may point out. Every article, however, of this kind,
particularly spirits or wine, is to be kept on a separate wag-
gon or mule, and never entrusted to the soldiers. The most
clamorous and troublesome among the wounded in the field, or
before the walls of a besieged town, are generally the worst
characters of the army, and the most slightly injured. Great
discrimination, therefore, should be used in placing the wound-
ed in the carts, or on the mules, &c. destined to carry them to
the nearest hospital. Several even affect being contused, or
stunned by the recoil of their pieces, or by the wind of the
balls or shells ; their object being too frequently plunder, in
pursuit of which, the rations and medical comforts of their
suffering fellow-soldiers are often the first object of their ra-
pacity.

CHAPTER 11.

GENERAL NATURE AND FIRST TREATMENT OF WOUNDS,

COURSE OF BALLS, &C.

Since the invention of gunpowder, war, which was former-
ly decided by muscular strength, has been conducted upon
more scientific principles, deduced from theory, and confirm-
ed by actual experiments. Generals are not only aware of
the strength of the army they command, but can, to a certain
extent, estimate its probable reduction by the effects of
the fire of the enemy; hence we find, that, prior to the
French Revolution, when the adoption of an entirely new
system of tactics put all calculations at defiance, there was a
certain scale upon which the casualties of a campaign were
usually computed ; it was supposed, that, on taking the field,
three men in every hundred would be upon the sick list; —
that, in the middle of a campaign, this number would be
doubled,— and that, towards the close of operations, it might
be increased to ten or twelve per cent, exclusive of the effects
which might arise from any epidemic disorder.* The wound-
ed after a general engagement were calculated at the rate of
ten per cent.; and we even find, that the proportion which
the wounds of different parts of the body bore to each other
were also estimated. Dr. Zetzell, in a discourse on the dis-
eases of the Swedish army,f read bef(>re the Royal Academy
at Stockholm, states, that in a battle between two armies com-

• Ravaton, p. 63.5.

f Tal oiii Sjuklighetci) e fatlt, 4lo. Stockliolm, I77S».

COURSE OF BALLS. 81

posed of infantry, the upper part of the body is most in danger,
and that, for two shot in the belly, three or four will take effect
in the neck or breast, seven in the head, ten in the arms and
bands, four in the hips, five in the logs, one in the knee, and
two in the feet. This, however, is a division altogether arbi-
tary, and must necessarily vary according to the position of the
contending parties.

It may not be uninteresting to detail a few circum-
stances which can be calculated with a considerable degree
of accuracy, and which, without leading us far into the
doctrine of projectiles, may throw some light upon injuries
from gunshot. The Chevalier Folard, in his account of
the Catapultae, Balistae, and other engines of the ancients,
states, that their powers were little inferior to those of our
modern instruments of destruction, and, indeed, in the works
of Celsus, (lib. vii. chap. 5,) we find that the effects of
leaden bails and stones, projected from the engines then
in use, were by no means unknown ; but of their precise
velocities we know little or nothing. By the calculations
of D'Antoni,* it appears that the initial velocity of a cannon-
ball is nearly two thousand feet in a second, and that of a
musket about seventeen hundred ; but these velocities rapidly
diminish from the moment the ball quits the mouth of the
gun, and are also greatly influenced by the quantity and
quality of the powder, the force used in ramming the wads,
the elevation of the gun, and the length of the bore; the
weather also influences the velocity of a ball, for, in a very
dry state of the atmosphere, it is a seventh greater than when
it is loaded with vapour. In sieges, balls of very heavy metal
(321b.) are employed; in engagements in the open field, the
largest shot seldom exceed 12 lb., and go down to lib. ; the
other species of shot are the common Musket Ball, fired singly

* Treatise on Gunpowder, &c. by D'Antoni, translated by Thomson, 8?o.
London, 1789.

32 FIRST TREATMENT OF WOUNDS.

from muskets, or discharged in cases from field-pieces ; Grape,
which consists of small iron balls, disposed in linen bags fast-
ened to a wooden bottom, in the middle of which is a spindle,
round which the balls are secured by cord or wire ; or Case-
shot, which consists of the same small iron balls put into tin
cylinders, the bases of which are closed by two circular pieces
of wood. The last kind of projectiles are shells, or hollow
iron spheres, filled with powder, which may act either before
or after their explosion. The closer the contending parties
are to each other, the more deadly will be the effects of all
these balls ; thus, according to D'Antoni, a 3"2 lb. shot may
pierce a file of 70 men, a 161b. a file of 48, an 81b. a file of
40; a 13 oz. shot a file of 20, a 6 oz. a file of 16, a 1 oz. a
file of 4; if very close to them, and propelled by a certain
degree of force, — while a shell will pass through from two to
five men, and will kill or wound by its splinters from six to
nine ; the distance and the resistance will of course produce
great variation in the action of all these missiles. It must be
confessed, however, that, much as the artillerist and engineer
are interested in ascertaining these points with correctness, it
leads to little improvement in surgery, except in as far as it
shows the enormous violence with which the bones may be
fractured, and their fragments dispersed either into the me-
dullary cavities or the surrounding soft parts.

Among the ancient surgeons, who had learned and abstruse
theories to support, respecting " the burnings," and " the
poisonings," and " the concussations," of gun-shot wounds,
every little accidental variation in the external appearance of
the shot-hole, and every shade of mental agitation in the
wounded man, were fondly dwelt on as illustrative of their own
f)articular doctrine ; and even to the present hour some writers
enlarge on these appearances, as if they were at all essen-
tial to the treatment, and puz/Ic tluMuselves with definitions,
us if every practitioner acipiainled with the subject, even
from books, did not know that a gun-shot injury is a violent

COURSE OF BALLS. 3S

contusion, with or without solution of continuity, suddenly
and rapidly effected by a solid body projected from fire-arms ;
— and nothing more, so far at least as definition is concerned.

The effects of a gunshot wound differ so materially in dif-
ferent men, and the appearances are so various, according to
the nature of the part wounded, and the greater or lesser force
with which it has been struck, that no invariable train of symp-
toms can be laid down as its necessary concomitants. If a
musket or pistol ball has struck a fleshy part, without injuring
any material blood-vessel, we see a hole about the size of, or
smaller, than the bullet itself, with a more or less discoloured
lip, forced inwards ; and, if it has passed through the parts,
we find an everted edge, and a more ragged and larger orifice
at the point of its exit ; the haemorrhage is in this case very
slight, and the pain inconsiderable, insomuch that in many
instances the wounded man is not aware of his having received
any injury. If, however, the ball has torn a large vessel, or
nerve, the heemorrhage will generally be profuse, or the pain
of the wound severe, and the power of the part lost. Some
men will have a limb carried off or shattered to pieces by a
cannon ball, without exhibiting the slightest symptoms of
mental or corporeal agitation ; nay, even without being con-
scious of the occurrence ; and when they are, they will coolly
argue on the probable result of the injury : while a deadly
paleness, instant vomiting, profuse perspiration, and universal
tremor, will seize another on the receipt of a slight flesh
wound. This tremor, which has been so much talked of, and
which, to an inexperienced eye, is really terrifying, is soon
relieved by a mouthful of wine or spirits, or by an opiate; but,
above all, by the tenderness and sympathizing manner of the
surgeon, and his assurances of his patient's safety. Where some
important or vital organ is injured, considerable pain and much
anxiety is a general consequence ; these will be more parti-
cularly considered in treating of the wounds of particular
parts.

34 FIRST TREATMENT OF WOUNDS.

If the ball has passed through the fleshy part of the arm,
thigh, or buttock, we do no more than sponge the part clean,
place a small bit of folded lint on each orifice, which we retain
by two cross slips of adhesive plaster, and lay over, at most,
two or three turns of a roller. The ball will frequently have
passed nearly through the limb, and be retained only by the
elasticity of the common integuments; there we cut upon and
extract it at once; and we should lay it down, as a rule not to
be deviated from, to extract on the spot every extraneous body
that we possibly can, either by the forceps alone, or with the
aid of a bistoury, But those who best know the tield of battle
will easiest admit how often it is impossible to do all in this
respect that they could wish.

A ball will often strike the thorax or abdomen, and to an
inexperienced eye, will appear to have passed directly across,
or to be lodged in one of the cavities. If great difliculty of
breathing, or haemorrhage from the mouth, with sudden pale-
ness and laborious pulse, in the one case; or deadly faintness,
coldness of the extremities, and the discharge of stercoraceous
matter from the wound, in the second — are not present, we
shall find that perhaps the ball has coursed along under the
integuments, and is marked in its progress either by a redness
which Mr. Hunter compares to a blush, or by a wheal, or dusky
line, terminated by a tumour ; on opening which, it will be
easily extracted.* In some of these long and circuitous routes
of balls, where we have not this mark, a certain emphysema-
tous crackling often discovers their course, and leads to their
detection.

The ball is, in many instances, found very close to its point
of entrance, having nearly completed the circuit of the body.
In a case which occurred to a friend of mine in the Mediter-
ranean, the ball, which struck about the i*onmm Adami, was

• See his Observations on Digestion, contained in " Observations on certain
Pans of the Animal Economy." Lond. 1780, p. 106.

COURSE OF BALLS. 35

found lying in the very orifice at which it had entered, having
gone completely round the neck, and being prevented from
passing out by the elasticity and toughness of the skin which
confined it to this circular course. This circuitous route is a
very frequent occurrence, particularly when balls strike the
ribs, or abdominal muscles ; for they are turned from the direct
line by a very slight resistance indeed, although they will at
times run along a continued surface, as the length of a bone,
along a muscle or a fascia, to a very extraordinary distance.
If there is nothing to check its course, and if its momentum is
very great, it is surprising what a variety of parts may be
injured by a musket ball. I have seen cases where it has tra-
versed almost the whole extent of the body and extrenylies.
In one instance which occurred in a soldier with his arm ex-
tended in the act of endeavouring to climb up a scaling ladder,
a ball which entered about the centre of the humerus, passed
along the limb, and over the posterior part of the thorax,
coursed among the abdominal muscles, dipped deep through
the glutaei, and presented on the fore-part of the opposite thigh,
about midway down. In another case, a ball which struck the
breast of a man standing erect in the ranks lodged in the scro-
tum. Sometimes two balls are fired, and inflict two distinct
wounds ; or one large wound may be inflicted, both balls enter-
ing together and passing through ; or one ball may pass through,
and the other lodge; — no deviation from the common principles
of treatment is required on such occasions.

A very slight obstacle will suffice to turn balls from their
course; and many " hair-breadth 'scapes" are narrated among
military men, where a button, a watch, a book, or a handker-
chief, has been the means of preserving life. It was at one
time rather a prevalent idea, that silk had the power of ren-
dering its wearer, to a certain extent impenetrable to a musket
ball ; and, as a very natural consequence of this opinion, waist-
coats of that material were recommended to be worn. I know
of no instance where silk has been more useful than any ther

D 2

36 FIRST TREATMENT OF WOUNDS.

substance in turning a ball. A case has come within my
knowledge where an officer was struck by a ball, which, first
impinging against a silk handkerchief worn in his breast, not
for safety, but convenience was so far from being turned, that
several duplicatures of the silk were actually carried into the
pectoral muscle : it served, however, one useful purpose, for,
on withcTrawing it from the wound, the ball was extracted,
bedded in its folds. Another case has still more recently been
stated to me, where a musket ball struck the thorax, and car-
ried into the cavity several plies of a silk handkerchief; others
have occurred where the ball has, as it were, concealed itself
in the plies of the silk, and a severe contusion has alone marked
the situation of the blow.

Where a ball has entered any of the cavities, its course is
often rendered very obscure. The discbarge of the peculiar
fluids, as air, urine, feces, &c. will very clearly detect it, if the
organs containing tliem are wounded ; but I have observed
and demonstrated several cases in which the ball has fairly pe-
netrated the parietes of the thorax, but more frequently the
abdomen, and yet the organs contained under the point of its
entrance, or even at that of its exit, have not been injured. I
was first led to an examination of the passage of balls, not only
along a convex surface, but also along a concave, from seeing
the course of some musket balls which had deeply grazed along,
but not penetrated the arm, when it was in a curved position,
as in a soldier when firing his musket. In this posture of the
soldier, 1 have frequently seen the mark of the ball commencing
at the wrist, and, instead of going through, or perhaps flying
off at a tangent, and striking the breast, go all round between
the shirt and the skin, furrowing the latter, and going out at
the point of the shoulder, thus describing a portion of the
circumference of a circle. In mounted officers also I have seen
many instances where the ball has struck the outside of the
calf, and, from the bent position of the knee, has been thrown up
into, or above the popliteal space, rendering all search after it

COURSE OF BALLS. 37

useless for a long time. Indeed, one eminent London surgeon,
who was consulted in a case of a general officer whom I attended,
and who had been wounded in this very way, could not believe
that the ball had lodged at all ; it was discovered, however,
in the thigh, by a Parisian professor, where I asserted it would
be found ; its entrance had been clearly demonstrated by an
abscess, which formed in its course, and discharged, on being
opened, several pieces of stocking and pantaloon, with clots of
blood ; but the most accurate and patient investigation could
not detect it for many months.

In six fatal cases which I very minutely examined, this oc-
casional course on a concave surface was very visible. In two,
the ball passed between the lungs and pleura costalis, entering
on the right of the sternum, coursing round, and passing
through the opposite side near the spine. In one, the ball
entered over, and was supposed to have passed through the
spleen ; on dissection, it was found to have passed along the
posterior part of the spleen, and lodged beside the spine,
leavina: a furrow all round from its entrance to its lodg;ement.
In one, the ball entered exactly over the spleen, and passed
round to the middle of the tenth rib of the right side, furrowing
the diaphragm. In two, the balls entered close to the umbilicus,
and passed out exactly opposite, beside the spine ; the men
were supposed to have been shot through the bowels ; but it
was found that the balls had passed round the abdominal
parietes, running between them and the contained viscera,
without opening them, and had passed out. In all these cases
inflammation was present to a very high degree ; and in one,
gangrene was so far advanced as to render dissection extremely
offensive. A further proof of the propensity of balls to take
a curved direction, is often seen in cases where they strike
the front of the hat, and, running round, carry off the hinder
tassell.*

* See Le Vacher, in Memoires da rAcademie tie Chiiurgic, tome iv. or tome xi,
of the 12mo. edition, for some valuable observations on this subject

38 PRIMARY AMPUTATIONS.

If the ball has passed fairly through the parietes of the
thorax, or abdomen, we dress both orifices, as in the first case,
and if no haemorrhage has followed, take away from sixteen to
twenty-four ounces of blood from the arm. We should be
equally attentive to the abstraction of blood, in cases where a
round shot, or piece of shell, has grazed the head, neck, thorax,
abdomen, or any of the joints, or where they have been
contused by the splinters of a shell, flying stones, or clods of
earth. In all these cases we may also derive much future
benefit from unloading the bowels by a calomel pill, with some
antimonial powder; a medicine, which, both from its purgative
power and its portability, should always be ready in the field
panniers. In cases where tlie skin is only slightly torn or
ruffled, we dust a little scraped lint or charpie on the track, and
lay a pledget of emollient ointment over it. It is astonishing
how diflerently a wounded man feels and speaks of the surgeon
ytho performs these simple little oflBces for him in a neat and
dexterous manner, and of him who roughly, confusedly, and
without any apparent interest, hurries over his dressings with
a slovenliness ill concealed by prodigality of plaster, lint and
bandages.

The remarks I have now made refer to simple wounds, where
no important or vital organ is injured. I shall next advert to
the field treatment of the more complicated cases arising from
gunshot, and which either require amputation on the field, or
shortly after removal to the fixed hospitals.

1st. — It frequently happens that an arm or leg, or perhaps
both, are carried completely o(i" by round shot, leaving an
irregular surface of jagged and lacerated soft parts, and a pro-
jecting bone shivered to pieces. The obvious plan to be fol-
lowed in this case, is to reduce this horrid-looking wound to
the simple state of a limb which has been separated by art.

Wc carefully examine the extent of the injury done, parti-
cularly to the bone, and amputate on the sound part, as far
beyond thr injurv as wc conveniently ran. Il', however, the

PRIMARY AMPUTATIONS. 99

bone is splintered to the very joint, or so close as to excite our
fears as to future consequences, we operate beyond it, on the
upper part of the limb. If the head of the humerus itself is
injured, or the shaft splintered, with much destruction of the
soft parts ; or if the head of the bone alone is left in the
glenoid cavity, the rest being carried off, we forthwith take it
out of the socket ; an operation as simple, if properly planned,
as any in surgery ; and one which, on all occasions where the
bone is injured high up, is infinitely preferable to amputation
lower down. It not unfrequently occurs that the arm is
carried completely out of the socket; and in this case very
little more remains for the surgeon than to pass a ligature
round the arteries, even though they do not bleed, as often hap-
pens, to cut short the leash of nerves, which in this case usually
hangs far out of the wound, to bring the lips towards each other
by adhesive straps, and to support them by proper compress
and bandage.

The operation of Excision of the Head of the Humerus, as
recommended and practised by Boucher, Thomas, Moreau, and
other French surgeons, and by White and Park in England, is
a proposal well known to all military surgeons. It is not,
however, generally adopted ; I have never seen it performed on
the field, and in hospital practice I have only seen one case of
it. The frequency of its removal by M. Larrey and Mr.
Guthrie should encourage us to hold the plan in view;* but I
have not enlarged upon it as di field operation ; its seriousness,
the comparative rarity of the cases requiring it, and its doubtful
utility, rendering it a subject of consultation in the hospital,
and one not to be lightly treated of from theory alone, or from
a few successful cases. If the bone is much splintered, and
particularly if its periosteum, for any extent towards the
condyle, is injured, we have no means to guide us to the pro-

* See Park on Carious Joints ; Guthrie on Gunshot Wounds of the Extremities,
p. 113, London, 1S15 ; Larrey's Memoires,

40 PRIMARY AMPUTATIONS.

bable boundaries of inflammation or death of the shaft; and a
perfect amputation may become necessary, from these events,
after the head of the bone has been removed. If the ball has
only struck, fractured, or otherwise injured the head of the
bone, without extensive laceration of the capsular ligament,
injury to the great vessels or nerves, &c. the surgeon would be
utterly unjustifiable, either in the amputation of the limb on the
field by a joint operation, or in the excision of any part of it.
Upon the whole, I am inclined to think, that the excision of
the head of the humerus will be found to be an operation
more imposing in the closet than generally applicable in the
field.

Simple and safe as the operation of amputation is, at the
articulation of the upper extremities with the trunk, it becomes
one of the most serious in military surgery, when the lower are
engaged. There is not one patient in a thousand that would
not prefer instant death to the attempt. Obliged as we are
coolly to form our calculations in human blood, there is still
something in the idea of removing the quarter of a man, at
which the boldest mind naturally recoils ; and yet there are
cases in which we have it only left to balance between certain
death and this tremendous alternative ! The propriety, and
even the necessity of this operation, has been so ably and fully
treated of by Mr. Guthrie, and is so well supported by two
living instances, (one performed by himself at Brussels since
the publication of his work, in which I had the pleasure of
being one of his assistants,) that 1 should not do justice to
the subject, did I not reier to his truly practical book on this
point.*

2dly. — Extensive Injuries of the Joints form an urgent class
of cases for immediate amputation. I am well aware that some
very favourable joint cases have ended successfully without re-
moving the limb; but 1 will venture to assert, that the pain and

• I'arlhfr dctuil.s will he givfii in iht cliu|ilcr on Ainputulion.

PRIMARY AMPUTATIONS. 41

inconvenience of the cure, the subsequent inability of the mem-
ber, and its proneness to disease, have infinitely counterbalanced
the benefit derived from saving it.

An instance has come to my knowledg-e, in which an eminent
army surgeon recommended amputation for a case of this
description. Unfortunately for the patient, he listened to the
hopes held out to him by other practitioners of saving the limb.
After a tedious confinement, and much misery, the limb re-
mained appended to his body; but, at the end of thirty years,
he solicited his original adviser to remove the part, which was
accordingly done, to his great relief.

In civil society, where the patient has always led a temperate
quiet life, and the injury has been inflicted perhaps by a clean
cutting instrument, or a small ball has passed near or partially
injured the articulation, (a case so very different from that
occasioned by a large shot passing into or near it, where the
patient has to be dragged over heavy roads, in bad carriages,
without surgical aid or medical comforts,) I know that cures
have been effected ; and even in military life there are instances
to be found of the same kind. I would still, however, lay it
down as a law of military surgery, that no lacerated joint,
particularly the knee, ancle, or elbow, should ever leave the
field unamputated, where the patient is not obviously sinking,
and, consequently, where certain death would follow the oper-
ation.

3dly. — Under the same law are included, by the best and
most experienced army surgeons, all Compound Fractures close
to the joints, especially if conjoined with lacerated vessels or
nerves, or much comminution of the bone, particularly if the
Femur is the injured bone.

4thly. — Extensive loss of substance, or disorganization of
the soft parts, by round-shot, leaving no hope of the circulation
and other functions being carried on, in consequence of torn
arteries, nerves, &c.

42 PRIMARY AMPUTATIONS.

5thly. — Cases where the bones have been Fractured or Dis-
located, without rupture of the skin, or great loss of parts, but
with great injury or disorganization of the ligaments, &c., and
injuries of the vessels, followed by extensive internal effusions
of blood among the soft parts.

Life has certainly been prolonged and even preserved under
all these unfavourable circumstances ; but the chances are ex-
tremely precarious, and few would choose to retain existence
on such terms. It is very rarely, indeed, that a patient does
not conform himself implicitly to the opinion of the surgeon in
cases of this kind ; and I have generally found all classes press-
ing for the removal of their limbs.

Before proceeding to amputation, the nature of every injury
which the patient may have suffered should be inquired into.
It has happened that amputation has been performed where
there has been a mortal wound through the body.

The question of immediate amputation has of late attracted
an attention which its great importance naturally caljs forth ;
but it appears to me that an idea has been impressed upon
the minds of practitioners in civil life, that doubts as to tbe
propriety of the practice had existed among the British army
surgeons. For my own part, I have never known any differ-
ence of opinion on the point; in books, it is true, it has been most
amply discussed before the present generation were in existence,
but in British practice, all doubts have long been at an end.*

• For a most interesting historical summary of the arguments, see Professor
Thomson's Report of Observations made in Bclgiuu), Acp. loO. I siiall add one
other opinion to those collected by Dr. Thomson, viz. that of Rotallus, in whose
day (16(Vt) amputation was a more serious affair than at present. That experienced
surgeon says, after poinling out the inutility of general scarifications in gunshot
^TOund8, " De liis autem ijuic i)arte3 vel particula; corporis fueruiit, auferendis,
si digitus vel pes, nianus bracliium, vel tibia, taliter sint fracta ; cum carnis ao
vasorum lacerationc multa (quod stcpc magna: bombardte facere solent) sic ut de
horum membrarum vita, nulla sit nnipliiis spes, illicn illii (niijiiitdtida esse cniseo."
Antwerp edition of the works of Ferrius, Rotn, and Hotallu.H, i)y Coninx, 1583.
Botallus, chap. ii. p. 14.

QUESTION OF AMPUTATION. 43

It is but justice to British surgeons, both naval and military,
to declare, that immediate amputation is neither a new doctrine,
nor a recent practice among them. How long it may have been
in use in the former service I cannot undertake to say, but
every naval surgeon with whom I have conversed informs me,
that he always employed the knife where its use was indis-
pensable, at once, — which implies a much earlier opportunity
than army surgeons can possibly enjoy. To advert to the
experience of our service in the late wars; surgeons who
served in 1794 on the continent assure me, that the greatest
benefit resulted from immediate amputation, which they had
recourse to, wherever they possibly could. I have the authority
of my friend. Dr. Pitcairn, Deputy Inspector of Hospitals, who
served as surgeon on the Staff of the Egyptian expedition, to
state, that whenever the surgeons could operate upon the field
in that country they did so; and for himself he only lamented
that he could not remove more limbs in that situation, having
never had any doubt upon the point, and being still more con-
firmed in the justice of his opinion, by the results of the deferred
operations. On the first landing of our troops in Portugal, the
propriety of the practice was impressed upon the surgeons, as
I have been informed by Mr. Gunning, then senior surgeon
upon the Staff, and subsequently Surgeon-in-Chief of the
Peninsular army ; the practice was constantly followed, and
the precept orally delivered from surgeon to surgeon during
the whole period that I served in that country, and the able
work of Mr. Guthrie forcibly elucidates its propriety ; while
the utility of the same practice, as adopted by the French, is
fully shown by M. Larrey. Finally, the results of the field
amputations, after the battle of Waterloo, confirm the published
experience of both these writers, and it is to be hoped that the
question is now set at rest for ever.*

* From the returns of the British army on the Peninsula, Mr. Guthrie found
that the comparative loss was as follows : Upper extremities 12 secondary to I

44 QUESTION OF AMPUTATION.

Men may certainly be found at all times, who, not having
their own opinions formed from experience, will communicate
their doubts and hesitations to those around them ; but surely
their crude and vacillating speculations are not to be assumed
as the measure of information that has been obtained by others.
Have those who conceive that the question of early amputation
is still unsettled, consulted the opinions of the better-informed
army-surgeons of the present day, or the writers of the past ?
If they have, it must be a strange misinterpretation, or a wilful
misunderstanding of both, still to persevere in supposing that
it wants further confirmation. The fact is established as tirmly
as any other in surgery ; and perhaps, in the whole range of the
science, there is not one point where opinions have so little
varied, among English practitioners, from Wiseman downwards.
That author (anno 1676) expressly says, that the practice was
to amputate on the instant, when the patient was free from
fever. From him, who was writing a treatise on the duties of
the army and navy surgeons, not from guess, but from actual
experience, it was to be expected that he would have touched
upon the subject; he has done so, — and he has dismissed it in
one line as a settled point. A later author (anno 1712,) who had
also the benefit of great experience in the service, and who was
writing a treatise on physic, mentions this surgical practice
incidentally, and as a well-known fact, tending to illustrate the
opinions contained in his book, a circumstance, by-the-bye,
which adds much more weight to the value of the opinion than
if it had been pressed into the service, and marshalled among a
line of (juotations on the side of a question in literary warfare.
" It was very obvious to me," snys White,* in his book De

primary; lower extremities 8 secondary to 1 primary. He also found that at
Toulouse 38 cases out of 17 terminated favourably when amputation was imme-
diately performed, while '^1 out of h\ died where the operation was delayed.
Guthrie, pp. 42, 11.

• Dc Recta Sanguinis Missionc, or new and exact Observations on Fevers, in
which IcUing of blood is uhowed to be the true and itolid basis of their cure, as

QUESTION OP AMPUTATION. 45

Recta Sanguinis Missione, " from Chirurg-ical practice, that
where amputations are requisite, they succeed ten to one better
if the operation is performed immediately after the misfortune,
than four or five days after. This all our surgeons in the army
very well know, as well as in the navy." Dr. Francis Home
(anno 1759) lays it down as a general rule, that " Where an
operation is necessary, it ought not to he delayed a minute."*^
Mr. Geach, a surgeon of Plymouth, who published a volume
of Observations on Inflammation of the eyes, the Venereal
Disease, Ulcers, and Gunshot Wounds (8vo. London, 1766)
speaks in strong terms of the propriety of immediate amputa-
tion. In " terrible gunshot wounds," he observes, where they
are very near the joints, and the bones are much shattered,
we know that fever, abscess, or mortification will quickly
aucceed the injury, pp. 62, 76. Mr. Hunter is the leading
English writer who has thrown any doubts upon the question ;
but he considered it from partial experience only ; and Mr.
O'Halloran, who has taken the same side, had hardly any prac-
tice in those cases.f The truth is, that the point was princi-
pally agitated among the French surgeons, and not among us ;
it was proposed as a question by their Academy in 1756, after
the battle of Fontenoy, and the answers occupy a large portion
of their valuable memoirs and prize essays.

The propriety of amputation on the field being admitted, the
question naturally suggests itself, what is the proper period ?
instantly on the receipt of the wound, or consecutively? The
practical reply is. With as little delay as possible. While

well as of almost all other acute diseases," &c. By J.White, M.D. London, 1712
6vo. p. 7. This author was a naval surgeon, and practised in 1703 and 1704, upon
the coasts of Spain and Portugal. He afterwards settled at Lisbon, where he suc-
cessfully applied his practice of venesection to the fevers and dysenteries of that
country,

* Medical Facts and Experiments, by F. Home, M.D. 8vo. London, 1759,
p. 113.

+ Vide a Complete Treatise on Gangrene and Spacelus, by A. O'Halloran,
London, 1765. Chap. xiii. and xiy.

46 QUESTION OF AMPUTATION.

hundreds are waiting for the decision of the surgeon, he will
never be at a loss to select individuals who can safely and
advantageously hear to be operated on, as quickly as himself
and his assistants can otler their aid ; but he will betray a
miserable want of science indeed, if, in this crowd of sufferers,
he indiscriminately amputates the weak, the terrified, the
sinking, and the determined. While he is giving his aid to a
few of the latter class, encouragement and a cordial will soon
make a change in the state of the weakly or the terrified ; and
a longer period and more active measures will render even the
sinking proper objects for operation. If, however, he is dis-
appointed in his hopes, surely the dictates of common sense
will point out the necessity of procrastination, and will restrain
the surgeon from performing what he knows must ultimately be
done, at a period where it is manifestly counteracting the object
he has in view, to do it at once. Would he in the cold stage
of ague administer the same remedies as in the sweating, or in
the intervals of the paroxysm .'

When, therefore, an army surgeon finds a patient with a
feebleness and conceutration of the pulse, fainting, mortal agony,
loss of reason, convulsions, hiccup, vomiting, irregular chills,
stiffening of the whole body, universal feeling of cold and
numbness, sense of weight, change of colour, and other
symptoms of collapse, so well described by Le Conte,* he waits
patiently for a return towards life ; he administers wine, warmth,
volatiles ; he soothes and he encourages; and when due re-
action is established, he performs that humane operation, the
utility and necessity of which are now confirmed beyond the
possibility of doubt, or the influence of cavil.f

It is a very prevalent idea among the uninformed private
soldiers, and some of the junior officers, that the surgeons "lop

• Memoire par Lb Conle, Frix de I'Acad. loin. viii. 12mo. edition.

+ Bilguer, however, takes a very different view of this operation. " De Am-
pulationt'." Halle, 1701. The operation was at one time forbidden by authority
iji ilii- I'russian rtrr\icc, to which lu- btlonf^cd.

FRACTURES. 47

off," as their phrase is, limbs by cart-loads, to save trouble ;
and sorry am I to say, that some private practitioners, whether
from ignorance or design, have assisted in propagating the
scandal. I shall not descend to a formal refutation of this
opinion; as well might the army surgeons be charged with the
deaths that occur on the field. Where the greatest number of
serious injuries occur, there will the most lives and the most
limbs be lost, and one day's action may occasion a greater de-
struction of both, than the best employed civil practitioner
could witness in a lifetime. To form comparisons, therefore,
between the amputations called for in civil and in military life,
is not only absurd, but places the person who makes them,
however high in rank, upon a level in point of intellect with
the lowest vulgar. His own conscience is but too frequently
the sole reward of the military surgeon ; it will solace him
under such unmerited reproach; and under its influence, and
with science and experience for his guides, he will sometimes
see cause for hope, under circumstances of apparently desperate
ill omen.

Where a compound fracture happens from a musket ball, at
a distance from a joint, without great destruction of the soft
parts, splintering of the bone, or separation of its periosteum to
any great extent, and where we conceive it possible to effect
the preservation of the limb, we must pick away all the splinters
of bone or shell, bits of cloth, dirt, &c. that we conveniently
can. If there are sharp pieces of bone sticking out, we saw
them off*, and then apply the many-headed bandage and proper
splints, cushioned off" by tow or rags. We bleed the patient
in proportion to the violence of the injury, administer a purge,
and lay him on the litter, or in the waggon that is to carry him
to his ultimate destination, with the limb in the most relaxed
and easy position. If the fracture is of the humerus or fore-
arm, we may be more particular in making our extension and
coaptation, and apply our bandages and splints with the view
to their remaining more permanently fixed than we can in

48 SABRE CUTS — CONTUSIONS.

fractures of the lower extremity, particularly the thigh; for, in
the latter case, it is utterly impossible to set the limb as it
ought to be upon the field ; and we are yet, I fear, in want of
machinery to keep it steady during the journey to the rear.
We are guided by the same principles in cases where balls have
passed through, or but partially injured, the hand or foot.
Cases have been stated where the humerus has been dislocated
at the same time that a fracture has taken place; in these cases
the rule should be, to reduce the dislocation immediately, as
we would in private practice and in simple fractures, for if the
dislocation be not reduced before the i)ones are united, the
time will be passed for effecting the reduction.

In open sabre cuts, thrusts from pikes, bayonets, or small
swords, in muscular parts, we may commence our* plan of cure
upon the field. After cleaning away the blood and filth, and
removing any extraneous matter within our reach, we lay the
lips of the wound neatly together with straps, or, if necessary
and practicable, with ligatures, and support the part with a
bandage ; or, if it is a deep thrust, we lay a compress along its
course, and bind it up moderately tight. If the joints or cavities
are injured, we employ the lancet unreservedly, and administer
a brisk purgative: if the intestines are cut, and hang from the
wound, we secure them to its lips by a few close stitches : if
they are sound, we replace them, and close the orifice with
ligatures and straps.

The gigantic blows by which bones are divided and limbs
severed are not frequent occurrences in modern days. Most
serious incised wounds are, however, infiicted by the sabre ;
the cavities of the joints are laid open, their appendages
injured, the tendons divided, and the bones so deeply wounded,
that, without the greatest attention, the preservation of the
power of the limb becomes very (juestionable. The sabre
wounds of the bones, like those by gunshot, are more dangerous
the nearer the joint, and they, of course, become more so if
extensive fissure or fracture is combined with the injury effected

CONTUSIONS. 4^

by the cultiiig edge (tftlie weapon. If the parts are not greatly
hicerated, immediate union should be attempted, except where
a small fragment of bone is separated, or its periosteum
abraded, and there it will be better to remove the part at once,
than run the risk of its dying for want of circulation, and
afterwards acting as an extraneous body. In wounds of the
Cranium, if the separated bone is large, and firmly connected
to the calvarium, a considerable relaxation of this rule may be
allowed, for the reunion of these bones often takes place in a
very remarkable manner.

There is no bone which is more frequently tho subject of
sabre cuts than the Scapula, and none which, if preserved from
motion, appears to unite with greater readiness, and less future
inconvenience. Wounds about the wrist and back of the hand
require more attention than any others. I have now before me
a case, where, in consequence of the surgeon having neglected
to place a proper splint under the palm of the hand, when the
back was injured by the oblique blow of a sabre, the bones
have overlapped each other so much as to form a most unsightly
pyramidal tumour.

In all contusions, sprains, lacerations, or burns, from the
explosion of detached cartridges or ammunition waggons, little
more can or ought to be done, than cleaning the parts and ap-
plying compresses dipped in ol. terebinth, or liniment saponis,
or acetous acid and water, or the simple element itself, as may
be convenient; and, if there is a great loss of substance,
pledgets spread with some mild ointment.

In every case where we can get at any large artery that may
be injured, we should invariably tie it, although at the time it
may not bleed. From a neglect of this rule, many lives have
been lost; and, on the same principle, we should be liberal
in our distribution of tourniquets among the wounded pro-
ceeding to the rear, although pointed in our caution as to their
employment.

50 SCARIFICATIONS — PRISONERS.

There still prevails among foreign surgeons, and parlicularly
the French, a strong prejudice in favour of the immediate
Scarifications or Dilatations of all gunshot wounds. This
practice originated in the idea that the wounds were poisoned ;
to allow, therefore, of a free discharge of the poison, and to
admit of the more ready application of antidotes, was a leading
indication. To change the figure of the wound was also another
object, for the older surgeons had observed, that the more
malignant and obstinate ulcers were of a circular form; but the
employment of scarification had its opponents, and was early
reprobated by Leonardus Botallus, one of the most judicious
of the older surgeons. Our own Hunter, between whose
opinions and those of Botallus there is a very remarkable coin-
cidence, has contributed very much to show the inutility of the
practice, and, among English surgeons, the knife is now rarely,
if ever, employed in the first instance, except for the purpose of
extracting balls or splinters of bone, and other extraneous
bodies, or for facilitating the application of ligatures to bleeding
blood-vessels.

In giving- this sketch of a few of the leading duties of a
military surgeon in the field, I have gone upon the supposition
that there is every convenience for conveying off our wounded,
and that the field of battle has been our own. Should a reverse,
however, take place, it then becomes the duty of a certain
proportion of the hospital staff to devote themselves for their
wounded, and become prisoners of war along with them ; and
it may be an encouragement to the inexperienced, while it is
grateful to me to observe, that I have never witnessed, nor
traced, on iiujiiiry, an act of unnecessary severity practised
either by the French or English armies on their wounded
prisoners; while, on the contrary, the contending nations have,
in numerous instances, vied with each other in acts of tender-
ness and humanity to thos<; whom the chance of war had thrown
iu\<) their hands. It is also a soothing refiection, that, where
the wounded are very numerous, and parlicularly with com-

PRISONERS, &C. 51

pound fractures, there will be a vast saving of human life by
leaving them in the power of the enemy, and not dragging them
with a retreating army.

Should we retain possession of the field, but without the
necessary conveyance to carry off all our wounded, parties with
refreshments, bread, wine, beer, soup, &c. and, above all,
canteens of water, should be sent frequently over the field; and,
when possible, huts, or shelter by boughs, hides, or blankets,
should be thrown up, until the wounded are removed to the first
station or receiving-hospital.

CHAPTER III.

PREPARATION, ARRANGEMENT, AND SELECTION OF THE
FIXED AND RECEIVING HOSPITALS.

Where an action, skirmish, or series of" mo\enients, take
place in the neighbourhood of a town which contains fixed
military or civil hospitals, the accoraniodation for our wounded
is at once ready for use, and the various conveniences of stores,
kitchens, baths, pumps, &c. are a very serious advantage. In
defect of hospitals, churches, manufactories, barracks, and other
public buildings, must be used; and when these are not
sufficient, or that particular circumstances render it necessary,
private houses must be employed. The procuring of these
accommodations is always an important part of the duty of the
senior medical officer, and it is unnecessary here to point out
all the particulars to be attended to. It sometimes, however,
may happfn, that an officer of little experience may be thrown
into a situation which requires him to look out for accommo-.
dation for his wounded or sick, and for his guidance I would
oiler a few sugg(!stions, which may materially contribute to the
ease, comfort, and safety t»f the wounded, and abridge the
labours of all classes of their attendants.

That building makes the best hos])ital which is situated
high, dry, and detached, in which there are sufficient doors and
windows admitting of cross ventilation, with open fire-places,
and secure roofs and walls, with rooms of easy access, lofty,
and of moderate size. With regard to this last particular, had
I my choice, I should, for the njiijority of |)ur|)oses, prefer
wards <<»[)able of accomniodating fr(»m twelve to sixteen beds;

PREPARATION, &C. 53

they are more under the eye and control of the ward-master
and servants ; they are kept clean with less labour, and there
is less accumulation of animal effluvia. Smaller rooms are
occasionally required for special purposes, and convalescents
may be accommodated in those of larger size. Long* suites of
small rooms, communicating one with the other by a common
entrance, are very objectionable; ground floors should be
avoided, and hence the galleries and other elevated parts of
churches are preferable to the floors, and these last are always
rendered more healthy by having the beds raised from them by
boards and tressels. Hammocks or cots, I should suppose,
would be useful under many circumstances, particularly for
convalescents. Marquees are excellent as hospitals in good
weather, and temporary wooden buildings may be made highly
useful ; but permanent and moveable articles of this nature are
excessively expensive, unfit for transportation, cold in winter,
and insufferably hot in summer.

In calculating the accommodation of an hospital, the rooms
should be appropriated to the number of patients, by measure-
ment or estimate of the number of cubic feet in each ; thus, a
room 10 feet high, 16 long, and 10 broad, contains 1600 cubic
feet. Allowing 800 cubic feet for each patient, such a ward
will accommodate two extremely well. Sometimes we are
forced to occupy smaller bounds, and in a room of the dimen-
sions described, we may be obliged to place three beds, thus
reducing the allowance of air very considerably. It should be
a general rule, that where there are any fractional parts above
the specific allowance, such fractions should always be allowed
as an equivalent to the portion of air displaced by the bed-
steads, tables, forms, &c. Whatever the height or cubic contents
of a room may be, each bed should have a space of at least 6
feet by 6, or 36 superficial square; in rooms with low ceilings,
8 by 8, or 64 feet, and as much more as possible. The beds
should never touch each other, or be distributed in pairs, as is
sometimes to be seen in civil hospitals. An invariable rule

54 PRHTARATION AND ARRANGEMENT

should be, never to crowd, and to let each bedstead be com-
pletely isolated, without communication with either walls,
pillars, or the other beds in its neighbourhood ; to place it out
of a direct current affecting the body of the person who lies in
it, but to admit as much air as possible above, below, and
around it; to shift it often, so as to clean beneath it; and,
whenever it can be done, to remove the bedding, and let it
remain in the open air, or else to fold it up in such a manner
that the air may freely perflate it while it lies unoccupied on
the bedstead. Tenon, from whose works a vast deal of useful
information may be derived, states, as the lowest allowance
proper for each convalescent patient, 6| cubic French toises,
each toise equal to 76.734 English inches, and 7 cubic toises
for each sick patient, and, in proportion as that allowance
has been greater, so, he says, has been the healthfulness
of the hospital.* I should recommend never to crowd patients,
under any circumstances where it can be avoided, in a space
of less extent than the highest recommended by Tenon, and, if
possible, to give them 800 cubic feet of nir, except the means
of ventilation by cross windows, doors, fire-places, &c. are
peculiarly good.

For hospital purposes in general, the larger public buildings
of a city, or spacious and commodious private houses, should
be selected. Churches, granaries, convents, barracks, have all
their advantages, and are often preferable to buildings originally
appropriated for the use of the sick, if they are not well ven-
tilated. Some small detached houses should also be always
kept in view for particular cases. Cutting down some of the
windows to a level with the floor, and elevating others to the
line of the ceiling, and judiciously checpiering these alterations
so as to ensure the most steady and j)erfect entrance of cool
fresh air, and the exit rtf that which is luit, foul and stagnant.

* See Tenon, Mfemoires sur les Mopiiaux do PariM, 4to. Paris, 1788, p. 198, et
srq. Universal oxjicricncc proves the jubticc ot Ttnon's remark.

OF HOSPITALS. 55

will go far to render any building fit for the reception of
patients, and for forwarding their recovery ; but it should be
recollected, that churches in Catholic countries are often used
for burial-places, and as, in the well known instance of Dijon,
become fruitful sources of disease ; hence buildings of this
description must be cautiously avoided.*

The leading principle upon which all our plans for ventila-
tion should be founded, is the simple fact, that -air heated by
respiration naturally rises to the tops of the wards, while the
cooler and heavier air occupies the lower parts ; hence judi-
cious openings at the tops and bottoms of a ward will always
ensure the exit of the upper stratum of air, and, consequently,
produce an influx from below to occupy its place. To prevent
violent currents, the mouths of the perforations should be
protected by slips of board, properly disposed, at the distance
of a few inches, which not only prevent the air from rushing
at once into the wards, but direct it along the walls and floors,
and under the beds, or any other points where we have reason
to suspect the stagnation of a tainted atmosphere. In cases
where opportunity admits, these fresh sources of ventilation
should be opened in all the walls of each ward, and should be
furnished with sliding shutters, turucaps, or similar contri-
vances, so as to admit of being opened and shut at will, in
order to regulate the admission and exit of the air. This
should be managed in such a way that the lower, or recipient
openings, should be on the windward side, and the higher, or
evacuating openings, in the contrary direction ; but where this
arrangement cannot be made, all the ventilators should be
towards the most healthy aspects, avoiding as much as possible
close areas, confined courts, crowded streets, manufactories,
burial groumls, hospital offices, necessaries, &c. or any other
permanent or occasional sources of confined or vitiated air.

* See Guyton Morveau, " Traite de Moyens de desinfecter I'Air," 8vo. Paris,
1801.

56 VENTILATION, &C.

which cannot be obviated in temporary and fortuitous esla-
hlishnienls.

It will be necessary to appropriate some place of accommo-
dation for the purposes of a Receiving Hospital. This ought
to be either a large building, near the entrance of the city or
town where the fixed hospitals are situated, or, if that con-
venience cannot be found, a house, yard, or barn ; or even a
few tents near each hospital, or a temporary bivouac, may
always be employed for this purpose. Here all the wounded
should be brought; the Purveying Ollicers should attend to
supply soup, wine, bread, and such other refreshments as the
Medical Officers may think proper, and to register the names,
regiments, and companies of the patients, receive their arms,
accoutrements, and necessaries; to furnish them with hospital
dresses, or shirts, or, if these are not to be had, at least to take
from iheni their bloody and filthy clothing, and oversee the proper
ablution of their persons. Some steady medical officers should
also be placed here, to relieve each other at stated intervals,
in dressing and classifying the patients according to the site
and nature of their wounds, which, on their arrival at their
final destination, is to form the basis of their arrangement in
divisions and wards. With each convoy of wounded thus sent
off, a comprehensive return should be transmitted to the resident
medical officer at the Fixed Hospital.

When time will at all permit, fatigue parties should be
incessantly employed in preparing the fixed hospitals for the
reception of the wounded ; or, if they cannot be procured, hired
labourers, or natives pressed into the service, and paid after-
wards by the commissariat at a rate fixed by the local autho-
rities. JJy these peoph', nndi'r the superintendaiice of proper
overseers, and under the immediate orders of the purveying
officers, every species of filth ;iikI nuisance ouj^ht to be most
carefully removed from lln- rooms, staircases, galleries, and
passages of the various buildings, whii h should b(;, if possible,
nhile washed ; large fires or slov«'s slniiild lie wsi'd wherever

VliNTlLATlON, &C. 57

damp or confined air may be suspected ; the kitchens repaired,
or new ones erected ; the necessaries cleaned, and proper
drains cut from them, or fresh pits sunk; the tanks, wells,
pumps, or pipes, placed in proper repair, and under strict con-
trol; places of security set aside for the arms, &c. of the men,
and for the stores of the purveyor and apothecary; and all that
variety of preparation made which experience may suggest,
and which the exigency of the moment, or the nature of the
service and of the accommodation may demand.

There is, perhaps, no body of men more thoughtless, when
left to themselves, than soldiers : they have been so long
accustomed to have all their wants supplied or anticipated, and
have, in fact, been so completely transformed into machines,
actuated and directed by their superiors, that, if uncontrolled,
they are either helpless or degenerate. It is then that one of
their characteristics, while under the eye of their officers, is
completely laid aside; in their absence, and in the indulgence
which they suppose a residence in an hospital implies, they
forget, or wilfully neglect, the most obvious means of clean-
liness and regularity, and sink into filth, sloth, and debauchery.
These men, the greater part of whose lives has been passed
in the open air while with their corps, no sooner get within the
precincts of an hospital, and beyond the immediate cognizance
of their officers, than they shut up every aperture of their
wards, whether accidental or constructed for the purpose of
ventilation; and so long as the means of closing a window, door,
Hre-place, or ventilator, is left them, more especially German
and other foreign soldiers, so assuredly do they close them up.
I have found it almost impracticable to prevent these persons,
Germans particularly, from smoking tobacco, and I have often
made use of this propensity as a means of admitting fresh
air into the wards, by overlooking the appearance of the
tobacco-pipe, if its smell gave no very strong evidence of a
stagnation of the air.

58 VENTILATION, &C.

A very excellent mode of ventilation was adopted by the
French in the Peninsular war, copied from their permanent
military hospitals at home ; viz. perforating- the walls of each
ward with two rows of conical tubes, about one foot in diameter
at their largest end, and eight inches at their smaller, the larger
diameters towards the inside of the ward ; one row on a level
with the floor, the other with the ceiling, at the distance of
from ten to fifteen feet from each other, and so distributed, that
the tabes of the upper or ceiling row correspond with the
unbored space of the lower range.* By these means, or by
leaving vacancies in the glass of the windows, so shaded over
as to prevent the entrance of rain, as in many of our manufac-
tories at home, we may, with great attention and strict watch-
fulness, ensure a certain freedom of circulation of air in the
wards : but without taking the doors and windows off their
hinges, or removing the panes from the latter, in crowded
rooms, or hot weather, we can never promise to ourselves a
complete and sufficient freedom in this respect. Closets,
presses, cupboards, &c. so far from being useful in the wards of
an hospital, I have always found a serious disadvantage. They
occupy a large space, and thus diminish the quantity of air;
they obstruct its free circulation if they project into the wards ;
in the very best hospitals they favour the accumulation of tilth;
and in but too many they are not only favourable to its increase,
but to its concealment ; foul linen, old bandages, remnants of
bread and meat, and even more offensive materials, are often
thrown iiside in them, by lazy, drunken, or peculating servants.
Where they can possibly be removed it ought to be done, but

• The principle of this plan was acted upon, in 1761, at Bremen, by Dr. Monro,
though not to tin- extent here recommended. lie cut holes in the lower part of
the door, and one in the corner of each window; the cold air rushed in by the
former, and the healed escaped by the latter. See Observations on preserving the
llr»i)th of Soldiers, 2ik1 edit. vol. I. p. KM. In the Memoirs of the Academy of
Sciences for 1780, is a paper by M. Le Roy. in which this principle is elucidatod
fully, p. 69S.

VENTILATION, &C. 59

if they form an integral part of the building, they should be
kept always open, their doors should be removed, and their
contents (if any are allowed) should be always placed within
view. Shelves are liable to the same objections as close closets.
Tables and forms are much more suitable for the purposes of
holding food or medicines.

Great additional ventilation, and increased facilities for
detecting and removing filth, will always be gained by fixing
the beds at least one foot from the walls of the ward, so as to
admit of a complete passage round them ; and the higher the
bedstead, or boards and tressels, are from the ground, so much
the greater advantage do we acquire in these essential points.*
A very simple means of ventilation has been proposed by Dr.
Van Marum, and may be employed under many circumstances,
viz. suspending a common argand lamp from the roof of a ward,
and keeping it burning under a funnel which communicates
with the open air, or rises above the roof, with a ventilator
fixed to its end; indeed, the power of fire in confined places is
one of the most efficacious means of ventilation, and should
always be had recourse to. A still more simple method
than that just mentioned of availing ourselves of the effects
of fire, is to perforate a hole into the flue of a chimney, a
few inches below the ceiling, when, on lighting the fires, two
strong currents are established, one through the ordinary, and
one through the newly formed passage. Still, with all our
endeavours, we but too often fail in preserving the purity of
the air of our wards. Whether it may proceed from the che-
mical changes it undergoes, or from the admixture of animal
effluvia, or from the change in its electrical qualities, from a
positive to a negative state, as shown by the experiments of

♦ The heads, and not tlie sides of the bedsteads, should be turned towards the
walls, where the breadth of a ward admits of it. In long narrow passages this
cannot always be done.

60 VHNTILATION, &C.

Mr. Reid,* certain it is, that the air, loaded with the exhala-
tions from the human body, requires, for its elfectual removal,
a very strong- and fresh current directed from the windward, so
as to sweep every part of the room.

We are often so circumstanced, that we are obliged to lay
our patients on the ground, either on paillasse cases, or sheets
sewed together to serve as such, filled with straw or other ma-
terials ; and the urgency of circumstances sometimes compels
us to lay them on loose straw, or even the bare floor. In all
these circumstances the most rigorous attention should be paid
to ventilation and cleanliness. The patients should be allowed
as much room between each other as possible; the loose straw
should be formed into mats, or made up into light trusses, and
not allowed to be laid down in corners, or close to the walls or
partitions ; the site of the bed should be shifted as frequently
as possible, and the straw removed and burned.

Every effort on the part of the medical officers should be
used to procure boards and tressels, or other temporary means
of removing the beds from the surface of the floor; for, in-
dependently of the comfort and cleanliness, and the prevention
of damp, it is a fact now well known in military hospitals,
that the lower portion of the atmosphere of the occupied
wards is invariably the least proper for respiration, and that in
which sores heal most slowly.

To establish this proposition in an unanswerable manner,
M. Brugmans resorted to chemical agents. The results were,

• Seo Pliilosopliif al Transaclions for I704-, Vol. Ixxxir. p. 266. Some
Tt-ry iinporlanl Ob.sfr\alion«i will also he found on the VLntilation of hospitals,
in the Proceedings of the Board of Health of .Manchester, publislied in 1805;
in the works of Count Ruinford ; in the works of Monro and Brocklesby ; and
in a paper by Sir (leorge Paul in the H)lh volume of the Transactions of the
Society of Arts and Manufactures. In permanent establishments, the injfenuity
of the artist and the phiioso|(h( r can have full scope; but simple nu-ans, appli-
cable in all situationH, arc what the army surgeon requires, and what he should
be prepared for, by consulting the best works on the subject.

VENTILATION, &C. 61

that even in the best regulated and constructed hospitals, and
in which no case of hospital gangrene exists, the layer of air
nearest the floor contains a larger proportion of carbonic acid
gas than that of the higher parts of the same ward. At the
height of two feet, sometimes even two feet and a half, the
proportion of carbonic acid gas is commonly tI^ to -j^-^f^, and
close to the floor, t'o"o ; and even a larger proportion has been
observed. The flame of a candle, made to approach the floor,
visibly fades ; and lime-water, in an open vessel, rapidly be-
comes opaque.*

A great aid to the cleanliness of an hospital, is the selection
of a proper apartment or gallery, in the vicinity of the kitchen,
for the purpose of messing ; or tents may be employed for the
same purpose. Indeed, a supply of these articles is of the
most serious import in an hospital, as all cases of fever, con-
tagious diseases, or those peculiarly requiring seclusion, may
be promptly and eSectually removed into them from the wards.

Whatever may be the extent of our accommodation, it
ought to be formed into three grand divisions, which may be
larger or smaller as circumstances demand ; viz. the Surgical,
the Medical, and the Convalescent branches ; the two latter, of
course, will not be so urgently wanted immediately after an
action or series of field movements as the first ; but they
should be held in view, as ultimately of great consequence to-
wards the safe conduct of the medical part of the campaign.

* See " Annales de Litterature, &c." par MM. Kluyskens et Kesteloot,
Vol. xix. or Nos. 106 and 107, where a paper of considerable interest is given
by Professor Brugmans of Leyden, which contains a very valuable addition to
our knowledge of the state of the atmosphere in military hospitals, whether un-
der ordinary circumstances, or the dreadful infliction of contagious gangrene. I
have not repeated the professor's experiments, but I have observed, on various
occasions, a general improvement of the wounds and ulcers take place in the
military hospitals, after a supply of boards and tressels, or otlier means of
elevating the beds from the floors. The same has been observed on board the
Hospital Ship, on the coast of Egypt, by my friend Dr. Dickson of Clifton, in
patients elevated above the decks.

62 WOUNDED OFFICERS.

I would recommend it also as a general rule, never to open
several hospitals for the reception of the wounded at the same
time, although we should always hare them ready prepared
for such an event ; but always to permit one to be tenanted,
and its oflicers appointed to their several duties, before we
commence upon another. The attention of the medical and
purveying officers is thus directed to one object only at a time ;
and when an hospital is once put upon the proper establish-
ment, without being confused by additional admissions, the
business will go on with the utmost regularity. On the same
principle, wards, sub-divisions, and divisions, ought all to be
completed before others are opened. The size of the ward
will entirely depend upon the nature of the building employed
as an hospital. One hundred beds, however, are amply suffi-
cient to form a subdivision, and as many as one assistant in
ordinary cases can possibly manage, even if of the slightest
nature. — To this there should be one ward-master and six
orderly men at least. The employment of females is one of
the greatest sources of irregularity in an hospital ; every species
of excess, idleness, and plunder, is carried on under their
auspices.

In accommodating the wounded officers, if an hospital can
be procured for them, which is a matter of high importance,*
the same systematic arrangement may be easily adopted ; but,
at all events, certain streets or sections of a town or city ought
to be solely appropriated for their reception. Without some
arrangement of this kind, inconceivable difficulties will arise
in administering to them the necessary professional assistance,
as I have painfully experienced on more than one occasion.
Much is to be conceded to the peevishness of sickness, and
much to the habits of command in which oflicers have been
educated ; bat with every allownnce for their sufferings and

• For some practical remarks on this subject, sec a pamplilat by Dr.
FaulkontT, on the Kxpodiency of an Hospital for Officers.

CLASSIFICATION. IBS

their rank, the attending professional man, especially if of a
junior class, will have much to bear; and, with great respect
for the valour and honour of British officers, I am forced in
justice and candour to say, that in some instances I have ob-
served, that the most slightly injured, and the lowest in rank,
have been often the most troublesome and unreasonable ; and I
have heard the medical officers reprobated in the most insulting
terms for non-attendance at specific hours, upon the very indi-
viduals whom I have known to be the most constant frequenters
of the gaming table and the brothel. A false delicacy in those
cases is sure to be followed by calumny and complaint ; and the
medical attendant should at once inform the senior medical
officer, and respectfully submit his reasons for declining further
responsibility without proper investigation.

The fixed hospital being ready prepared, the compound
fractures should all be first removed, and placed in airy wards,
either on the first floor, or in those apartments easiest of ac-
cess. They should be classed according as the upper or lower
extremities, or their joints, may have suffered, and as the upper
or lower portion of each individual limb may be implicated ;
so as that all cases of a similar nature may be near each other,
and the men of the same corps brought together as much as
possible.

The same classification and general arrangement should be
pursued in the wounds and injuries of the head, neck, breast,
abdomen, pelvis, and extremities. The labours of the medical
officers, whether purely professional, or as referring to the con-
struction of the necessary returns, are thus seriously abridged,
and the due attendance upon the wounded accelerated and
assisted.

We shall now suppose our hospitals filled, our patients laid
comfortably in their beds, their diets regulated, and the whole
machine in motion. The diet table, as now in use in the Bri-
tish hospitals, is admirably calculated to ensure a sufficient
supply of nourishment to the soldier ; and the privilege of al-

C4 CLASSIFICATION.

lowing some extra articles to those on the lowest rates, if not
abused, must effectually meet every dietetic want. There is
no point in which a young practitioner is so apt to be deceived,
or in which his humanity may so often lead him astray, as in
this. The fewer extra articles, therefore, that he orders, he
may rest assured, the better for his patients. To prevent all
mistakes, the diet should be regularly marked by his own hand
at the bed-side; and if wine or spirits are allowed, they should
be invariably given under his own eye, or mixed with his
patient's medicine.

It is obvious, that whatever arrangements facilitate the exe-
cution of the duties, must ullimalely benefit the wounded; and
a conscientious oflScer will employ the time saved to him in this
way, in redoubled exertions for the advantage of those com-
mitted to his care, and will endeavour to identify his own
comfort and convenience with that of his patient. Punctuality
of attendance, preparing dressings and medicines in the in-
tervals of the visits, and a regular registration of cases, will
enable any man of common industry to acquit himself with
credit in his situation ; while men with the purest and most
scieutitic views, without these mechanical helps, exhaust their
strength, and redouble their toil.

CHAPTER IV.

DRESSINGS AND GENERAL MEDICAL TREATMENT.

There is no urgent necessity for removing the dressings
which have been applied in the field to the more simple wounds
of the extremities, for the first two or three days, whether the
wounded have arrived in the hospital, or are only on their
passage to it, provided the slips of plaster and bandage are
sufficiently secure, the dressings unstained by a sordid bloody
oozing, or no serious stiffness or uneasiness is perceived in the
part by the patient himself. In this, however, we must be
guided by season, climate, and the constitution of the indivi-
dual, or the peculiarity of his wound. It will generally be
sufficient to keep the dressings moistened with cold water,
either alone or mixed with a little spirits, vinegar, or wine ; or,
if the weather demands, and convenience on the march permits,
the same moderately warmed. As soon as possible after this
period, the field dressings should be removed, and the limb
either covered with cloths, moistened in an appropriate liquid,
or laid in emollient poultices moderately warm. It has of late
years become a fashion to decry the application of poultices,
and to dwell on the harm they viay produce, putting entirely
out of view the essential service that we actually derive from
them; but, after long experience on this point, and judging
from the feelings of the patients themselves, and the obvious
effects upon their wounds, I have no hesitation in saying, that a
soft and moderately warm poultice of bread, meal, bran, pump-
kin, carrot, or any other emollient substance, carefully applied,
and removed at least twice a day, until the sloughs begin to

66 DRESSINGS AND

loosen at the edges, and a purulent oozing is seen issuing from
under them — ^in fine, till the process of suppuration is fairly
commenced, is the best and most appropriate remedy in the
early stages of simple gunshot wounds, attended with much
contusion of the soft parts, and high inflammation.* They
should not be continued after this period, nor should they at
any time be applied, except under the direction of the attending
surgeon. It is to the abuse of continuing poultices day after
day, indiscriminately to all states and stages of wounds, that
their rejection by many is to be attributed, and that their
bad effects are due. If the inflammatory symptoms do not run
very high, and that the sloughs are beginning to separate
kindly, a pledget spread with any simple ointment, or merely
dipped in oil, and covered with cloths moistened in acidulated
water, will be quite sufficient as an external application ; while
the general state of the system should be cautiously attended to
in all cases. Compresses dipped in simple cold water have
lately been much recommended by Kernf and Assalini, as a
substitute for almost all other dressings ; and I have seen them
employed with considerable advantage. Where this plan is
adopted, oil-skins should be employed at the same time,
otherwise the beds get saturated with moisture, and severe
pulmonary attacks, or rheumatism, may ensue.

The history of the employment of water as a dressing to
wounds is curious and instructive. Soon after the introduction
of gunpowder, it became a common remedy among the Italians ;
but they did not conceive it to possess any medicinal powers,
until it had undergone certain mysterious and magical cererao-

* The time of the seimralion of the sloughs or eschars is quite uncertain.
Ravaton supposed, that in the sanguiue, and people of fair complexion, they
separated from th(! fifth to the eighth day, and in the brown and melancholic from
the tenth to tiie fifleenlh. The fact is, liicy separate sooner or later, according to
the rapidity with which healthy suppuration is produced.

•f Avis aux Chirurgiens sur les Pansemens de Blesses, Vienno, 1H(K). Sec also
the Observations of Mr. Outhrie on this subject, in tlie chapter on Simple Gun-
shot Wounds, in his last edition.

GENERAL MEDICAL TREATMENT. 67

nies; so that it long- remained in the hands of quacks and
medical conjurors, although Blondus published an essay on its
efficacy, at Venice, in 1542, under the title " De Medicamento
Aquffi nuper Invento et De partibus ictu sclopeti sectis ; " and
Gabriel Fallopius, Felix Palatius, Joubert, and Martel, all
followed upon the same subject, between the year 1560 and the
beginning of the following century. Joubert directs the water
to be used " sans aucun prononcement de verbes metapho-
riques, ni sur icelle, ni sur les drapeaux et charpies ; " and
Martel, with a discrimination rarely to be found even in later
times, says, " Je pense qu'un des principaux moyens pour
haster le guerison des playes est de les tenir bien nettes ; or
est il que I'eau les netoye et deterge bien fort. L'eau par sa
froideur empesche I'inflammation, tempere I'ardeur des hu-
meurs," &c. (Apologie pour les Chirurgiens. Lyon, 1601.)
Notwithstanding these enlightened views, cold water never
came into general favour ; and it must be confessed, that if
there existed gross deceptions among the quacks, there were
also gross prejudices among the regulars; for although they
could not deny that wounds were healed under the employment
of water solely, many of them affected to attribute this conse-
quence to arts magic and unchristian, and therefore continued
to scald their patients with boiling hot oil, or to grease them
with a composition of whelps stewed down alive; indeed, it is
questionable whether a patient, with any pretensions to piety,
would have submitted to the employment of the simple element,
labouring, as it then did, under the anathema of the church.
Without asserting that water is infallible, we must acknowledge
that it is often highly useful, and that, with the precautions
already mentioned, the surgeon can never be at a loss for a
remedy which is seldom injurious, and rarely, if ever, interferes
with the efforts of nature.*

* Baron Percy has given a valuable notice on the surgical employment of cold
water, in the article '• Eau," in the '■ Diclionnaire <les Sciences MeJicales,"
from which I have quoted the words of Joubert and Martel, whose works are
exceedingly rare. F 2

68 DRESSINGS AND

Few subjects bear free and full purging better than soldiers ;
and, under certain limitations, they are equally tolerant of the
lancet. Great prejudice exists among some of the younger
surgeons on the subject of phlebotomy, as applied to soldiers ;
they have some idea that this class of men cannot bear evacu-
ations, particularly of that kind, so well as the lower orders in
civil life : but the very reverse is the fact ; their whole plan of
diet, exercise, &c. or, as it is termed, the non-naturals, tends
to carry their system to the highest possible pitch of vigour,
(I, of course, am speaking of the effective bayonets;) and the
daily practice of our hospitals proves, that the recruit just taken
from the plough, witli all the appearance of health which a
ruddy countenance and a corpulent person can convey, will not
bear the lancet nearly so well as the same individual in a few
months after having been accustomed to the fare and mode of
living of a soldier. I have almost daily instances, in the
hospitals under my inspection, illustrative of this fact, where
blood has been drawn, for severe inflammations of the lungs
and other viscera, to an extent, one-third of which would
probably have sunk the patients beyond recovery a few months
before, when employed as day-labourers or mechanics.

Few, if any, of the veterans are without either confirmed he-
patic affections, or a strong tendency to them ; and it has never
fallen to my lot to see any class regular in their mode of diet,
without the strictest enforcement of rigid discipline. Hence
frequent derangements of the chylopoietic organs, and strongly
marked determination to the head and breast, where the least
access is allowed to spirituous or vinous potations ; or where
the fre(jucnt long fasts and the irregular system of cookery,
unavoidable in severe marches and grand movements, are
succeeded by the plenty of victory ; in which cases, by the
mistaken kindness of their comrades in the hospitals, or on the
jouniey to them, the wiiunded are often gorged with food and
intoxicating liquors; a practice which for the first few days no
precaution can altogether prevent. It should never be forgot-

GENERAL MEDICAL TREATMENT. 69

ten that the state of the stomach and bowels has a remarkable
influence upon the discharge from a wound, and is in turn
influenced by it; a degeneration of the discharge and a de-
ranged state of the intestines being almost always inseparably
connected ; and very frequently the approach of a change for
the worse in the wound, may be prognosticated some time before
its actual accession, by the torpor or relaxation of the intestinal
canal, and the depraved quality of its contents.*

The state of the skin is also an object of particular conse-
quence in preventing or moderating fever ; and in this view
the antimonial preparations will be found of the most essential
service, administered either in the aqua ammon. acet. or in an
anodyne draught, if severe pain and spasmodic twitchings
about the wound render opiates necessary. In ordinary cases,
however, I would recommend the sparing use of opiates; and
in the more severe, particularly if attended with fractures, we
should always reserve them to the latter part of the cure, when
they become so indispensably necessary. Where a temporary
lowering of the system is an object of importance, and the use
of the lancet is to be restricted, nothing is more effectual than
nauseating doses of the antimonial class. It must also be kept
in view, that, independently of the symptomatic fever which
more or less attends all wounds, men labouring under them,
and crowded together in large hospitals, are particularly subject
to the prevailing diseases of the country where they serve, even
though they may be complete acclimates; their irritable and
debilitated state rendering them particularly obnoxious to every
species of contagious affection, common among the inhabitants,
and to some peculiar to themselves.

When the parts are brought into free suppuration, great
attention becomes necessary in the dressings, to prevent the

* Among modern authors on this subject, I would particularly refer to the
works of Hamilton and Abernethy ; but the observation did not escape the illus-
trious Boerhaave, who published his Thesis in 1693 at Leyden, upon the utility of
inspecting the evacuations of the sick.

70 DRESSINGS AND

formation of sinuses, by the proper application of pressure with
compresses and bandage, by carefully removing all stagnant
purulent matter, and, if occasion requires, facilitating its eva-
cuation by a regulated use of the bistoury in the enlargement
of particular points, or by the forming of counter openings ; by
the removal of all the loose sloughs and extraneous bodies which
we have not been able to effect on the field or at subsequent
dressings ; and, finally, by carefully continuing every means
which may restore the healthy action of the system. It is under
the strong fascise of the thigh and arm, and among their long
muscles; and in wounds about the back and loins, that we have
particularly to dread the formation of sinuses : but if, in spite
of all our endeavours, they do form, we should not trust to
pressure, but at once have recourse to the knife, for which no
adequate substitute can be found, either in the mechanical or
chemical stimulants of the seton, or injection. Here, and here
principally, it is that Scarifications are truly useful ; and in such
cases they merit all the praise that their indiscriminate admirers
have bestowed upon them.

In the tumefaction also of the muscular parts of the extre-
mities, confined by strong fasciae, which are attended with great
pain and high fever, a prudent use of the knife will be of
essential service; inasmuch as, by removing the strictured state
of the parts, suppuration is prevented, or, if it has taken place,
a free exit is given to the matter, and its insinuation among the
interstices of the muscles is obviated. But the trilling and
superficial scratches often made at the orifices of shot-holes are
entirely useless, and scarcely ever attempted by surgeons of
experience. As the following case shows the inutility of the
one and the great advantages of the other, I select it from many
othcsrs of a kimilar natun* in illustration of this fact.

GENERAL MEDICAL TREATMENT. 71

Case I."

Illustration of the Effects of Scarification,

A sergeant of dragoons was shot through the external part
of the thigh at Waterloo, and was dressed for the first week by
a Belgic surgeon. The lips of each orifice, which were plugged
up with charpie, had been scarified in a radiated manner to
about half an inch deep, as he said ; but were nearly healed on
my seeing him. Shortly after, heat, pain, and tumefaction took
place in the limb, attended with considerable fever and great
derangement of the head and stomach. This at last proceeded
to such a degree, that the assistants requested me again to
examine him, which I did on the 14th day. I found one orifice
still open, and that some superficial scarifications had been
repeated, and the limb fomented, but without effect; it was
extremely tense, hot, and painful to the touch ; it could not
be moved without great uneasiness ; the lower part of the limb,
from the knee down, was oedematous, while the thigh itself was
swollen up to the external trochanter ; interiorly it was lest so,
but rather puffy. I made a long and deep incision from the
trochanter nearly down to the knee, completely through the
fascia, and about the centre of the limb I dipped almost to the
bone. So far from this occasioning pain, the man begged me
to go on ; and, although there was but a very slight discharge
of matter from the wound, he felt easier within an hour.* The
bleeding from the part was encouraged by warm fomentations ;
and in five days the sergeant was able to walk about, and was
soon after discharged convalescent.

* The effusion occasioned by tight bandaging, or by stricture on the parts from
their being bound down by the fasciae, never is followed by a healthy suppuration,
but by a burrowing and destruction of the parts. This is very strongly illustrated
in cases of paronychia.

72 DRESSINGS AND

The knife, as we have already seen, is often indispensable in
our search after balls, splinters, and bleeding vessels. It is
also highly useful in relieving the strictured state of the parts
tied down by fasciae, when that stricture is forming, or formed,
but neither does the stricture form in all cases, nor does early
scarification prevent it, because the tumefaction depending
upon violence of injury, locality, and circumstances of consti-
tution and treatment, the scarified parts may, and often do,
heal before the occurrence of the contingency for which it has
been employed. I have often seen repeated scarifications "in
expectation," if I may so call them, performed on individuals
who never required them, and several on individuals some days,
and even weeks, before they were required, and although the
parts often wonderfully sustain these repeated cuttings, I have
occasionally seen them rendered highly irritable, and sometimes
callous.*

It may not be amiss to observe, (although I have rarely met
with the case myself,) that on some occasions an herniary pro-
trusion of the muscles lakes place after extensive slitting of the
fasciae, or removal of these coverings by contusion or sloughing;
a sup[)orting bandage, with occasional adhesive straps, is the
only plan that 1 sliould recommend on such occasions, together
with such a position of the liuib as may favour the return of the
muscles to their natural situation.f

The labours of the medical officer will be much abridged in
the necessary duty of dressing, if, in addition to his tray, fur-
nished with ready prepared dressings and common formulaj of

• It was with great pliasiire that 1 found, by a communication from Dr.
Jackson, whose indefaligubli; labours in the medical department of the army are
so well known, that the remarks I have made on scariOcations, poultices, &c.
arc conformable to his experience, an account of which he published so long since
as 1790, in a paper in the " Loudon Medical Journal," vol. xi. j). 3G3. See also
Botallus, chap. ii. and Hunter, chap. ii. On the otliir hand, Percy, Larrey, and all
the French surgeons, strongly recommend the practice.

f See Report by Dr. Thomson, p. 125.

GENERAL MEDICAL TREATMENT. 73

medicines, he provides a portable camp stool, to sit at ease by
his patient's bed-side while dressing; for, without this, or some
such relief, if the beds are on a low platform, or on the floor,
and the cases of a nature which require long attention, as in
compound fractures, he will be exhausted before half the labour
of the day is finished. To these should be added a basket for
the reception of all the old filthy dressings, and an oil-skin to
preserve the bedding from wet, and purulent matter or blood.
Without these little aids the young surgeon will be seriously
embarassed on his first appearance in a military hospital after
an influx of wounded.

A great deal of confusion and filth will also be saved, if, at
the early morning visit, all the slighter cases and those not con-
fined to bed are ordered into the open air or a tent, and there
dressed, and on no occasion permitted to lounge in the wards,
or lie on their beds with their clothes or shoes on.

Jf the patient cannot sit up in bed, the oil-skin must be placed
under the limb, and the former dressings gently moistened by
a sponge and warm water, and then carefully withdrawn, the
refuse poultices, lint, &c. thrown into a bucket or basket for
removal, and the soiled roller laid aside for the purpose of
being washed for subsequent use. All filth must now be
attentively removed from the surface or lips of the sore; if it is
a stump or a point where a vessel has been tied, if long liga-
tures are left, they must be very cautiously handled ; if adhesive
straps have been used, they must be taken off one by one.
Gentle pressure must be made all round to bring away any
concealed matter; and if abscesses are formed, they should be
opened on the spot. The fresh dressings must now be applied
without any unnecessary delay, all their loose edges and
redundancies removed, and a neatness and even nicety of shape
observed in the straps and dossils, which, though we ourselves
know not to be essential, weigh amazingly with the patients and
attendants. In the application of the roller, however, nicety
is essential, as on its due employment the removal of existing

74 DRESSINGS AND

evils, and the prevention of many more entirely depend. As a
support to parts requiring approximation or separation; as
preventing the insinuation of matter, blood, or serum, among
the interstitial spaces ; as expelling them and preventing their
re-accumulation when formed ; as repressing redundant or pro-
truding growths, or stimulating their absorption; and, finally,
as retaining other applications in contact to the parts — ^too
much attention can scarcely be paid to the application of the
roller : and yet candour compels me to say, that foreigners of
almost all countries excel us in this fundamental part of our
art. Our young students may study, philosophize, and reason
well; but neither books, reflection, nor arguments, will teach
the application of a bandage, without repeated practice.

The most judicious medical treatment and the ablest surgical
operation will fail, if not assisted by good bandaging ; and
errors in both will soon be recovered, if a proper system is
adopted. T have seen innumerable instances of most promising
stumps degenerating in a few days under an inefficient or care-
less dresser; and I have even traced some deaths to such a
cause ; while rapid amendment and the saving of a limb often
result from the due use of a proper system of dressing and
applying the roller.

Escharotics, so useful under certain circumstances, are fre-
quently grossly abused ; and an insensibility, or sometimes very
high morbid irritability of parts induced by them. In simple
cases of redundant or luxuriant granulations, a little scraped
lint, with pressure from a compress, will be found quite suffi-
cient for their removal ; and the same will accelerate the skin-
ning of a wound, as well as lunar caustic, or cupreous solutions ;
with these two last, old soldiers are well acquainted, and they
should never be trusted with their use. In no instance cither,
should the orderly men or the patients themselves be permitted
to apply the dressings or rollers; and at the time of dressing,
all the necessary prescriptions should be administered, and all
th<' minor operations, as bleeding, ^c. performed. 1 should

GENERAL MEDICAL TREATMENT. ^

not do justice to this part of my subject, did I not refer to the
excellent observations to be found in Professor Thomson's
Lectures on Inflammation, on the management of Dressings,
and, above all, did I not particularly recommend a mild and
humane demeanour to the dresser.* The soldier, who is so fierce
in the field and so submissive in the operation room, becomes a
most fretful being under the smarting of his wounds ; and he
frequently looks upon our best directed endeavours for his
relief as only experiments upon his fortitude. I am sorry to
say, that I have but too often seen surgeons, even of high rank
and long experience, yielding to a prurience for operation, take
up the knife, the forceps, and the probe, on every opportunity,
and handle in the most inconsiderate manner even the fractured
limbs of their patients.

* Lectures on Inflammation, by John Thomson, M.D. Edinb. 1813, p. 294. See
also a Letter, by Dr. Dewar, upon a particular State of Gunshot Wounds,
addressed to Staff-Surgeon Boggie, Edinb. 1815. A paper on the subject is also
to be found in the Medico-Chirurgical Transactions, Vol. vii. p. 482, Part ii. by
the same author.

CHAPTER V.

EXTRACTION OF FOREIGN BODIES.

We have sufficient occasion, in the course of a surgical
campaign, for the use of our whole Arraamentum Chirurgicum,
without having recourse to superfluous scarifications and
pokings ; and even under the most judicious employment of
instruments, we are frequently foiled in our intentions, par-
ticularly in the extraction of foreign bodies ; which, by the
violence and rapidity with which they have been forced into
the living solids, sometimes take very unusual and deep-seated
routes, not at all to be accounted for by any preconceived
theories drawn from the doctrines of projectiles, nor to be ex-
plained by diagrams founded upon mathematical rules.

A recollection, however, of the texture of the different parts
through which the ball may pass, and a comparison of its firm-
ness, its soft or its elastic nature, conjoined with that of the
general doctrine of projectiles, will be no mean assistance to
our judgment in forming an opinion of the probable course of
a ball.

The older surgeons were sadly puzzled on the subject of the
extraction of foreign bodies, and had, as usual, recourse to
magic, to prayers, and to charms, when their prepared load-
stones and rude lire-hals failed,* The natural anxiety which

* Those who have neither leisure nor opportunity to consult the original
authors, will find a very learned and salisfalory account of the means used by the
older surgeons for the extraction of foreign bodies in the " Tableau rapidc des
diflerens inbtriimcnts," &c. by M. Percy, in his " Manuel du Chirugien d'Arm^e ;"

EXTRACTION OF FOREIGN BODIES. fS-

every wounded man feels to have the supposed cause of his
pain removed, and the praises which he and his friends so
liberally bestow on a successful operation, have, at all times,
made surgeons anxious in the invention of those very inge-
nious and very useless articles, bullet extractors ; the employ-
ment of which is completely superseded by the common for-
ceps ; or still more by that of M. Percy, used with a little in-
genuity ; for wherever a bulky and complicated bullet ex-
tractor can enter, the former instruments can go down with
in6nitely greater ease; but, unfortunately for both instru-
ments, we most require their mechanical power in tortuous
passages, or deep-curved and angular cavities, where we can
least make use of them.

The great point is, to discover where the extraneous matter
lies; and he must possess very little manual dexterity indeed,
who cannot remove it from the soft parts, if the removal is ad-
visable. These bodies naturally divide themselves, first, into
the inflicting body itself, or the articles attached to it; secondly,
substances forced in with the inflicting body ; thirdly, compo-
nent parts of the limb or organ wounded, but which have been
rendered extraneous by their total or partial death. All these
may be found either in or near the wounds themselves ; or by
their gravitation, by muscular action, or by other causes, may
have been carried from their original situation, and deposited
in or near other distant organs.

Balls of every kind, from the smallest carbine bore to that
of a field piece, surrounded with cartridge paper or flannel,

and a very good summary account of their superstitious and peculiar notions con-
cerning wounds, will be found in the " Liber Quintus Practicae Medicinte, Pars
Quarta," of Daniel Sennertus, under the heads, " De Rebus alienis e vulnere
eximendis;" " De Csesaris Magatiet Ludovici Septalii curandi vulnera methodo
judicium;" " Desclopetorumvulneribus ;" " Deunguento armario;" and above
all, in his twenty fourth chapter, part iv. where the following question is fully
debated : " An liceat Christiano periaptis et sigillis appeusis, vel similibus
raodis, se ab armis inviolabilem prestare ?" See also Pare's Works, lib. ij.

78 EXTRACTION OP' FOREIGN BODIES.

and pieces of shell from the most miuute size up to the weight
of several ounces, are daily instances of the first class. To
these may be added, though of less frequent occurrence, bay-
onet and sword points, lance heads, &c. To the second class
are referable, pieces of clothing, buttons, coins, parts of breast-
plates, of watches, their chains and seals, keys, and all the dif-
ferent contents of a man's own pocket, or of the pocket of a
near comrade ; splinters of wood, stones, earth, &c. In the
last class, which are by far the most troublesome and danger-
ous, are included splinters of bone of all sizes, coag^ula, and
sloughs. It may be asked, how can such large masses pos-
sibly be contained in a limb, or lie among muscles without be-
ing betrayed by their bulk? The explanation is not difficult;
the immense rapidity with which they are propelled not only
forces them into the soft parts, but compacts these parts close-
ly together, while the space they originally occupied is filled
by the projected body. The elasticity also of the parts allows
of substances of a very large size to pass in without the exter-
nal entrance in any degree corresponding to the size of the
body : thus musket balls are often found to leave only traces
of an orifice which admits little more than a common sized
bougie, and I have seen grape extracted from an orifice which
before its enlargement, was not a fourth part of the diameter
of the ball. The orifice is also still farther contracted by the
swelling which takes place, and the existence of a ball within,
is frequently rendered more obscure by the absence of pain or
any unusual sense of weight.

When, however, after some lime the living fibre recovers
sufficient tone, the natural tumefaction which necessarily pre-
cedes the throwing ofi" the dead matter, soon produces such a
degree of pain, as gives notice of the troublesome guest.
Sometimes where the constitution is less irritabh^ or the
wounded parts possess but little sensibility, or where the fo-
reign body is small and polished, f)r may have formed a secure
bed for itself in the belly of a muscle, or in an interstitial

EXTRACTION OF FOREIGN BODIES. 79.

space, no derangement whatever succeeds ; and the part heals
up as if no extraneous body were present. Masses of very ex-
traordinary, and almost incredible sizes, are found in various
parts of the body. I have frequently seen them of one, and
sometimes of two pounds weight. Mr. Guthrie (p. 185) has
seen a ball of eight pounds weight lodge in the thigh, without
making a very large opening, and remain undiscovered until
the limb was amputated, and then it rolled out. In the first
edition of this work, I gave the case of Lieutenant F. an
officer of the 12th regiment of infantry. 1 stated it as it
appeared in the periodical papers of the day, and as it was
related to me by many officers who served in India ; but by
the kindness of Dr. Kennedy of Edinburgh, formerly Superin-
tendent Surgeon in the East India Company's service, I am
enabled to give a much more accurate account of it than I
could possibly do at that time.

Case II.

Cannon Ball lodged in the Thigh.

" The particulars of the wound," says Dr. Kennedy, " by

which Lieutenant F , of his Majesty's 12lh regiment, was

killed at the siege of Seriugapatam, were stated to me a very
few days afterwards, by the late Dr. Alexander Anderson, the
superintending surgeon and chief medical officer of the army,
as follows :

" A shot from a heavy gun came rolling along the ground,
like a spent ball, towards the trenches. It rolled over that

part of the banquet under which Lieutenant F happened

to be lying down, and buried itself under the skin and muscles
of his hip. He was immediately put into a dooly and carried
to Dr. Anderson's tent. Upon layiug down the dooly, the
bearers complained of the difficulty they had found in carrying
it from the trenches, owing to its having been unusually heavy

80 EXTRACTION OF FOREIGN BODIES.

on one side. Dr. Anderson, upon running his fingers into the
wound, was surprized to find a mass of iron of such unusual
size, that he concluded it must be part of a large shell which
was lodged there. Lieutenant F ■ ■■■ being then moribund,
the shot was not cut out till after he died, when it proved to be
what Dr. Anderson called to me unequivocally a thirty-two
pound shot. One circumstance only throws any doubt upon
its having been actually a shot of this calibre, and it is this : —
It was afterwards said that this shot had been fired from a gun
very conspicuous, during the siege, both from its being
mounted upon a high cavalier, and also from the mischief it
did, and it was also said, that after the place was taken, this
gun was found to be only a French 24-pounder, which gives a
calibre of nearly twenty-eight pounds English. Whether this

shot which killed Lieutenant F was fired from this gun I

do not know, but it is certain that a shot thrown from this very
gun into the Head Quarter line, (which was an unusual dis-
tance,) and which lay during the rest of the siege near to
Lord Harris's tent, was afterwards looked upon and spoken of
as a 32 pound shot."

The following cases are of a more ordinary kind, but are
still interesting and instructive.

Case IIL

Grape-shot lodged in the Sole of the Foot.

A mounted officer was wounded, at the battle of Waterloo,
by a grape-shot; it struck between his foot and stirrup; im-
mense tumefaction of the parts, and an approach to gangrene,
took place ; no suspicion was entertained at the time that any
foreign body was lodgjsd, but on examination with a probe,
after the high inllamniatory symptoms had subsided, a mass
of metal, nearly as large as the closed fist, was extracted from

EXTRACTION OF FOREIGN BOniF.S. 81

under the plantar aponeurosis, by Dr. O'Beirne of the Royal
Artillery ; it was not weighed. By great attention to ban-
daging and position, (he officer has recovered the use of the
foot, and the loss of substance has been repaired.

Case IV.

Grape-shot lodged in the Thigh.

A soldier of the 95th regiment received a wound from a
grape-shot at the storming of Badajoz, which entered about
the centime of the glutrei muscles of the right side, but without
injuring the bones of the pelvis. Very violent inflammation
and extensive sloughing took place, and the fever ran so high
that it was nearly five weeks before the patient was free from
danger. At the end of that period, he complained of a sense
of weight in the thigh of the leftside; and, on examination,
a slight discoloration and an obscure sense of fluctuation
could be perceived. As every attempt at finding the ball had
been vain, we began to hope that it had coursed round under
the muscles, and lodged about the point where the uneasy
sensation was felt. The man was therefore directed to lie, as
much as possible, in a position favourable to its gravitation ;
and the part was fomented at intervals of four hours. On
the second day after the adoption of this plan, evident fluctu-
ation was felt, and a hard body, lying loose within the abscess
could be distinguished when he was placed in a favourable
posture ; but whenever the limb was moved, it seemed to re-
cede. On the third day a large ball was plainly felt, lying
near the edge of the sartorius muscle, and apparently in con-
tact with the femoral artery ; but still receding from it if the
position of the limb was changed. I now made a cautious
puncture over the site of the ball, which was followed by
the discharge of about a pound of very foetid matter, mixed
with clots of blood, and a ball of large size could be felt by

82 EXTRACTION OF FOREIGN BODIES.

the probe and finger. The man fainted, and obstinately re-
fused to permit any enlargement of the opening. As all fear
of haemorrhage from the artery was now over, he was ordered
a glass of wine and water, an anodyne at night, and the appli-
cation of a soft and warm cataplasm to the part. The next
day he willingly submitted to a further operation, when an
incision being made along the edge of the sartorius muscle,
the ball was extracted by one of my assistants with very little
difficulty, and his recovery was, from that period, progressive.
On examining the ball, it was found to be of iron, crusted
over with canvas, and weighed eight ounces.

By the kindness of Staft-Surgeon Brownrigg, I was afforded
an opportunity of seeing the following case, which is detailed
by Assistant-Surgeon Reid, 25th regiment:

Case V.

Splinter of Shell lodged in the Abdominal Muscles.

John Brown, private 2d battalion 1st Foot Guards, was
wounded at Waterloo, on the I8th of June, 1815, by a frag-
ment of a shell, which produced a considerable degree of la-
ceration of the glutaei muscles of the right side, passed over
the spine or semicircular edge of the ilium, and lodged itself
between the internal oblique and transverse muscles of the
abdomen. The orifice of the wound, which was dressed with
dry lint, soon assumed a healthy appearance, and showed a
disposition to cicatrize; but as the patient's health gradually
declined, and as he frequently complained of obtuse pain in
his abdomen, accompanied by a sense of weight and pressure,
there was reason to suspect that these complaints originated
in some cause which had hitherto escaped detection. This
idea was rendered more probable by the immense purulent
discharge which issued from the wound, when the patient

EXTRACTION OF FOREIGN BODIES. 83

was turned on his right side; the integuments liowever of
the abdomen still preserved their natural colour, and no hard-
ness, swelling, or extraneous body was perceptible to the
touch. Three weeks after the injury had been received, the
patient informed me, when dressing his wound, that he felt a
hard substance in his abdomen, which changed its place to a
certain degree according to the position in which he placed
himself. He was now visited by Dr. Thomson of Edinburgh,
and by Mr. Brownrigg, Surgeon to the Forces, who agreed in
opinion, that an incision should be made directly over the
hard body alluded to, which was now distinctly perceptible
to the touch, in the centre of the right lumbar region. An
incision, four inches in length, and about half an inch in
depth was accordingly made, which enabled the operator,
Mr. Brownrigg, to discover and extract a piece of shell, of
an irregularly quadrangular form, weighing nine ounces and
a half avoirdupois, together with several small pieces of bone,
which had been detached from the ilium. The wound was
kept open by the insertion of dry lint, in order to promote the
discharge from the cavity which had been formed by the
piece of shell, and to excite the process of granulation in the
contiguous surfaces. The discharge, which was purulent and
healthy, from this time gradually diminished ; and the patient's
health and strength improved rapidly. On the 20th of Au-
gust, the original wound on the ilium was completely cicatrized,
and the purulent discharge from the incision was almost imper-
ceptible. The patient's health was now quite good ; and,
from the favourable manner in which the cure proceeded, I
have no doubt, but it was soon after completed.

Case VI.

Pieces of Coin lodged in the Thigh,

A mounted Staff-Officer, in one of the actions previous to
the decisive one at Waterloo, was knocked off his horse by a

G 2

84 EXTRACTION OF FOREIGN BODIES.

round shot, which carried away the arm close to the elbow, and
inflicted a very extensive lacerated wound on the external part
of the thigh of the same side. Amputation of the arm was
performed as soon as he got within reach of medical aid, and
the thigh was dressed, not without some fears upon the part of
the surgeon, that amputation of it also would ultimately be
necessary. In the great confusion, and frequent change of
attendance, which the exigencies of the service required, the
gentleman who operated was not able to continue his attend-
ance, and I was sent for. I found the teguments and part of
the fascia of the thigh, and subjacent muscles for about three
hands' breadth, dreadfully lacerated, and in a highly irritable
and sloughing state, with a thin, sanious, fetid discharge ;
his skin hot and dry ; his tongue covered with a whitish fur,
particularly at the back part, and trembling when exposed to
view ; the epigastric region somewhat swollen, and tender to
the touch; the eye suffused, and intolerant of light; the
sensorium much confused, but when his mind was brought
to any particular point, he would converse rationally for a
few moments, though it was obviously with an effort.

I found, from his servant, that he had had no stool for two
days, and what he had passed was described as very " filthy
stuff." I ordered five grains of the mass of blue pill to be ta-
ken immediately, and, in the course of a few hours after, a so-
lution of 5J. of sulpliat of magnesia in 58 of water, with 3J. of
antimonial wine, which is the common purgative I use, in pre-
ference to more elaborate forms ; occasionally adding an aro-
malic, Ife was directed to take a wine-glassful every hour or
oftener, until it operated. A large emollient cataplasm was at
tlie same time ordered to the wound, and I \v.ft directions to
give him an 4inodyne at night, with some antimonial wine, if
the purgative should have sullicienlly opened his bowels ; and
to have his skin well sjionged with tepid water, and a little
vinegar. His kind hostess implicitly obeyed all my directions ;
and in the morning I had the pleasure of finding all his symp-

EXTRACTION OF FOREIGN BODIES. 85

toms much relieved: the skin was soft and cool; the pulse,
which had been above 100, had sunk to 80 ; the tongue had
become cleaner, and the discharge from the wound much more
favourable ; he had had several stools, of a blackish, pitchy,
appearance, and intolerable felor.

By the occasional use of the purgative mixture, with the
antimonial anodyne at night, he was much amended in a few
days ; and at length, after suppuration had been fully estab-
lished, Mr. Lorimer, the assistant who dressed the case, in
cleaning the sore on the thigh, discovered an extraneous sub-
stance deeply imbedded in the vastus externus muscle, which,
on removal, proved to be his pantaloon pocket, of coarse linen,
containing two five-franc pieces and two small copper coins.
I need scarcely say, that, after such an injury, in a constitution
debilitated by former severe wounds, the recovery was very
slow, and the irritability excessive, although great relief was
obtained from the extraction of those articles.

Case VII.

Pieces of Coin lodged in the thigh.

A Hanoverian soldier received a severe wound from a
grape-shot on the 18th of June 1815, at Waterloo, which
struck him on the external part of the thigh, producing very
extensive laceration. On the second day he was brought into
the hospital, and tlie usual dressings were applied. On the
fifth day a long narrow passage was discovered by the probe,
seeming to run nearly the whole length of the vastus externus
muscle. On cutting into this, three pieces of coin (which,
from the very curious mode in which they were compacted
together, I thought worthy of presenting to the Director
General of Hospitals) were extracted from the parts. This
poor fellow, a raw recruit, had no money whatever about him,
nor even a pocket to contain it, and fervently protested against

86 EXTRACTION OF FOREIGN BODIES.

his right to this forced loan. He accounted for it by supposing
that the money was carried from the pocket of his comrade,
who stood before him in the ranks, and who was killed by the
same shot which wounded him.

The coins, consisting of two five-franc pieces and a Dutch
stiver, were obviously first struck by the shot, and carried
along by it; for nearly one half of their flat surfaces, the
silver pieces adhered closely together ; on the other, where
the ball had struck their edges, the metal was flattened out,
and somewhat hollowed. In this hollow lay the copper coin,
in some degree adapted to the shape of the depression on the
larger pieces.

I cannot omit noticing here a trait strongly illustrative of
the mobility of mind which characterizes soldiers, and their
proneness to superstition and belief in omens, which a surgeon
acquainted with their character can often turn to their benefit.
The part of these two coins which had been flattened out hap-
pened to be that on which Napoleon's head was impressed.
From one it was nearly effaced ; and on observing this circum-
stance to the patient and his comrades, a universal burst of
joy echoed through the ward ; the young Hanoverian exulted
in the share he conceived he had personally had of contri-
buting to the downfall of the French Emperor ; his health ra-
pidly improved, and I have no doubt that this simple cir-
cumstance produced a good effect upon every man who wit-
nessed it.

Case VIII.

Piece of a Cranium loihjed in the Thi<jh.

A soldier of the Ti'Jd regiinmt was wounded at Badajoz
by a ball, which carried oil" his arm. He lay for some time
in the breach among the iuaps ol" his wounded comrades, the
enemy keeping up an incessant lire upon them. When

EXTRACTION OK FOREIGN BODIES. 87

brought into the hospital at Elvas, several fragments of the
bones of a cranium were taken from a lacerated wound on his
thigh.

Case IX.

Piece of the Ulna and Olecranon lodged in the Bend of the

Elboto.

A French officer of the German regiment of Nassau was
wounded at the same siege; his fore-arm was dreadfully la-
cerated, and, gangrene supervening, it became necessary to
remove the limb above the joint. In the bend of the elbow
a piece of bone was found; firmly imbedded, which, on exami-
nation, proved to be part of an ulna and olecranon of another
person, that had been driven in by the ball.

Case X.

Tooth lodged in the Temple.

On extracting a ragged angular musket ball from under
the temporal fascia of a sergeant, who was wounded at Burgos,
Staff-Surgeon Hughes, then of the Portuguese service, felt
what he supposed to be a bit of loose bone ; but on withdraw-
ing it with his forceps, it proved to be the body and crown
of a bicuspid tooth of the soldier who stood a little in front of
the sergeant, and who, wounded by the same ball, had almost
all the teeth of the left side of the under jaw fractured and
carried away.

Examples of this kind are still more frequent in naval ac-
tions, proceeding from the crowding and more irregular forma-
tion of the combatants ; and some distinguished officers have
been the subjects.*

• Admiral Duckworth, Sir Edward Berry.

88 EXTRACTION OF FOREIGN BODIES.

It would be superfluous to give more instances of this kind,
especially as I shall have to offer some others of a remarkable
nature in treatinjj of particular wounds. I shall therefore pro-
ceed to a few practical observations on the subject.

The experience of all ages has confirmed the dictates of
common sense in giving the preference to the finger over all
other instruments, for probing a wound. By a judicious tact,
the state of the parts, and the nature and site of the extraneous
matter, can be generally ascertained, and foreign bodies re-
moved or brought within safe and easy reach of the dressing
forceps, particularly in the limbs, where counter pressure will
much assist us in bringing them forward more immediately
to the point of the finger. In doing this, the limb should be
relaxed, and put into a position favourable to the gravitation
of the ball, &,c. towards the surface, if it can be done without
much pain ; and if no serious inconvenience follows, the patient
should be placed, as recommended by all the older surgeons, in
the position in which he received the injury ; but in many cases
this is impracticable, and in none indispensable, although the
practitioners of former days attached such value to it, that in
some instances, if the wounded man happened unfortunately to
be a trooper, they placed him on horseback to facilitate the
extraction of the inflicting body ! * Fully to answer every
purpose expected from this plan, not only the posture of the
wounded man, but that of his assailant, should be determined.

The surgeon should never omit a moderate search after
extraneous bodies at every dressing, if he has evidence or sus-
picion of their being lodged in (he wound. A casual visitor
may, without this precaution, frefjuently snatch from him the
praise due to a long and assiduous attention; for it not unfre-

* See GeHDcr's " Obhcrvat. de (Jhinirgiu: iligiiitatc ut prsstantin," as quoted
by Wiseman, p. 8*i+, fol. edit. I.oiiil. 170.'). Or the collection published by Gesner
at Zurich, in 1565, which contains the lualisc, iind lliose of Maggius and Ferrius
with many othcrb.

EXTRACTION OF FOREIGN BODIES. 89

quently happens, that, after the most particular and cautious
search, some accidental movement of the patient, or some in-
ternal revolution in the wound, — either tumefaction or profuse
flow of matter, will brin^ the substance lodged within our
reach; nay, it is often spontaneously discharged, and found
enveloped in the dressings or poultice.

It often happens also that extraneous bodies remain for years
without inconveniencing the patient in the smallest degree;
sometimes in the spot where they originally lodged ; sometimes
making occasional deviations, and at others taking such
courses as are not at all to be anticipated, indeed often con-
trary to every calculation.

Authors abound with histories of extraneous bodies, pre-
senting at points not only different from that where they entered,
but at points where they must have arrived, contrary to the laws
of gravitation, and influenced only by the action of the muscles.*
If they lie very deep (which smooth leaden balls are particularly
apt to do) without giving pain, they ought never to be removed;
when they come from their lurking-places, and present at the
skin, or near the surface, the extraction becomes a matter of
great simplicity.

Except the ball or other foreign matter is completely in our
power, we should never use the knife to enlarge the wound, or
promise a certain extraction, however urgent the patient may
be; for as nothing is more cheering than presenting him with
the ball, so nothing is more disheartening, or tends more to

* See, particularly in the Philosophical Transactions, abridged by Hutton,
Shaw, and Pearsou, vol. xii. p. 590, cases of pins swallowed, and discharged at the
shoulder ; and a needle in the left arm of a woman, discharged at the right breast,
by Dr. Lysons of Gloucester. A case is given by Gasparetti, in his " Osserva-
zioni," of a piece of glass, after nine years, shifting from one hand to the other;
and numerous instances of articles swallowed, and passing out by the muscles,
bladder, vagina, neck, and region of the liver, may be found in Valisneri, Opera,
lorn. i. p. 360, and by Silvy in Memoires de la Soci6le Medicale d'Emulation,
An. 5, p. 181.

90 EXTRACTION OF FOREIGN BODIES.

shake his confidence in his medical attendants, than a disap-
pointment under these circumstances.

Some useful information may be drawn from the appearance
of the ball, as to the nature of the matter carried in by it, or
of the injury it may have inflicted upon the bone. Shreds of
cloth, the metallic particles of an epaulet, a piece of lace, of
breast-plate, or other ornament, are frequently found solidly
imbedded in it ; and these appearances may lead us to a more
certain knowledg-e of the existence of foreign matter in the
wound.

Balls also are flattened out in various degrees, in proportion
to the violence which which they strike a bone, and the shape
and hardness of the bone itself. They are sometimes singularly
elongated, and jammed in between bones which are naturally
separated, or which they may have fractured ; and their ex-
traction is thus often rendered difficult and painful.

A leaden bullet also occasionally leaves a part of its own
metallic composition in the wound, as it is frequently split, or
cut to various depths against the sharp edge of a bone, as the
tibia, vomer, &c. or against the remaining sound edge of the
cranium after eff'ecting a fracture in it: not unfrequently the
fragment is found at a distant point, and sometimes in situations
where no such event could be anticipated. The following case
is a curious illustration of this fact.

Case XI.

Fra(/me7it of Ball lodt/ed on llie Jit(/iil<ir Vein»

A soldier of the corps of Brunswick Oels, was struck at
Waterloo by a musket ball on the tip of the nose, which split
upon the bony edge where it is joined by the cartilage. A piece
of the ball was extracted on the spot, and it was supposed that
the bull itself had been purposely cut into pieces, as is some-
times done by foreign rillenicn. The cure went on without

EXTRACTION OF FOREIGN BODIES. 91

accident until tbe tenth day, when the man was seized with a
violent hajmorrhage from the mouth and nose, which came on
suddenly, and carried him off in the course of the night. On
dissection, it appeared that a very minute portion of the ball
had penetrated along the basis of the skull, lodged in the sinus
of the left internal jugular vein, forming a sort of sac for itself
close upon the vein, which, having inflamed the coats of the
vessel, at last ulcerated and burst. This case occurred in the
practice of my friend Dr. Pockels, now Surgeon-in-Chief of
the troops of Brunswick.

Balls also sometimes split without being mechanically cut,
possibly from a flaw in the casting. Thus, in a case to which
I was called at Brussels, by my friend Staff"-Surgeon Lindsay,
be found a part of a ball lying in a fracture of the os frontis,
which it had obviously struck directly in front, without at all
interfering with the edges of the sound bone. — The case termi-
nated successfully after the application of the trephine.

The process employed by nature for confining extraneous
bodies in muscular parts, and cutting them off from the general
system, is very simple. Their presence gives rise to irritation,
inflammation, and thickening of the cellular substance, which
forms a sac around ; this sac is generally in contact with the
extraneous body, a minute portion only of serous fluid bedewing
its surface ; occasionally, however, there is an increased secre-
tion, and the extraneous body is moveable in its sac* In bone,
inflammation also takes place, but no regular boundary of
osseous matter appears to be found. In the viscera the same
process of thickening, as in the muscular parts, has been ob-
served to occur, and even in the brain a sort of defined envelope
has been found.

* In some cases which have come under the treatment of Mr. Guthrie, the sac
was found to adliere so strongly to the ball, that it was necessary to remove a por-
tion of it ; in these cases the ball had been lodged for years. Guthrie's 2nd edit,
on Simifle Gunshot Wounds.

CHAPTER VI.

OP CONTUSIONS AND OTHER SERIOUS INJURIES FROM

SHOT AND SHELL.

Beside those slight injuries effected by the passage or the
lodgment of a ball or piece of shell, the most serious conse-
quences at times result from thea:. These mav be arranged
under the heads of severe contusions or concussions, and their
effects: fracture and disorganization of the bones and appa-
ratus of the joints, and injuries of the blood-vessels and nerves,
which are not of such a severe nature at first as to justifv the
removal of the limb.

ft very often happens that while all is smooth and sound to
the eye, or there is perhaps only a slight erosion of the skin, a
very serioas injury has been done to the subjacent parts. This
is more particularly the case where a spent ball of large size
grazes along any of the cavities; or where they have received a
severe injury from the wheels of a gun, the explosion of an
ammunition waggon, or other violence; on all these occasions,
great advantage will be derived from taking a few ounces of
blood from the arm, and embrocating the contused part with
some linimentum saponis, or any other mild stimulant. If the
Titality of the part is not entirely destroyed, it will soon be re-
lieved ; bat where that is the case, a circumscribed tumour,
soft and pulpy to the feel, forms on the spot ; the skin, at first
of a natural colour, gradually assumes a dusky shining hue, and
either slooghs off, leaving beneath a dark glossy flabby muscular
mass, discharging tenacious bloody sanies ; or else a chain of
ill-conditioned abscesses forms, which soon run into one another.

CONTUSIONS, &c. 93

and burrow deep beneath the disorganized mass of skin and
muscle, if not prevented by timely evacuation. There are two
points to be most particularly attended to in these cases ; first,
the external application used as a discutient should neither be
purely sedative nor powerfully exciting, but of a mildly stimu-
lant nature ; otherwise the whole surrounding parts will be
overspread with an erysipelatous inflammation, and their vitality
will be destroyed. Secondly, when the effusion of blood or
formation of matter is clearly ascertained, it should be removed
with the strictest attention to the rules of art, particularly as
they regard smallness of aperture and cautious exposure to the
air; otherwise an accident easily remedied by proper treatment
in the beginning, may ultimately prove fatal. The following
melancholy case will illustrate this :

Case XII.

Fatal Contusion from a Cannon Ball.

A gallant artillery officer received a contusion from a spent
round shot at the battle of Vittoria, which struck him exactly
between the scapulae, barely leaving a discoloration of the skin,
and a slight stiffness of the parts. To this he was advised at
first to apply cloths wet in a saturnine solution, which he gra-
dually increased in strength. He derived, however, very little
relief from this mode of treatment ; the stiffness still continued,
the discoloration increased, and he was advised by some casual
visitor to apply a blister to the part. In an evil hour this
advice was acceded to, and, in a very few days, the whole back,
down lo the lumbar region, was covered with a dusky erysipe-
latous inflammation. In a day or two after this appearance, au
abscess formed on the part where the ball bad struck, and
another a few inches lower down, over the spinous processes of
the vertebrae; the surgeon who attended, unadvisedly laid open

94 CONTUSIONS AND SIMILAR

the tumour in its whole extent.- I saw the patient in con-
junction with Assistant-Surgeon O'Beirne, (who latterly took
charge of the case,) on the thirtieth day from the receipt of the
wound ; he was then emaciated to a great degree, his pulse
beyond 120, his skin hot and flushed, his tongue foul, appetite
almost gone, and his strength so reduced, that he could not sit
up without support. On opening the wound, the smell was
almost insupportable, and the discharge a thin acrid sanies ;
the opening was of about four inches long, the edges hollow
and flabby, the bottom smeared with a greyish, tenacious, pu-
rulent matter; through which, at different points, appeared
dusky specks of muscular flesh, and some bits of tendon. At
some points, the spinous processes of the vertebrae could be
distinguished through a thin covering of this glairy fluid, and
the angles of one of the scapulae had eroded a hole through the
skin, which lay loose all around the sore for several inches; the
destruction of the parts was evidently going on beneath, and
a sort of bag, composed of the separated teguments, and filled
with the same matter as besmeared the wound, was formed at
its lower part near the sacrum, which the assistant had just
punctured in a depending position, to prevent any further
accumulation. Under these desperate circumstances, little
could be done; the constitution had almost sunk beyond the
powers of art ; it was resolved, howerer, to remove him from
the hot and unwholesome air of Vittoria, by easy journies, to
the sea coast of Biscay, to which I was then proceeding on
duty ; to continue the infusion of bark, with sulpiiuric acid,
which he had been for some time in the use of, and to dress the
wounds with mildly stimulating applications. In spile of every
eflort for his preservation, layer after layer of muscle peeled
away, till at last the whole surface of the sore became com-
pletely coated with masses of coagulat»*d blood, oozing from
the mouths of the vessels at all points; and in fifteen days
death closed the scene.

INJURIES FROM SHOT AND SHELL. 95

In all cases of this kind, the parts struck by the ball or other
body are, to a certain extent, deprived ot" their vitality, or even
completely killed ; and the principles of the cure are the same
as those which guide us in the removal of a part in which
death has occurred from any other cause. The cure is always
slow, and the proper treatment consists in moderately stimulant
external applications, as camphor, volatile alkali properly
diluted, spirituous fomentations, &c.; and a liberal diet, wine,
preparations of bark, and pure air.

To apply strong saturnine solutions, or leeches, to a part
under these circumstances, is extremely injurious, because they
tend to depress still more the powers of life ; to overstimulate
by blisters, is equally destructive of the vitality of the parts,
and more hurtful to the general constitution.

The effects of severe blows by spent or oblique shots striking
the head, thorax, and abdomen, are still more dangerous, both
from the violent concussion they give the spinal marrow, and
the different organs contained within those cavities, and the
rupture of vessels, or the disorganization of parts, which they
produce ; in which latter cases they are invariably fatal. This
concussion is various in degree, proceeding progressively from
the involuntary tremor and shuddering consequent on a flesh
wound, to partial or universal-spasm, sense of weight, numbness
and cold, suppression of urine, involuntary stools, vomiting,
jaundice, nervous tremors, great irregularity and lowness of
spirits, (which, in some particularly irritable habits, cease only
with life,) loss of hearing, sight, speech, and even of life itself
when the head or spine are the parts peculiarly affected.

Under this class is to be ranged death from the wind of a
ball, which has given rise to such a multiplicity of fables, and
on which so much argument has been exhausted.* I should

* See some ingenious papers in the Edin. Med. Joum., vol. viii. pp. 1, 161,
810. Vacher, in Mem. de I' Acad, de Chirurg., &c. Sur quelques particularit^s
concernant les playes faites par les annes a feu, torn. si. 12mo. tora. iv. 4to.

96 CONTUSIONS AND SIMILAR

be very far from denying altogether the influence of the shock,
whether (hat is electrical or not; because we frequently meet
with cases where uo local injury can be delected after death.
That the compressed air alone, or the friction of the ball, has
no such effect, appears to me satisfactorily proved by the usual
arguments, drawn from instances of near comrades being killed,
or parts of the body torn off without the individual being de-
stroyed ; and it is rendered, if possible, still stronger by in-
stances of escape, owing to a sudden contortion of the body, in
the attempt of evading the summary military punishment in-
flicted in some foreign countries, by blowing men off from the
mouth of a gun.

The two following cases are, I think, worth notice; death
was occasioned in both bv the same ball :

Cask XIII.
Death from an unknown Cause.

A slight lad, of about 24 years of age, was employed on a
fatigue party at the fort of Puntales, in advance of Cadiz, when
the enemy from the opposite fort of Matagorda, about 1000
paces distant, opened a very heavy fire. A 241b. shot struck a
sand-bag which he was carrying on his head towards a new
traverse throwing up in the works ; he immediately fell, and
was brought to the barracks, about a mile dislant, and placed in
the hospital. On examination, no morbid appearances could
be traced, except a derangement of the hair, extending along
the sagittal sulure, and about two inches wide, much resembling
its appearance; in a person placed on an insulated stool, and
subjected to electricity. Tiio pupil tif ont' eye was considerably
dilated; the other preserved ils natural contractile power: his
face was pale, his limbs cold, a clammy sweat bedewed his
wiiob; body, and he lay <|uite insensible; his pulse was soft,
compressible, and reduced to 50 beats in the minute, but

INJURIES FROM SHOT AND SHELL. 97

without any intermission : his breathing slow, but uniform, and
without any stertor ; his efforts to vomit were incessant, but
frequently unavailing". In this state he remained for twenty-
four hours, when he expired in a violent and general con-
vulsion.

On first receiving the injury, he was bled, by an assistant on
duty in the fort, to about sixteen ounces, and on his passage to
the barracks he lost some more blood by the loosening of the
bandage. On his arrival some Madeira was forced down his
throat, and was ordered to be continued to the quantity of a
wine-glassful at intervals of two hours. On examination of the
body, not the most trivial morbid appearance could be detected
in the head, nor any derangement whatever in either the
thorax or the abdomen, where I expected to discover the rup-
ture of some large vessel, or severe injury of the liver, spleen,
or some other viscus.

Case XIV.

Rupture of the Vena Azijgos and Intercostal Artery, from

Contusion.

The same ball struck a soldier of the 30th regiment on the
right breast, brushing along the pectoral muscles, but without
raising the skin, or occasioning any fracture of the bones. He
lay stunned for some minutes, and was then carried on a bearer
to the general hospital. I had not an opportunity of seeing
him that night; but the next evening I called at the " Hos-
picio," where I found him evidently dying; his face bloated,
and of a purple hue; his eyes starting from their sockets, his
respiration excessively rapid, and his pulse feeble and quick
almost beyond counting ; in fact, he died thirty-six hours alter
the accident, with all the symptoms of suffocation. On ex-
amining the body, the vena azygos was found ruptured, and also

98 CONTUSIONS AND SIMILAR

the intercostal artery of the fourth rib of the injured side ;
and two pounds of blood were extravasated in the cavity of
the thorax.

In many cases of death, both on the field and after arrival
at the hospital, we find lesions of the liver, of the spleen,*
or other abdominal viscera, and rupture of the mesenteric ar-
teries, and sometimes of the intestines themselves, from the
violence of concussion.

Frequently where immediate death does not occur from the
organic lesion, the infiammation runs so high as to bid defiance
to medical means, and ulceration and subsequent effusions take
place into the abdominal cavity.

I give the two following cases of severe contusions of the
abdomen, (although they did not occur in the field of battle,
nor in consequence of gun-shot injury,) as they are sufficiently
interesting in themselves, and as they are fully illustrative of
the symptoms and most rational mode of treatment of these
highly dangerous accidents, as well as of the morbid appear-
ances on dissection. I owe these cases to my lamented friend
Mr. Steel, late of the 23d dragoons. The first is in the words
of the reports made at the bedside.

Case XV.

Contusion of the Abdomen and Ruptured Intestine.

Joseph Richmond, aged 21, was admitted into the hospital
on the 28th of July 1811, having, about an hour before, re-

* See Morgagni, Letter 6tlh ; Dr. Cliisholm, in the Edinb. Med. and Surg.
Journal fur July ISjl, vol. vii. p. 'i.)7. For a case of ruptured bladder, see
Medical f^immunicalions, vol. ii. p.'iSl-. For a dissection very soon after deatli,
80C the article Injuries of the Spleen, in the present work. See a Case of Rupture
of the Jejunum in a Child, occasioned by a fall from a chair, by Mr. Todd, in
the Dublin Hospital Reports, vol. i. p. 311. Some remarks on Fractures of the
I^g, Arm, and I'orc-arm, sec Cooper's Dictionary, p. 5-i, KK), lof^, 17 I, '181, '188,
Mh>, VXi. &v.

INJURIES FROM SHOT AND SHELL. 99

ceived a violent kick from his horse on the superior central
part of the hypogastric region ; he feels much pain in the
part, and it bears a red mark corresponding with the shape of
the horse's shoe; he is unable to void his urine, and it is pro-
bable, from the feel, that there is much of that liquid in the
bladder. The catheter, therefore, was introduced with ease,
and about twelve ounces of urine discharged, which was of
the natural colour. He was bled to eighteen ounces, a saline
purgative was ordered, and the abdomen was fomented assi-
duously with a decoction of chamomile.

Evening Visit. — The pain has been considerably relieved ;
and he has slept soundly since he was bled ; his pulse is 80,
and soft ; he voided his urine naturally about an hour ago ;
he has vomited three or four times ; he has not been purged.
Let the bleeding be repeated to eighteen ounces ; let him
have a spoonful of liquor ammon. acetat. every third hour,
and barley-water ad libitum; continue the fomentation.

Jul)/ 29th. — He was visited at nine o'clock last night, at
which time he was suffering severely from acute shooting
pains in the hypogastric and umbilical regions ; his pulse was
hard, and his bowels were constipated. He was bled to
eighteen ounces ; enemas were thrown up, and repeated until
several copious evacuations by stool were produced, and the
griping pains were relieved. He has had a return of the
pain this morning: he is at present free from it; but there
is considerable tension of the abdominal region: he has just
had a copious evacuation by stool, of the natural appearance ;
he sometimes has an attack of vomiting, but it is not violent.
Let him lose twenty-five ounces of blood, and continue his
medicine and fomentation.

Evening Visit. — The pain in the abdominal region returned
about noon, and has continued with considerable violence during
the evening, and is at present very severe. The swelling,
hardness, and tension of the abdomen, have increased consider-
ably during the day; his pulse is intermitting, low, and tremu-

H 2

100 CONTUSIONS AND SIMILAR

lous ; it is also very quick ; his countenance has assumed a
leaden hue ; he has frequent retchings, and he sometimes
vomits up a greenish-yellow matter ; he is very restless, and
thirsty ; he passes his urine freely ; his stools are copious,
and evacuated without difficulty. Let him be immediately
put into a warm bath; after which, let a blister be applied to
the abdomen, and injection of decoction of linseed be thrown
up every two hours.

Eight o'clock. — The warm bath produced a general diapho-
resis, and an alleviation of the acute pain in the abdomen ;
the swelling- and tension of the abdomen were also considera-
bly reduced; his pulse, however, was not raised, and it conti-
nues very quick, weak, tremulous, and intermitting. His
breathing is become short and laborious; he has had one eva-
cuation by stool since he came out of the warm bath ; he has
had no return of vomiting since six o'clock. The pain having
been relieved by the balh, the blister was not applied. IJe had
just now taken half a pint of warm gruel, with about an ounce
of wine and a little sugar : this is to be repeated every two
hours, and the fomentation and glyster continued.

Ten o'clock. — During the last two hours he has laboured at
the verge of dissolution ; his breathing has been short and
difficult, and his pulse imperceptible to the feel. The extre-
mities have been cold ; but the temperature of the rest of his
body considerably above the natural standard : he has been
exceedingly restless, anxious, and apprehensive ; he has taken
his panada regularly ; has had some retching and frequent
eructations ; he has had one fit of vomiting, and he threw up at
least two pints of green bilious matter. With the view of sup-
porting the powers of life, the extreme prostration of which
has been strongly indicated, by the coldness of his extremi-
ties and failure of his pulse, together with his anxiety and
difficulty of breathing, he has taken a little volatile alkali and
tincture of opium in sumll doses, 'I'lie temples have been
rubbed with li(|. vol. 'c. c. which has also been applied to his

INJURIES FROM SHOT AND SHELL. 101

nostrils. These remedies, with the occasional administration
of panada, are ordered to be continued.

Eleven o clock. — He is much worse in all respects ; his
pulse, during- the last hour, could not be felt, and the cold-
ness of his extremities has increased. His difficulty of breath-
ing has also increased considerably ; his countenance exhibits
a deadly pale colour, and his lips are blue; he swallows with
much difficulty, and his anxiety is extreme ; the pulsations of
the temporal artery can be felt ; it is at 120, low, and feeble.
At twelve he died.

Appearances on dissection, July SOth. — The abdomen having
been opened by a crucial incision, the first remarkable circum-
stance which presented itself was an immense quantity of
effused liquid, mixed with feces ; and it was soon discovered
that a rupture of about an inch and a half in extent had been
made in that part of the intestinum ileum which crossed the
cavity of the abdomen anteriorly, about two inches below the
umbilicus, and immediately opposite the part which bore the
mark of the horse's foot. The whole of the intestines were
exceedingly vascular, from the violent inflammation which had
taken place ; but this was more particularly remarkable in the
convolutions of the ileum, which was wounded by the blow.
A considerable quantity of coagulable lymph had been effused
by the vessels communicating with the wound : a small quan-
tity of pus was also visible ; the whole of the omentum was
uncommonly red, with great turgescence of its vessels; the
bladder was found perfectly sound, empty, and collapsed ; the
stomach and liver were perfectly free from disease ; the galU
bladder was distended with bile.

Case XVI.

Contusion of the Abdomen and Ruptured Intestine.

Samuel Holt met with an accident nearly similar to that
detailed in the former case, and the treatment was conducted

i02 CONTUSIONS AND SIMILAR

upon the same plan ; hut in spite of every remedy that could
be employed, he sunk in twenty-two hours and a half after he
received the blow.

On the contents of the abdomen being exposed, a large cir-
cular hole was discovered in one of the convolutions of the
jejunum. It was situated in contact with the peritonaeum,
about two inches obliquely below, and to the right of the
umbilicus. The fibres of the intestine surrounding the hole
had the same appearance as is generally presented by the
margin of a recently contused wound ; the whole of the small
intestines had a bright red colour from the numerous ramifica-
tions of their inflamed vessels, That part of the canal ex-
tending a few inches above and below the hole was remark-
ably inflamed; and the vessels had already secreted a puru-
lent-like matter, which adhered to the surface of the intestines
in its vicinity. About two quarts of yellowish fluid were ex-
travasated in the pelvis, and among the convolutions of the
intestines; the peritona3um was highly inflamed to a consi-
derable extent, in the neighbourliood of the injury. The
bladder was empty and collapsed, as were also the large
intestines.

In both these cases it is remarkable, that the blood drawn
from the arm is not stated to have been covered with bufl".

On some occasions, the appearances on dissection do not so
satisfactorily account for tlie symptoms during life; and in
others, wo are left in total obscurity. The following case oc-
curred in a civil hospital of great celebrity:

casi xvir.

Contusion of the Ahdomen.

\ man, about sixty' years of age, was brought ij)lo the hos-
pital in r«»nsc(|uenre of luiving been riui <»ver by '» ('arriagc.

INJURIES FROM SHOT AND SHELL. 103

The wheel had passed over the iliac and hypogastric regions.
He felt acute paiu on pressure, but no other symptom of in-
flamed bowels ; on the contrary, their functions remained na-
tural and undisturbed. Next day he was bled to twenty-four
ounces, which relieved the pain and reduced the pulse ; but
very shortly afterwards it rose to 140, full, and somewhat
hard. Venesection was repeated the next day to twelve
ounces. Pain still continued ; and on attempting a repetition
of the blood-letting, none could be procured from the arm.
He died on the fourth day from the accident. On dissection,
a quantity of dark-coloured blood was found effused under the
peritonaeum covering the abdominal muscles in the iliac and
hypogastric region, and some in the pelvic region. The
cellular membrane about the pubes was particularly injected
with it. The peritonaeel coat of the intestines was somewhat
more vascular than common ; but not the slightest symptom of
inflammation or organic lesion could any where be traced,

I may here remark, that death often succeeds to injuries
apparently superficial; in which the brain seems to suffer
sympathetically merely from their extent, a circumstance which
favours the ideas of those who consider the whole nervous sys-
tem in the light of expanded brain. The treatment on such
occasions must altogether depend on the nature of the symp-
toms ; but, generally speaking, a guarded use of stimulants, as
the Pulv. Ipecac, comp. and volatile alkali, with the tepid
bath, will be found conducive to recovery.

104

CHAPTER VII.

INJURIES OF TIIK BONES.

I SHALL now make some observations on injuries of tlie^
Bones of Ihe extremities, the Joints, and their appendages; a
train of accidents which, especially if from gunshot, are of the
most serious importance, highly dangerous to the patient, and
demanding the most cautious management and sedulous at-
tention from the surgeon. In truth, a knowledge of the pa-
thology of bones is indispensable to the army surgeon and
forms the very basis of his art. Severe as injuries may in
other respects appear, if the bone be not implicated, their after
consequences are comparatively of but little importance. In-
juries of the muscular parts, however extensive, are rarely
very obstinate in sound constitutions, and under proper ma-
nagement; those of the arterial system, urgently as they call
lor immediate aid, after that aid has been aflorded, proceed in
most instances to a favourable termination ; but injuries of the
bone can never be called unimportant, however early surgical
assistance may be obtained, and very seldom, under the most
favourable results, do they afford either to the patient or his
attendants adetjuate compensation for all the miseries and ac-
cidents of a tedious and protracted cure. Still, however, the
preservation of a limb, where any rational chance of saving it
exists, must be a serious object lo the patient, and a desirable
result for the surgeon.

I have already observed, that some information may be de-
rived from the appearance of a musket ball after it has been
extracted Irom a wound. NVIkmc it has brushed nblifpiely by

INJURIES OF THE BONES, 105

a bone, and injured its external plate, its surface is often
jagged, and presents the appearance of a file clogged with
raspings of ivory, Sometimes it is flattened against the bone
without doing such material injury to the periosteum as to oc-
casion exfoliation ; but more frequently, long and tedious
throwing off of scales follows the injury, and this sometimes is
so severe, though fracture may not have taken place, that
disorganization of the medullary vessels is the consequence,
and abscesses form in the canal. This proceeds from the
injuries inflicted by spent round shot and shell principally.*
A musket ball often lodges between bones, as those of
the fore-arm and leg, or the ribs, and by being flattened or
indented, and in some respects adapting itself to the ridges
of the bones, it becomes a very difficult matter to extract
if. In some cases it will take out a portion of the diameter
of the bone ; and in others, though more rarely, perforate the
shaft completely, without entirely fracturing it. More com-
mon instances of this perforation occur in the spongy heads
of bones, as the humerus and tibia ; in all these cases the
injury is comparatively simple in the recent state, and our
duty is confined to watching the approach of inflammation,
and removing any splinters, &c. that may present or come
within our reach. In their after stages, however, these perfo-
rating wounds of the cylindrical bones become of most serious
import, and almost constantly turn out to be cases for se-
condary amputation.

In some severe cases, where the ball lodges in the bone,
particularly about the condyles, by making deep and cautious
incisions before great swelling of the soft parts comes on, we
may occasionally succeed in removing the metallic mass with a
forceps or elevator, either unaltered, or beat out into irregu-
larly angular shapes. Sometimes, however, it is so firmly flxed
that it can bo removed only by sawing the bone, with the

* See Ravalon, Obs. 17

106 INJURIES OF THE BONES.

crown of the trephine or other instrument. The accident is
always highl}' serious ; but it is possible, under circumstances
of peculiar good fortune, in a temperate subject of sound con-
stitution, to save the limb by the operation, as in the fol-
lowing case :

Case XVIIl.

Ball lodged in the Condyle of the Femur,

Jose dc Santos, a quarter-master-sergeant in the 9th Caga-
dores, passing along the bridge of Burgos on the 27th of
September 1812, was struck by a musket-ball on the outside of
the knee, which brought him to the ground. " I found him,'*
says Staff Surgeon Hughes, to whom I owe the history of the
case, ** at the Hospital Del Rey, about three hours and a half
afterwards, in great pain; the parts surrounding the joint
swelling rapidly, and a Portuguese surgeon endeavouring to
persuade him to suffer amputation. The ball was lodged and
could not be found, although the wound had been a little
dilated to facilitate examination. Measures to subdue inflam-
mation were immediately adopted; on the morning of the 28(h
he had a violent shivering fit, and another at midnight;
copious suppuration was found to have taken place on the
29th, with an abatement of pain, and the ball was easily felt,
but immoveable, and seemingly stuck in the bone. Poultices
and fomentations were now applied ; and on the 1st of
October, I found lie had had another shivering fit the preceding
night, and that a piece of cloth had come away with the dis-
charge, whi» h was much increased. This evening he was
attacked with dianha-a, and vomited some bilious matter; the
suppuration now be<;amc profuse, the diarrhoea grew pro-
gressively worse, and his rigors contlrnied to return with an
exhausting purulent discharge until the 7th, when amputation
was again pi'tposcd, as the onlv means of preventing; a rapidly

INJURIES OF THE BONES. 107

fatal termination ; but he persevered in his resolution to prefer
death to this operation. As the only alternative, I extensively
dilated the wound down to the bone, when the ball was
found fixed in the centre of the External Condyle of the
Femur, nearly a quarter of an inch below the bony surface.
The crown of a trephine was now applied, and a flattened ball
was extracted, with several portions of cloth. Light dressing
was applied, and next morning it was found he had escaped his
shivering tit; his diarrhoea was abated, and he had enjoyed
sleep ; which, since the first day of his wound, had been
nearly a stranger to him. The discharge continued gradually
to decrease, and his health to improve; and on the 22d, (when
circumstances caused the removal of the wounded,) the parts
were healing rapidly, and anchylosis taking place. He bore
his journey in a waggon well ; and, when discharged from the
service three months after, was in good health, and had a to-
lerably straight knee."

I have never met with a case requiring either the trepan or
any other contrivance, except the common forceps, for the
removal of balls thus lodged. In eight thousand cases. Baron
Percy has not met with one requiring the head of the trepan,
and only three in which he used his " tire-fond."*

Where a ball has lain long in the bones, the cancelli break
down and admit of its rolling about in the cavity, if it still
retains its rotundity. Nothing short of an operation with
the head of a trephine or saw, can in this case possibly remove
it; the contraction of the orifice by irregular points of ossifica-
tion confining it completely within the bone.f There are

* See " Reponses aux Questions Epuiatoires," p. 13, annexed to his " Pyro-
technic Chiiurgcale, 12mo. Paris, 1810.

■f In the brute creation, under certain circumstances, the orifice closes alto-
gether, and little inconvenience seems to be felt; thus, on cutting pieces of ivory,
metallic balls are sometimes found bedded within them, without any mark of
their entrance. Tlicy must obviously have entered the pulp before the secretion
of enamel, to cover the adult tooth, had taken place.

108' INJURIES OF THE BONES.

some instances on record where the ball has remained quietly
in this situation so long as twenty-five years ; but in the
majority of cases, a majority so vast as to admit of no shadow
of comparison, the violence of the inflammation, the excru-
ciating pain, the profuse suppuration, diarrhoea, and fever, lead
to the removal of the limb as the only chance of recovery.*

A curious instance of a ball lodging in bone is given us by
Pare. It is a very rare occurrence, but the case is valuable
oji many accounts. " The King of Navarre," says he, ** was
hurt with a bullet in the shoulder a few days before the as-
sault of Rouen, anno 1562. I visited and helped to dress
him, with Master Gilbert of Monfpellier, his own surgeon,
and others ; they could not find the bullel; I searched for it
very exactly ; I perceived by conjeclure, that it had entered
by the head of the adjutorium, and that it had run into the
cavity of the said bone. The most part of them said it was
entered and lost within the body. Monsieur, the Prince of
Roche-upon-Yon, who intimately loved the King of Navarre
called me aside, and asked if the wound was mortal. 1 told
him yea, because all wounds made in great joints, and prin-
cipally contused ones, were mortal." Pare remained steiidy
to his prognostic, always declaring that the limb would fall
into gangrene, which it did, and the king died on the
eighteenth day after the wound. A dissection was ordered,
and, much to the honour of Pare, the ball was found in the
very middle of the cavity of the os humeri. He concludes
the case by saying, that he returned to Paris, where he dressed
several of those who were wounde<l at the siege. " There
•were divers," says he, " that recovered, and others died. I
believe," he continurs, (cn)pliatically a(ldr(!?-sing Gourmalin,
a volunteer critic ol lliat day, whom he invariably calls, " the.
adversary,") " I believe, my little master, you were called

* See Percy, Manuel ilu Chirurg. d'AniiC'r, j). 1H>.

INJURIES OF THE BONES. 109

in to dress some of them, for the great number there was of
them."*

In a case of this kind, where the track of the ball is clearly
ascertained, no delay can be admitted of, nor can any operation
succeed, except that at the joint. f

But the most serious accidents of all are Compound Frac-
tures, particularly of the Femur ; that bone, whose fracture,
as observed by Pott, " so often lames the patient, and dis-
graces the surgeon." Every thing connected with these in-
juries is worthy of the most particular attention ; they are,
like fractures from other causes, various as to their situation
and their complexity ; the bones are either broken transversely
or in an oblique direction, or they are fractured in two or
more different places; or again, as in the fore-arm and leg,
one of the bones only is injured, while the other remains entire,
and preserves the form of the part. The principle of reduc-
tion, coaptation, &c. &c. is the same as in fractures from
ordinary causes ; but the sources of irritation are infinitely
more numerous and more complicated ; and the shock occa-
sioned by the injury spreads to a much greater extent, and
seems to implicate the whole system.

The estimate of the mortality occasioned by compound
fractures of the thigh from gunshot is most melancholy. In
the French army, Baron Percy has calculated that scarcely
two in ten recover. In the English army in the Peninsula,
Mr. Guthrie found, that, on a review of his cases, not more
than one-sixth recovered, so as to have useful limbs ; two-
thirds of the whole died, whether amputation was performed
or not ; and the limbs of the remaining sixth were not only
useless, but a constant source of uneasiness to them for the

* The Voyage to Rouen, 1562, lib. 29. Johnson's Translation,

t Some valuable observations on the Lodgement of Balls in Bone, will be

found in Mr. Guthrie's third edition, in the chapter of Simple Gunshot Wounds,

p. 91.

110 INJURIRS OF THE BONES.

remainder of their lives. In the campaign of Holland in
1814, of eight cases, seven of which were not amputated,
one only recovered, in Staff-Surgeon Cooper's hospital at
Oudenbosch ; — that patient retained an useless limb. I have
not made any accurate calculations myself, but I am strongly
inclined to assume Mr. Guthrie's calculation as correct,
even including the cases of officers, who are not subjected to
the risks encountered in crowded hospitals ; in these situations
the cases which I have witnessed have, on some occasions,
been deplorable. Not a single case has done well where am-
putation was deferred, and even where it has been performed,
two out of three have died. In other instances the losses
have not been so severe, but I have never known a larger
proportion saved than tliat assigned by Mr. Guthrie.

The ends in view in remedying these cases are sufficiently
obvious ; the means are still a subject of discussion. One of
the most powerful modes of restoring the use of the limb is
its posture ; and even in this necessary preliminary the great-
est diftereuces of opinion prevail. The bent and the extended
position of the limbs has each its advocates. Much as
English Surgery owes to Mr. Pott, it is chiefly indebted to him
for his excellent remarks on Fractures ; he first placed in its
proper point of view the rational mode of evading or mode-
rating the powerful action of the muscles. The posture re-
commended by him has for years been adopted as the proper
one in British practice; in France, however, a directly oppo-
site mode is pursued, and not without considerable success.
It was handed down from the first dawn of rational practice
io that country in tlie days of Pare ; and it is a curious coin-
cidence, that the very opposite modus of treattnent recom-
mended by those two most eminent men were illustrated in
their own persons, each suH'cring a severe compound fracture
of the limb, and each submitting to, and directing the appli-
cation of, the rules they had laid down for the treatment of

INJURIES OF THE BONES. Ill

those accidents.* The relaxed position of Pott was carried by
himself to the very highest state of improvement ; but Parens
was progressively amending from his own time down to that
of Desault and Boyer. A due consideration of both the
methods will, however, show us, that in neither are all the
muscles fully relaxed ; and we are in both obliged, to a certain
extent, to paralyse them by our pressure, and by our long-
continued extension. In cases so tedious in their cure, as
gunshot fractures, the question will, in some degree, resolve
itself into one of convenience to the patient and his surgeon ;
and I am warranted, from ample experience, to infer, that
lying on the back, with the limb extended, is by far the most
tolerable to the patient, and admits of much easier access and
dressing; and, what is still more important, is, in its ultimate
success, equal, if not superior, to either the bent position of
Pott, the patient on his side ; or the semiflexion of the knee,
the patient on his back, and the limb in a fracture box.-f

In mentioning the removal of fractured limbs from the field,
I recommended, that, after the bones were placed in as close
apposition as the nature of the case could admit, and properly
secured, the limb should be laid in a relaxed position ; this
relaxation preparatory to a move, or pending the violent inflam-
matory re-action which is certain to come on in a few hours
after the receipt of the injury, is by no means intended to be
continued through the whole period of the cure; indeed, it
has become a question with some able surgeons, whether, if
the compound fractures could be set at the moment of infliction,
and the proper apparatus for continued extension was at hand,
it would not be advisable at once to put them in position.
In many situations this is utterly impracticable, from the

* See Pare, lib. xv. chap. 23 and 24, and Pott's Life, prefixed to his Works,
by Earle.

t See Bell's Operative Surgery, vol. ii. p. 346, Ed. 2d, Lend. 1814. Cooper's

and Travers's Essays, Part ii. p. 49. Sir A. Cooper's Work, 4to. on Dislocation

aud Fractures of the Joints, p. 140, el seq.

112 INJURIES OF THE BONES.

nature of the service, from the violent spasmodic action of the
muscles of the limb, and sometimes, though more rarely, from
the obstinacy of the patients themselves.

But, very fortunately, the position in which the limb may be
placed on the first infliction of the injury, is by no means of
such consequence to the future recovery of the patient, as, from
reasoning a priori, we might be led to suppose. Chance, which
has such frequent and powerful influence over us, perhaps
originally suggested what experience has fully proved to be
founded in truth; and in no situation can these fortuitous oc-
currences more frequently present themselves than in military
practice. Here the inexperienced surgeon, reduced almost to
despair at the want of all the comforts and conveniences of
the establishments of a rich metropolis, and anticipating his
patient's destruction and his own disgrace, will gradually dis-
cover that utility is often made subservient to show, where the
means abound; while, with all their privations and incon-
veniences, and with their exhausted supplies of even the most
common materials, the converse of the fact is demonstrated in
army hospitals.

The situation of a wounded soldier on a field of battle is
pitiable in the extreme : with every means and every wish to
relieve, surgical aid cannot be immediately offered to the
sufferers, from the nature of the operations carrying on. Hence
it is that frequently both victors and vancpiished lie for hours
undressed in indiscriminate heaps.

After some of the skirmishes in the Pyrenees and near Pam-
peluna, subsequent to the battle of Vittoria, we received into
the hospitals of that city several conipouud fractures, (particu-
larly into the church division of St. Domingo Hospital, which
was principally filled with these cases, under my charge,) the
majority of which had been barely dressed with the common
splints and rollers; some had been left undressed for many
hours ; and none were placed in the regular position for some
days after, (in not a few instances for so many as twelve or

INJURIES OF THE fiONF-

113

^vorteen,) hariiig for part of th *
hospital, and dariiii' ' ^ ^ - '
Tumdng TCTy higb. Al JJ ,
Ae exeraeiatisg- t ^ r * : r .

snbsided o>a :

they w&^e r

G^nan s '.•..:_ ^ :._,..._.

traction of the limb —as s. ^r^:.:
daced iLe m::' -x.:.:/.- :.:■:_■.
action « a.- 5 '■ . ; 1 : , '.:. ..\ :..-: .
than natural
had been mu _
woold hare produced an :.
aootUng plan, asnffici'^rL. ei - ^
in SMne days in all their : : -es.

In the same action a y oaog- offi
not placed in position before the 23
of his case,, as fiv as connected with
briefly these : — A mosket ball pa - s
the middle third of the thigh, it: :

in a nearly straight Uiie, ^ .

fenaiTeiy. Fonr days ;^ ^^
Br 55tx and safely dep > r

. had been a :_ : . r : . : _ : ..
;-;.. - :.-. :ed r«L_x-T J .-. L:_
to evr ■ .-'r ::^ui.t::": :-..:
WhcQ be Gic : •; . ;,- r ;..; ...

.3 L

in tranritu *.o the

5TiCh pio-
oscolar

-- ri:rter

edof

nr^

- ends ot the bone ex-

-e he was Ixonght to

sr. f "ling whidk period

■._- :'.;•"■:. r 5 in whidi he

". _ ■:• - - i - '.- - -J, coBtraiy

used with him.

uoie pain an
had eren ecu
These fev
^ow, that hbuir
cable in adl ?f^<
present comf ^

CA'

I U I '-J 1 c

rlQpU

.rcted from a "^
ension, ooapta.
-T-r are they ahs :

s^iietv of tfce p

cedi in a {Hoper po-

f time, and with so

1 ' betiere that I

-- riniciently
Xo wbieb afso

Jl VJ C u v«

114 INJURIES OF THE BONES.

I may add, that, having been principally employed in the fixed
hospitals, during the Peninsular war, and the campaigns of
the Netherlands, 1 have consequently had ample opportunities
of viewing the state in which the fractures arrived from the
field. And, although in many, the hands of a master were
easily recognized in the mode of dressing, in none did I ever
see the limb in such a state as to preclude the necessity of
going over all the steps of resetting, and consequently of re-
doubling the patient's anguish.

I shall briefiy state what appears to me the most rational
mode of treating these very complicated injuries, and which I
exclusively adopt, from a conviction of its merits, drawn from
a comparison with other plans ; premising that I shall suppose
the more serious cases (which I have already laid down as
calling for amputation on the field) have been operated on, or at
least marked for operation, when circumstances, as fever, high
inflammation, or excessive collapse, may permit; and repealing,
that T am well convinced the sum of human misery will be most
materially lesseried hy permitting no ambiguous case to be sub-
jected to the trial of preserving the limb ; constitution, conve-
nience for treatment, and local circumstances, having their full
weight in the decision.

As compound fractures of the lower extremities, especially
the thigh, are the most important, I shall dwell particularly
upon their treatment; the same general principles, however,
are applicable to those of the upper.

A very short time after a compound fracture is inflicted, a re-
action, influenced in its violence and the period of its attack by
the severity of the case, the original constitution of the patient,
or the accidental circumstances of the wound, always takes
place. During this re-action, the process of ossification is com-
pletely at a stand ; and, indeed, throughout the whole cure, the
high inflammatory and suppurative actions are incompatible
with the formation of bone. The irritabilily of the muscles is
increased in a very great degree, and violent spasmodic con-

COMPOUND FRACTURES. 115

tractions of their fibres takes place; the periosteal tube, which,
in simple fracture, supports, as in a case, and sustains the
vitality of every part of the bone to which it adheres, is la-
cerated to a greater or lesser extent, and in part destroyed ; the
invariable effect of which is, extensive inflammation and thick-
ening of that membrane, followed by the death of those pieces
of bone, whether detached or not, which are deprived of it. The
first stage, therefore, of compound fracture, is one demanding
the most rigid antiphlogistic treatment, the most perfect ease
and quiet of the patient, and, except in regulating the fever,
requiring but little aid from mere surgery, beyond the removal
of detached splinters and extraneous bodies. Much, however,
may be done by proper management, particularly of the beds.
As the irregularities of an ordinary paillasse would obviously
injure our patients, one great source of comfort and ease to
them will be, preparing a set of well stuffed cases of combed
straw, wool, chaff, or any other material that may be procured,
and placing them on the firmest wooden bedsteads we can get,
or on boards and tressels. A.s it often happens that these can-
not be procured, then the paillasses must be placed on the
floor, guarded from the damp and cold, if the nature of our
hospitals expose them to such causes, by tarpaulins or water
deck ; and occasional irregularities must be corrected by
bolsters, cushions of chaff, hair, wool, &c.

In the inflammatory stage, which lasts in general from five
to fifteen days, I am in the habit of leaving the limb in the
exact position described by Pott; but v/ith the bandage of de-
tached pieces of roller, commonly called after Scultetus, reach-
ing for six or eight inches above and below the fracture, instead
of the eighteen-tailed one, over which it possesses several ad-
vantages from its simplicity, and the ease with which it is ap-
plied, and its different parts removed, by simply pinning to any
of the soiled pieces a fresh slip of roller, and drawing it under
the limb into the proper situation, by the same movement
which displaces the rejected parts. Over this I place two

116 INJURIES OF THE BONES.

splints of whalebone, such as are usually supplied to the array,
moderately tight, and in such a way as to admit of dressing the
orifice or orifices, if the ball has passed through the limb,
without removing them. The irregularities of the limb are
stuffed with tow, or rags, or bags of chaff, and the whole is
kept moist with cold saturnine solution of moderate strength,
and with the addition of some camphorated spirit.* When the
inflammatory symptoms are subdued, I then proceed more
accurately to adjust the fractured bone ; and to this end, place
the patient on his back, a change of posture which invariably
gives relief, filling up all hollows, and arranging the limb pre-
cisely after the mode recommended by Professor Boyer,t and
applying the bandage of Scultetus afresh, with a roller, mode-
rately tight, on the lower portion of the limb, and proper com-
presses "along the parts. I employ the improved splints of
Assalini,t if they can possibly be procured ; if not, I place
two common long splints in the usual way— one from above the
hip to the ancle, or from above the knee to the ancle, as the
case may be, and the other of proportionate length on the
inside,— and, fixing the pelvis of the patient by a bandage to
the upper part of the bed, (if overlapping of the bones renders
such extension necessary,) I stretch out aud retain the limb by
means of tape fixed to the bottom, or what I have found answer
still better, by a common tourniquet, the centre of its strap
firmly fixed round the knee or ancle, and buckled over the
bed post, so that, by turning the screw, the extension may be
moderately made and increased as circumstances demand.
This, which was suggested to me by Professor Thomson, at
Brussels, I have found of very great assistance in some obsti-

• Thougl. I recommend the splints, I have seen numerous cases where they have
been omiUed, and the patient has done perfecUy well, the parts being merely co-
vered with compresses m«isloni<l with ccld water. , . ^ ,, , ,r ■„.

t noycr, Lcions sur U-.s Malndi.-s d.-s Os ; or the Translation by Farrel. Trait6
deft Maladies Chirurgicaies, tom. iii. page 2W).

; Uettcribed in his *' Manuale di Chirurgia," pp. 279, 287.

COMPOUND FRACTURES. 117

nate and complicated cases.* In this mixed mode we reap the
advantages both of the position of Mr. Pott, and that of Pare
and the more modern French surgeons. The patient is in ge-
neral extremely tired of his relaxed position before the lowering
of the inflammatory symptoms indicates the time for placing
him on his back, a change from which he receives great relief;
we may rest assured that the process of ossiGcation has not
commenced until that period; and that, consequently, the ap-
plication of machinery to extend the limb, or splints and
bandage to confine and regulate the new callus, is unnecessary,
if not hurtful.

The speculative objection that may be offered against the
plan of leaving the bones so long unset, is the possibility of an
irregular or distorted union, but with daily attention, this can
scarcely occur. 1 have only met with one instance of it; it was
in an officer who would admit of no treatment but what he
himself deemed proper. In consequence of this, he very nearly
paid the forfeit of his life in the first instance, and he is now
obliged to wear a high heeled boot, the thigh being considerably
shortened and curved.

The great error of all the machines for fractures, from Hil-
danus downwards, is their complication, and their not admitting
of the limb being freely dressed without disturbance, added to
which, their price forms a very great barrier to their general
introduction.

In compound fractures of the humerus and fore-arm complex
machinery is not called for. With ordinary splints and a leather
sling, furnished with a strap to go round the neck and support
the limb, we are able to manage extremely well. When fever,
or some other untoward circumstance, does not forbid it, I
always encourage patients with these injuries to keep out of bed
as much as possible, the weight of the fore-arm assists consider-

* If the patient lie on tlie floor, pickets, or some similar m^eans, must he
adopted as fixed points.

118 INJURIES OF THE BONES.

ably in keeping fractures of the humerus in a proper state of
coaptation, while the Oexine at the elbow often prevents
sinuses from running down under the integuments and among
the muscles of the fore arm, which sometimes occurs when the
patient lies long in the horizontal position, and especially if the
fore arm is spread out in a line with the humerus, as I have
more than once seen.

The after management of compound fractures is a most serious
duty, requiring industry, judgment, and humanity, as well as
great discrimination in both the medical and surgical treatment.
The position we shall suppose to be established by the means
already described ; its continuance can be ensured by frequent
inspection only, which should never be seldomer than twice in
the twenty-four hours, when all occasional irregularities of
posture, or unequal pressure, should be corrected, and all
filth (which, from the great discharge, accumulates rapidly)
should be removed. Once in the day at least, a compound
fracture should be regularly and formally dressed. On these
occasions, all depositions of matter should be carefully pressed
out, splinters felt for and removed, and clean slips of bandage
applied, in lieu of those soiled or destroyed by the suppuration.
To prevent the soaking of the bedding, a piece of coarse cloth
or oiled skin should be placed permanently under the whole
limb, and occasionally renewed ; and, to obviate the ill effects
of the matter stagnating in the wound, the lightest scraped lint
should be laid on it. In some cases I have effectually obviated
this stagnation, when the position of the wound did not favour
the How of the matter, by placing a soft sponge over the limb,
which absorbed the pus almost as soon as formed, and by
drawing a woollen thread through it, and connecting it with a
proper dish below, it has performed the part of a syphon.
During the employment of these surgical means, the bowels
should be kept in a natural state by saline laxatives when
required ; and in aiding the patient on those occasions, a very
simple addition to our common be(J j^ns would be most useful;

COMPOUND FRACTURES. 119

viz. making the edges opposite tlie handles 'cornea/, as I have seen
in the Hanoverian and other foreign hospitals, so as to thrust
them gradually under the nates, without forcibly or suddenly
displacing the body of the patient. Purging, however, must be
very cautiously employed ; the necessary movements are almost
certainly injurious to the patient. Anodynes are urgently called
for in these cases, and are best combined with antimonials, to
obviate their heating and constipating effects. Of the anodynes,
the extract of hyoscyamus, when properly prepared and fresh,
will be found eminently useful. If fever should come on, not-
withstanding the most rigorous antiphlogistic diet, perfect quiet,
and thorough ventilation, the lancet may be then had recourse
to, but with great caution ; for the period of debility is soon
hurried on by the sufferings of the patient and the profuse
discharge; and we must rather trust to leeches and to internal
remedies where the slightest ambiguity prevails.

Fresh formation of matter and chains of abscesses often
succeed feverish exacerbations, and frequently depend on the
presence of splinters. If these sources of irritation can be de-
tected, their removal must be attempted cautiously ; and in all
cases when the existence of matter is ascertained, it must be
evacuated by direct puncture or counter openings. When all
fever has subsided, and the discharge is kept up by debility
alone, a light nourishing diet, with a moderate allowance of
wine, must be permitted ; and in such cases, if no local irrita-
tion forbid, pressure made uniformly over the whole limb by
adhesive straps and rollers, tends much to prevent the formation
of sinuses, and to lessen the purulent discharge. Kirkland's
defensative plaster, spread moderately thick, is recommended
on good authority, both in these cases and in dislocations ; it is
composed as follows: R. Emplastr. Plumbi. partes ij.; Pulv.
CretsB. 01. Olivte, Acid Acetic, ana partem j.; Solve leni
calore, et Misce ut fiat Emplastr. : it is stated to be a powerful
repellant in all cases of violent local inflammation.* In short, the

* See Sir A. Cooper on Dislocations and Fractures of the Joints, 3d Ed. p. 251.

120 INJURIES OF THE BONES.

symptoms in compound fractures assume the most Protean

shapes, and can only be met by assiduous and unremitting

attention, guided by a thorough knowledge of professional

principles. Our best endeavours, however, will at times fail

in conducting our patients to a speedy or even an eventual

cure. I have seen one or two fortunate cases where the

compound has been changed into a simple fracture by the

healing of the external wound before the osseous union had

commenced ; but these were not from gunshot, and I believe

such a fortunate result never happens after such severe injuries.

In some cases, the disposition to osseous formation is so slow,

that, however well the limb is managed, union does not take

place for months. In other instances, osseous matter is thrown

out from the sides of the bones; but the fractured ends remain

nearly in the same state as when the solution of continuity was

first effected. In some individuals, no cause can be rationally

assigned for this tardy union ; in others, it can be traced to

constitutional causes, and in some to the existence of extraneous

bodies within the wound, cither keeping up the irritation or

actually interposing between the fractured extremities of the

bone, and mechanically preventing their coalition. We are

sometimes so lucky as to get at the body thus interposed; but

more frequently the rapid sinking of the constitution forces us

to amputation. In the case of Captain , of the Artillery,

who was wounded at Waterloo, the efforts of his surgeon. Dr.
O'Beirne, directed as they were by great professional skill, and
aided by a most excellent apparatus on 13oyer's plan, together
with the sound constitution of the patient, and his enjoyment of
pure air and every domestic comfort, were ba/lled for several
weeks without any clue which could lead even to a suspicion of
the cause, till at length a large fragment of shell, nearly an inch
in thickness, was luckily discovered and removed from between
the fractured ends of the femur. I have found a piece of
leather in a similar situation, and in the course of my examina-
tion of several amputated limbs removed from incurable com-

COMPOUND FRACTURES. 121

pound fractures, I have discovered, that, notwithstanding every
care, both in dressing and position, a piece or pieces of bone,
including- the whole cylinder, not displaced from their position,
(and therefore not to be remedied or suspected,) but with the
periosteum injured or destroyed, had formed an invincible
barrier to the junction of the living extremities of the bone, be-
tween which they had been interposed.

When the dead pieces of bones are small, and only partially
detached, the vessels pour forth that matter which is afterwards,
by a peculiar process of nature, to become osseous ; the frag-
ments are enveloped in the new bony case, and are placed
exactly in the same situation as the sequestra in instances of
necrosis, from different causes. In general the cure is tedious,
the discharge is irregular in quantity, and often singularly
offensive in quality ; sometimes, however, the pieces of dead
bone give very little, if any uneasiness, until cold, external in-
juries, or excess, give rise to violent and deep-seated inflam-
mation, abscess, and exfoliation.

We have not the same means in our power to excite the ossific
action in compound fractures as in those of the simple kind;
irritation of various sorts, pressure, friction, external stimulants
to the skin, or even the operation of the seton, as practised by
Dr. Physick, Mr. Rowlands,* and others, which have been
successfully had recourse to in the indolent state of the latter,
are inadmissible in the former; where, if union is suspended,
it is generally from mechanical obstructions, from excessive
action, or from disorganization of parts. Original malposition,
or subsequent derangement of the bones, are occasional causes
of their not uniting. I have lately examined the fore arm of a
naval officer, in which the radius was fractured transversely by
a musket ball some years since; some of the muscles have got
between the fractured ends, which are rounded by absorption ;

* See Mcdico-Chirurgical Transaclions, vol. ii. p. 47; and vol. v. p. 398; aiid
Air. Amesbury's Work on the Non-union of Fractures.

122 INJURIES OF THE BONES.

and althongh, from the ulna still retaining its situation, no dis-
tortion of the limb has taken place, a species of ginglymoid ar-
ticulation, and a partial luxation at the wrist is formed, which
greatly detracts from the power of the limb.

While we sometimes meet with cases where no union takes
place, notwithstanding a close apposition of the broken extre-
mities of a bone, we meet with others, where, on the contrary,
union occurs, although the parts are far from being favourably
disposed ; sometimes the fractured ends overlap, and the sides
of the shaft alone touch each other; sometimes the broken end
of one portion of the bone touches the side of the other at a
distance from the point fractured, and yet, notwithstanding this
very unfavourable position, osseous union is efl^cted, but with
a distortion of the limb proportioned to the distance to which
the broken ends of the bone are thrown from each other.

The process adopted by nature for the union of simple frac-
tures has been ascertained with considerable accuracy, and is
as follows : There is first an effusion of blood around the ex-
tremities of the broken bone and into the adjoining soft parts ;
then a tumefaction of the periosteum and the muscular parts ;
an exudation of coagulable lymph ; an absorption of the
effused blood, and deposition of a limpid gelatinous fluid in its
place; an extension of the periosteum over this fluid, and a
formation of new vessels in it; and finally, a deposition of
osseous matter, which appears to take place soonest at the
points nearest the old periosteum. Thus far we are enabled to
ascertain the steps of the process of re-union, as detailed from
the experiments of Dr. Thomson, and Dr. Macdonald, in the in-
augural dissertation of the latter;* we also know that osseous
matter is deposited in the medullary cavities of the hollow
bones in the neighbourhood of the fracture, and that these
cavities are obliterated, and so continue for an uncertain

• De Necrosi ac Callo. Edin. 1799.

DISEASED APPEARANCES. 123

period; * but we are more at a loss as to the mode adopted bv
nature permanently to obliterate the opening of the medullary
cavity, at the ends of the bones in overlapping fracture ; there
is evidently a new effusion of osseous matter both on the sides
of the bones which overlap, and at their open fractured ex-
tremities, and a considerable degree of exertion of the modelling
action of the absorbents; but I am not aware of any correct ex-
periments which have hitherto been made upon the subject. In
compound fractures we are sometimes enabled to observe the
process of reunion of separated bones where there is not much
splintering or laceration of soft parts. Granulations are thrown
out from both surfaces, a fleshy union appears to take place»
and, finally, osseous matter is gradually deposited in this new-
formed flesh.

It was supposed among the older surgeons that there was a
precise period at which the osseous union of the different bones
was effected ; thirty days was the period assigned for the union
of a clavicle, thirty-five for a humerus, and from forty to fifty
for the thigh and leg. It is quite impossible to predict with
certainty how soon the union may take place ; in young healthy
subjects it is always most rapid; in the more simple fractures
much less time is required for an union than in the compound ;
and the upper extremities are found to unite sooner than the
lower. These are points to which we can speak with accuracy,
and we know also, that in all instances a free pure air is most
powerfully conducive to the cure, and that, wherever he may
be placed, temperance and cleanliness are of the greatest im-
portance to the patient,

I have had numerous opportunities of examining the effects
of disease in cases of compound fractures which have remained
long disunited, both after death and after the removal of the

* M. Beclard states, that in the tibia, or femur, the cavity is re-opened in from
90 to 100 days ; 1 have, however, known it to remain obstructed for some years.
See his paper in the " Bulletin de la Faculte," &c. vol. iii. p. 430.

124 INJURIES OF THE BONES.

limb. In the soft parts I have met with enormous abscesses
extending far and wide around the fracture, so that the ends of
the bones have been constantly immersed in the contents ; and
the muscles in many cases, and in some the periosteum, sepa-
rated for several inches from them. The infiltration of matter
has extended far in the interstices and in the fleshy bellies of
the muscles themselves, in some cases dissecting these organs
very completely one from the other; in others, partially de-
stroying them; and, in numerous instances, leaving no dis-
tinction of parts whatever, but a flabby, putrid, offensive mass
of decomposed animal matter, the more fluid part of an intoler-
able fetor, and having thready masses of cellular substance
floating in it ; while the more solid have had so little cohesion,
that they were easily broken down by the handle of the scalpel,
bearing in many instances a most striking resemblance to
chewed paper, or the pulp of rags.

The blood-vessels have been observed very often lacerated, '
and coagnla in various stages, from recent formation to hard
consolidated masses, have been found effused from them, sepa-
rable into different layers, and retaining, even when removed
from the diseased parts and washed repeatedly, a very nauseous
putrid smell. The coats of the vessels have been in many in-
stances found thickened and inffamed, and the veins partially
filled with purulent matter; but I cannot say that J have ever
met with these appearances distinct from the general disease of
the soft parts, probably because I have not had many opportu-
nities of examining very recent cases, my experience having
been chiefly confined to cases of long standing, and where there
has been greater leisure for anatomical researches. Indeed few
army surgeons could spare time immediately after an action l»
make long and accurate dissections. The bones have not, in
8ome instances which I have examined, participated so much
in disease as the soft parts ; nor have the joints in the vicinity
of llic fracture appeared to suffer nearly so much as might have
been imagined. This exemption has only occurred in two cases;

DISEASED APPEARANCES, . 125

and in both, of officers of high rank and sound constitutions,
who most punctually fulfilled all the directions given to them
by me, and were exemplary in their strictness of regimen.

One, the Honourable Colonel S , was an elbow case;

the fracture one inch above the condyle of the os humeri :
soft parts nearly gangrenous : joint filled with puriform
matter, without any traces of inflammation of its synovial mem-
brane : bones in close apposition, their ends covered with
a very florid spongy flesh, but no appearances of ossification.
These appearances were observed three weeks from the receipt
of the wound. The other was an ancle-joint case, Lieutenant-
Colonel B' Two inches from the joint: soft parts
beginning to run into gangrene : bones in pretty close appo-
sition ; the ends covered with a florid spongy flesh, very easily
separable, but without any trace of ossification : joint with some
puriform matter, but no traces of inflammation. Dissection six
weeks from the receipt of the wound.

In the remainder of about fifty cases that I have examined
myself, or been present at the examination of; and thirty ex-
amined by gentlemen in whom I place the highest confidence,
more or less of disease was observable in the bones, exclusive
of the solution of continuity effected in them. The appearances,
which were sometimes separate, but much oftener combined,
were generally as follows : Roughness of the extremities of the
fracture ; denudation of the sides of the bones, and worm-eaten
absorption of them; inflammation and ulceration; exfoliation
of various sizes, and of different stages of looseness, on the ex-
tremities of the fractured ends, but not often including the
whole circle; the same on the sides of the bones in the vicinity
of the fracture ; the same at a distance from the fracture, but
not continuous with it; a line of separation between the bone
and its epiphyses or processes very evidently marked, and of a
vascular appearance; (this last appearance I have seen only at
the ends of ihe bone farthest from the source of circulation;
and in such cases, abscesses were formed over the dise^ised

126 INJURIES OF THE BONES.

points;) loss of the cancelli in the medullary cavities of the
bones, with destruction of the medulla itself, or conversion of
it into an offensive bloody ichor, filling almost the entire canal ;
loss of the cancelli, with a bloody fungus, filling the medullary
canal like a stopper or tompion ; loose adhesion of the muscles
to the bones, to such an extent as that separation could be
effected by the handle of the scalpel or by the finger; the whole
neighbourhood of the fractured bone of a greasy unhealthy ap-
pearance ; and, finally, necrosis, or complete death of the bone,
with deposition of new osseous matter; the deposition being
irregular, and evidently unhealthy, distorting the limb to a great
degree.

Such have been the local appearances on dissection. AH
this organic injury cannot be supposed to exist without great
general disease ; the fever, the cough, the diarrhoea, are all
harassing and alarming to the greatest degree ; they sometimes
invade separately, and sometimes in combination, and produce
not only all the appearances of pulmonary consumption, but too
frequently its fatal termination. If tubercles, or a tubercular
disposition exists in the lungs, no medical aid will relieve the
sufferer; and, indeed, while the great source of irritation re-
mains, even the temporary alleviation of his misfortunes is
looked for in vain. The first approaches of these insidious
bowel and pulmonary affections, are much better combated by
management and diet than by any medical means. This I am
authorized to assume as certain, from having traced them in a
vast variety of instances, to errors in these important points ;
having checked them when forming, by proper restrictions, and
having prevented them altogether in cases where they have
been naturally looked for from the examples of preceding-
victims ; and these errors have been so very rarely on the side
of abstinence, that the exceptions merely tend to confirm the
general rule of " strict limitation." Restriction in tho use of
wine is one of the most dinicull to effect in military hospitals;
but it is one that calls most loudly for attention. The idea is

NECROSIS, &c. 127

absolutely erroneous, that a large quantity of this cordial is
necessary in the advanced stages of fractures and wounds.

The disposition to Necrosis in gunshot injuries of the bones,
a circumstance of daily occurrence in military hospitals, is
always tedious, highly troublesome, and frequently dangerous.
The precise time of its commencement is not easily ascer-
tained ; I have detected it on the twenty-first day from an
injury ; but it is more frequently a disease of the advanced
periods. It is most frequent in bones covered by their soft
parts, while caries takes place more readily when they are ex-
posed to the air. Where the periosteum is removed for any
extent by a gunshot or lacerated wound, or suffers disorganiza-
tion afterwards from any cause, whether inflammation, ulcera-
tion, or erosion ; or where the medulla is injured or destroyed,
it becomes a never-failing occasion of the death of that part of
the bone in the immediate vicinity of the injury.

This is not the proper place to enter upon an inquiry into
the power or influence of the periosteum in the formation of
bone, as a question of pure theory or physiological research.
The fact that bone is never regenerated where the periosteum
is extensively injured, is beyond all doubt.

There are few military surgeons accustomed to the examina-
tion of limbs removed by amputation from causes affecting
the bones, who have not found the diseased or fractured part
suffering a loss of its healthy colour, and acquiring a spon-
giness, or an honey-comb apppearance on its surface ; but
to speak more accurately, exhibiting proofs of the action
of the absorbents. If an attentive examination be made
of the soft parts surrounding the injured bone, osseous
granulations will be frequently observed in various degrees
of progress to perfection. In some places they lie in small
irregular masses, hanging by very slender membranous fila-
ments, and easily separable by the finger or probe, or even by
simple agitation in water. In others, they form a continuous
surface of various extent, and seem like an incomplete sheath

128 INJURIES OF THE BONES.

or irregular envelope thrown over, or around the injured
bone, studded as it were on its inside face with hard bony
particles; and often, if the living- bone is examined, a cor-
responding granulated tissue or efllorescence will be observable
on it, as if proceeding to meet the former. All these pheno-
mena clearly appear to depend upon the action of the perios-
teum, whether adhering to the living extremity of the fractured
bone, or separated entirely from it ; but still possessing vas-
cularity and life by its connection with the soft parts. The
following case, selected from many others, affords a very
striking example of this kind :

Case XIX.

Secondary Injury of the Femoral Vessels, and of the Os

Femoris.

A soldier of the fourth regiment of infantry received a
wound at the storming of Badajos from a musket slug, which
brushed over the course of the femoral artery, nearly where it
dips under the sartorius, and passed through posteriorly at the
centre of the limb. Both orifices of the wound healed in a very
short time ; soon after which a hartlness and fulness of the
part manifested itself, attended with slight pain, supposed to
proceed from some pieces of cloth, or other irritating cause,
though afterwards, from concomitant circumstances, conjec-
tured to be aneurismal. Shortly after, the man was attacked
with the fever of the season, by which ho was very much re-
duced in .strength ; and, having been a Walcheren subject,
little hopes of his recovery were entertained, as a tumour of
the spleen had evidently formed. The progress of the tumour
of the thigh had been rapid during this febrilo attack ; and his
general health was much impaired. It appeared that the
tumour was attended with the most excruciating j)ain on

NECROSIS, &C. 129

pressure, and particularly at night, even from the weight of
the bed-clolhes : it spread upwards to within a hand's breadth
of the groin, and downwards to the ham. The lower limb
was oedematous and almost insensible. It was now obvious
that something must be immediately done ; and, as little
chance appeared by performing any palliative operation, it was
determined to remove the limb. The operation was performed
on the twenty-first day, by Assistant-Surgeon Scott, then of
the 11th regiment, afterwards a resident practitioner iu Dublin,
without any thing remarkable occurring, except the number of
small blood-vessels to be tied. The limb was carefully dis-
sected by Assistant- Surgeon Edwards of the 43d regiment ;
the soft parts were flabby, oedematous, and in some spots dis-
organized, and the great vessels either shrunk or obliterated ;
but no actual rupture of them could be traced. A large ca-
vity, capable of containing about two pints of fluid, was found
deep in the centre of the thigh, involving the course of the
slug, and filled with a mixture of grumoos blood and fetid
purulent matter. The bone, for the space of about four
inches, was found denuded of its periosteum, and rough to
the touch. On sponging out the parts, the centre of the cavity
appeared occupied by the bone, and its sides were partially com-
posed of a sheath of bony granulations, in some spots nearly of
a quarter of an inch thick, firmly adhering to the periosteum,
(which itself adhered to the mass of muscles,) and evidently
proceeding from it. The detachment of the membrane from
the bone appeared to have been produced by a deep-seated
collection of blood, most probably proceeding from sloughing
of the coats of the femoral vessels, and slowly exuding into
the track of the wound which formed the original cavity. It
is likewise probable that the slug, in its passage, had brushed
the bone and killed its enveloping membrane; and that when
the space between the bone and injured membrane (which
always separates) became distended with fluid, the sound part
of the periosteum was forced up by the pressure on it. Be

130 INJURIES OF THE BONES.

this, however, as it may ; Nature had made considerable
progress towards the formation of a new bone, in the short
period of three weeks, solely, as it appeared, by the agency of
that membrane. This bony exudation from the periosteum is
still oftener apparent where amputation is obliged to be per-
formed a second time, from causes which I shall hereafter
mention ; or where, the operation being already performed, the
patient falls a victim to the irritation of a diseased bone.

Professor Weidmann has collected a number of authorities
on this subject, and particularly relates an instance where Jus-
tamond had removed a necrosed bone by gouge and mallet ;
but having totally destroyed the periosteum, no bone was ever
regenerated afterwards.*

The practical inferences to be drawn from this power of the
periosteum are particularly valuable, as guides to the boun-
daries we should ascribe to the extraction of splinters from
compound fractures. If the splinter is large and adherent at
many points, and particularly if it is longitudinal, it will be
worse than useless to attempt its removal by force. I have
seen several instances in which fever, intense pain, and even
death, have followed such a wanton interference with the ope-
rations of nature. ]f the periosteum is not irrecoverably
damaged, partial or even entirely new formation may take
place, and the separate portion of bone will re-unite; if it is,
nature will herself point out the necessity for removal, by the
gradual loosening of the parts, which at length becomes per-
ceptible to the finger or probe.

The two following cases, furnished me by my friend Dr.
Knox, bear strongly on this point ; and the latter serves to il-
lustrate some of the observations made on the extraction of

balls.

• The Professor's cxccllfiit Latin Treatise Du \ecrosi Ossium, Francofurti,
nd Mitnum, 1793, folio, is exceedingly scarce ; hut a good translation has been
published at Paris in 1808, by M. Jourda, one vol. 8vo.

SPLINTERS. l3l

Case XX.

Longitudinal Fracture of the Tibia.

A French prisoner of war had been wounded by a musket
ball in the left leg. It fractured the tibia about two and a
half or three inches above the ankle-joint. The fracture ex-
tended longitudinally, and as several loose pieces of bone were
ascertained to exist, it was proposed to extract them by an
incision, as they seemed the only obstacle to the completion of
the care and final recovery of the limb. An extensive incision
was made ; but nearly all the loose pieces adhered by one or
more points, and could not be brought away by any reasonable
force. The wound was therefore allowed to heal up, and
nature to resume her own operations, till towards the latter
end of the third month from the infliction of the wound, the
largest splinter and the only one then remaining loose, actually
protruded of itself, and was easily extracted by the common
dressing forceps. The wound almost immediately healed, and
the patient was sent to his own country.

Case XXI.

Compound Fracture of the Thigh,

A French prisoner was brought into Brussels soon after the
battle of Waterloo, severely wounded in action with the
Prussians ; he received after he fell several bayonet and sabre
thrusts, and one lance wound through the chest ; but the most
serious injury was a compound fracture of the right thigh from
gun-shot. Three musket balls had struck nearly at the same
time on the outer side of the limb, splintering the os femoris
from the middle of the upper third of the bone to within two

K 2

132 INJURIES OP THE BONES.

inches of the condyles. The discharge, as might be expected,
was enormous ; but his appetite fortunately remaining good, he
was enabled to support a waste of fluids scarcely to be credited.
Whilst under cure, many extensive incisions were made to
extract bones and balls ; but with most extraordinary want of
success. After the failure of these incisions, one of the balls
spontaneously presented at the orifice, and another came away
in a cataplasm. Although a recurrence to more ample in-
cisions was pronounced the only chance for the poor fellow's
recovery, no further operation was attempted ; but by minute
attention to dressings, supporting his strength, and, above
all, moving him to another hospital which enjoyed a purer air,
the fracture consolidated, a very few minute splinters were
easily removed by the dressing forceps, and the man recovered.

In some instances, though more rarely, no apparent exfolia-
tion whatever takes place, notwithstanding that the bone is
considerably shattered and exposed to the air, a cause which
so frequently occasions its death and separation. Nothing but
the youth and sound constitution of the patient, which admits
of the recovery of the injured membrane, and the cleaning of
the ulceration of the bone, can account for this. The more mi-
nute scales or comminuted portions are carried ofl" by the flow
of purulent matter, either totally unobserved, or in small pal-
pable particles.

Deep incisions, will, indeed, often produce exfoliations, but
they are then the consequence of the unnecessary injuries in-
flicted \>y the surgeon, and not the result of nature's eftbrts at
regeneration. 1 iiiight produce a great mass of evidence il-
lustrative of the propriety of patiently waiting the event, and
not hurrying into operations under the false idea that exfolia-
tion must necessarily follow every injury inflicted on a bone.
I have often seen extensive and most painful incisions made
down to the bone, and in the whole course of a limb that has
l)een fractured, for the ostensible purpose of admitting of the
free removal ol fragments, and 1 am convinced I have often

EXFOLIATIONS. 133

traced the eventual loss of the limb to such causes. I would
not by any means be supposed to insinuate, that incisions are
not called for and highly proper in many instances, particularly
where a free discharge is not afforded for purulent matter, or
loose spicula lying within a confined cavity ; but I would wish
to impress on the younger surgeon the propriety of sparing his
incisions until he has some determinate object in view, and
while in quest of dead bone or deep seated abscess, not to lay
the foundation for both, by his own ill-judged attempts at de-
tecting them.

The natural efforts at exfoliation commence at different pe-
riods, and its progress is rapid in proportion to the smaller or
greater solidity of the bone, or the state of the periosteum ;
the separation of the scale or piece being always more rapid in
proportion as it is more or less deprived of that vitally important
membrane.

A method for the excitement of exfoliation in carious cases,
or the removal of the sequestra of bones in a stale of necrosis,
has been long a desideratum among surgeons, and has produced
several contradictory and some ludicrous remedies. Rasping,
burning, boring, and cutting, have all had their advocates, and
oiling, drying, and immersing the bone in strong pickle, or even
in aquafortis, have been considered useful by others. Some
place their faith in the external application of euphorbium and
burning oils; others rely on internal medicine; and one author
places all his hopes in the exhibition of assafoetida in this man-
ner, having no confidence in topical remedies.*

I have long laid aside all topical applications to bones about
to exfoliate, the common simple dressings excepted ; and with
a due attention to cleanliness of the parts, and to the state of
the stomach, bowels, and skin ; with gentle excitement by a

♦ Block, see Weidman. p. 40, and the authorities quoted by him, or the Trans-
lation by Jourda, p. 115, et seq. See also Monro in Medical Essays or Edin-
burgh, vol V. article 21.

134 INJURIES OF THE BONES.

probe or forceps, and a prudent and regulated use of the knife
or prepared sponge, although the cure may be tedious, T have
generally found it complete.

In cases where the separated pieces lie loose, and cannot
easily be got at by the forceps, setons have been employed with
some advantage, for the purpose of bringing them away; and
when judiciously applied, and not carried to such a length as to
affect sound pieces of bone with caries, and thus produce what
they were meant to remove, they may often be usefully had re-
course to. Staff-Surgeon Boggie showed me some cases at
Brussels in which he had employed the seton with success, and
an account of a case in which he adopted the plan, is published
in the 7th volume of the Medico-Chirurgical Transactions.
Doctor Arthur, Surgeon to the Forces, has also successfully
used them in old cases at the General Hospital of Chatham.
But to the indiscriminate introduction of setons in gunshot
injuries, either of the bones or soft parts, I cannot help enter-
taining strong objections. They are at best but a clumsy and
unmanageable substitute for the knife, and in numerous instances
much more painful and irritating.

In limbs with a diseased bone, the state of the soft parts
depends, in a great measure, on that of the bone. The exfo-
liations, or the protrusions of sequestra, are generally announced
by an alteration in the appearances of the part, as well as in the
quality of the discharge, and to attempt any permanent im-
provement in either, is perfectly hopeless, until the state of the
living bone is ameliorated ; but much temporary advantage may
be derived from external applications and the proper use of
pressure and bandages, with the occasional employment of the
knife. Cloths immersed in vinegar and cold water, or in
moderately strong saturnine lotions, may be placed around the
limb if much inllaniniafion is present; and S(jlutions of the sul-
phate of copper applied to the sores will be found very useful
to correct the uvAot of the discharge, and stimulate the vessels
to a more healthy action. Aluminous solutions are also of con-

COMPLICATED FRACTURES. 135

siderable utility in correcting the foetor, and a diluted nitric
acid will often be advantageously employed in very sluggish
cases with a luxuriant fungus, or a sloughy disposition. Very
little, however, is to be expected from any of these remedies,
if the general health is not supported, and the most rigid clean-
liness and ventilation observed in the wards where such cases
are treated.

Where the patient can move about, exfoliations are often re-
markably promoted by moderate exercise of the affected limb.
While using the very simple machinery of Hilsea Hospital,
hereafter to be described, I was much struck by this circum-
stance. A great deal is no doubt to be attributed to the im-
proved health, which admits of, and is connected with exercise,
and respiring a pure air out of the wards of an hospital ; but I
conceive much is also to be referred to the mechanical action
of the muscular fibres upon those points of bone into which
they are inserted, and which, if loosened from the main mass by
disease, must certainly be considerably influenced by a steady
and protracted natural force acting upon them, without the aid
of surgical instruments, or the violence of operations.

Where, however, a perfect necrosis has taken place, and the
dead bone is invested with a living covering, respectable as the
authority of Weidmann is, for leaving almost all to nature, I
must, from my own experience in military practice, strongly re-
commend having: recourse to the more active measures usual
amonff British surgeons to save a life at least, if we cannot
save an efficient soldier to the country. In determining the
proper period, it is always to be kept in view, that the new en-
velope is much more dense when fairly formed than the
original bone ; it is entirely destitute of cancelli, and the earlier
the opening of it is made, the easier will it be to the operator,
and the patient will be saved much misery and irritation. It
should also be recollected, that in fractured bones, when union
has taken place, the medullary canal is obliterated at that part,
and filled up by the new callus, which is not absorbed for a

136 INJURIES OF THE BONES.

length of time. Hence, partially perforating the shaft of the
bone in search of sequestra is often useless. The septum
formed across the cavity will render a perforation necessary,
above and below the union, should sequestra exist in both the
upper and lower division.

I shall now advert to a species of the Comminuted Compound
Gunshot Fracture, which, although at first of but little conse-
quence in appearance, is of most serious importance in its
results. This occurs where a musket ball has perforated a
cylindrical bone, without totally destroying its continuity, and,
consequently, without producing any distortion of the limb, or
other symptoms which characterize a fracture. The foundation
of infinite mischief is, however, laid; for not only is the shaft
of the bone injured, but fragments are carried into, and lodged
in the medullary canal ; and if the limb has been in an oblique
position, or the ball has taken an oblique course, these frag-
ments are often driven in to a great distance, and firmly im-
pacted in its cavity, there keeping up a constant and uncon-
trollable irritation, and destroying both the medulla and its
membrane, together with the cancelli, which naturaJly support
it. I have repeatedly seen this separated portion of bone
lying in the medullary canal, at the distance of from four lines
to an inch and half from the circular hole formed by the passage
of the ball, retaining its shape, its colour, and its solidity, while
all the surrounding osseous parts were diseased, and formed a
spongy, discoloured mass of bony granulations around it; the
periosteum for some way, both above and below the wound,
being entirely separated from the bone. To attempt to save
such a limb is imposing a task on the powers of nature, which
nineteen times in twenty she is unable to elfect, even under the
most favourable circumstances. If a ball has passed through
without carrying in any fragments of bone, a case which some-
times happens in the thigh, when the man is standing erect,
and the ball has struck the bone fairly and <lirectly, the case is
more favourable than when the wound is oblique, as in the arm.

COMPLICATED FRACTURES. 137

which is so often thrown into a variety of postures ; and, con-
sequently, where there is a greater chance that the channel of
the ball should be formed obliquely, and the spicular fragments
forced up into the medullary cavity. But even of this favourable
variety I have seen only two cases cured, both of persons struck
on the centre of the femur, the wound admitting a finger to be
passed into the bony ring, or perforation, and there to find a
clear, unembarrassed, and comparatively simple loss of parts.
By far the most frequent result is the loss of the limb sooner or
later, after a very tedious and distressing train of symptoms,
exhausting to the patient, and baffling every endeavour of his
attendants. On examination, we find bony fragments lying
beyond the reach of operation, either in a parallel direction in
the cavity of the bone, or fairly wedged across it, the medulla
destroyed, the cancelli absorbed, and, if the posture of the
limb admits of it, the fragments falling down deeper into the
canal, as the bony net-work is removed. To obviate these
mechanical injuries, nature makes many inefficient eftorts, and
throws out large shapeless bony masses, which either envelope
the diseased parts completely, or else so embarrass and partially
fill up the orifices of the wound in the bone, as to render the
extraction of fragments, or even their detection, next to im-
possible. The attempts of nature to remedy this state are often
continued so far as to form orifices, or Cloacae, in this newly
formed bone, for the discharge of the fragments. In some cases,
the parts of the bone which originally formed the sides of the
ring, and kept the limb in its natural position, and at its due
extent, are entirely absorbed; little or nothing but the new and
loose osseous sponge remains, and the muscular power being
constantly exerted on it, a shortening and thickening of the
limb succeeds.

I shall, in further explanation of this important point, offer
a very interesting case, with which I have been favoured by my
friend Dr. Denmark, Physician to the Fleet, and late of Haslar
Hospital.

138 INJURIES OF THE BONES.

Case XXII.
Complicated Fracture of the Thigh.

" James Wood, a marine, belonging to his Majesty's ship
Ajax, aetatis 25, was admitted into Haslar Hospital, 27th Sep-
tember, 1811, for a gunshot wound through the right thigh,
the ball passing from before backwards, about tive inches above
the patella. I saw him nearly a year previous to this, (on the
day succeeding to the injury,) and recommended the able
surgeon under whose care he was, on board the Ajax, to
attempt the preservation of the limb. Neither the joint, nor
any important blood-vessel being implicated, justified, ia
my opinion, the trial, although it was sufficiently apparent
that the ball had passed directly through the diameter of the
bone.

" On my appointment to Haslar Hospital, in May, 1812, I
there found him a patient, deriving all the advantages which
hospital treatment and professional talents could aft'ord, during
this long period, without being one whit nearer recovery. The
lower half of the thigh was now much enlarged, visibly shortened,
the muscles having nearly lost all power over the flexion and
extension of the knee-joint, and the constitutional health ma-
terially injured.

" The occasionally favourable but deceptive appearances of
the wound, together with the patient's youth, constitution, and
entreaties to defer the operations, were the chief causes of
procrastination. The discharge would, at times, become greatly
diminished ; the healing process would, for a while, seem to go
on rapidly, with the absence of pain, and subsidence of in-
flammation, when, all at ouce, these last would again recur,
with the formation of deep-seated abscesses, bursting out of
matter, and high symptomatic fever. Such harassing alterna-

COMPLICATED FRACTURES. 139

lions induced him at length to coincide in the impropriety of
further delay towards the removal of the limb. It was,
accordingly, performed on the 7th September 1812, nearly two
years subsequent to the infliction of the injury.

" The soft parts, down to the bone, integuments, cellular
substance, muscles, and periosteum, were all much thickened,
from the interposition of consolidated lymph, consequent upon
long preceding inflammation. The periosteum was exten-
sively diseased, thickened, and highly vascular round the
wounds to a considerable distance ; and a large mass of osseous
matter was thrown out. A detached portion of bone lay in a
transverse position between the upper and lower extremities
of the fracture. The apertures in the bony mass were nearly
blocked up with an adhering gelatinous substance, separable
only by maceration, which, no doubt, (by its closing from
time to time round the detached bone, so as to confine the
discharge,) contributed to the above phenomena of favourable
appearances, succeeded by pain, inflammation, burstings of
matter, &c. This man was soon discharged cured, having
recovered quickly from the operation."

In some severe gunshot fractures, especially of the thigh,
the bone is divided into different fragments ; and that part of
the shaft which is not comminuted, is fissured to a greater or
lesser extent, proportionate to the violence of the blow. This
is a case very serious at best, but desperate, if, as occasionally
happens, a piece of bone be driven into the medullary cavity,
where its first effect is to kill the medullary membrane ; and,
secondly, it acts exactly like a wedge, and keeps the sides of
the fissured bone so effectually asunder, that they do not ad-
mit of being placed in juxtaposition. Yet even here, nature
endeavours to bring about an union of the disjoined parts, by
an effusion of new osseous matter.* The femur had originally

* la plate 1, fig. 3, of the second edition of this work, there is a specimen
which illustrates this point.

140 INJURIES OF THE BONES.

been fissured in four places, and the separated pieces were
kept asunder by the interposition of a transverse wedge of
bone, in the same manner as a port-crayon or tire-ball, when
the pencil or ball is between its blades. At one point an
osseous bridge is thrown across between two of the separated
portions which are seen in the present view. The posterior
portion, which cannot be seen in the engraving, is connected to
the other parts by a mass of irregular osseous matter, in which
several insulated fragnients are imbedded. The history of this
individual case I am unacquainted with; the subject must
have retained the limb for some time after the injury; but
whether amputation was subsequently performed I cannot say ;
I owe the preparation to Professor Thomson.

It very often happens, after gunshot injuries of the bones,
that the limb feels and looks more like a plaster cast, than a
living organized part, from the quantity of irregular osseous
matter thrown out. This matter sometimes involves the neigh-
bouring joints, and occasions incurable anchylosis, which is a
still more certain consequence if the surfaces of both bones
are injured, in which case, each contributes its proportion of
osseous granulations, in which the sound portions of bone
become imbedded. The removal of the limb is in these cases
frequently our only remedy. In some cases this matter is
thrown out in profusion, and yet the fractured parts remain
disunited.

In some cases, this osseous deposit is not confined to the im-
mediate vicinity of the injured bones. I have in my posses-
sion some specimens, where an irregular osseous fungus has
sprouted out, as it were, from the sound shaft of the bone,
one or two inches from the mass of disease, and completely
detached. This operatiun of nature has taken place in some
instances at several distant points at the same time, and all the
fungi have become successively involved in the advancing and
increasing deposit.

NEW OSSEOUS FORMATION. 141

In some cases, these osseous exudations appear on the ridg-es
of bones, sticking out from them in tbe form of spicula, and
giving the bone a serrated appearance : in others, the surface
of the bone is covered with new formed osseous matter, di-
vided into numerous sulci parallel to each other, and with
processes of the periosteum dipping in between them, in a
manner very nearly resembling the surface of the stones of
some fruits ; but in the ordinary process of the formation of
a new bony sheath from necrosis, the surface is more uniform,
with irregular minute holes into which these processes sink.
In the recent bone, these irregularities are all concealed by
the investing thickened periosteum, which, by its affording an
uniformity of covering, often gives rise to a deception, in some
cases so complete, as to lead to the supposition that the heads
of the bones participated in the renovation of their shafts.
This is never the case ; the process of renovation in necrosis
goes on only in those parts of bones corresponding with their
medullary cavities, and the apparent renovation is shown to be
illusive on the removal of the periosteum by careful maceration.
If the removal is attempted by the unassisted knife, the
effect is very incomplete, the membrane is glistening in
appearance, and in consistence somewhat like cartilage, and
only loosens by long maceration, when it peels off in a tough
leathery coat, connected to the subjacent bone by vascular
threads ; and on its removal, a smooth narrow ivory-like line
is found to connect the new formation to the original epiphysis,
while the old bony shaft is in various stages of decay. If the
necrosed part be examined, while nature is in full work, that
part of the new bone most recently deposited, can always be
very readily known by a beautiful distinctive mark ; the exter-
nal periosteal covering is thickened, red to the eye» and when
peeled off, the subjacent parts, before they are clean washed,
give exactly the appearance of a piece of parboiled pork, from
which the rind has been torn ; the surface of the bony crust is
covered with dots where last deposited, while, when of older

142 INJURIES OF THE BONES.

date, it is covered with sulci, formed apparently from several
dots being- united in parallel lines, by the absorption of the
solid interstitial spaces, which at first existed between them.

Two processes of nature are frequently going on at the
same time in bones ; viz. the effusion of the substance which
I have denominated, from its irregular shape, osseous fungus ;
and the separation of pieces of decayed bone by the process
of disjunctive absorption. The appellation of Spina Ventosa,
is sometimes applied to this appearance ; but, I conceive, very
erroneously, as that name is applicable only to internal ab-
scesses of the bone, accompanied with caries.

A proper selection of cases for amputation, and an early
performance of that operation, will prevent the occurrence of
many tedious secondary affections of the bones ,• but notwith-
standingr all our care, dangers of this kind will arise in cases
where, in their original state, no such consequences were to be
apprehended, the injuries having been simply contusions with-
out fracture. Constitutional or local irritation, and errors of
diet, are the principal causes of these untoward occurrences ;
they are always preceded by rigors, febrile heat, loss of ap-
petite, deranged state of the bowels, restlessness, deep-seated
pain in the bone, erubescence, and tumour extremely sensible
to the touch, all indicating periostitis, and affection of the
medullary membrane; which, if going on to inflammation of
the bone itself, or to suppuration within its cavity, or to in-
flammation and abscess of the neighbouring joints, is often
fatal. The obvious course to be pursued in the commence-
ment of such cases, is the antiphlogistic plan, rigorously en-
forced ; — nauseating doses of autimonials, purgatives, and,
above all, local bloodletting, by leeches, or the scarificator;
while, after having been blistered, the affected parts should
be covered with compresses dipped in cold applications, of
which cold water, with a small proportion of vinegar, is per-
haps the best. If by these means relief is not afforded, an
incision down to the bone, freely dividing the tense and in-

EXCORIATIONS. 143

elastic periosteum, will be the most likely means of succeeding.
I have often tried it, or seen it tried successfully ; but I must
confess that I have also often seen it followed by no favourable
results, and that true Spina Ventosa, or suppuration within the
bone, aud necrosis, have supervened.

During^ the period that a patient labouring under a com-
pound fracture, or an injury of the joint, is necessarily confined
to bed, great attention should be paid to the prevention of
those troublesome affections of the skin and muscles, known
under the name of " bed sores ;" even in civil life, these af-
fections are extremely apt to occur ; but in military hospitals,
where the materials of the beds are often extremely coarse
and ill arranged, they are much more frequent. Where the
patient is laid on his back, and the extended posture of the
limb is adopted, it is almost impossible to prevent excoriations
of the heel, the calf of the leg, and the buttocks ; but by
proper management they may be greatly alleviated. Old linen
properly folded, or tow, or pads stuffed with bran or any soft
material, should always be placed so as to relieve the parts
most subjected to pressure; these parts may also be defended
by adhesive plaster, or the soap plaster spread on leather ; but
the most useful articles of all are circular pads of various
sizes, hollow in the centre, so as to resemble the rim of a
bed-pan, and well stuffed ; these are so placed under the
buttock or heel as to support them effectually from the pressure
of the bed. Nothing is more annoying to a bed-ridden
patient, or sooner gives rise to excoriations, than the crumbs
of bread which so frequently accumulate around him, and
which are soon hardened by the heat of his body. The patient
cannot take his food out of bed, and the surgeon will find it
well worth while to pay some attention to this apparently
trifling object, which can be so easily obviated.

In hot weather great difficulty is often experienced in keep-
ing sores of all descriptions, but especially compound fractures,
free of maggots. Much may be done in the way of preven-

144 INJURIES OF THR BONES.

tion, by proper attention to cleanliness, and particularly by the
removal of fragments of food, which soldiers are always in the
habit of concealing about their beds, if not strictly watched ;
some surgeons wash the sores with decoctions of bitter herbs,
for the purpose of removing these troublesome guests. I have
not seen great advantage derived from this practice, and I
prefer, apon the whole, the lotion of vinegar and cold water.

Proper cradles for defending fractures from the pressure of
the bed clothes are one of the first of the minor comforts ;
those which have been hitherto supplied to military hospitals
are of wood, very clumsy in general, very fragile, and occupy
a great deal of room ; it would be a considerable improvement
if these articles were made of wire. Any person of common
ingenuity can strike out some substitute, by bits of hoop, or
twigs, whenever a deficiency of them occurs.

I have already mentioned an improved bed-pan for the use
of patients with fractured limbs ; no person who has not been
accustomed to these cases can be aware how greatly his patient
is relieved by attention to points of this description : the na-
tural awkwardness of a wounded man, his pain and fretfulness,
and the ignorance or moroseness of servants, tend greatly to
aggravate his sufferings; but, independent of motives of
humanity, cleanliness is greatly promoted by attention to the
supply of proper utensils for receiving the evacuations of the
sick. From economical motives, pewter has received the
preference in the manufacture of those articles, but coarse
earthenware, properly glazed, is less offensive to the smell,
under any casual accumulation of filth ; and they are also
much more easily cleaned, an object of no small importance, by
enabling us to apply the labours of the servants to other ur-
gent purposes.

145

CHAPTER VIII.

OF INJURIES OF THE JOINTS.

This is a most iiuportant class of injuries, and forms, as I
have already stated, one of the leading causes for amputation
on the field of battle ; but serious as the consequences in ge-
neral are, when a large joint has been injured by the passage of
a musket ball near or through it, there are highly favourable
cases, in which the limb may be saved. Where shells or grape
brush or graze along the joint, and even partially open it, as
sometimes happens, there is also a possibility of saving the
limb ; but in all those cases, however anxious we may be to do
so, we should never allow our hopes or our wishes to deceive
us ; we know not the moment that inflammation may set in and
mar our most sanguine prospects ; and it is but justice to our-
selves and our patients, to explain to them or their friends the
probable failure of all our endeavours. The cavities of the
joints, especially of the shoulder, are often opened by sabre
wounds ; and if they are immediately closed, and proper atten-
tion is paid to the after treatment, a cure is frequently effected.
Among the native Indian troops, especially where the tendency
to inflammation is not nearly so violent in general as among
Europeans, I understand that wounds of this kind are not con-
sidered as particularly troublesome or unpromising.

In all cases where we may be induced to attempt the preser-
vation of a joint, the extent of the wound, its vicinity to the

146 INJURIES OF THE JOINTS.

large vessels or ueives, the comparative injury done to the
bones forming the articulation, the constitution, habits, and
mode of life of the patient, the possibility of enjoying rest
and quiet, the nature of the accommodation to be procured for
him, the purity of the air, the crowded state of the hospitals,
and the facilities afforded to his medical attendants of seeing
him and enforcing their orders, must all be maturely weighed.
Scrofula and habitual drunkenness are almost insuperable bars
to effecting a cure under any circumstances.

In my own practice, I have met with only two cases where
the limb was saved after a serious injury of the knee joint,*
and in one of them only was the perfect use of it restored. 1
never met with an instance where the ancle or elbow-joint was
perfectly restored after severe gunshot injury, though some
where the limb has been saved. Of the shoulder-joint the
recoveries are more frequent than in either of the other cases,
probably in consequence of its less complicated structure.

Mr. Hunter f gives us the case of a man, C. D. who was
shot through the joint of the knee. The ball entered at the
outer edge of the patella, crossed through the joint under that
bone, and came out through the inner condyle of the os femoris,
This man, and four others, bad nothing done to their wounds
for four days after receiving them, having secreted themselves
in a farm house, and, when brought to the hospital, the wounds
were only dressed superficially, and they all got well. Had this
man been placed in a waggon or on horseback, and carried for
some miles to an hospital, with his usual allowance of food,
would the result have been the same ? I confidently answer.
No. Nothing but quiet and abstinence could have produced

• The head of the fibula is in some favourable cases the part alone injured ; and
it has in some of these instances been removed without any farther operation, and,
of course, without implicating the joint dirtctly ; even this, however, is by no
means a frequent occurreiicf.

t Treatise on the Blood, Inilammation, and Gunshot Wounds, London, 1812,
vol. ii. p. 43S.

INJURIES OF THR JOINTS. 147

such an exemption from inflammation ; and, even with these
circumstances in his favour, the case is one of a thousand.

The more general results of injuries of the knee-joint (which
are the most frequent of all) are pointed out in the following-
cases, furnished me by StafF-Surgeon Simpson, late of the 36th
regiment.

Case XXIII.

Of Wound of the Knee- Joint terminating fatally.

A soldier, at the action of the Nivelle, received a musket
shot in the knee-joint. The joint was thoroughly perforated
near its centre; the temporary dressings usually employed on
such occasions were applied. When the heights were crowned
by our soldiers, and the enemy dislodged from their last posi-
tion, our wounded were conveyed into the huts previouslv oc-
cupied by the French troops. On a more minute examination
of the different casualties of the day, no case appeared to
demand more attention than the one I have mentioned. It was
already late in the afternoon; the wound, in its original state
sufficiently severe, had now assumed an appearance inOnitely
more alarming; inflammation had set in all round the joint, and
threatened to proceed with extreme rapidity and violence; the
pain was excruciating and incessant, and the screams and
groans the patient uttered indicated the most agonizing bodily
torture. It was necessary that something should be done for
his relief, and that too without loss of time. With a single
exception, every voice, and the patient's among the number,
decided in favour of immediate amputation. That exception,
in spite of all his earnest entreaties to the contrary, sealed the
fate of the unfortunate sufferer ; the attempt to save the limb
was to be made. That same evening we marched after the
enemy, and I never saw him more. From some of his com-
rades, who soon after joined the regiment, I learned the termi-

148 INJURIES OF THE JOINTS-

nation of the case. He had experienced no relief from pain;
the inflammation had extended all over the limb ; and, worn out
by suflering, and the acuteness of bodily anguish, on the 4th
day he had expired.

Case XXIV.

Of Wound of the Knee-Joint terminating fatally.

A soldier, seated on a sloping piece of groand, with his knees
bent, and his legs drawn close to the thighs, was wounded by a
chance shot from the rear. The ball entered the thigh, frac-
tured the femur near its lower extremity, passed close behind
the knee-joint, and came out again near the head of the fibula,
after injuring that bone. Here again, in defiance of every risk,
from the complicated nature of the wound, and the threatening-
symptoms which speedily showed themselves, the limh-saving
system was adopted. The inflammation in the injured parts, as
well as the general excitement, ran high, and the life of the
patient was in the most imminent danger. Flis sufferings from
the extension of the limb were most acute; the abatement of
the first violent inflammatory stage produced but little relief
from suffering; the swelling continued almost as great as ever;
the discharge of pus alarmingly profuse and debilitating; the
knee became implicated in the general mischief; extensive
abscesses and sinuses formed in the thigh and around the joint;
and, after a lapse of about six weeks, which had been produc-
tive of nothing but ruin to the constitution of the patient,
and sensations of the most painful regret in the minds of
the medical attendants, a moment favourable for the perform-
ance of amputation was takrn advantage of — it was too late.

The following case is illnstrative of the practice to be pur-
sued in injuries of the joints; and, as it is particularly inte-
resting from being related in the words of the |)atient himself,

INJURIES OF THE JOINTS. 149

Lieutenant-Colonel R. Dragoons, and remarkable for the

rigour of the practice, and the cheerfulness with which it
was submitted to, I shall make no apology for inserting it
here.

Case XXV.

Of Wound of the Knee-Joint terminaling successfully.

" Owing to circumstances of the service on the 16th June,
1815, I had a common tea breakfast, and at night, after a fifty
mile march, a piece of bread, with a little spirits and beer. On
the 17th 1 had a meat breakfast, and, throughout the day, was
emplo}ed in a very severe skirmish in heavy rain. At night I
took a small piece of bread, and a little spirits. On the I8th,
I took for breakfast, at seven o'clock in the morning, a very
small quantity of meat, and one glass of wine.

•* Sunday, ISth June, Waterloo — About two o'clock I re-
ceived a musket-shot in the outside part of the right knee-joint;
a surgeon, who saw it almost immediately, was prevented cut-
ting out what was then thought to be the ball, protruding on
the opposite side of the knee-pan, by the heavy fire of the
enemy. I moved back towards the \illage of Waterloo, and on
the road met with another surgeon, who looked at my wound
and it was decided that amputation above the joint was the
only means of saving my life. The instruments were brought
for the purpose, when a reiterated attack from the enemy's
cuirassiers caused orders to be issued for our immediate re-
moval. I moved on to Brussels, where I arrived at half-past
eight P. M. I had my limb washed, was stripped, and put to
bed. No dressing or application whatever was used, but I re-
ceived a caution from a medical gentleman, who accidentally
saw me, to take only lemonade ; my diet, therefore, this day,
was water and lemonade.

150 INJURIES OF THE JOINTS.

" Monday, \Qth. — I was recommended to send for Mr.
Hennen, the principal medical officer of the Jesuits' Hospital,
who was entrusted with the general charge of the wounded
officers and staff. I was taught to place the most perfect con-
fidence in him, and I accordingly wrote to him. My diet this
day was entirely confined to lemonade. Tuesday, 20th — Mr.
Hennen did not come till towards evening, and then placed me
on his own private list of patients. Before his arrival the
assistant-surgeon of my own corps brought a staflf-surgeon to
remove the limb ; but the latter gentleman, after carefully ex-
amining it, said he did not feel justified in amputating it without
a consultation. Mr. H. ordered me immediately to lose sixteen
ounces of blood from the arm, to apply twenty-four leeches to
the knee, and to purge copiously with Epsom salts, keeping
the part covered with cloths dipped in cold water, and prevent-
ing inflammation by all possible means. His directions were
complied with, and I felt relieved, but much debilitated; — diet,
water and lemonade. Wednesday, 2\st. — The assistant-surgeon
called in the morning, and applied fifteen leeches ; Mr. Hennen
called in the evening, and ordered thirty to be applied instantly
by a native surgeon, which was done eff'ectually, and reiterated
his direction to live low, and keep down inflammation by all
possible means. I now felt very languid, and, in addition to
my water and lemonade, took one basin of gruel and one small
roll (weight two ounces) of very fine white flour. Thursday,
22nd June. — Bled again with thirty leeches in the morning, and
thirty in the evening; some of the orifices continuing to dis-
charge from one bleeding to the other; — diet as yesterday,
with tea to my roll. Friday, 2Sd. — Sixty leeches applied
this day, and the cold application continued as usual night
and day. Breakfast, tea and half a roll; dinner, a very little
vegetable, and hall" a r(j|l ; supper, gruel and a roll. Mr.
Hennen made a very cautious opening on the spot where I
fancied the ball was: he found a large portion of bone, but did
not extract it. This whole day I had much pain and some

fevtr. Saturday, 2ifh. — The same treatment < ontinued, but I

INJURIES OF THE JOINTS. 151

had only thirteen leeches ; in the morning fever less ; pulse
very low, hard, and wiry ; diet as yesterday. During the whole
morning I felt very cold, and changed my bed linen, as every
thing was wet about me. In the evening Mr. H. came.
The cold I had complained of had become excessive ; I was
much shook by it, and felt wretchedly. He ordered an imme-
diate change of application to hot fomentation continued for
two hours at a time ; and after that a large warm poultice to the
knee. The hot fomentation increased my pulse so much, that
after midnight it was more than 100 per minute. I perspired,
however, and my breathing was free ; and though the pulsation
in my head was violent, I had no pain or other symptom of
fever. The pain in the knee was much lessened, and from that
period gradually diminished. Sunday ^bth June. — Mr. H. and
the assistant saw me in the morning ; all going on well, and al*
alarm removed. Ordered to strengthen my diet; breakfast,
gruel and one roll ; dinner, vegetable soup, (no meat,) one roll,
coffee ; supper, gruel and one roll. Wednesday, 2Sth June. —
The two last nights have had slight night sweats ; again ordered
to strengthen my diet. A healthy discharge now came from
the wound ; some small pieces of bone bad been removed ;
eleven leeches were applied on Monday evening; diet —
breakfast, gruel, one roll ; basin of veal soup and one roll at
eleven o'clock ; dinner, peas soup and one roll ; evening, basin
of veal soup and one roll ; supper, gruel and one roll.
Thursday, 29th June. — There had been a swelling and pain
on the inside of the knee, and above the joint where I fancied
the ball had lodged. This morning on removing the poul-
tice, a considerable aqueous and bloody discharge was found
on it. The swelling was reduced, and the pain diminished.
The veal soup, added to my vegetable diet, had the desired
effect, and I had no more night sweats.

" Friday, 30</t.— Discharge less, and of better quality ; or-
dered to take a little meat and a glass of wine. Diet as on
the 28th, with the addition of one ounce of solid meat, and

152 INJURIES OK THE JOINTS.

one ounce of claret. Saturday, U< Ju/y.-A beallhy dU-
cbarge. and doing well: about the 5th or 6th July cold gon-
lard was applied to the part, which removed a heat of the
skin caused by the poultices and fomentation. Diet was now
gradually increased to about three ounces of meat, and two
Luces of claret. I have gradually and rapidly improved m
bodily strength, and the knee goes on as well =^ ?»-'"-
The wound is closed up, and seems quite sound. July ZUIi.

18IP."

In this case the ball, the course of which was never accu-
rately ascertained, was supposed to have lodged in the vic.n.t,
of the joint. When I saw the colonel, iunammation was about
to set in, and there was considerable tumefaction of the whole
limb : one orifice only appeared, and that much swollen and
nearly closed in consequence. On the 6th da, I felt a move-
able substance on the inner side of the patella, wh.ch I
imagined might be the ball; I cautiously scratched but on
discovering that it was a portion of the patella itself, fractured,
but so closely connected with the original bone that o remove
it would be in effect to open the knee-joint, I re-placed the
skin which I had drawn over in the same mode as ,f I had been
cutting for a loose cartilaginous body in the joint itself, and it
adhered in a very short time. On the evening ot the 7th day
some slight rigors, and the appearance of the knee, indicated

the formation of matter, which '''-^^''>-''\'''\f'Zl

application. The very rigorous treatment employed during he

innan.matorv s.age limited this formation considerably; on the

8tb day, a' tl,r,.a.ening of inllammation induced Assistant-

Lrgeo Prosser, who paid most unremitting attention to his

colonel, to apply some more leeches, which enec.ually stopped

: pr,.gress. During the whole period, from the luflic ion of

.be wound lo the change of external application on t e 7tb

day. which includes the period of inllainmation, the q-""'^ "f

blood lost, including the .jen^ral bleeding winch preceded the

INJURIES OF THE JOINTS. 153'

application of the leeches, (which I would recommend always
to be had recourse to, and in a very full stream,") amounted, by
calculation, which I consider to be much within the mark, to
235 ounces. I think it more probable that the amount was
250, because, even in England, about one ounce per leech is
the estimated quantity lost, and it must be admitted that the
foreign surgeons are generally more expert in their manage-
ment of these animals than we are. The oozing between the
bleedings was also very great, and one day particularly, even
active. The quantity of food taken during these seven days,
or rather during the last four, was so small, that in comparison
Valsalva's diet was excess ;* but to this, certainly, much of
the preservation of the limb was due. Much, also, must be
attributed to the previous exhaustion from want of food, and
from fatigue, as well as to the powers of a sound constitution,
and a cheerful mind.

The following interesting case of recovery, after a desperate
wound of the kuee-joint, I have received from Dr. Pockels. I
had myself an opportunity of seeing Major B. in July 1815.

Case XXVJ.

Gunshot Wound of the Knee-Joint terminating successfully.

" Major B., aged 28, of a strong and healthy constitution,
was wounded on the 18th of June, and brought into hospital

* The rigid mode employed by Valsalva for the cure of aneurisms is
detailed by Morgagni, Letter 17, Article 30, and is as follows:— The patient
after losing as much blood as was deemed necessary, was confined to bed, from
the commencement of the cure until its completion, restricted to a most abstinent
diet, gradually diminished in quantity till he could scarcely move himself. The
solid food was diminished so low as to half a pound of pudding in the morning,
and half that quantity in the evening. The drink water only, and that within a
certain weight, which he medicated with what he called ice of quinces, or the
lapis osteocoUa ground down into a very fine powder. The return to a more nu-
tritive diet was equally slow.

154 INJURIES OF THE JOINTS.

on the 20th. A piece of a shell had lacerated the skin
of the right knee to the extent of four inches, fractured the
patella in five places*, and slightly grazed the anterior part of
the condyle of the femur. The knee-joiut was in consequence
laid open, and the pieces of the patella remained attached to
the capsular ligament, the tendon of the rectus, and the liga-
mentum patellae. The swelling of the surrounding parts was
moderate.

" Several observations made in former campaigns had
proved to me, that wounds of the joints, attended with an
extensive laceration of the surrounding skin, are not so fre-
quently followed by fatal suppuration, as those which (caeteris
paribus) are made by a sharp or pointed weapon, or by a small
ball, which merely opens the capsular ligament, without de-
stroying tlie surrounding skin to any extent. This, and the
robust constitution of the patient, but, above all, the dread of
the fatal fever, made me determine not to amputate the limb
immediately.

" June 2lst. — The traumatic fever was moderate in the
evenings of the succeeding days, as well as the pain and swel-
ling of the limb.

" 2iih. — A rigor before the accession of fever.

*' 26<7i. — Swelling of the external part of the femur, extend-
ing about six inches towards the pelvis, with deep seated fluc-
tuation ; on compressing the femur from above downwards,
some drops of pus issued from a small fistulous opening in the
wound of the knee at the external part of the tendon of the
rectus muscle I made an incision at the external part of the
femur, four inches in depth, and more than a pint of pus was
evacuated ; the abscess extended as far as the swelling, and
surrounded the bone of the femur, above the vasti muscles.
I was much pleased with this circumstance, and was in hopes
that suppuration would not take place in the joint itself; this
hope was gratified, and healthy granulations sprung up on the
tenth day after the receipt of the wound. Uniform conipres-

INJURIES OF THE JOINTS. 155

sion of the thigh and leg prevented the further extension of
the abscess, and long splints to the ham did not permit the
smallest flexion of the knee. Decoctions of cinchona were
injected twice a-day into the abscess, and the wound of the
knee was dressed with charpie.

" July 6th. — A portion of the patella, detached by superfi-
cial suppuration, was removed ; the granulations of the wound
in the knee became luxuriant, the swelling is consequently
more considerable ; no suppuration in the cavity of the joint,
which appears to be closed by the granulations. The abscess
continues to discharge a considerable quantity of pus, which
debilitates the patient; fever in the evening, thirst slight, ap-
petite good ; — nourishing diet, decoction of cinchona, wine.

" Ibth. — Swelling of the knee considerable, owing to the
luxuriant granulations, which hitherto I have not compressed
by adhesive straps, for fear of internal suppuration. The dis-
charge from the abscess is much diminished. Another piece
of the patella easily removed from the granulations.

" 20/A. — Luxuriant granulations cover the joint ; slight and
equal compression by adhesive bandages ; the swelling is as
large as the head of a new-born infant; the abscess in the
thigh beginning to close from above, but still extending to-
wards the external part of the thigh ; compression on this
side by splints.

'* 28M.— Swelling of the knee continues ; granulations con-
fined by adhesive plaster ; the discharge from the abscess di-
minishes daily. Being obliged to accompany the army, I left
the patient on the 30th of July, in the state above described.
Much reduced by the discbarge, but the spirits and appetite
good ; slight fever in the evening.

" I again saw Major B. in the month of December. The
wound of the knee was completely healed, the abscess closed,
and the swelling of the knee much diminished. The three
pieces of the patella remain fixed, the joint is completely an-
cbylosed. The patient walks with crutches, but constantly

156 INJURIES OF THE JOINTS.

wears the splints in the ham, and a circular bandage on the
thigh and knee. In the following year occasional slight ex-
coriations took place in consequence of the over exertion
of the patient in 'walking, and mounting his horse, but they
were always removed in a few days. Since 1817, he has
walked without crutches, can dance, and mount on horseback.
He only complains of pain during a change of weather; by
way of precaution, he continues to wear a splint in the ham.

" The cure of this injury was, in my opinion, assisted, 1st,
By the vigorous constitution of the patient ; 2d, J3y the great
laceration of the >kin surrounding the joint, which produced
extensive inflammation instead of that affection concentrated
in the cavity; 3c?, By a large and deep abscess of the thigh,
the opening of which could be directed in such a manner that
the pus could not affect the joint."

On examining tlie joints of limbs removed after gunshot
injury, it is curious to find to what an extent disoigauization
may have proceeded in some cases, while in others the severe
constitutional effects are not at all accounted for by the lesions
apparent on dissection. Many of the phenomena presented
by joints affected with M hite Swelling, are to be observed in
some of the more protracted cases of gunshot injuries, and
particularly a great diminution of their specific gravity ; but
in those where the removal of the limb is earlier had recourse
to, the effects of high degrees of inflammation, absorption of
the cartilages, thickening of the synovial membrane, softening
of the bony extren)ities forming the joint, effusion into the
joint itself, and into the bursie in its neighbourhood, are the
derangements principally to be observed, the coiuiections or
organization of the hones and surrounding muscles not being
affected in tlie.NO early stages.

Balls often pass through or along the bones of the hand or
foot, and, except in very severe cases attended with great loss
of substance, amputation of the member is not immediately
necessary. The strength of the fascise covering those part8»

INJURIES OF rHE JOINTS. 157

andtbe number of minute bones composing them, will, however
render extensive openings peculiarly requisite. These bones
never suffer from necrosis, nor do they ever become regene-
rated, as far as my experience goes ; but if the aid of an
appropriate supporting splint, assisted by proper bandages, is
had recourse to, their loss is soon supplied by a new formation
of soft parts, approaching to a cartilaginous nature ; and by the
approximation of the sound bones to each other.

However desirable it may be to save a hand or foot, yet, in
severe and complicated lacerations of the wrist and ankle-joints,
the frequency of tetanic aflFections should at once lead us to
adopt immediate amputation. Gunshot injuries of the joint of
the great toe are always extremely troublesome, and accompa-
nied with excruciating pain, often giving rise to severe nervous
affections, and often terminating in tetanus ; amputation of the
toe will therefore be the safest mode of treatment, and it
should be a general rule to amputate all lacerated toes and
fingers in preference to attempting their preservation, when
the injury is of a severe and complicated nature.*

Balls are sometimes, though very rarely, lodged in the ca-
vity of the joint of the knee. I have met with no such cases
myself, but they are reported on good authority ; and what
renders them of more importance is, that, by flexion of the
joint, and by cautious incisions, they have been removed, and
the limb has been preserved. Nay, Baron Percy quotes a case
where the ball remained in the joint for some time, and the
wound cicatrized; he also refers to other cases where they have
lodged in the ankle.f On his own authority the same excellent
writer mentions an instance of a ball lodging in the patella. I
have met one case where, I am confident, had the ball been
looked for in time, the limb might have been saved. It lay for

* In these cases, however, as in all others, we shall hold in view the constitu-
tioa of the patient, the state of the hospitals, the season, and various other con-
siderations already stated at the commencement of this chapter.

t Chirurgien d'Armee, p. 163—165.

158 INJURIES OF THE JOINTS.

three weeks under the ligament of the patella, until at last all
distinction of parts was confounded in wide spreading in-
flammation.

The injuries occasioned by balls lodging near or about the
joint of the hip, are among the most serious of military surgery.
The fever, the profuse discharges, the tedious exfoliations, all
tend to sink the patient, and are but too often fatal. In some
of these cases, the course of the ball is so obscure, and
its place of lodgment so uncertain, that it can only be detected
after death. I have seen balls lodged in almost every part
of the trochanters, neck and head of the bone, and yet the
most accurate examination during life did not lead to a dis-
covery of their situation. In the last case of this kind which
I examined, we found the ball lodged deep in the great tro-
chanter ; but as the patient lay in bed, its entrance was so
completely covered by the tendon of the obturator externus,
as to preclude the possibility of detection. It is possible, if
tlie surgeon is early called in, and can at once decide on the
nature of the case, that the application of the crown of a
trephine, aided by strong forceps, may enable him to remove
the ball if thus lodged ; but in general the encouragement to
attempt such an operation is but slender, and little hope re-
mains but from the performance of amputation at the joint, — a
truly awful alternative.

It sometimes happens that partial fractures of the neck of
the femur take place from gunshot injuries, which for a long
time escape detection; other injuries also of the joint have
their foundation laid on the infliction of the wound, aud only
develope themselves in the progress of its treatment, when
little or nothing can be done for them. Of this kind I have
been furnished by Stan-Surgeon Hughes with the following
interesting case of spontaneous luxation : —

INJURIES OF THE JOINTS. 159

Case XXVII.

Of Spontaneous Luxation of the Hij)-joint.

On the evening of the 22d July 1812, a mounted officer, of a
highly scrofulous habit, was wounded by a musket ball, which
entered about the centre of the dorsum of the ilium, and seem-
ed to have passed obliquely downwards among the glutaei
muscles, towards the great trochanter; its course, however,
could not be traced farther than about two inches, and it could
not be felt. He suffered but little inconvenieuce that night,
and the third morning after I found him in good health and
spirits, and free from pain in the wound, which was without in-
flammation. After some days continement to bed, he was
suffered to get up, and walked to a sofa placed at a window of
his room, where he passed the day, and this he repeated for
about seven or eight days, when he was moved to another more
commodious quarter. About the 15th of August he was
seized with excruciating pain in the groin and hip, so much so,
as to excite violent screaming on the apprehension of being
moved or even touched, although the wound itself and all the
surrounding parts seemed perfectly free from inflammation,
nor did he labour under any constitutional febrile irritation.
The discharge from the wound was thin, and in small quantity.

In this state he continued with occasional temporary miti-
gation of his sufferings until September, when he became
easier, and on the 16lh of that month the wound was healed,
and there appeared no difference between the wounded and
the sound extremity. This case, however, was of short dura-
tion, and the wound having again opened, and the discharge
become synovial, a retraction of the thigh to the extent of
more than three inches was found to have taken place between
the dressings. His sufferings became dreadful, and, to add
to them, he was seized with dysentery. Under this accumu-

160 INJURIES OF THfi JOINTS.

lation of misery, be was obliged to be removed in November
from Salamanca to Almeida, and from thence to Oporto.
There I saw him iu March 1813 ; the wound healed, and his
health perfectly restored, bat the limb permanently shortened,
and the toes turned outward. I saw him again in April 1816.
The head of the femur had formed a cavity for itself on the
dorsum of the ilium, and he enjoyed a considerable motion of
the thigh.

Whether the luxation in this case was produced from a pri-
mary injury of the bone, or of the cartilages, and sebaceous
glands of the joint, or from a secondary scrofulous affection, it
is impossible to say with certainty ; the probability is, that it
proceeded from a combination of both, for the scrofulous dia-
thesis, as is well known, is peculiarly unfavourable to the cure
of every species of injury of the joint.

I have met some cases of gunshot wounds near the upper
part of the thigh, in which a partial luxation was effected ap-
parently by the irregular efl'usion of osseous matter, which, in
the last case 1 examined, had formed a large tumour in the
groin, that by its pressure on the nerve had produced excessive
pain, and a wasting of the limb. A case of this nature is ir-
remediable, but I have known some relief obtained by the em-
ployment of warm bathing.

ini

CHAPTER IX.

OP CONTRACTED EXTREMITIES.

In all the injuries of tbe bones and joints, and in many others
"which only affect the muscles of the limb, contractions of various
tlegrees take place. These may originate either in a loss of
parts, whether in the bones or the muscles which move them, or
in a rigidity of the joints from the effects of inflammation, or
from improper posture, generally the bent one ; or a combina-
tion of all these causes may exist.

To remedy these contractions, a variety of mechanical con-
trivances have been had recourse to; but I am persuaded, that
the more simple the plan, provided it has sufficient power, the
more likely it is to succeed. That in use at Hilsea Hospital is,
perhaps, the most simple of any, and can be easily, and without
expence, erected in every hospital. It consists of a firm wooden
chair, with a strong jugum of wood, of the shape of the letter
U, for confining the thigh, if the contraction is in the knee-
joint; or a piece of wood with a hinge, like the letter V, if the
elbow be the joint affected; some small brass pulleys made for
screwing in the floor, wall or ceiling, with a proper cord ; a shoe
with three loops of iron, one at the toe, and one at each side,
half way between the toe and heel, and a tin or other vessel for
containing some weights. The inventor of this very simple
machine I do not know, but of its utility, under Staff-Surgeon
Coates, and Doctor Knox, I have had several most convincing
proofs.

The mode of usins: it for a contracted knee is as foflows :
The patient being seated on the chair, the jugum, properly

102 CONTRACTED EXTREMITIES.

cushioned, is fixed over the thigh, so as to prevent it from
rising, and the shoe being put on, and steadied by cords and
hooks applied to the external iron loops, and fastened to the
wall, a cord of whatever length may be judged proper, previ-
ously brought through one or more pulleys, and, with a hook
attached to the end of it, is fastened to the loop in the toe of
the shoe; at its other end is the scale or vessel for holding the
weight. Now, it is evident, that, on putting- a weight into the
vessel at one end of the cord, the other must be acted upon ;
and if the weights are properly graduated, force to any degree,
from the most gentle, can be made use of. In the same way,
the arm being secured in the hinged jugum by straps to a pro-
per table, the cord hooked in the jugum, and first passed through
a pulley in the floor, and then through one in the ceiling, as in
the other case, will have the effect of gradually stretching it.
-The advantage gained by each trial can be measured by a com-
mon ruler. Simple or medicated frictions, or the affusion of
cold or tepid water, may be employed during the time of using
Ihe pulley, and the limb may be subjected to it as often during
tlie day as may be thought necessary. Morning and evening
are the usual periods at llilsea, and hitherto there have been no
states of contraction, except those depending on anchylosis,
which have not derived benefit from it.

By a judicious application of bandages, and a strict attention
to posture, in the early stages of wounds, these accidents may
in most cases be prevented; and in all, their future ill effects
considerably lessened ; but it is a matter of serious importance
that a surgeon, unacquainted with military practice, ^>hould be
put upon his guard against their voluntary occurrence, the
frequency of which in the army has no parallel in the records of
civil hospitals. 'I'lic judgment and discretion of the surgeon
will point out to him the means to be adopted in each indivi-
dual case; it may, not, however, be amiss to mention a few
leading points. Permanent contractions in the joints of the
fingers, and rigidity of the flexor tendons, will be always best

CONTRACTED EXTREMITIES. 163

guarded against by layin<i- the baud flat out on a splint of wood
adapted to its general shape, digitated at its extremities, and
properly secured ; while, in the intervals of the dressings, a
gentle motion of the fingers, thumb, and wrist, should be en-
couraged in the patient, or if, as often happens, he obstinately
objects to it, effected by the hand of the surgeon himself. This
should be done with tenderness and caution, wherever the
injury may be; but if the alleged contraction or rigidity is
attributed to a wound, through a part where the principal
nerves have not been injured, and the muscles of which have
evidently no power over the joint affected, all tenderness is
criminality. (See chapter on Feigned Diseases.)

If the injury is real, and irrecoverable, as where the tendons,
or a large mass of muscles, are destroyed, or if an anchylosis
threatened, we must endeavour to solicit such a position as may
be least inconvenient to the patient. In the knee-joint the
straight position is obviously the most convenient ; in the
ancle, the foot should be placed at a right angle with the leg ;
in the elbow, the arm should be kept in the position usually
employed when it is in a sling; in the fingers, the half bent
position will be in general found the least liable to accidental
injuries. If a cicatrix is formed on the parts affected, and is
much contracted or ossified, the cure should not be despaired of
before the effects of incision are tried, from which good effects
have been derived on many occasions.

In the treatment of fractures, a false anchylosis, or a stiffness
of the joints, which are necessarily immoveable during the cure,
must take place to a certain extent. This was combated by the
older surgeons, by fumigations with the smoke of aromatic
gums or balsams, as benzoin, &c. The application of simple
heat by steam, gentle friction, and moderate exercise of the
joints, will soon restore their mobility. It is in the joint situ-
ated below the fracture that the most serious stiffness occurs,
according to the observations of Professor Boyer, and to this,
consequently, the attention should be more particularly directed.

M 2

164 . CONTRACTED EXTREMITIES.

I have met lately with a secondary species of contraction,
which admits of no relief that I am acquainted with. A ser<^eant
had his pike wrenched out of his hand by a grape shot, which
struck the shaft of it. He felt no inconvenience at the moment
but shortly afterwards he complained of a prickling sensation,
and loss of power of the root of the thumb. This lasted at in-
tervals for twelve months, when a gradual wasting of the mus-
cles took place, the thumb doubled inwards to the palm of the
hand, and at last became so immoveably fixed, that no degree
of force which could with prudence be used, could restore it to
its natural situation.

In some contracted cases which have fallen under my ob-
servation, the muscular fibres have been observed either to be
ruptured, pr forcibly separated from each other, and sometimes
absorbed to such a degree as to be unequal to the act of bending
the limb. In one or two instances, an osseous deposition has
been remarked on their bellies and their tendons. These cases
admit of no cure.

The French government has long since established military
hospitals, in the immediate neighbourhood of some of the most
celebrated hot springs in France, for the use of its sick and
wounded soldiers, and, however we may explain their operation,
the fact is, that vast numbers of men who have laboured under
violent contusions, sprains, contractions of the joints, muscles,
and tendons, thickening of the ligaments, tedious exfoliations,
incipient anchylosis, fistulous ulcerations, wandering pleuritic
pains, cutaneous affections, &c. the consequence of gunshot in-
juries, have derived the most serious advantages from the
employment of these waters as baths. The hospitals are erected
at Bareges, Digne, St. Amand, and Bourbonne-Ies-bains. The
first of these places is best known to our countrymen, several of
whom have resorted thither. It is obvious, however, that the
benefit of these waters are only to be obtained by a few oflScers
of rank and fortune. To these it may be of importance to know,
that the best season for the baths of Bareges and Bourbonne-

CONTRACTED liXTREMITlHS. 165

les-bains, is considered to be from the month of May to Octo-
ber; those of Digne, from May to September; and those of St.
Amand, near Valenciennes, from June (o September ; there
are also at the latter place mud baths, which are much resorted
to. The waters of Bareges are of the sulphureous class, and
raise the thermometer, at different springs, from 73° to 130° of
Fahrenheit; they are remarkable for their soapy feel, and for
rendering the skin soft and pliable. The French army surgeons
conceive them injurious ia aneurismal affections, and in diseases
of the heart, in penetrating wounds of the thorax, and in
phthisical cases. The baths of Digne and St. Amand are also
sulphureous ; those of Bourbonne-les-bains are saline. Besides
these, there are some other medicinal springs in France, cele-
brated for their efficacy in the sequelae of gunshot wounds ;
Bonnes, near Pau, the waters of which were formerly styled
•* Eaux d'Arquebusade ;" Bourbonne, near Moulins, where
there are also mud baths similar to those of St. Amand ; and
Bagneres near the Spanish frontiers. This last is celebrated
for the removal of the nervous affections which remain after
gunshot wounds.

It is certainly well worth consideration whether the numer-
ous wounded soldiers of the British army might not be seriously
benefited, at a very inconsiderable ex pence, by the erection of
a military hospital in the neighbourhood of the hot springs
which our own island affords. On this subject I cannot pretend
to enlarge ; but I would beg to suggest to those in authority the
great utility of having fixed baths to the different military hos-
pitals ; a small apartment near the kitchen or wash-house might,
with great ease, and at a very trifling ex pence, be fitted up
with bathing tubs, and tubes communicating with the ordinary
boilers ; or the highly ingenious plans of Mr. Sylvester might
be adopted.* Every hospital, it is true, has a slipper and

* I cannot specify these here. Every person interested in hospital should
study Mr. Sylvester's book. It is entitled " Tlic Philosophy of Domestic Eco-

166 CONTRACTED EXTREMITIES.

shower bath among its articles of barrack furniture, but, from a
variety of causes, they are seldom employed to the extent that
they might, and that they assuredly would be, if more facilities
were allbrded for their employment. As they exist at present,
they occasion great increase of labour and expenditure of fuel,
and are a source of much noise, filth, and irregularities in the
wards; hence they are always reluctantly prepared by the hos-
pital servants, and often applied in a very imperfect and slovenly
manner.

nomy, as exemplified in the mode of Warming, Ventilating, &c. adopted at the
Derbyshire Infirmary." -ito. London, 1S19.

167

CHAPTER X.

OF INJURIES OF THE BLOOD-VESSELS.

It is a popular opinion among surgeons, and even soldiers,
and in a great measure a well-founded one, that a bleeding
gunshot wound is highly dangerous. A small vessel, or con-
geries of vessels, suffers immediate death from the rapidly
inflicted contusion of a ball, and the wound in which they lie
either discharges a few sluggish drops, or its hemorrhage ceases
after a momentary spirt, and a secondary kind of oozing. A
moderate sized vessel often bleeds actively, but within the
power of timely assistance. A large artery, on the contrary,
pours forth its fluid contents, if not to a fatal extent from
quantity, from the deranged balance of circulation which the
wound produces, death is most commonly the consequence.
Much of the flow in all cases will depend upon the vessel being
cut quite across and admitting of retraction ; much will depend
upon a small ball or sabre cut partially opening the vessel in its
transverse or longitudinal direction ; but fatal experience shows
us, that the numbers who die from the opening of a large and
principal artery by shot, shell, or sabre, however inflicted, so
pre-eminently exceed the survivors, as to set all calculation at
defiance.

How the vessels escape so often as they do, has been a
source of great surprise among surgeons, and is truly wonderful.
Balls bufl" along them, pass between them, and traverse their

168 INJURIES OF THE BLOOD-VESSELS.

courses in all possible directions, but leave tbeni unhurt.*
Their elasticity has been considered as in a great measure
contributing to this effect, and no doubt it does ; something
also may depend upon their being in a state of dilatation or
otherwise when the missile passes across them, but still much is
left ime.'tplained in the attempt of accounting for these pheno-
mena. f Where a round shot injures a large vessel, or a sabre
divides it, (the carotid for instance, or the femoral,) immediate
death is almost universally the consequence. Where a vessel
of this class is opened within the cavities, no chance of recovery
remains; the cause and effect are almost simultaneous, and
even in the first case death amounts so near to certainty, that a
bare possibility of escape is left, and no practical deduction
can be drawn from a few solitary instances to the contrary. It
must be recollected, however, that if a limb is entirely carried
off, or if it is excessively bruised, little or no bleeding takes
place : the vessels are paralyzed, and their organization almost
destroyed ; the effect is nearly the same as if they had been
actually seared, a process to which the older surgeons, who
were so familiar with hot irons, often compared it. A very
singular instance of escape is given by M. Larrey in his
JNIemoires, in which an Aide-decamp received a gunshot
wound, which cut the external carotid at its separation from the
internal, and at its passage through the parotid gland. The
immediate application of pressure from the fingers of an intel-
ligent soldier upon the spot, and M. Larrey's subsequent ban-
dages, saved the patient. I know of an English oflicer who
was also saved in India from the effects of an arrow wound in

• A case was n'portod as liaving occurred in Flanders, where the ball passed
close undertho arch <»f tlieaortn, tind the patient surviviul sonio days. The ball cer-
tainly jjasscd in that f/n<r//o;(, but not having examined the bt)dy after death, I
cannot vouch for the fact.

t See Morgagui, Letter 63, Obs. Sk Dr. Parry has denied the dilatation of
the arteries, but, as this (piestion is Toreign to my subject, I shall merely refer to
his " Experimental Kntjuiry into the Nature, Cause, and Varieties of the Arterial
Pulje." Bath, 1S1«.

INJURIES OF THE BLOOD-VESSELS. 169

the carotid by the same means. In the JJth volume of the New
Medical and Physical Journal, p. 95, is given the case of a
man wounded in the femoral artery at Spithead, and saved by a
subsequent operation at Haslar Hospital ; and in the 3d volume
of the Medico-Chirurgical Journal, page 2, is given an in-
stance of the carotid bursting- and being taken up on the spot
by the late JVIr. Fleming, a naval surgeon.

We have occasional opportunities in the field of at once tying
the extremities of lacerated arteries, and these should never be
neglected, although perhaps in every case not indispensable.
These occur where a limb has been carried off by a cannon
shot, and where the vessels hang out like cords from the wound,
without the least flow of blood from them; or where the ex-
tremities of the wounded vessels can be seen partially throwing'
out their blood in the bottom of a deep wound. In these, and
in all other cases of divided arteries, the least reflection upon
the anastomoses of the vessels will lead us to secure both the
end next the source of circulation, and the more remote ex-
tremity. Mr. Guthrie, in his excellent cases inserted in a
periodical publication,'- has called the attention of military sur-
geons to this point, and his observations cannot be too forcibly
impressed on their minds. But many cases occur where
nature has herself com;)leted the entire process of cure without
any interference of the surgeon. I owe the following to that
very able and experienced officer, Dr. Dickson of Clifton, Phy-
sician to the Fleet. —

Case XXVIII.

Arteries divided ivithout Hemorrhage,

" Sergeant Kelly of the 54th regiment, in the battle of the
13th of March, 1801, in Egypt, had both arms shot away at

* New Medical and Physical Journal, vol. iv. and also in the excellent work of
Mi. Hodgson.

170 INJURIES OF Tlir, BLOOD-VLSSKLS.

the elbow-joints by the same cannon ball, and on the following
evening was received, with a great number of wounded men,
on board the Braakel, of which ship I was surgeon. On re-
moving the dressings, I was much surprised to find no appear-
ance of a single blood-vessel being tied by ligature. Conceiving,
I imagine, the case to be desperate, a piece of linen had been
merely wrapped round each stump, and the supervention of
syncope seems to have saved his life, by stopping the further
effusion of blood. The left arm, which was the most ragged,
and having the olecranon still attached, was amputated; but
from the low state to which the man Avas reduced, and the
pressure of other cases, I was obliged to postpone doing any
thing with the other arm; and, considering, after the time had
elapsed, that there was but little danger of bleeding, and
wishing to see the result, a tourniquet was merely put on loose. '
The second operation could not be performed until the 2-jth,
and the dissection of the amputated portion then satisfactorily
showed, that ample provision had been made against the possi-
bility of such an occurrence, for the end of the torn artery was
con^etely obliterated and lost in the surrounding flesh, and
for upwards of an inch from its extremity was described, by the
surgeons who assisted me, to be solid, organized and carnous.
I say described, for, while on other duty, it had been thrown
overboard. The poor fellow fevered, and died on the 4th of
April."

From a few dissections which I have been able to make in
similar cases, I can confirm this report ol" the appearances.
But in the dissections and observations made by some eminent
men, in experiments instituted expressly for the purpose, or
undertaken under circumstances favourable to tlu^ elucidation of
the point, where accidental injuries have presented themselves,
clots of blood, or of coagulable lymph, or membranous septa,
have been found at unecpial distances from the orifice of the
artery, and at distant points of tim«*, so far as three weeks after
the iiillictioii iif ilic injury. Dr. 'J'homson, who lor many years

INJURIES Ol' TliE ULOOD-VliSSIiLS. 171

has paid unremitting- attention to this subject, has found the
internal coat burst on some occasions of non-bleeding ruptured
arteries. The process of nature by which hemorrhage is
stopped, appears to be as follows: On the first opening- of an
artery, the vessel retracts within its sheath suddenly, and with
considerable force ; the blood which continues to flow notwith-
standing this retraction, is efl'used into the cellular substance
between the vessel and its sheath, as well as into the more
distant cellular texture ; there it coagulates, entangled among-
the stretched and lacerated fibres, and shortly fills up the open
orifice of the vessel. This process is greatly assisted by the
weakness and faintness consequent upon the loss of blood.
Besides this external coagulum, Dr. Jones describes an internal
one, produced from the quiescent blood which lies between the
wound and the first collateral branch. The next step in this
important process is inflammation and the effusion of coagulable
lymph, by which thQ surrounding parts are soon firmly united.
The same process of nature takes place in that part of the
vessel most remote from the heart. The impervious part of the
artery gradually shrinks, and is converted into a ligamentous
substance, while the enlargement of the inosculating branches
establishes a complete communication between the divided ends
of the vessel. In Dr. Jones's unrivalled Treatise, where many
of the original experiments conducted by him and Dr. Thomson
are detailed ; in the excellent Treatise of Mr. Hodgson, where
Mr. Guthrie's cases are re-published ; and in the papers of
Messrs. Lawrence, Travers, and Crampton, in the Medico-
Chirurgical Transactions, is to be seen the sum of all our pre-
sent knowledge on this subject.*

It is in the hospital that our most guarded attention is called
for, and our most saving efforts made, in the expectation, or
actual occurrence of secondary hemorrhage. In those cases,

* A Treatise on the Process employed by nature in suppressing Hemorrhage,
Lond. 18U5. By J. F. D. Jones, M.D. Hodgson on the Diseases of Arteries and
Veins, Lond. 1815. Medico-Cliirurgieal Transactions, vol. iv. vi., &c.

172 INJURIES OF THE BLOOD-VESSL LS.

we must avail ourselves of every assistance which the history
of surgery has from time to time presented to our notice. To
pressure, to cold, and to styptics, we must give their due
value, and a full trial to such an extent as prudence may
warrant; but it is to the actual ligature of the vessel that we
are to trust in all cases where a trunk or important branch is in-
jured ; and in cutting for them, correct anatomical knowledge
is our only resource. Often, unfortunately too often, we find,
that even this will not enable us to meet the exigencies of
actual practice, and that the tnere anatomist has made but one
step to being a perfect surgeon ; a principal one, indeed, but
no more conclusive, than the tributary arts of the chisel or the
pencil are to the formation of a perfect architect. Much un-
merited blame has been thrown on the army surgeons, on this
as well as other points, by men who, with a minute knowledge
of the natural structure, have not adverted to tlie pathology of
wounded vessels. They prick for arteries in a dead subject,
and they readily find them; but the state of a blood-vessel in a
wounded limb is very essentially diflerent from what it is in a
sound state, or in a body laid on the table for the practical
purposes of anatomy ; and I have more than once seen a person
of this class, after having cut upon a living blood-vessel with
the utmost precision, and described its course with the most
laudable minuteness, confess, with great surprise, that he was
unable to secure it, and had actually left his patient much worse
than he found him. The state of general health, the cause,
extent, and nature of the wound, the diseased state of the
vessels or their natural connecti(jns, the " engorgement" of the
parts with extravasatt'd blood, or putrid sanies, the possibility
of irretrievably injuring the limb by cutting its nerves or the
tendon of some muscle essential to the due performance of its
motions, should all be minutely examined, and balanced in
the operator's mind ; and he will have certainly the best claim
to the character of a judicious surgeon, who saves the limb of
his f>ati<nt, if possible, but who does not hesitate between the
probable salvation of it, and the certain loss of life.

INJURIK^ OF THE BLOOD-VESSELS. 173

But cases will occur, where, under circumstances the most
promising to the patient, the loss of his limb is the sole means of
preventing the loss of his life. These are cases, where an artery
unfortunately gives way in the bottom of a deep wound, and
where, by a few pulsations of the heart, the interstitial spaces
of the muscles, and even their component fasciculi of fibres,
are so completely injected with blood, that the distinction of
parts becomes lost, and the vessel is not to be detected. This
is an accident which I have seen more than once in military
hospitals, in the view of the attending surgeons, men of bold-
ness, humanity, and dexterity. But even among the less
tumultuous scenes of a civil establishment, and during the
routine of diurnal duties, the same unavoidable accident will
occur. From within the walls of one of the most eminent,
and under the cognizance of some of the most able surgeons,
I select the following example, of great iuterest and high value
in a practical point of view.

Case XXIX.

Arterial Hemorrhage, source unknown.

A middle aged man was brought into one of the hospitals
of the capital, for a compound fracture of the left tibia, unac-
companied either by extensive laceration or contusion. He
was placed under the charge of an excellent assistant, and the
limb, for some weeks, seemed to be doing well, when suddenly
hemorrhage came on during dressing, the assistant at the bed-
side, and the surgeon of the hospital expected every moment.
He lost about 20 ounces of blood before the artery at the
groin was effectually compressed, and the tourniquet applied.

The most diligent search could not detect the bleeding
vessel. Amputation was therefore had recourse to. On ex-
amination of the arteries, it was some time before the branch
from which the hemorrhage had proceeded could be discovered.

174 INJURIES or THE BLOOD-VESSEI.S.

It at last was found to be the anterior tibial, and the orifice in
it was so minute, as with difficulty to admit three hogs hrislles.

In another case, with which I have been favoured by Dr.
Thomson, a fatal secondary hemorrhage occurred about the
30th day after a pistol shot in the upper part of the thigh,
where no trace of the wound of an artery could be delected,
ex'en hy the aid of injection of the diseased limb.

Where a ball has passed close to, or lodges near or upon a
principal blood-vessel, the utmost caution as to excess of every
kind is to be most rigidly observed; and more particularly
when the sloughs begin to separate, and the eschars from the
arterial coats may be naturally supposed to loosen. And here
I must entreat the young army surgeon not to allow himself
to be lulled into a fatal security, by a supposition, that se-
condary bleedings from gunshot wounds are but of imaginary
importance, and of rare occurrence. The supposition is ab-
solutely erroneous.

Experience shows, that from the 5th to the 11th days are
in general the critical periods to be watched. Dr. Thomson,
with that accuracy and discrimination which characterized his
writings, divides secondary hemorrhages into three species,
taking place at three distinct periods ; hemorrhage from in-
creased determination of blood occurring from the 1st to the
5th day; hemorrhage from sloughing of the arterial coats
from contusion from the 5th to the 10th ; hemorrhage from
ulceration of the coats of the \essels from and after the 10th
to anv distant period. To these the Doctor adds, what he
appropriately compares to the spontaneous hemorrhage from
capiiiarv vessels opening on mucous surfaces ; a species occur-
ring at a late period, and peculiarly connected with excesses.*

Severe, and often fatal hemorrhage, occurs now and then
from the large venous trunks, as well as from the arteries. If

• Report of Obscivalioiis mack- in tlif IJiilisli .Military Hospitals in Belgium
KiliiihiirKli. iHUi. ]>:\nv 11.

INJURIRS OF THE BLOOD-VESSELS. 175

these vessels are within reach, and pouring out their blood
profusely, I should not hesitate to tie them, although some
ingenious objections have been made against ligature of the
veins, on account of their well-known disposition to inflamma-
tion ; a point on which I shall enlarge hereafter. I believe
there are few, if any, army surgeons of the present day, who
would not be as averse to applying a ligature to a vein, the
hemorrhage from which could be stopped by pressure, as he
would be to leaving an artery unsecured, even though it did
not bleed. Yet cases will occur, especially in amputation,
where the large veins may, under certain circumstances, be
secured with a fine ligature, not only without danger, but
with advantage ; in truth, if there was such imminent danger
as has been apprehended, the needle, by which the vein was
included in the same ligature as the artery, before the tenacu-
lum came into general use, must have been a most destructive
instrument ; thousands of successful operations, however, at-
test the contrary.

When a bleeding artery is in a state of perfect health, and
within reach, then the actual ligature, is, beyond all question,
the proper means of relief. By careful dissection the vessel
may be traced from the wound itself, and must be secured by
a fine silk ligature on each orifice, drawn sufficiently tight to
cut the internal and middle coats of the artery, which, although
not indispensable, greatly accelerates the adhesion of the
opposite sides. If, however, as often happens, the original
breach in the vessel cannot be discovered, or if, in the prose-
cution of our search after it, a number of enlarged and newly
formed collateral vessels are opened, and a general oozing
takes place, the main trunk above its first branch in the vici-
nity of the wound, or at its nearest and most convenient part,
should be secured. If the operation is performed before
the patient is debilitated by excessive loss of blood, and when
his constitution is yet sound, and unaffected by fever, Avhich
remarkably predisposes to rupture of vessels ; or before the

176 INJURIES OF THR RF.OOn-VF.SSELS.

occurrence of gangrene, there is reasonable hope of success:
but where he is suffering under disease, the vessels, whether
in the wound itself, or much nearer to the heart, burst but too
often under our ligatures, or ulcerate soon after their applica-
tion, and leave amputation alone as our last resource, and
even that resource not always to be depended on.

The reducing the immoderate size of ligatures ; the sepa-
rating the threads of which they were composed, and placing
them in convenient points along the face of the stump or
wound ; the actual removal of one half of the ligature em-
ployed in securing the arteries, as soon as it had served its
purpose of effecting the knot ; * — all these were progressive,
and arrived at by very slow degrees ; but an improvement,
which appears to me of great consequence, was the last of in-
troduction, and is now the slowest of adoption, although the
artery once secured, and the value of adhesion duly acknow-
ledged, it is the most obvious of all. I allude to the plan of
removing the ends of the ligature altogether, and thus leaving
to an extensive wound the greatest possible chance of imme-
diate union.

There are few practical surgeons who must not have occa-
sionally experienced great inconvenience from the length and
thickness of their ligatures. Independent of their acting as
foreign bodies, they often prove a great source of irritation,
even under the most delicate management ; but when they get

• For this very serious improvement in ligatures, we are, 1 believe, obliged to
a naval stirgeon, James Veitch, Esq. late of the Naval Hospital, Plj nioulh, who,
in a modest and convincing jiaper, published in the Edinburgh .Medical and Sur-
gical Journal, vol. ii. p. 170, under the title " The Inquirer," and with the
assumed signature ur J. D., gives an interesting account of it. It is sufliciently
well known, that ParO revive<l, or rather reinvented, the ligature, in the latter |)art
of the 16th century; it had been previously known to (.'elsus in the 1st, but had
not been applied in am|Mitation before be time of Par^-, nUhough frequently
employed by Galen, Paulus yKginHa, Aviccnna, Guy de Charliac, &c. in acci-
dental wounds of the blood-vessels.

SHORT CUT LIGATURES. 177

encrusted with blood or pus, or are entaugled in the dressings,
especially if in the hands of young and inexperienced assis-
tants, they are often a source ^f infinite uneasiness, and even
danger to the patient. An ingenious foreigner, M. Roux,
surgeon of the extensive establishment of La Charite, where
he must have often felt these inconveniences, acknowledges
that the project of cutting all the threads of ligatures, made
on the surface of a wound that is to be healed by the first in-
tention, had long since suggested itself to his mind, without
his having dared to do any thing in it. His visit to the hospi-
tals of London was made in 1814, and he was so well pleased
with the result of an attempt made by Mr. Lawrence at St.
-Bartholomew's, that he evinces an inclination to claim for
French surgery the honour of having conceived the same idea.
The practice, however, belongs neither to France nor to Mr,
Lawrence. It is of British origin, and I believe was first
practised by a naval surgeon at Haslur Hospital; a fact with
which I was not acquainted until long after I had published the
first edition of this work, and after I had claimed the merit af
having been the first British army surgeon who followed the
practice and circulated the account of it ; although I dis-
claimed all pretensions to originality. Some merit, humble
though it be, I still believe I possess, and 1 shall not sully it by
withholding justice from others ; but, before stating what
further inquiry has enabled me to collect, I shall detail my owa
, -experience on the subject.

In the early part of September 1813, an ingenious young
gentleman, Assistant Staft-Surgeon Hume, then in charge of a
large ward filled with gangrenous cases, suggested to me, what
he informed me he understood to be the practice of an Ameri-
can naval surgeon, (to which he was led, if I mistake not, by
an accident,) viz. cutting the ends of the ligature off close to
the knot, and allowing the parts to heal over it. I was mucli
struck with the proposal. Independent of the plausibility of
the plan, as promoting immediate union, I anticipated good

178 INJURIES OF THE BLOOD-VESSELS.

effects from any accidental violence to the ligatures, or the in-
trusive interference of the younger dressers to accelerate their
loosening bein^? thus prevented ; for I had seen several in-
stances, where, from the most gentle efforts, the ligatures were
removed from the diseased vessels, and alarming hemorrhages
took place. The plan was therefore adopted ; thirty-four cases
were at different times, between September and the January
following, treated in this way ; and as no inconvenience what-
ever followed, nor did the small particle of silk left behind
give rise to any apparent irritation, I made a very favourable
report of the " short cut ligatures" to Dr. Charles Forbes,
Deputy Inspector of Hospitals, and then principal medical
officer of the station, in my monthly report for October, and
through him to Sir James M'Grigor, the head of the staff", pre-
senting him at the same time with some of the small circles of
silk, a part of which had come away with the dressings, while
some had floated out on opening the little pustules, which
formed over the face of the stump, at the points where the
arteries had been tied. Some few of the ligatures never made
their appearance, and the patients complained of no uneasiness
whatever.

Fully impressed with its utility, I recommended it on all
occasions in conversation, and in the operation-room ; and, on
my arrival in England from the south of France, published an
account of it in a paper, which appeared in the London
Medical Repository, upon the subject of Hospital Gaugrene.*
Upon presenting this paper to a very ingenious practitioner.
Dr. Maxwell of Dumfries, I found that he had adopted the
plan, as far back as 1798, and had not only been in the practice
of it himself since that time, but, at his recommendation, it had
been adopted in various operations, by more than one surgeon
in the neighbourhood, with unvarying success. He was con-
vinced that the silk, as an animal substance, is absorbed, after

• Sec vi)l. iii. p. 177, and vol. v. j). 221.

SHORT CUT LIGATURES. 179

Laving- suffered a decomposition. On this point I cannot speak
with certainty. I have, however, dissected several stumps,
at different periods, from eight to twelve weeks after amputa-
tion, where the patients have died of diseases unconnected
with the operation, and where the little circle of silk has lain
quietly at the shrunk lig-amentous-like extremity of the artery,
in a small cyst, formed by a thickened cellular membrane;
but its more common fate is to be discharged with the dres-
sings. The campaign of Waterloo furnished me with many
additional proofs of the excellence of this plan, and whatever
may be the intention, whether to heal the wound or not, I now
never hesitate about cutting short the ends of the lig'atures. A
single thread, well waxed, (or at most two) is quite sufficient
for any ligature ; the artery should be well drawn out from its
sheath, and the ligature placed as high as possible. The natural
retraction of the vessel will in most instances carry it out of
sight ; and unless gangrene or excessive sloughing takes place,
it will frequently never more be heard of, and, I am convinced,
never will do harm.

Mr, Guthrie, in his work on Amputation, makes an objection
to the short cut ligatures ; and, as every suggestion of his is
entitled to the utmost attention, I shall state his observations,
which, upon the whole, ai'e favourable to the mode I recommend,
and then very briefly remark upon them, as far as my experience
authorizes me to do. At page 94, he observes, " I know that
many cases treated in this manner in the campaign of 1813
ended successfully, and healed in as short a time as the most
favourable ones by the usual method; and at Montpelier, in
June, 1814, M. Delpech, Professor of Surgery in that univer-
sity, showed me at least 20 cases, in which he had and was still
practising this method with success." (I find that the Pro-
fessor adopted it in the same disease as I did, the hospital gan-
grene.) " I have seen, however," continues Mr. Guthrie, ** in
two or three instances, some ill-looking abscesses formed by
tliem, and I suspect some disagreeable consequences will

180 INJURIES OF THR BLOOD-VESSELS.

occasionally ensue if this practice be continued." Tn opposition
to this suspicion, I can with the most perfect confidence appeal
to all those gentlemen who saw the practice, and assisted in it
at Bilboa,* in cases of the most irritable and threatening nature,
and to Messrs. Bingham and Crofton, my confidential assistants
at Brussels, who saw it adopted repeatedly there by me, and
assisted in the after treatment, for supporting me in the asser-
tion, that neither pain, heat, nor tumour, febrile exacerbation,
or formation of pus, could be fairly traced to the short cut
ligatures, which would not, in all human probability, as readily
have succeeded to the ligatures usually employed ; while, on the
contrary, the progress of healing has been sensibly more rapid
where they have been used. Mr. Guthrie considers the im-
provement as very valuable in all cases that will not unite by
the first intention, from its lessening irritation; adopting the
practice, as he says, " in a view diametrically opposite to thai
of its advocates, — but it will be found very advantageous in all
cases of operations performed in unsound parts, or in irritable
or bad constitutions, where union will not take place, or only
in a slight degree. "f

• The opinion of Dr. Cuinmin of Glasgow may be seen in a letter, addressed
by him to Mr. Lawrence, and published in the 8th volume of the Med. Chir.
Trans, p. 495. He says, " The practice appeared particularly advantageous
in the hospital near Bilboa. I never saw, nor, until the i)ul)lication of Mr.
Guthrie's book, did I ever hear of any bad effects following the use of short cut
ligatures."

t See Med. Chir. Trans, vol. vi. p. 150, and vol. viii. p. 490, for Mr. Law-
rence's papers. As I am only anxious for the fair investigation of this subject, I
woiil I also refer to an ingenious paper in the I.ond. IMed. Hop. vol. vii. p. 353, by
Mr. Cross, whose di'ductions, principally from experiments on brutes, are not in
favour of the short cut ligatures. L)r. Thompson, who frequcnliy saw me use
them at Brussels, informed me, that in experiments which he had performed on
dog.*, he finiiid the lurgc short cut lij<atiiri-s wliirh he then ust-d, work tlieir way
out through the integuments, at jjoints distant from their ajiplicatinn on the large
arteries, and without producing any injury whatever. My friend Dr. Fergusson,
Inspector of Hosjiitals, since tells me, that in a tour through Sweden, during the
peace of Amiens, he witnessed the employment of them by the surgeons of Stock-
holm, and without any inconvenience resulting from their use. See also Cooper's
•ndTraTPrs's Essays, Part 1st.

SHORT CUT LIGATURES. 181

Mr. Lawrence, who, it appears, was as ignorant of what I
had done, as I was of what had been done by others, read a
very interesting paper to the Medico-Chirurgical Society in
July, 1814, which was afterwards published in the 6th volume
of their Transactions. At that period he had employed the
shortcut ligature in ten or eleven amputations, in six operations
on the breast, and in the removal of two testicles. Of these
operations one only was unfortunate ; it was the case of a man
whose thigh was amputated, and who died of an affection of the
lungs ; all the others succeeded perfectly, without abscess or other
inconvenience. That kind of silk twist called Dentist's Silk, is
the substance he employs for his ligatures, so minute that the
finest, after the knots are tied, and the ends cut off, do not
exceed in weight a sixtieth part of a grain. In a subsequent
volume of the same work, Mr. Lawrence gives a still further
testimony in favour of the short cut ligatures. He states, that
since his first communication he had constantly employed the
method both at St. Bartholomew's and in private practice, and
he says that the general result of his experience is, " That this
plan, by diminishing irritation and inflammation, and simplify-
ing the process of dressing, very materially promotes the com-
fort of the patient and the convenience of the surgeon, while it
has not produced ill consequences, or any unpleasant effect, in
the cases which have come under his own observation.

" 1 have found," he continues, " in ray own practice, what
has been confirmed by others, who have communicated to me
the result of their experience, that the small knots of silk ge-
nerally separate early, and come away with the discharge; that
where the integuments have united by the first intention, the
ligatures often come out rather later, with very trifling suppu-
ration, and no painful inflammation, and that in some instances
they remain quietly in the part.

•' In two or three instances I have been told that the ligatures
seemed to have caused irritation and pain. These were ampu-
tations ; and we are accustomed to see effects quite as con§i^

182 INJURIES OF THE BLOOD-VESSELS.

derable as were alluded to here, produced by the state of tLc
bone and other causes, where the ordinary method of securing
the arteries is practised ; so that I could not, on close inquiry,
find anv reason to ascribe what was complained of to the use
of the silk ligatures, and the practice of cutting off their ends
close to the knots." Med. Chir. Trans, vol. viii. p. 490

In a paper on the Ligature of the Aorta, by Mr. Astley
Cooper, contained in the first part of his valuable Essays, that
eminent surgeon states as follows:-- My friend Mr. Lawrence
has proposed that the silk usually employed for ligatures should
be cut oft^ close to the knot, so as to heal the wound over it. It
has occurred to me, that catgut would answer the purpose
better ; and I shall give the result of the trial which I have
made, wishing it to be understood that I consider the sub-
ject at present as undecided, and only as one for future inves-
tigation.

" Catgut, employed as a ligature, being more of the nature
of the animal matter in which it is embedded, will be more
easily absorbed than silk; or. if even not absorbed, will be
less likely to excite irritation in the parts," p. 126. He then
details a case in which a catgut ligatnr previously soaked in
in water, about the temperature of 100°, was employed in a
case of Popliteal Aneurism, and both ends cut off, the edges
being then closed together by adhesive straps. The patient
was a man of the advanced age of eighty, but in good health.
The operation was performed at Guy's Hospital, on the 24th
of October, 1817; the wound was completely united on the2Sth,
and the cure was perfected without any appearance whatever
of irritation from the ligature, by the 17th of December fol-
lowing. In three weeks after the operation, this man walked
about in the ward with the aid of a crutch, and never suffered
any constitutional irritation whatever throughout the course of

the cure.

I shall now add to these testimonies in favour of the shortcut
ligaturf, another which 1 have but recently x\v \ with, although

SHORT CUT LIGATURES. 183

given in a well known periodical publication. I consider it
as of high value, from its enabling me to do justice to un-
assuming- merit, as well as from the facts which it contains. It
also may serve to fix the date of the first introduction of this
improvement as far back as the year 1786 at least, and probably
much sooner. In a paper in the 7th volume of the London
Medical Journal, entitled " Remarks on Mr. Lucas's Practical
Observalions on Amputation, communicated in a Letter to Dr.
Simmons, F. R. S. by Mr. Lancelot Haire, Surgeon at South-
minster in Essex, Member of the Corporation of Surgeons of
London, and formerly Assistant-Surgeon to the Royal Hospital
at Haslar," the author, at page 389, states as follows : — " With
respect to the success of healing the stump by the first in-
tention, at Haslar Hospital, it always exceeded our expecta-
tions in emaciated subjects, and when the constitution had been
previously much reduced ; but where itwas performed on sub-
jects in full health, in cases of accident, it did not succeed, — a
violent inflammation and swelling coming on, burst the adhe-
sions, the muscles shot out, and occasioned almost as open a
stamp as in the old method of operating. The ligatures some-
times became troublesome, and retarded the cure. An intimate
friend of mine, a surgeon of great abilities, proposed to cut the
ends of them off close to the knot, and thus leave them to theni-r
selves."

*' By following this plan, we have seen stumps healed in the
course of ten days. The short ligature thus left in commonly
made its way out by a small opening, in a short time, without
any trouble, or the patient being sensible of pain." — South-j
minster, Essex, November \st, 1786.

Considering the thickness of the ligatures in use at the above
period, this testimony to their success is very satisfactory;
although Mr. Lucas, in his Reply to Mr. Haire, contained ia.
the 8th volume of the above named work, p. 142, takes bo
notice whatever of the proposal.

184 INJURIKS OF THE BLOOD-VESSELS.

For many years past silk has been the material chiefly used-
in the army for the formation of ligatures ; and 1 believe it to-
be the best. I have little doubt, however, that on emergencies
an army surgeon might successfully avail himself of an artery
or vein dissected from the amputated limb. By experiments I
knovr, that either of these substances are sufficiently strong for
the purpose ; and they might be easily removed from the dis-
membered part. They certainly would be less of the nature of
extraneous bodies than any other that could possibly be ima-
gined. It is not probable that any deviation from the ordinary
material will ever be required, except on particular occasions;
but if the experiment is ever tried, it should be performed in a
limb in perfect health; as, for instance, in those injured by
machinery, gunshot, or other sudden violence, where there
exist no fears of communicating gangrene, or any other disease,
by inoculation. A nerve, or a portion of tendon, will serve a
similar purpose. Hair also suggests itself, as an animal sub-
stance, of which we can avail ourselves more immediately than
any of the others.

Gunshot injuries often lay the foundation for Aneurisms*.
There are some instances, however, where our interference is
not only highly improper, but often fatal. These are the cases
where a ball, passing close to or between the artery and vein
of a limb, but without primarily opening either, has so far pre-
disposed the parts to sloughing, that an eventual Varicose
Aneurism is formed.

The following case illustrates the progress and symptoms of
this injury of the blood-vessels, and the fatality of operation.
I shall briefly relate it, premising that moderate pressure,,
open bowels, and abstinence from every species of excess,
form the rational mode of treatment ; and that, if operation is
deemed necessary, ampU' time should beallowetl for the growth
or enlargement of anastomosing and collateral vessels; and a
much longer period, it is to be observed, will be re(juired in a

INJURIES OF THK BLOOD-VESSELS. 185

case of this kind, than in that where the whole undiminished
force of the ventricle, and of the peculiar arterial action
which prolongs the impulse, is employed upon the column of
blood.

Case XXX.
Varicose Aneurism of the Femoral Artery.

Private —— , of the regiment, aged 24, received a

musket ball at Waterloo, in the fore part of the right thigh,
which brushed along the course of the femoral artery, about
half an inch above the giving off of the profunda; it passed
inwards and lodged. The wound healed without the smallest
untoward symptom, and the man was soon so well, as to be
employed about the wards. Tie left the hospital under my
immediate charge, early in July, and on the I8th of the same
month, or the SOth day from the wound, he was taken into
another hospital as an orderly. On the 6lst day, he complained
of a tumour which had been forming for three weeks, and had
been attended with much pain. It came on, he said, in the act
of running up stairs in the hospital, after having drank Lord
Wellington's health. The extent of this patriotic draught I
ascertained to be nearly one pint of brandy, and some quarts of
strong Brussels beer, swallowed within three hours in an adja-
cent brothel, where he had passed the night with a most
abandoned crew of Belgian prostitutes. I was called in at a
very early hour of the morning, to see the case, and I found an
irritable pulsating tumour, about the size of an egg, on the
apex of which appeared the cicatrix of the original wound.
It disappeared on pressure, and the neighbouring cutaneous
veins, (which were all remarkably full, and, if emptied by the
finger run along them, instantly filled on its removal,) swelled
in proportion as the contents of the body of the tumour were

186 INJURIES OF THE BLOOD-VESSELS.

pressed out. The limb in all other respects appeared perfectly
natural. I requested the staff-surg-eon who had called me in,
to mark this peculiarity, and I directed his attention to the
sibilation and tremulous jarring motion of the veins, clearly
distinguishable on each pulsation of the heart. This peculiar
noise, motion, and compressibility, had been more perceptible;
and, soon after my first examination, had ceased entirely.

I deprecated all attempts at operation, as I was decidedly of
opinion, that a communication had been formed between the
artery and vein ; and the plan of cure then proposed was the
immediate abstraction of 20 ounces of blood from the arm, the
application of a cold saturnine lotion externally, the internal use
of the tincture of digitalis, and a rigid diet on the plan of Val-
salva. I heard little more of poor except his dying

groans. In an evil hour, an operation of tying the external
iliac had been proposed and performed, some time after T had
ceased visiting him. In less than 60 hours afterwards he was
no more, gangrene having supervened immediately. Not a
drop of blood had been transmitted to the limb, and the truth
of my prognostic was publicly proved, by a communication
which appeared between the vessels on dissection.

A case where a varicose aneurism occurred in consequence
of a wound of the left carotid and jugular vein, is given in the
Bulletin of the Faculty of Medicine of Paris, for 1819, No. 6.
The symptoms were great dilatation of the vein, which commn-
nicated a peculiar thrilling as far as to the clavicle; undula-
tions corresponding to the arterial strokes, perceptible to the
eye, and a sound to the ear resulting from the passage of the
blood through the unnatural opening ; there was a small tumour,
which diminished cm pressure, but its volume and pulsation
were unchanged by pressure on the artery below; the left arm
was numbed and painful. This case occurred to Dr. Dospa-
ranches, who very judiciously left it to nature; the man's health
was good, and the tumour was not increasing.

. INJURIES OP THE BLOOD-VESSELS. 187

. Varicose aneurisms may also arise in consequence of a passage
having been formed between a vein and artery by wounds from
pointed or cutting instruments. That at the bend of the arm,
occasioned by accidents in venesection, is the most common
form. Baron Larrey, however, gives examples from punctured
wounds in other situations. One in the ham, one in the arm-
pit, and one in the upper part of the breast, near the articula-
tion of the sternum and clavicle, (vol. iv. p. 341.) This case
underwent a spontaneous cure. As we have examples of injuries
of this kind continuing without any detriment to the patient for
twenty and thirty years, it is, in my opinion, both unnecessary
and injudicious in the extreme to attempt any operation. It
becomes a different case where an artery alone is engaged;
there, after giving a fair trial to cold, pressure, and the plan of
Valsalva, the operation should be no longer deferred.*

An interesting and instructive case has very recently occurred
in the hospital of the D2d regiment in Edinburgh Castle, in
which the external iliac has been tied by Mr. Hicks, the surgeon
of that corps, assisted by Dr. Thomson and Mr. Mackesy. It
adds one more to the instances of this splendid triumph of
British surgery, which the French operators even to this hour
can scarcely credit. But it is rendered, if possible, still more
interesting, by the circumstance, thatj after the artery was se-
cured, although gangrene supervened in the limb, a successful
amputation perfected the cure. The heads of the case are
briefly as follows : —

Case XXXI.

Where the External Iliac Artery ivas tied.

" William Bisset, a man whose constitution had been much
injured by mercury, was admitted into hospital on the 1st of

* See note at page 151, on Valsalva's plan, in the Clinique Chirurgicale of
Pellctan, toui, i.^ oiucli valuable infonnation on the subject will be found.

188 INJURIES OF THE BLOOD-VESSELS.

December, 1816, with an extensive, irritable, and sloughing-
bubo in tbe groin. On the 26th of the month, the external
pndic artery, which was involved in the ulceration, burst and
discharged about a pint of blood, which was restrained by
pressure ; a second hemorrhage took place next day, and the
ulceration spread still farther. On the 31st, the blood sprung
from tbe artery in a full jet, when the actual cautery and pres-
sure restrained it. On the 12th of January, the hemorrhage
again returned, and was controlled by pressure. It continued
to recur so often from this period, that the life of the patient
was in imminent danger, until, on the 22d, a dreadful discharge
of blood threatened at once to terminate his existence. Con-
stant pressure was now applied, and, next day, on consultation,
the parts were accurately examined, when, on removing the
clots, it was found that the lemoral artery itself had given way.
No other resource now remained but tying the external iliac,
which was accordingly done as follows : An incision was made,
between three and four inches in length, tbrough the integu-
ments, in the direction of the artery, beginning at Poupart's
ligament, and carrying it upwards. The lower edge of the
internal oblique and transverse muscles being divided, the
artery was exposed, which being, with some difficulty, separated
from the surrounding parts, and from tbe vein, a blunt curved
needle was passed under it, a single ligature applied, and the
edges of tbe wound brought together. On the 24 ih the limb
felt cold, and was insensible, except when firmly pressed upon.
On the 20lh, tbe skin about the knee became discoloured, and
a copious sanious discharge took place from the wound. On
the 26tb, the discoloration extended, a vesicle formed about the
centre of the tbigli, and a considerable (juantity of coagula and
sanies was removed from the groin. On the J3lst, the leg was
extensively morliliod. On the 1st February, tension and pain
of the abdomen came on, wbich was relieved by a dose of castor
oil. On the 2d, separation in various parts of tbe tliigh began
to esfablish itself. On theOHi, ampulatioo was performed at a

INJURIES OF THE BLOOD-VESSELS. 189

point close up to the trochanter, every thing went on well after-
wards, and the man perfectly recovered."*

The cases of hemorrhage produced by excess of various
kinds are numerous and striking; and in none more obvious
than where there has been unrestrained indulgence with the
fair sex. One case has come within my knowledge, in a wound
of the chest, where fatal hemorrhage from the lungs took place
from this cause ; and one, where an officer died of uncontrol-
lable bleeding from an amputated arm, brought on by the
same. A young oflicer, a patient of my own, with an amputated
thigh, which was healed within half an inch, had seven weeks
after the amputation, an hemorrhage so violent from an excess
of this nature, and a subsequent opening up of the stump
to such an extent, as detained him under cure for three months
longer.'}-

The older surgeons, abounding as their works do with ab-
surdities, lay down some judicious rules for the management
of the diet and the passions of their patients. Abstinence is
frequently enjoined by them, and no doubt much of the success
of their charms, and of their sympathetic ointments and powders,
depended upon the due observance of these rules. Paracelsus
■was most particular in this point. Wherever the inflicting
weapon was greased with his ointment, great caution was to be
observed. " Quo die quis inungit telum," says Crollius,
describing the rules to be observed on this occasion, " abstineat
a venere

* This case has also heeu noticed in an Inaugural Dissertation, by Dr. Tod,
surgeon, 62d regiment, entitled, De Feraoris Ainputatione in Cavitate Cotyloidea,
Edinburgh, 1817.

+ The examples of " Mors in Coitu" are very numerous among the collectors
of cases. Donatus has recorded several, lib. iv. chap. xvii. p. 394. Morgagni
gives some observations on the subject, extremely well worth perusing, in his
26tli Epistle, where the immediate cause has been the rupture of a blood-
Tessel. Some celebrated military men, among them Attila, have beea carried oflF
thus.

190 ' INJURIES OF THE BLOOD-VESSELS.

Hemorrhag"e from blows on the face of stumps are very
frequent; and many officers, who have boasted of an early cure,
are in a worse situation at the end of three months, from ex-
posing themselves to accidents, than those who have been
confined to their chambers for the whole period. The great
vascularity observable about the ends of stumps which have
been injected after death, will sufficiently account for this ; and
the inexpertness in the use of crutches, and the want of balance
and support, which the removal of the principal part of an
extremity occasions, will naturally produce numerous acci-
dents. In these distressing cases, rest, moderation in diet,
acidulated drinks, and the local application of cold, are the most
useful remedies.

One more species of hemorrhage, but fortunately not a very
frequent one, is produced by the secondary opening of an
arterial branch in the parts concerned in compound fractures.
No defined period can be assigned to the accident, nor is there
any peculiarity in the mode of cure. I have already given
a case of this nature, in which no cause could be assigned ;
in some instances, it is occasioned by spicula of bone opening
the vessel.

In addition to the direct injuries to the blood-vessels now
mentioned, it very frequently happens that the veins of a
wounded limb become extremely turgid, and at length com-
pletely knotted and varicose ; this varicose state is generally
observable between the wound and the part of the limb most
distant from the heart, but in some cases I have observed that
it has spread still farther, and involved the whole limb. The
following is a case of this kind : —

Case XXXII.

Varicose Veins after a Gunshot Wound.

An officer, Lieut. -Col. II. received a wound from a musket
ball at IJergen-op-Zocmi, on the night of tho Hfh March, 1814;

INJURIES OF THE BLOOD-VESSELS. 191

the ball entered the right leg externally at about three inches
below the head of the tibia, and passed through somewhat
higher np on the inside, going between the bones, and partially
fracturing the fibula. I saw him in June, 1818; the wound
was then perfectly cicatrized, but from the roots of the toes up
to the crest of the ilium, the limb was completely^ varicose. In
the intervals of the knotted veins the teguments were of a
doughy feel, and pale oedematous colour, and the leg, and par-
ticularly the knee-joint, were very much debilitated, and very
painful, especially on a change of weather; but particularly
whenever there was frost or snow ; or that the season was at all
approaching to cold.

This sensibility to cold is very frequent after gunshot injuries,
and I am not aware of any remedy so useful for it and the va-
ricose state of the vessels, as the laced stocking, or a bandage
of calico or flannel, as the state of the weather may require,
together with friction either simple or medicated, and the use
of the local shower bath, cold or warm, of fresh or sea water,
according to the circumstances of the patient, and the degree
of relief he obtains from these applications. The effects pro-
duced by a difference of a few degrees in the heat of the
water, is often much more remarkable than we could have
imagined a p?^iorij and the feelings of the patient should always
regulate our practice with regard to its temperature. I have
seen many cases relieved by the cold shower-bath, while severe
rheumatism has succeeded its employment in others, and some
patients have been, or supposed they have been, relieved by
sea water, while the fresh has had no effect, and vice versa.

Id3

CHAPTER XI.

INJURIES OF THE NERVES.

The mechanical injuries of the nerves are entirely beyond
the power of art to relieve effectually ; but they are objects of
great curiosity, and illustrative of many most important symp-
toms that occur in the course of practice. Complete divisions
of a principal nerve are instantaneously followed by a total loss
of motion and sense in the parts supplied by it. In partial
lesions, the privation is not so complete. A secondary paralysis
very frequently takes place without any immediate injury of the
nerve, as in those cases where a ball has passed so close to a
large one, or the plexus from which it proceeds, as to occasion
an inflammation and consequent thickening of the neurilema or
investing membrane; or where, in a more distant transit of the
ball, tbe tube formed by its passage swells to an extent sufficient
to press on the nerve or plexus.

In some cases, the loss of motion and sensation on the injury
of a nerve, either by a direct or partial division, does not take
place to an equal extent in all the parts between the injury and
the extreme points of the limb. I have seen several cases
where the nerves have been injured in their passage down the
humerus, and the extremities of the fingers alone suffered, all
the intermediate parts possessing their full powers ; and others,
where pressure on the crural nerve, close to its exit from the
body, has all'ecled one or two of the toes only. This can per-
haps never be explained, until we can ascertain what particular
nervous chords, or fasciculi of chords, go to particular parts
and organs.

INJURIES OP THE NERVES. 193

A very common and most distressing- set of sensations are the
shooting pains and sympathetic feelings, referred by the patient
to the fingers or toes of an amputated limb, which in some
persons exist for months, or even years after the operation. In
some, cold or damp veeather, lightning, or an electric state of
the atmosphere, or an easterly wind, will produce it; in others,
mental agitation, violent bodily exertion, intense thought, or
excesses, particularly in venery, are sure to bring it on. In
some instances it can be traced to no obvious source, in others
it very clearly depends upon mechanical irritation. The fol-
lowing case is well worthy of notice.

Case XXXIII.

A general oflScer, of distinguished gallantry, was struck by a
round shot during a very desperately fought action, which
buffing along his breast in an oblique direction, destroyed the
arm, and left only the head of the bone and a very small por-
tion of the shaft remaining. He was carried to an adjoining
hovel, where the common amputation was performed under
very unfavourable circumstances ; the night was coming on,
the supply of candles was scanty, and the enemy's shot were
flying in all directions. The General was placed under my care
on the day after the operation. The variety of cross accidents
from fever and extensive sloughing, it is not within my purpose
at present to enlarge upon, but the first attempt at clearing the
ligatures, and making gentle pressure on them, was attended
with pain so excruciating, as to leave no doubt that each in-
cluded a nerve, or was in a certain degree connected with some
large nervous filaments. This agonizing sensation was not felt
except the ligatures were pulled at, and then not in the stump
itself, but was referred to the finger, thumb, wrist, elbow, or
even to the external skin of the lost arm, as one or other liga-
ture might be handled. I have sometimes been led to think,

194 INJURIES OF THE NERVES.

that the General uniformly felt the same sensations when the
same ligature was touched, as I generally made my attempts to
extricate them in a regulated succession, and his complaints
were often of the same succession of parts. More attentive ob-
servation, however, convinced me that this was not the case;
for if any one was pulled with more steadiness than another,
he complained of all the parts suffering pain simultaneously.
One small ligature, if pulled in an oblique direction inwards
towards the axilla, always gave him imaginary pain about the
elbow or in the skin ; but if the same was pulled strongly and
directly downwards, the fingers were complained of. He has,
frequently after the smarting of dressing was over, with great
accuracy pointed out on my arm the course of the internal cu-
taneous nerve, as the site of his ideal pain; often he has de-
scribed that of the external ; and, on one occasion, I, with
utter astonishment, had the general neurology of my arm and
fingers traced by him. But unless the ligatures were pulled at,
he had no other uneasy sensations than those which usually
occur in persons whose limbs have been amputated. Once only
did I ever know him refer his pain to the seat of the sensorium
itself. On that occasion, from using an artery forceps to the
ligatures, on which the slide moved rather stiffly, I exerted a
greater force than I had intended. He convulsively put his
hand to his head, expressed a sense of exquisite pain in his
brain, involuntary tears dropped from his eyes, a paralytic con-
traction momentarily afiected his mouth, an universal paleness
spread over the uncovered parts of his body ; and, although
unusually tolerant of pain, and of a most remarkable equanimity
of temper, he ut'.ered a piercing cry, and exclaimed, " that the
agony in his head and neck was insuH'crable." The state of
collapse was so great, that I was obliged to send an aid-de-
camp instantly for volatile alkali, and a glass of Madeira, by
which he was soon relieved ; but the painful sensation, and the
prostration of his strength, continued through the day. A
Briti-jh Admiral was present on this and various other occa-

INJURIES OF THE NERVES. 195

«ions, and observed to me, after I had confessed my inability to
explain, even to my own satisfaction, the cause of all these
sensations, " that he never saw the General dressed without ap-
plying mentally to the w onderful sympathy manifested on those
occasions, the expression of Pope, * it lives along the line.' " I
believe we must be content with the fact, without seeking for
the explanation.

To account for the mode of action of the nerves, or the con-
nection between mind and body, will perhaps never be permitted
•us in our present state of existence ; and we, who, to use the
language of the Swedish philosopher,* " have calculated the
laws of motion for distant worlds," are in profonnd darkness
on important points connected with our own. There is no
doubt, however, that the principle of perception exists in full
integrity in the cerebral mass, even after these " iuternunciate
chords" are divided. The investigation of this most curious
subject belongs to the physiologist; unfortunately, the little
purpose to which it has hitherto been pursued is but too
obvious. It remains for me to say, that, after various gentle
attempts at cutting, pulling, twisting, and a graduated and
constant strain by means of appending small weights, or tying
the separated threads of the ligatures over little quills of
plaster, and similar contrivances, fully a year elapsed before
the last ligature was removed by my friend, Dr. Irwin, Deputy
Inspector of Hospitals. The General's health did not suffer;
and the unanimous opinion of the best informed surgeons was,
to try no violent measures or extensive incisions, but trust to
constant gentle means and the slow operations of nature.f An

* View of the Progress and Present State of Animal Chemistry, by J. J»
Berzelius. Translated from the Swedish by Gustavus Brunnmark. London,
1813.

t Mr. Bingham, Hospital-Assistant, assisted nie in dressing the General daily.
He was also occasionally seen by Mr. Guthrie, Mr. Gunning, Surgeon-in-Chie^

o 2

196 INJURIES OF THE NERVES.

experiment of placing a ligature on the axillary plexus, or on
any single nerve in the dead subject, will show what an ob-
stinate resistance is offered after the protrusion of the medullary
substance, by the subsequent puckering of the tough investing
membrane, which during life will not admit of the ligature
sliding off, either until the part is absorbed in course of time,
or the materials of which the ligature is composed undergo
some decomposition.

Althousjh examinations after death, or after the removal of
a limb, by showing the site of balls, splinters, ligatures, &c.
will often very satisfactorily explain the source of many
nervous symptoms, yet we are frequently left altogether in the
dark.

In the very interesting case given us by Dr. Denmark in the
Medico-Chirurgical Transactions, vol. iv. the source of the
patient's torture, which approached to tic doloureux, was sa-
tisfactorily traced to the imbedding of a portion of a Jeadea
ball into the posterior part of the radial nerve ; but although a
lesion of this nature was suspected previous to amputation, and
indeed almost demonstrated, by the symptoms and the site of
the wound, yet, on mature reflection, amputation was preferred
to any partial excision of the nerve. I apprehend, if we con-
sider the great extent to which the thickened and diseased state
of the investing membrane of the nerves may reach ; the cer-
tainly of greatly lessening, and perhaps eventually destroying
the motion and sensibility of the parts to which they are dis-
tributed, by cutting off the communication with the seusorium ;
the contracted or distorted state in which the limb generally is,
and the possibility of exciting universal and highly dangerous

and by Drs. Thomson and Somerville. Mr. Rrownrigg suggested some ingenious
modes of removing llie ligature.

Portal, Cours D'Anutoinie Medicale. vol. iv. p. "JJX), may be advantageously
consulted on this curious subject ; and aUo I.aniorier, in the Mem. de I'Acad. de
Montpelier, anno 1737. See also the Acta Medica Rerolin. Dec. 2, vol. viii.

INJURIES OF THE NERVES. 197

commotion of the system; we will rather prefer the almost cer-
tain effects of amputation, where any operation is required, to
the more brilliant but ambiguous promises held out by a dex-
terous dissection.

Surgery has little positive aid to give in cases of wounded
nerves, and even of tbe phenomena attending them our know-
ledge is limited. In the living subject, according to Prochas-
ka, a divided nerve retracts, and the medulla is expelled from
its extremities, but more copiously from the upper than the
lower end. In many cases, however, particularly in the ax-
illa, the nerves protrude considerably, so as to require removal
in cases of high amputation. Tbe ends of divided nerves are
united by a new formed matter, but it has been disputed whe-
ther this was real medullary matter or not. Dr. Haighton, in
the Philosophical Transactions for 1795, proves that this new
matter will perform the functions of a nerve, and this appears
to me conclusive upon the point. These functions are, how-
ever, restored but very slowly, and not by any means uni-
formly. Nor does tbe assertion of Cuvier, that the power of
motion is restored upon the re-union, but the sensation lost,
universally hold good.

With regard to the re-union of divided nerves, it has been
asserted by Professer Meyer (Bibliotheque Germanique, vol.
vii.) that the reproduction of nervous matter is more rapid
in the tibial than in the ulnar nerve, and that in the sciatic the
re-union is the most difficult of all. This may have happened
in the Professor's experiments on animals, but I cannot say
that the fact has ever struck me in my examination of military
men, who have been invalided in consequence of their wounds.

The total division of a partially wounded nerve is the only
operation recognized by modern surgeons. The experiment
is, however, hazardous and uncertain, and I have principally
confined myself to venesection, with emollients to the parts,
which 1 have employed with advantage where the accident was
suspected.

198 INJURIES OF THE NERVES.

CEderaa is a very frequent consequence of gunshot injuries
of the extremities, and is generally complicated with pressure
on the lymphatics, or injury to the nerves, either immediately,
or from the tumefaction of the parts from inflammation. By
the use of gentle friction, with moderately stimulant embroca-
tions, succeeded by the local shower-bath, and the subsequent
application of a firm flannel roller, this troublesome symptom
will be in general benefited after some time. I have also de-
rived essential relief from the distressing numbness of the fingers
in such cases, by the frequent evaporation of sulphuric aether
upon the part. 1 have never noticed injuries of the lymphatic
vessels themselves, unconnected with general affections of the
limb.

To the authorities already referred to in this chapter, I would
add Mr. Guthrie's excellent and practical chapter on gunshot
wounds, accompanied with lesion of the large nerves, in his
third edition. In the course of the present work, while treat-
ing on wounds of particular parts, I shall incidentally notice
various affections consequent upon injuries to, or pressure oa
the nerves.

CHAPTER XII.

OF SOME GENERAL AFFECTIONS OF THE SYSTEM FROM

WOUNDS.

The prevention of fever, or the lowering of its violence
when formed, is an object of most serious importance in the
medical treatment of wounds ; and without strict attention to
the constitutional symptoms of our patient, the best operation,
and the most judicious local treatment afterwards, are of no
avail. In the preceding observations, T have with this View
touched upon the necessity of carefully investigating the state
of the bowels and the skin, and regulating the diet of the
wounded, their personal cleanliness, and that of the hospitals
in which they are placed. It does not come within the limits
I have prescribed to myself to enter at large into the detail of
the various species of fever which appear in military hospitals,
or supervene upon wounds. I shall, however, make a few ob-
servations on some points that appear to me of considerable im-
portance to be attended to by the less experienced practitioner.

The Inflammatory Symptomatic Fever, which succeeds to
wounds and operations, is by no means uniform in its period of
attack, nor does it run through its course in conformity to any
known or established laws. Its invasion, which is most generally
influenced by the violence of the injury, the irritability of the
patient, or the importance of the injured parts, is sometimes
remarkably retarded, so as to give rise to very fallacious hopes;
and whether it is, that this violence is only suspended to ac-
quire additional force, or that its late appearance throws both

200 SOME GENERAL AFFECTIONS

patient and snrg^eon off their guard in the very important point
of diet, it so happens, that those cases are generally the most
ambiguous in their results.

Neither are the quickness of pulse, nor the heat of skin, in-
fallibly indicative of the presence of fever, or of its probable
termination ; and therefore it is, that the state of the tongue,
stomach, and stools, and of the senses, should be most particu-
larly attended to. Sobriety is so rare a virtue among soldiers,
that many alienations of mind are attributed to drunkenness,
which, in reality, are the consequences of fever; and the decep-
tion is the more complete, that the look and general appear-
ance often combine with the state of the senses, to deceive the
incautious and superficial observer. But though he may be
misled as to the presence of intoxication, he can never do
wrong if he treats the case as if that state actually existed ; for
it should never be lost sight of in practice in military hospitals,
that there prevails an almost universal propensity to excess,
both in drinking and food, which is increased by the military
theory that refers all disease to weakness, and is countenanced
and assisted by the attendants, who are of the same class of
society, and imbued with the same prejudices as the patients.
The principal remedy, then, in the cure of this fever, will na-
turally suggest itself ; this is, purging; and the grand preven-
tive is abstinence. In the administration of the remedy, no
difficulties will be thrown in the way of the prescriber; but
he is constantly assailed by solicitations to relax the rigour of
diet; and it requires a very strong conviction of its necessity,
and no small share of self-command to resist. The character
of a young man stands high with the soldiers in proportion to
the extent of extras on his diet-roll, but the success of his prac-
tice is invariably in an inverse, ratio. Where, however, indul-
gences may be conceded with safety or advantage, his humanity
will be best exerted in witnessing Iho administration of the ar-
ticles he orders ; for too often they are commuted for spirituous
liquors, for the mutual partici[)ation of patient and nurse.

OF THE SYSTEM FROM WOUNDS. 201

In the Symptomatic Inflammatory Fever from Wounds of the
head, thorax, and abdomen, our grand dependence is upon
general blood-letting ; but it is not often necessary in wounds
of the extremities, without evident topical congestion in the
more vital parts. The use of local blood-letting by leeches is,
however, of great importance, as is also the topical application
of cold ; although insuperable objections, from the immobility
of the patient, often exist to the employment of the general
affusion.

If the fever is obviously kept up, as in compound fractures,
by great local irritation, our only resource is Opium; and,
however theory may condemn it, or practice sanction the con-
demnation in idiopathic fevers, we have no better remedy in
those now under consideration ; but it should invariably be
administered by the prescribing officer himself, or under his
observation.

There is a circumstance well worth attending to in the ad-
ministration of opiates, viz. their effects on the bowels, skin,
and urine. The well known constipation they induce, must
be guarded against by proper remedies ; but an effect of the
sympathy which exists between the skin and kidneys, and
which produces an increased flow of perspiration, together
with the secretion of a very great quantity of animal mucilage
and lithic acid, on the use of opiates, is not to be confounded
with the slate of the skin and urinary depositions resulting from
fever.*

The camphor mixture, with a sufficient quantity of the extract
of hyosciamus, forms an anodyne of high utility in those cases
where opiates are necessary, I have used it principally in pri-
vate practice, and since the conclusion of the war of 1815; the
quality of the hyosciamus formerly supplied to the army, not
allowing so many opportunities of applying that remedy as I
have since enjoyed.

* For a full view of the symptomatic and hectic fevers, see Thomson's Lectures
on Inflammation, pp. J02 and 323.

202 SOME GENERAL AFFECTIONS

The Hectic iorm of symptomatic fever, of which so much ha&
been written, and for which we have no positive preventative
or remedy in medicine, is as irregular in its periods of attack,
in its violence, and in its duration, as the inflammatory symp-
tomatic fever which generally precedes it. Hectic seldom, if
ever, comes on without the existence of suppuration, and yet
the speedy establishment of a healthy suppuration is one of the
most promising- preventatives to its appearance. All states and
stages of wounds are subject to hectie, but I am not aware of
any in which it can be predicted to a certainty, although the
weakly, and those who complain much of pulmonary and of
rheumatic affection, or constant ingurgitators of ardent spirits^
have been the general subjects in my practice. Where the
diseased part admits of removal, it is the only cure; and on the
proper period I shall offer some observations when I treat of
amputation. Where it does not, the whole treatment may be
summed up in the words of the venerable Heberden. " The
principal, if not the sole attention of the physican, must be
employed in relieving symptoms." Here, again, restrictions in
diet are of the most vital importance, and the access to wine or
spirits is poisonous. The medicines to be employed must en-
tirely depend upon the particular circumstances of the case.
Opium is extremely useful, and with some. Bark is held of con-
siderable importance.

On the mode of administering Bark, and even on its necessity
or utility, a great diversity of opinion prevails at the present
day. For my own part, 1 have given it what I conceive to be
very fair trials ; and although I would not reject it altogether,
I must confess its powers appear to me by no means to justify
the reputation it once possessed. That it has been abused, not
only in the quantity and mode of its exhibition, but in the
cases in which it has been employed, admits of no doubt; upon
the whole, from the result of many trials, 1 am led to prefer
aromatic bitters, with occasional alkalies, to any form in which
the bark can be used in general hospital practice. As an ex-

OF THE SYSTEM FROM WOUNDS. 203

ternal application, I am now convinced it is at best inert; and
it has the very serious inconvenience of disguising the appear-
ance of wounds, and detracting much from their cleanliness.*
The discovery of the Sulphate of Quinine, may doubtless obvi-
ate some of the objections to the bark, not the least of which
was, its bulk, and the large quantity of inert matter swallowed
in each dose. The portability of this preparation fits it pre-
eminently for military practice.

As a British soldier confessedly exceeds those of all other
nations in excellence and completeness ot clothing, in regularity
of the supply of food, and in external parade cleanliness, so is
a British barrack or hospital, while under proper control, and
a correct system of internal management, pre-eminently dis-
tinguished above all others. But while we bestow this praise,
so justly due to our own troops, let us not withhold from others
that justice which is due to them. In the armies of other
nations, drawn from southern Europe, sobriety is a leading
virtue. Cleanliness, although not very striking in their ex-
terior appearance, is much more generally attended to by
frequent bathing than among our own soldiers ; their periods
of rest and exertion, too, are more regulated than with us ;
their minds are more cheerful, and they are more inclined to
social converse ; while their communication with the other sex
is rather a sentiment, than an ebullition of brutal passion.
These are points so striking, as to be obvious to the most
inexperienced eye, even on a cursory glance : but to bring it
more fully into view, and to trace the effects of the difference
where they become most obvious and most essential to the
soldier's welfare, it is only necessary to look at a British and a
foreign soldier arriving wounded from the field of battle at the
gates of an hospital. The demeanour of the latter is such as
would almost lead to the opinion that he was equally drilled to

* When it may be thought necessary to employ bark, the judicious observa-
lions of Dr. Balfour should be attended to. See the General Preface to his Col-
lection of Treatises on Sol-lunar Influence. Svo. Cupar, 1811.

204 SOME GENERAL AFFECTIONS

the tactics of tbe hospital as the field. In our own soldiers,
their energy in action is seemingly unaccompanied by any
prospective view of what may happen them afterwards. They
too often come either furious or stupid from intoxication, totally
bereft of their necessaries, or with such masses of rags, as serve
only for fomites of contagion, and often with a female attendant
whose appearance and behaviour are more those of an iafuriated
bacchanal than a nurse. The humanity of our government
admits of a certain number of women per company to embark
with troops proceeding on service; and hence, perhaps, this
part of the evil is not to be remedied ; but to prevent, as much
as human foresight can do, the generation and introduction of
fever into a new-formed hospital, no individual of either sex
should be admitted, without a rigorous examination and purifi-
cation of their persons and their baggage.

In the establishments where proper stores have not been pro-
vided for the knapsacks or " kits," as they are technically
called, of the soldiers, they but too often form the pillow of a
wounded man, and, perhaps, from a defect of bedding, it may
so happen that the blanket, in which he himself, his wife, or his
child have slept, or been sheltered under for the course of a
campaign, becomes a part of his covering in the wards. Where
this evil is inevitable, a minute inspection of these articles
becomes an imperious duty ; the heterogeneous mass contained
in the knapsack of a soldier, particularly if a married man, is
often extremely oflensive ; no ceremony, therefore, should be
used in removing every thing from his immediate possession,
except his actual necessaries ; and whenever his blanket, or
ordinary clothing, can be subjected to immersion in boiling
water and subse(juent baking, it should never be omitted. The
visiting surgeon should not be contented with the ordinary
parade cleanliness of a smooth chin, and clean hands, but should
look especially to the body and lower extremities. To persons
accustomed to the decencies of civil life, it is inconceivable
what a varnish of filth is sometimes observable on the legs and

OF THE SYSTEM FROM WOUNDS. 205

Feet of soldiers, not only disgusting to the view, but demonstra-
tively obstructive to the due course of exhalation from the skin,
and beyond every doubt a most fertile source of fever of the
worst description.

The antipathy to a free admission of air, and the predilection
for crowding into corners and huddling up their bedding, are
also very common among soldiers, whether in health or under
the pressure of disease. A graduated temperature, and the
regulated admission of air into clinical wards, is the established
practice in all well-regulated hospitals ; but in the surgical
wards, especially after an action, and with numerous compound
fractures, and other profusely suppurating injuries, nothing
short of a full, free, and uniform current of air tbroughout the
whole can prevent infectious fever. In fact, a ward which
barely presents covering from the inclemency of the weather,
and shelter from the direct stream of air upon the bed of the
patient. The temperature of this air may be regulated by fires,
and individual cases may be accommodated with an additional
supply of blankets ; but the true process of disinfecting a ward,
or preventing its ever being subjected to contagion, is to pro-
vide for a constant renewal of its atmosphere. Occasional ven-
tilation will but partially remedy the evil, for the tenacity with
which the effluvia of animal bodies adhere to the substances
exposed to them is very remarkable. The late illustrious phi-
lanthropist, Howard, gives us a most striking proof of this, in
his observations on the air of prisons. " My reader," says he,
*' will judge of its malignity, when I assure him, that my clothes
were, in my first journeys, so off"ensive, that in a post-chaise T
could not bear the windows drawn up; and was, therefore,
obliged to travel on horseback. The leaves of my memorandum
book were often so tainted, that I could not use it till after
spreading it an hour or two before the fire : and even my an-
tidote, a vial of vinegar, has, after using it in a few prisons,
become intolerably disagreeable." — " Dr. Hales," he adds in a
note, " Sir John Pringle, and others, have observed, that air,

206 SOME GENERAL AFFECTIONS

corrupted and putrified, is of such a subtle and powerful nature,
as to rot and dissolve heart of oak ; and that the walls of
buildings have been impregnated with the poisonous matter for
years together."* Some of the villages in Portugal, which had
been occupied as hospitals during the peninsular campaigns,
became so saturated with contagion, that a few hours residence
insured to many a paroxysm of headach or fever, if a copious
bilious vomiting or diarrhoea did not prevent its accession.

The inefficiency of unassisted Fumigations is now pretty
generally acknowledged by their most sanguine admirers; where
I have lately employed them, it has been more from a com-
pliance with custom, than from any conviction of their utility.
That some of them correct the foetor of the discharges from
suppurating surfaces, is well known, and in such cases they have
their merits ; and if they cheer the spirits of the wounded, or
tend to promote the circulation of air, they are not to be
entirely rejected ; but where they, in the slightest degree, in-
terfere with thorough ventilation, or cleanliness, they must be
hurtful. The matter of contagion is constantly emanating from
the surface, and, perhaps, from the lungs of the diseased, and
is enveloped by, and retained in, their bedding. Admitting
that, by fumigation, we can destroy or neulralize the matter
that is formed, we cannot prevent the formation of more; but
by the constant access of pure and fresh air, we can dilute it
so as to render it innocuous, and this irom the moment of
its being evolved from the bodies of the sick, and when it
cannot have become concentrated, or have produced any elfect
on others.

An experiment, on a very large scale, was tried at Torgau,
under the supcriiitcndence of Dr. Gruefe, Surgeon-General of
the Prussian army, to determine Ihc ellicacy of lumigation.f

•

* The stale of the Prisons in Knglond and "Wales, by John Iluward, F. R.S.
Warrington, 1777, 4li). p. 13. Sic also IJrocklushy, |i. &J.

+ Sec Richtcr's Meilizinischc (ii'schichlu der ncliigtruiig und Einiianilie der
Fcslung Torgau, und Rpschrcibung dor I'.pidcniir, w«'lclie dnselhst in dan Jahren
JRIS und J8I4 herrschtf. Berlin, IHI t.

OF THE SYSTEM FROM WOUNDS. 207

Three nearly similar wards were selected, each containing' forty
beds; No. 1 was fumigated with muriatic acid; No. 2 with
oxymuriatic acid; and No. 3 with nitric acid. The fumigation
was repeated every two hours, with the proper precautions of
closed windows and doors, so as to keep up a constant smell of
the acids, but not to such an extent as to excite couffhins: in
healthy lungs, and the experiment was continued for six weeks
with every precaution, and with the utmost minuteness in ascer-
taining and detailing- the facts. The results were, that, in ward
No. 1, two of the attendants were infected, and six patients
died. In No. 2, one of the attendants was infected ; and in No.
5, three were infected, and among them a young' man, who,
•* ex officio," fumigated the wards, and respired scarcely any
t)ther than a medicated atmosphere.

On a late occasion, when I was employed in superintending
the conversion of a fever hospital at Glasgow into a temporary
barrack for troops, Dr. Balmanno, one of the physicians to the
establishment, was so good as to point out to me a small square
where, in consequence of the immediate vicinity of a private
manufactory, from which powerfully acid fumes were most
copiously evolved, the inhabitants constantly breathed a strongly
impregnated atmosphere, and yet there were few spots in
Glasgow where the typhus epidemic, which so lately existed in
that city, was more prevalent; so strong was the acid impreg-
nation of the atmosphere that I could not approach without
coughing, and yet I understood it was then comparatively very
moderate to what it usually was.* The substances which are
prepared there, are the oxymuriate of lime for the use of bleach-
ers, sulphuric acid, soap and soda, The substances principally
employed there are rock salt, lime, nitre, rosin, tallow and palm
oil. The gas chiefly evolved is the oxymuriatic, or chlorine ;

* See Sir James Fellowes's Reports on the Pestilential Disorders of Anda-
lusia, p. 396, for further proofs of the inefficacy of the FumigatioDS with the
Cases.

208 SOME GENERAL AFFECTIONS

but there are also muriatic, sulphureous, aud, probably, a
small portion of nitric ; for this information I am indebted to
Dr. Balmanno and Mr. Ray, Staff-Surgeon.

Where puirnonic complaints exist, these acid fumigations are
inadmissible in the occupied wards. I believe, upon the whole,
they will be found to answer best in rooms that have been
evacuated by the patients, and where the absence of the acid
smell can be made a test of the renewal of the air in a certain
time after the fumigation has been effected ; or in cases where
the bedding or clothing of the sick are to be exposed to medi-
cated vapours for the destruction of foul smells, or vermin,
previous to their being immersed in water, and subjected to the
operations of boiling or washing.

The discovery of the supposed powers of the acids in de-
stroying contagion has been much disputed ; the real history of
the point, I believe to be, that, so early as 1750, Sir John
Pringle, one of the greatest army physicians which this country
ever produced, knew the power, or supposed power, of the
acids. Johnstone published an account of the muriatic acid
gas (which he had used at Manchester in 1752) in 1758. Mor-
veau, in 1773, made use of the muriatic acid gas at Dijon.
Smyth used the nitrous gas in 1780 at Winchester. Neither
Pringle, Johnstone, Morveau, nor Dr. Lind, (who also was
acquainted with the supposed power of the acids,) tried them in
rooms inhabited by the sick, or, if they did, their trials were
not generally known ; that seems to have been first done by
means of the nitrous acid, and the accounts widely circulated
by Dr. Carmichael Smyth in 1780.

Among the numerous proofs that we have of the efficacy of
pure air on the sick, none is more interesting than that given
by the most scientific traveller of this or any other day, Hum.
boldt, in his Personal Narrative. " A sailor," says he, " who
was near expiring, recovered his health from a circumstance
that is worthy of being mentioned ; his hammock was so slung,
that there was not ten inches between his face and the deck. It

OP THE SYSTEM FROM WOUNDS. 209

■was impossible to administer tlie sacrament in this situation,
for, agreeable to the custom on board of Spanish vessels, the
viaticum ought to be carried by the light of tapers, and fol-
lowed by the whole crew. The patient was removed into an
airy place, near the hatchway, where a small square birth had
been formed with sail-cloth ; here he was to remain till he died,
which was an event expected every moment ; but passing from
an air extremely heated, stagnant, and filled with miasma, into
fresher and purer air, which was renewed every instant, he
gradually revived from his lethargic state, and his recovery
dated from the day when he quitted the middle deck."

The constant and uniform renewal of the air is an object of
prime importance at all times ; but it is at night that it is more
particularly required in the wards of an hospital. The eye of
the superintending officer can, during the day, always detect
the more obvious filth ; but at night the excrementitious dis-
charges of the patients are allowed to accumulate ; the beds of
the ward are occupied by many patients, who, during the day,
were kept for a time in the open air ; lamps and candles rn-
crease the consumption of the vital part of the atmosphere,
and it is highly probable that the natural nightly exacerba-
tions of disease tend to eliminate from the bodies of the pa-
tients, exhalations which still more powerfully contribute to
vitiate it.

I may, perhaps, be permitted to adduce my own case, in
further illustration of a subject, which can never be enough
impressed on the army-surgeon. While the British army was
encamped upon the heights of Sobral, covering the approach to
Lisbon, and watching the movements of the French undef
Marshal Massena, in 1810, it became a matter of necessity to
have the whole in a state of preparation for movement at the
shortest notice. Our baggage, therefore, was always ready
packed at night, and we remained ready to turn out at a mo-
ment's warning. I procured what 1 conceived to be a very
ingenious contrivance as a substitute for a bed ; I had a ne^

210 SOME GENERAL AFFECTIONS

blanket sewed up in the form of a sack, with a running string
at its mouth; into this I got at night, and, tying it round my
neck, slept very comfortably on a piece of -water-proof sail-
cloth. The tents undej: which we lay were not of British ma-
nufacture, but a very thin flimsy canvass, pervious to every
blast. I continue«d in perfect health until the retreat of the
French permitted us to get under cover of some half-burned
villages. After some days spent in marching, I got into a
house, and fixed my bed in a room with thirteen other officers,
where we were perfectly secured from the inclemency of the
weather. My birth was considered as particularly enviable,
being in a very dry sheltered corner ; I still used my blanket
sack, but the violence of the rains prevented the possibility of
exposing it to the air. On the third day I was attacked by
irregular chills and febrile heat, and before the 10th my life
was in imminent danger, from a combination of typhus and
dysentery, and nothing but immediate removal to Lisbon pre-
served it. Three persons, who, in succession, used my blanket,
and got into a snug corner, were attacked in the same man-
ner, while all those who slept under the windows, or in the
more exposed parts of the building, escaped all febrile affection
whatever.

To filth, irregularities of diet, whether in quality or quan-
tity, intoxication, crowding together and respiring a foul air,
as sources of fever, is also to be added, a fact well known to
all conversant with the diseases of armies, viz. the much greater
susceptihility of contagion after the active part of a campaign
is terminated, than while both body and mind are fully em-
ployed ; a conibination of all which causes often superadds to
the horrors of war, a scourge much greater than the sword
itself.*

* M. Larrcy dcscriles thi» fever as it occurred in Uie campaign of 1S03. as
docB Pincl, in his " Mt-decinc Cliiique." irufi-land also published an account of
it at Berlin in 1814; and Masnou has given some observations connected with it
inlUc medical history of the siege of Torgau, in Saxony, in the Journ. deM^d.

OF THE SYSTEM FROM WOUNDS. 211

From a consideration of the vast mass of evidence upon
some of the points now alluded to, a very ready explanation
is afforded of the peculiarities observed by the older surgeons
among- their hospital cases, and in theevents of their various
surgical operations. At some hospitals, one setof operations
failed ; another had its peculiar fatalities, each proportioned,
no doubt, to the number of cases of any prevalent disease for
the treatment of which the hospital surgeons were celebrated,
or the districts remarkable; while, in the larger establishments,
dedicated to the promiscuous reception of all cases, every ope-
ration, however trifling, was attended with unsuccessful re-
sults. Atmospheric influence, and all the absurdities of as-
trology, were called in by our fathers to explain this simulta-
neous deterioration of their patients, and various and discord-
ant states of the air weru charged with the ill effects, which
proceeded in a great measure from a want of its free diffusion.
Nor do the results of our hospital operations in modern prac-
tice bear any proportion to the success of those in private life,
although in each we attribute a fair share in the consequences
to the climate, the season, and the nature of the prevalent dis-
eases, as well as to the constitution of the individual.
• I would refer my readers to the admirable Memoirs of Tenon
for many points connected with hospitals, but especially for
some interesting observations on the fatal effects of operations
in establishments where there is a communication between
the fever wards and those appropriated for the wounded and
other surgical patients. It was found that gangrene attacked
the most simple wounds, ulcers became malignant, and all ex-
ternal maladies took on a bad character at La Charite, when
placed near the putrid fevers ; this appeared at first only in the
occupiers of the five or six beds nearest the fever cases ;— hence.

Vol. xxxvi. It is not consistent with iny plan to enlarge on it here; but I
trust some of the able army physicians, who served in Spain, will favour us with
their observations on it. Pringle affords an inestimable model for all works of
this nature.

212 AFFECTIONS OF THE SYSTEM FROM WOUNDS.

as a precaation, no patients with open sores were ever placed
in these beds.

On the powerful causes above alluded to, much of the pecu-
liar appearances of wounds will depend; and in proportion as
they are understood and attended to, a knowledge of the true
nature of these peculiarities will be acquired, and much of our
uncertainty in the discrimination of morbid phenomena avoided.
Hence, the history of particular epidemics will always be in-
teresting. Under this conviction, I shall, without enteniug
into a general description of the various forms under which the
disease has been observed by others, offer the result of my own
experience in one of the greatest scourges of military hospitals,
known under the various names of Hospital Gangrene, Malig-
nant Ulcer, Putrid Ulcer, Infectious Ulcer, Sloughing Sore,
he*

* The following account of the gangrene at Bilboa first appeared, nearly in its
present form, in the Lond. Med. Repository- for .March, 1815. An excellent sum-
mary account of the disease is given us by Professor Thomson, in his Lectures on
Inflammation, p. 456. Professor Delpech, of Montpelier, published a still later
account of hospital gangrene in 1815; and Assistant-Slaff-Surgeon Blackadder
publi!<hed an account of that which appeared at Passages in Spain, in his " Obser-
vations on Phagedena Gangrenosa." Edin. 1818. But the most interesting paper
that 1 am acquainted with, is one by Professor Brugmans of Leyden, in the " An-'
nales de Litterature Medicale, Etraugere et Nationale," for July, 1815; edited
by M.M. KUiyskens and Kesleloot. The 106th and 107th numbers of that work
or the first two of the 19th volume.

213

CHAPTER XIII.

OF HOSPITAL GANGRENE, AS IT APPEARED IN SOME OP
THE BRITISH HOSPITAL ESTABLISHMENTS IN SPAIN,
PORTUGAL, AND THE NETHERLANDS, AND OF THE OR-
DINARY MORTIFICATION OF GUNSHOT WOUNDS.

The military events on the Peninsula daring the month of
July, 1813, in which the action of Vittoria was fought, rendered
it necessary to form several hospital stations in the provinces
of Alava, St. Andero, and Biscay. Among these, Bilboa was
selected as capable of accommodating a large number of sick
and wounded, as being easy of access, and remarkable for its
salubrity.

The principal hospitals were distant about four miles from
the town, and six from the sea. They consisted of a noble con-
vent, which was occupied chiefly by medical cases, and of the
upper floor of a very extensive building, formerly a rope-walk
belonging to the Spanish government, which was exclusively
allotted to the reception of surgical cases, and placed under my
care.

The Cordeleria, or Rope-walk Hospital, was built on the
southern bank of a small but rapid stream, the Ibaicabal,
which runs through a fertile valley, gradually opening from
the town of Bilboa to the Bay of Biscay. Its waters, which
rise in the lofty mountains that bound Alava and Biscay, are
strongly impregnated with iron, and teem with wholesome fish.

211 HOSPITAL GANGRENE.

Tbe tide in the vicinity of the hospital rose between six and
seven feet, and extended its influence about four miles up the
stream.

The soil in the immediate vicinity of the hospital was dry and
gravelly, shelving gradually from the water, until, at the dis-
tance of a mile, a lofty ridge of mountains rose behind, and
perfectly screened it from the winds. These mountains, the
highest of which is said to be, by baromelical observation, about
1400 feet abbve the level of the sea, abound in iron. On the
opposite bank of the river, a chain of hills stretch along at the
distance of half a mile, leaving between their base and the water
a fertile and well drained flat.

Good water was scarce in the immediate vicinity of the hos-
pital; although, with a very little arrangemeiit on the part of
the natives, a pure and never-failing stream might be brought
from the neighbouring hills. This necessary article, as well as
our provisions, which were wholesome and abundant, was sup-
plied from the town by boats.

The prevailing winds, which were westerly and south-west-
erly, blew up the valley from the ocean, and a mild steady
breeze usually prevailed. The state of the barometer, and
quantity of rain which fell, were not observed for want of in-
struments. During the latter end of August, and the beginning
of September, at which period the hospital gangrene first made
its appearance, the weather was mild, and we had a few re-
frcshiug showers. The thermometer at this period ranged
from Gb^ to 70°; but, towards the close of September, the mer-
cury rose in the wards of the hospital to 74°, and one day as
high as 78'^. The nights were, however, generally, cold, cloudy,
and moist.

No e[)i(lemic disease occurred among the inhabitants during
our occupatif>n of this station. They were remarkably healthy
and robust, aiid numerous instances of longevity were to be met
with among them. The tctpography of the Cordeleria was not
more favourable towards its selection as an hospital, than the

HOSPITAL GANGRENE. *>15

interior of the building was comfortable, and adapted to the
purpose. It was 1200 feet long-, by 40 broad, and 16 in height,
well plastered and floored, and raised 12 feet above the surface.
A very important advantage enjoyed by this building, and one
which I would strenuously recommend in all erections for hos-
pital purposes, was, that the walls were perfectly free from
cornice, pillar, or any ornamental projection whatever ; neither
were there presses, closets, shelves, nor recesses, all of which I
consider as serving no purpose so effectually as collecting and
secreting filth, while the ends for which they are generally em-
ployed can be attained much better by a proper distribution of
tables and benches. In this hospital, also, we had the impor-
tant benefit of several doors and windows, extending to the
floor, with large staircases at each end of the building, and
ample room for our stores, provisions, &c. Had we had bed-
steads, I could not have desired a better hospital, even though
curtains had not been supplied, a deficiency so feelingly la-
mented by Mr. Roux * in his visit to our public establishments.
On the first occupation, however, there were deficiences in
many articles of comfort and convenience. The circumstances
of the times extinguished all hopes of receiving effectual assist-
ance from our allies, while the rapid movements of the army,
and the distance of our stores, cut us off from the prospect of
immediate supplies of our own. Our bedding, therefore, was
extremely scanty ; the wounded lying on straw spread upon the
floors, and very much crowded together, which was one cause,
no doubt, of the rapid progress of contagion. Our medicines
also, and other materials, which were purchased principally
from the Spaniards, independent of the great exorbitance of
their price, were of the very worst description. We did not
long, however, labour under these disadvantages ; the talents
and industry of Sir James M'Grigor, the head of the hospital

* Narrative of a Journey to London. Translated from the French, 8vo. London,
1S16.

016 HOSPITAL GANGRENE.

staff, soon removed every cause of complaiot, and our supplies
became excellent and abundant.

In an hospital, situated as I have described, I found, on my
arrival from Vittoria, in the last week of August, 1000 wounded
men ; tbe larger number of whom had arrived in successive
escorts from the same place, many in waggons and carts, but a
large proportion was so slightly wounded as to be able to com-
plete the journey (19 leagues) on loot. Tbe remainder of our
patients were brought from the lines before St Sebastian, by
seu ; and these exhibited by far the most formidable cases. The
sloughing sores had all been collected into a separate airy ward,
on the second floor, and were reported to me as mild and
yielding easily to the treatment adopted ; but, as I was well
aware of the insidious nature of these cases in a large hospital^
full to an overflow with gunshot wounds, pouring in under all
the circumstances of a siege, or a great battle, and of the con-
fusion consequent on such events, I was prepared for fever of
the worst kind, and the most contagious nature. Under these
impressions, I laboured incessantly on the police of the hospital,
under tlie able orders and support of Dr. Charles Forbes, then
head of the station ; had the building separated into wards, and
divisions, opened ventilators, removed nuisances both within
and without, and enforced the most rigid attention to personal
cleanliness, and to the fre(juent renewal and airing of the bed-
ding. I had a most striking instance, within my own experience,
of what attention to these points can effect in the way of pre-
vention ; for, at the general hospital at Elvas, of which I was
principal medical oflicer during the whole period of the suc-
cessful operation before liadajos in 1812, although 2500
wounded were treated there, yet not a single instance either of
hospital gan<;ren(! or lyphus fever appeared an)ong them,
although both these diseases had raged with unexampled fury
the two preceding years. This happy result I attributed to
cleauliness and ventilation, ami to the reuioval of an enormous
dunghill, the lower stratum of which was formed of the .semi-

iFIOSt'ITAL GANGRENE. 217

putrid tow, and bloody bandages left after the battle of Tala-
vera ; and which, on being- turned up, was incrusted with the
same kind of fungus mentioned by the older French surgeons,
as appearing on the dressings at the Hotel Dieu.* The smell
emitted, while removing this decomposing mass, was almost in-
supportable ; and, together with the effluvia from two stagnant
ponds, which 1 caused to be drained, threatened the safety of
the whole neighbourhood.

My fears were soon verified at the Cordeleria ; for in a few
days the whole hospital was overrun with gangrene, which I
more particularly dated from the arrival of some fresh wounded
men from Vittoria, of whom about thirty were in an advanced
stage of the disease, which, it was said, first appeared upon the
journey down. The ward appropriated to sloughing cases at
once became a horrid scene ; every sore in the house assumed
a malignant character ; and the deaths increased in nearly a
threefold proportion.

Our knowledge of the origin of contagions is altogether ex-
tremely limited ; I shall therefore offer no remarks upon the
subject of that under consideration here, as I propose to
confine myself solely to practical facts. These were observed
at the bedside of many hundred patients ; and, without any
reference to systematic arrangement, I shall describe them
from my notes upon the subject, and as they struck me upon
the spot.

Let us suppose that our wounded have all been going on well
for several days, when suddenly one of our most promising
patients complains of severe pain in his head and eyes, a par-
ticular tightness about the forehead, want of sleep, and loss of
appetite, and that these feelings are accompanied with quick-
ness of pulse and other symptoms of fever; his wound, which

* These fungi are very rapid in their growth, springing up in one night. Their
species, I believe, is not determined. They were supposed to exist only on ban-
dages moistened with oxycrate ; but they are by no means confined to them.

218 HOSPITAL GANGRENE.

had been healthy and granulating, at once becomes tumid, dry,
and painful, losing its florid colour, and assuming a dry and
glossy coat. This is a description of the first stage of our Bil-
bao hospital gangrene ; and if a brisk emetic was now exhibit-
ed, a surgeon, not aware of the disease that was about to form,
would be astonished at the amelioration of the sore, and the
unusual quantity of bile and of indigested matter evacuated by
vomiting. In many cases, and particularly if the ward was well
ventilated and not over crowded, nothing more was done ex-
cept to change the patient to another room, or, if that was not
practicable, to remove his bed from the place where it stood,
particularly if in a close corner of the ward, and not raised
from the floor by boards and tressels, and to order him an en-
tire change of bedding, while, at the same time, he was well
■washed with tepid water. If, however, this incipient stage was
overlooked, the febrile symptoms very soon became aggrava-
ted ; the skin around the sore assumed a higher florid colour,
■which shortly became darker, then blueish, and at last black,
■with a disposition to vesicate; while the rest of the limb be-
trayed a tendency to oedema. All these threatening appear-
ances occurred within twenty-four hours ; and at this period
also the wound, particularly if it was situated on a muscular
part of the thigh, buttock, or calf of the leg, ichatever viiyhl
have been its original shape, soon assumed the Circular Forfu,
The sore now acquired hard, prominent, ragged edges, giving
it a cup-like appearance, with particular points of the lip of a
dirty-yellow hue, while the bottom of the cavity was lined with
a Uabl)v blackish slouch.

This rapid progress and the circular form of the ulcer were
highly characteristic of hospital gangrene, and obtained almost
universally in every wound infected with it, wherever situated,
I have seen the external ear and IIm; palpebraj destroyed in this
manner, as if in a series of concentric circles. Even upon sur-
faces barely contiguous, as the lingers and toes, it generally
spread in a similar way j so that the sore, which might have

HOSPITAL GANGRENE. 219

been on the middle finger or toe, and confined entirely to it at
the morning dressing, by night engaged the adjoining sound
ones, and in less than twelve hours more embraced the whole
foot or hand. The originally affected spot was always the
centre of this wide-spreading diseased circle. Over the ribs,
also, or over the interdigitations of the serrati muscles, the sur-
face of the wound preserved the circular form, although the
bottom was irregular or angular. The discharge in this second
stage became dark coloured and fetid ; and the pain was ex-
tremely poignant.

The gangrene still advancing, fresh sloughs were rapidly
formed, the increasing cup-like cavity was filled up and over-
topped by them, and the erysipelatous livor and vesication of
the surrounding skin gained ground, while chains of inflamed
lymphatics could be traced from the sores to the adjoining
glands, there exciting inflammation and suppuration, which
often furnished a new nidus for gangrene. The face of the
sufferer assumed a ghastly, anxious appearance ; his eyes be-
came haggard, and deeply tinged with bile, his tongue loaded
with a brown or blackish fur, his appetite entirely failed him,
and his pulse was considerably sunk in strength, and propor-
tionally accelerated. In this stage the weakness and irritabi-
lity of the patient was such, that the slightest change of pos-
ture, or the most delicate examination of the sore, put him to
torture, increased by his inability to steady the limb, which, if
moved at all from the bed, was seized with tremors and spas-
modic twitches. I have never observed this spasmodic aftec-
tion increase to tetanus in any one instance of the many
hi^ndreds which I have seen; and I have been almost tempted
to imagine the two diseases incompatible.* When these nerv-
ous aftections came on, the bravest soldier betrayed a symptom,
which, in those of less strength of mind formed a striking fea-

* Mr. Guthrie, however, has seen the diseases coexistent, and venesection
effected a cure. See the paper of Sir James M'Grigor ou the Diseases of the
Army, Medicq-Chirurgical Transactions, Vol. vi. p. iod.

220 HOSPITAL GANGRENE.

ture in every stage of the disease, viz. the greatest imaginable
impatience of pain and depression of spirits. Men who had
borne amputation without a groan, shrunk at the washing of
their sores, and shuddered at the sight of a dead comrade, or
even on hearing the report of his deatb, instantly predicting
their own dissolution, and sinking into sullen despair. I have
never in one single instance seen this irritability ^yanting ; and
I am therefore led to suppose, that those practitioners who assert
that they have seen whole muscles, nay limbs, come away with-
out pain, must have mistaken %he nature of the disease they
witnessed, or have seen hospital gangrene in its chronic state,
when large sloughs were separating after the febrile disease
had subsided.

The third and last stage was now fast approaching. The
surface of the sore was constantly covered with a bloody ooz-
ing, and, on lifting up the edge of the flabby slough, the probe
was tinged with dark-coloured grumous blood, with which also
its track became immediately filled ; repeated and copious
venous bleedings now came on, which rapidly sunk the pa-
tient ; the sloughs, whether falling oif spontaneously, or de-
tached by art, were quickly succeeded by others, and discovered
on their removal small thickly-studded specks of arterial blood.
At length an artery sprung, which in the attempt to secure it,
most probably burst under the ligature; the tourniquet or other
pressure, was now applied, but in vain ; for while it checked
the bleeding, it accelerated the death of -the limb, which l)e-
came frightfully swelled and horribly fetid. Incessant retch-
ings soon came on, and with coma, involuntary stools and
hiccough, closed the scene. Often, however, the patient sur-
vived this acute state of the disease, and sunk under severe
irritation, absorption of putrid matter, and extensive loss of
substance, without any other symptoms than those of hectic
fever, arising from other sources.

While the acute symptoms, as above described, were pro-
ceeding in one part of the hospital, the same appearances began

HOSPITAL GANGRENE. 221

to spread through another at a distance ; for immediate contact,
though highly dangerous, was by no means necessary toward
the propagation of this most insidious disease. The stumps
which had been nearly healed caught the morbid disposition ;
those where healing by the first intention was reasonably to be
looked for, opened, retorted their edges, put on an erysipela-
tous appearance, and, at last bursting up altogether, presented
a frightful cup-like excavation, edged with the true character-
istic circular lip. The slightest scratch of the dissecting knife
festered ; ulcers, whether simple or constitutional, became gan-
grenous ; wounds long healed broke up, and fell into a state of
foul suppuration ; nay, the skin, although perfectly sound, which
had been touched with a sponge employed in washing the gan-
grenous sores ulcerated, and soon became itself a slough. This
was often observable among the orderlies and nurses. It was
not, however, a long residence in the tainted air that predis-
posed to the reception of the contagion, as 1 have seen illus-
trated in the case of a soldier of the Royal Waggon Train.
This poor fellow, who had just landed from England, and was
under the influence of mercury, employed for a venereal com-
plaint, died within forty-eight hours after his admission, the
gangrene having seized on an open bubo in his groin, eroding
the great vessels in the neighbourhood, and absolutely destroy-
ing the abdominal parieties to a large extent.

In this distressing state of our hospital, some few constitu-
tions resisted the febrile affection altogether ; some had exten-
sive local disease, without any general affection. Those cases,
however, I have principally observed to occur from the inocu-
lated slough among the attendants, who occasionally respired a
purer air than the patients ; and among the assistants, whose
accidental scratches were best treated by destroying the part
with nitrate of silver. I have, moreover, seen among the ser-
vants and washerwomen, the febrile symptoms without any
local affection ; and this was clearly traced to washing the
bandages and dresses. These cases readily yielded to proper

222 HOSPITAL GANGRENE.

remedies, principally emetics, succeeded by moderate and
steady purging.

Such were the symptoms which characterized the hospital
gangrene at Bilboa ; one of the most subtle and destructive poi-
sons that ever infested an hospital, attacking equally the most
robust and most debilitated, and, if unchecked by medical aid,
proceeding invariably to a fatal termination. Its existence
fortunately cannot be long overlooked in any situation ; for, to
those who have once seen it, a glance at the sore, or even the
smell of the ward, will immediately discover it. It can scarcely
be confounded with any other disease or any species of ulcers ;
it may indeed be mistaken by name (and T have seen this hap-
pen) for common gangrene, but the points of difference are
very striking. It does not proceed from impaired organization
of the parts, nor is it necessarily preceded by inflammation,
cold, or pressure; its progress is infinitely more rapid, and,
when its course is checked, separation takes place in detached
specks instead of the waving line. It is also often attended
with hemorrhage, which rarely occurs in common gangrene.
The two diseases, indeed, are frequently coexistent, and I have
seen numerous instances of the lower part of a limb gangrenous
from pressure, while a sore highly infected with hospital gan-
grene has occupied the upper part. To those who have seen
such cases, or have had opportunities of comparing the difler-
ence of appearances of the diseased parts in two individuals,
the diagnosis can never be difficult.

The skin and cellular substance, whether loose or condensed,
veemed to be the parts originally and principally atlectod in the
disease at Bilboa. This was obvious, oven in the living body, but
ou dissection, the disease of tht^se parts frecjuently was observed
to spread much farther than external ap|)carances would at all
warrant us a priori in concluding, as we often found a diseased
track running up into the groin or axilla, and completely dis-
seating the muscles and groat vessels. This was, indeed,
soDxetimog obvious during life, for on the separation of the

HOSPITAL GANGRENE. 223

sloughs, the muscles would appear as perfectly disengaged as
the most accurate knife could render them, at the same time
they would, for a long period, retain their florid colour and
preserve their action. In very violent cases, however, the
muscles partook of the disease, and either sloughed off in suc-
cessive layers, or became converted into a flabby disorganized
mass.

The thoracic and abdominal viscera did not appear to sulTer
peculiarly while the gangrene occupied the extremities ; but
where the ribs or abdominal parieties have been the seat of
disease, I have occasionally observed that the viscus, which
corresponded in situation with the external sore, took on a dis-
eased appearance. I have seen the lungs in two cases, and the
pericardium in a third, covered with gangrenous spots ; and I
have often observed the same appearance on the liver ; but I
have never traced any thing of the kind on the membranes of
the brain.

The bones, in some instances, resisted the contagion for a
long time, either exhibiting no morbid appearance whatever,
or barely throwing oft" a thin scale. In other cases, however,
particularly where the ribs, sternum, or cranium were denuded,
they became carious throughout, and sloughed away ; and the
caries assumed the circular form, in strict correspondence with
the shape of the soft parts. In some cases, a total absorption
of the phosphate of lime took place, and the bone was con-
verted into a cartilaginous mass ; this circumstance I have met
with twice, once in a diseased metacarpal bone, and once in
the femur. In the former case the dissecting-knife cut through
the bone with as little difficulty as if it had gone through the
cartilages of the ribs. The latter case was very remarkable ;
the patient suffered acute torture from a sloughing thigh stump,
which, on an accurate examination, displayed the following
appearances. A thickened cutaneous texture hung like a loose
pouch around a hard projecting mass, apparently consisting -of
a diseased muscle; within which, corresponding to the size and

224 HOSPITAL GANGRENE.

situatioD of tlie bone, appeared a lough, dark body, exquisitely-
sensible. It had been touched with escharotics, lay loosely,
and, on removal by a forceps, had all the external appearance
of a stopper of cartilage, about two inches in length. On ex-
amining the spot more closely, the whole of the parts contained
within the diseased skin appeared of the same nature, and the
disease seemed to spread up to the trochanter. The patient
had been affected only fourteen days ; and for the last four the
complaint appeared stationary. An operation was resolved on,
which I performed, by first taking up the femoral artery, im-
mediately under the ligament, and then cutting as deep an
inverted cone as I possibly could, I sawed off the bone imme-
diately below the trochanter. On examining the amputated
portion of the limb, the whole mass, with the exception of the
skin, was found to be cartilaginous, retaining the shape of an
enlarged bone, but not the smallest trace of osseous matter.
The tube of thickened periosteum in which it lay, alone exhi-
bited a few detached specks of ossification. The operation suc-
ceeded, and the patient embarked in six weeks.

The blood-vessels were affected as variously as the bones. In
some rare cases, I have seen the femoral and axillary arteries
pulsating awfully, and apparently unaffected with disease;
while all the surrounding parts were completely destroyed ; but
in a vast majority of cases the blood-vessels partook of the
general disease in which they were imbedded. They were not
only completely separated from their natural connections, but
their coats sloughed away at the immediate point of disease,
while the disposition extended far beyond the apparently
affected spot. Hence, our ligatures but too often failed on the
main branches, and any atttimpt on the smaller was invariably
injurious. We were here naturally induced to tie the artery
considerably above the seat of the disease; and this was done,
once on the femoral, and twice on the axillary artery ; the
former burst on the third, each of the latter on the second day
afterwards : these ligatures were a|)plie(l, no doubt, in the height

HOSPITAL GANGRENE. 225

'oF tbe g^angrene, when all operations are hazardous. In gene-
ral, the great vessels sloughed long after the acute symptoms
-of the disease had abated ; in severe cases, under such circum-
stances, we always dreaded the eleventh day of the disease.

The state of the vessels was well illustrated by the follow-
ing experiment. During the performance of an amputation at
the middle of the humerus, every preparation was made for the
injection of the limb : immediately on its separation a pipe was
fixed into the brachial artery, and a coarse tallow injection,
blood-warm, was slowly thrown in. The gangrenous cup which
occupied the bellies of the flexor muscles, and extended down
towards the wrist and the palm of the hand, was immediately
filled with injection, which oozed from every point of the sur-
face, while the main artery at once gave way.

In the treatment of the Bilboa hospital gangrene, although
the ulceration might seem to claim the first notice, yet it was to
the constitutional treatment that we paid particular attention.
We regarded external applications, notwithstanding an ob-
vious change of type in the accompanying fever, as merely a
secondary object ; and, in truth, I must confess, that I viewed
them as operating more by the cleanliness and attention to the
patient, which their frequent application implied, than by any
intrinsic value which they possessed in themselves.

In every case of the disease on the first invasion, as well as
on occasions of threatened relapse, the primae vice were cleansed
by full emetics, followed by purgatives ; and the state of the
bowels and skin were carefuUv attended to throughout its whole
progress.* On the supervention of typhoid symptoms, which,

* This was the mode of treatment I found established at the hospital, and
which -was continued for some time, until our want of success generally, and the
abuse of stimulants in some particular instances, together with the obviously in-
flammatory nature of the disease, forcibly arrested the attention of Staff- Surgeon
Dr. Boggle, to whom the merit of introducing venesection at the Cordeleria is due.
Dr. Boggie has since published a most interesting paper in the Transactions of
the Medico-Chirurgical Society of Edinburgh, vol. iii. part 1. lu which he

226 HOSriTAL GANGRENE.

during the months of August and September, very early made
their appearance, the cure was conducted on the same princi-
ples as guided us in the treatment of pure typhus, administer-
ing in the latter stages opium in large doses, aided by a nutri-
tious diet, and a liberal allowance of the best wine we could
procure. Bark, in decoction, was for some time much and
copiously employed, but I have seen great harm done by large
and injudicious doses of this drug, before full evacuations had
taken place and the sloughs began to separate. I need scarcely
say, that a remedy so strongly recommended as Venesection
had early occupied our attention ; but previous to the month of
October, the obviously typhoid type of the disease made us ex-
tremely averse from employing it. At that period, however, a
change in the weather, from sultry to cold, and even frost
(at night) took place, marked by a corresponding change in
the thermometer, which, at its medium range, was 20* lower
than in the preceding month. It progressively sunk during
the winter to the freezing point, while severe and long con-
tinued gales of windjgj from south and south-west, accompanied
with constant mists and thick fogs, prevailed. Catarrhal com-
plaints became very prevalent, and a general inflammatory dia-
thesis was apparent throughout the hospital ; but what more
than all convinced us of the change of type, and pressed on our
consideration the propriety of blood-letting, was, that the spon-
taneous hemorrhages, which formerly sunk the patient's strength,
were now accompanied with obvious relief. The greatest cau-
tion was therefore used in the administration of wine and
opium ; the dose of the latter, which, in some of the more se-
vere cases, had been extended to three and four grains in
twenty-four hours, was now gradually diminished to a bare
anodyne at night, and the wine was changed from Port to Vin

treats very amply on the subject, and altliouf^li we a]i|icar to differ in opinion, I
tihall ever consider my ablu and iiumanu friend witii the higliust consideration and
Qtteciu, and I recoinniend his paper to erury Ariny-Surgcoii us a model of caini
•bMrvatioii of facts, and p)iilo»ophical deductions from them.

HOSPITAL GANGRENE. 227

du Pays, with a diminution also of its quantity; while spirits,
which had occasionally been allowed, were entirely prohibited.
In short, a moderately antiphlogistic regimen was universally
adopted.

A favourable case for venesection at length presented itself;
the result was strikingly advantageous, and the practice be-
came general ; indeed the very patients themselves implored
the use of the lancet, and from that period to March following
we used no other remedy, either as a cure or preventive. If
it was neglected on the appearance of an inflamed ring around
a sore, attended with violent throbbing pain, and a foul bot-
tom smeared with unhealthy pus ; or if, in a suspicious stump
already healed, redness, pain, tension, and bounding pulse oc-
curred, gangrene assuredly took place, if full and early blood-
letting was not employed. Much to our surprise, we never ob-
served any of the lancet wounds assume a gangrenous appear-
ance, although previously in almost every other instance the
slightest puncture festered.

In the local treatment, a great variety of methods was pur-
sued ; an enumeration of them would embrace almost all that
have been proposed by authors ; with the exception of the actual
cautery, which has acquired great reputation in France, both in
this disease and in tetanus. There exists, however, so strong a
prejudice against it, that I hesitated much to encourage its
adoption in the British hospitals. Some applications, which
agreed for a day or two, became either inert, or hurtful at the
end of that period, and we were at length guided in their use
by the effect which they seemed to produce. In general, how-
ever, the sores were covered with a large fermenting poultice;
and if there was great tension and inflammation in the limb,
cloths dipped in saturnine solutions were applied. The more
irritable sores were dressed with lint moistened with tinct. opii,
or camphor dissolved in oil, or a paste of camphor and opium ;
where the fetor was very great, levigated charcoal, either alone
or mixed with bark, or camphor, was employed. An applica-

228 HOSPITAL GANGRENE.

tioD, also, from wliicli we derived some assistance, was diluted
nitric or citric acid.*

The French surgeons, some of whom did duty with us, used
to apply hot fomentations of walnut leaves to the sores, and
then sprinkle them with powdered nitrate of silver; but I ob-
served no better effects from this than from any other external
application ; and, indeed, I never observed decidedly bad con-
sequences from any, except hot burning oils and nitre, the
application of which, particularly of the latter, produced the
most exquisite torture, without any corresponding advantage.
Whatever dressings were employed, the utmost attention was
paid to the removal of all filth, by repeated washing with tepid
water. The sores, during the whole time of dressing, were
exposed to the fumes of nitrous acid gas, which was also con-
stantly diffused through the wards. The walls, roof, and floors
of the sloughing wards, were daily whitewashed; the same
cloth or bandage was never used a second time without
washing; and the sponge, or tow, (which is much preferable)
employed in cleaning the sores, an operation generally per-
formed two or three times in the twenty-four hours, was imme-
diately destroyed, to prevent all chance of inoculation, which,
in a large hospital, is frequently effected in spite of the best
precautions.

When our endeavours began to be attended with success, the
febrile symptoms began also to abate, and small florid specks,
about the fifth or seventh day, appeared to break through the
black sloughs, the edges of the circle lost their retorted and
tumid appearance, and the looks and spirits of the poor suf-
ferers considerably improved. The slough soon began to loosen,
and, at this stage, I lliink, the use of powdered rhubarb ex-
ternally was attended with beneficial effect, and assisted much
in cleansing the sores. In some cases, however, the sloughs

• Sixty (Iropg to Ibij. water wa» the proportion of tlie nitric acid. Tlie citric
was applied in the native form of lemon juice.

HOSPITAL GANGRENE. 229

were amazingly tenacious, and required a strong solution of
lunar caustic. A much more important object than the separa-
tion of the slough, was the removal of the patient to an airy and
separate ward, as no disease was more apt to recur than this.
I have seen a case, in which, in spite of our utmost endeavours,
the wretched patient suffered thirteen different relapses, and at
last sunk under the violence of the repeated attacks. These
occurred from the slightest local irritation, or error of diet, and
sometimes without any apparent cause whatever, and at a period
when cicatrization was rapidly going on. They also at times
occurred without any increase of fever; a small livid, or red
spot, covered with a glairy tenacious purulent matter, suddenly
making its appearance, and, however, frequently destroyed,
still continuing to increase, until at last the whole sore again
assumed the sloughing state. Hemorrhage frequently occurred
about the period of the separation of the sloughs ; it was best
restrained by pressure with a sponge, or compress, dipped in
oleum Iserebinthinae. When the main artery gave way, ampu-
tation, as high up as possible, was our only chance of saving
life; indeed, this dreadful alternative was, in a great majority
of cases, rendered indispensable, not from hemorrhage alone,
but from the extensive loss of substance occasioning destruction
of the joints, and from other sequelae of the gangrene.

The question of amputation, though a subject of much dis-
cussion in cases of common gangrene, could, in the hospital
gangrene that I have been describing, admit of no hesitation.
For, although the line of separation neither need, nor ought to
be waited for, in several cases of the former description, yet
the phenomena of the disease, and the appearances on dissec-
tion, forcibly impressed the impropriety of attempting to operate
before the fever had abated, and the sloughs began naturally to
detach themselves. To give amputation every possible chance
of success, separation of the patients on whom it was performed,
from those labouring under gangrene, was indispensable : the
skin was detached as little as possible from the muscles, and
the bleeding from the smaller vessels was restrained by pressure,

230 HOSPITAL GANGRENE.

and dossils of lint dipped in ol. terebinth, while the lig-atare on
the larger trunks was applied as described already, by cutting-
short both its ends.*

At this period I was not fully acquainted with the decisive
testimony of M. Delpech, in favour of the actual cautery, or I
should have assuredly tried it, notwithstanding the general pre-
judices against it; neither did I then know of the great efficacy
of arsenic, as employed by Mr. Blackadder at Passages, the
place from which, as I have already said, so many of our cases
were brought. There can be no doubt of the utilitv of arsenic
at the station where he first employed it. His mode, as he has
stated it, was as follows :

" As it is of great importance to have the sore made per-
fectly clean, and freed from the viscous discharge, and as this
cannot be easily effected by common means, without occasioning
a disagreeable oozing of blood, and a considerable degree of
pain, the following method will be found not unworthy of atten-
tion : — Two tin vessels should be provided, in the form of large
hospital teapots, and which are for the purpose of containing a
weak solution of the Subcarbonate of Potass, the one with cold,
the other with tepid water; as it is found, that sometimes the
one is most agreeable to the feelings of the patient, and some-
times the other; but the latter is the most effectual in cleansing
the sore. This solution, or wash, is to be poured over the
sore, while a basin is held in a convenient situation for re-
ceiving it, and which ought to be immediately emptied into
another vessel, placed at a distance from the patient. f During

• Dr. Forbes superintended, with the utmost anxiety, the whole progress of
this epidemic, and Dr. Boggie, .Messrs. Hume, Croflon, Fenton, and Dcthick,were
unremitting in tiieir attentions.

+ " As circumstajiccs may Ih- micIi as to render it impossible to keep patients
affected with this disease in a siparatc nportment by themselves, no precaution or
artifice that is calculated to pierent its propagation, or to impress a belief in its
conlayiowi nature, sliould be neglocted. if ventilation be neglected, the surgeon
muM Ix; more or less to blame; but, during his absence, the patients may have
direct interrourc with each other, which, in this disease, is at least equally dan-
feroul, though it cannot always be .so easily prevented. '

HOSPITAL GANGRENE. 231

this ablution, the glutinous matter which adheres to the sore
may be gently detached by means of small dossils of fine tow,
or lint; but these ought never to be used for two different
patients, rigid economy on occasions such as this being a very
mistaken principle. The use of sponges in such cases ought
to be entirely laid aside, as they can seldom, with safety, be
used above once; and such an employment of them is
evidently precluded, by the great expence with which it
would be attended. When the sore has been thus made as
clean as possible, a piece of fine dry lint is to be spread over
its surface, and gently pressed into all its depressions, with the
points of the fingers. If the surgeon be too nice for this ope-
ration, or if he has accidentally wounded his fingers, it may be
done by means of an instrument, consisting of a flat knob, or
ball, attached to an elastic piece of steel, two of which may be
readily made of a common elastic steel probang. When the
lint is removed, a quantity of the discharge will be found ad-
hering to it : and this operation must be repeated with fresh
pieces of lint, until the surface of the sore is made perfectly
clean and dry; in efi'ecting. which, considerable paiu may be
experienced by the patient, whose feelings must be soothed ;
but he will soon have occasion to be grateful for the pains that
have been bestowed upon him; for this preparation is greatly
conducive to the speedy operation of the principal remedy.

'* The solution of Arsenic (Fowler's) is generally found to be
sufiiciently powerful, when diluted with an equal part of water.
In some slight and recent cases, I have found two parts of
water to one of the solution answer every purpose ; and I have
sometimes used it undiluted ; but this will very seldom be found
necessary.

" The patient, or his attendant, should be provided with a
small wide-mouthed vessel, containing a quantity of this diluted
solution, and which ought always to be carefully set apart, and
every one made aware of its pernicious effects, when used in-
ternally. He should also be provided with a number of pieces

232 HOSPITAL GANGRENE.

of lint, cut into the shape, but a little larger than the sore; one
of which, previously soaked in the solution, is to be applied,
(the sore being previously well cleaned, as directed above,)
kept constantly moist, and renewed every fifteen minutes, or
half hour, as may be necessary ; for, when the sore is large, and
when there is much heat and inflammation, the evaporation is
proportionally increased, and renders it necessary to renew the
application more frequently. When the sore is in this painful,
and inflamed state, considerable benefit may be derived from
the frequent application of linen cloths, moistened with cold
water ; but, to prevent the solution from becoming thereby too
much diluted, it is necessary to cover the lint on the sore with
a piece of oil cloth, which, however, ought not to be larger than
to extend a short way beyond the edges of the sore.

'• When the disease has supervened upon a recent gunshot
wound, it is apt to penetrate deep, in the course of the ball ;
and when there is a counter opening, it not unfrequently ex-
tends through the whole course of the wound. In such cases
it is necessary to use a syringe, both to clean the sore, and to
inject the solution. A slip of fine.lint, well soaked in the so-
lution, may also be inserted, by means of a probe, into the
bottom of the wound ; and when the two openings are at no
great distance, and not in the immediate vicinity of the large
nerves and blood vessels, the lint may be drawn through the
wound in the form of a seton. Such cases require more per-
sonal attention on the part of a surgeon, as the application
of the remedy in this form cannot be entrusted to the patient,
or his usual attendants. As the Solution of Arsenic, on its
first application, always occasions more or less pain, it is some-
times necessary, particularly in irritable or debilitated consti-
tutions, to adiniiii.ster an opiate, and to repeat it according to
circumstances; but this will seldom be found to bo absolutely
necessary.

*' The period recpiired by this application, for eflectually
Ucilroying the morbid action in the soro, is longer or shorter,,

HOSPITAL GANGRENE. 233

according to the progress that has been made by the disease,
and the nature of the original sore. The best rule to go by is,
to continue its use, until an insensible, dark-coloured, and dry
slough, occupies the whole surface of the sore, and until the
patient is completely relieved from the burning and lancinating
pain, which is, in some degree, characteristic of the disease.

'* The slough being formed, the next step is, to assist nature
in detaching it; and this will, in general, be best effected by
the use of an ointment, composed of equal parts of the oil of
turpentine, and the yellow resinous ointment, or two parts of
Venice turpentine to one of the resinous ointment. These being
melted and mixed together, are to be poured over the sore, as
hot as the patient can possibly bear it ; over this, a pledget of
dry lint, or tow, is to be applied, and retained by a bandage;
and this dressing may be renewed, according to circumstances,
from two to three times in the course of the day, carefully
washing the sore each time with the solution of potass. Under
this treatment, the slough will be gradually detached, be-
ginning at the edges, and extending slowly to the centre; and,
wherever it appears detached, it ought to be pared off with the
curved scissors. It sometimes happens, that the whole slough
becomes apparently disunited, and can be readily moved in
different directions, while at the same time it is found to be
still attached by means of small ligamentous bands, which
occasion very acute pain when their laceration is attempted.
When these bands cannot be easily divided by the scissors,
the usual dressing should be continued for a day or two longer,
as the advantages attending an opposite practice is more than
counterbalanced by the pain to which the patient must be sub-
jected.

" Instead of applying dry lint, or tow, over the ointment, I
have frequently had recourse to a linseed meal poultice, with
the view of expediting the separation of the slough: and it cer-
tainly answered the purpose, but its effects appeared to be too
relaxing. I have also suspected that it acted otherwise than

234 HOSPITAL GANGEENE.

as a mere relaxant to the sore ; namely, by its heat and mois-
ture operating as a solvent on the morbific matter condensed in
the slough, (for there is no reason to believe that arsenic neu-
tralizes this matter,) and thereby allowing it to be again applied
to the surface of the sore, and to produce that recurrence of
ulceration which has been sometimes noticed in cases where
such an occurrence could not otherwise be so easily accounted
for. And, accordingly, when a poultice was employed, I founcj it
expedient, at each pressing, to touch the new granulations,
particularly at the edges of the sore, with the nitrate of silver.

" Wiien the slough is entirely removed, the same dressing
should be continued, until the granulations become vigorous
and high coloured ; but, as the morbid action in the sore is now
destroyed, the future treatment must be regulated by circum-
stances depending upon the nature of the original injury, and
the constitution of the patient. In general, however, the same
ointment applied cold, or with the addition of a small propor-
tion of the Sub-acet. Cupri, will be found the most useful dress-
ing. The lint on which it is spread should be cut into the
exact shape of the sore, and not so large as to cover its edges ;
over this should be applied a piece of smooth oil cloth, lightly
rubbed over with soap, and extending from one to two inches
over the sore : it should also be notched at the edges, so as to
produce a uniform pressure, by means of a roller, with which the
whole limb is to be liiinly bandaged. 13y the use of these
means, with proper attention to cleanliness, frequent dressing,
and correct applicatitm of the bandage, (upon which last vory
much depends,) the healing process will gradually advance;
but, after a sore has been affected with gangrenous phagedena,
the cicatrizing process seldom, if ever, makes a rapid pro-
gress." pp. 01 — o().

Mr. Blackadder, in his vory interesting work, from which
the above long but valuable (juolation is made, considers the
hospital gangrene as a local disease, and not communicable by
tlio atmosphere, but solely by inoculation. No man can doubt

HOSPITAL GANGRENE. 235

that it is very frequently communicated in the latter way, but
if what I have already stated, from my own knowledge of the
disease at Bilboa, is insufficient to show that it is also commu-
nicable by atmospheric influence, the following facts from the
paper of Professor Brugmans, to which I have already refer-
red, will, I think, very clearly prove it.

" At Leydeu, in the end of the summer of 1798, in the
French military hospitals, hospital gangrene prevailed in one
of the low wards, whilst the patients who had slight wounds,
and who were placed above this ward, in a well-aired garret,
were found to escape the disease. The surgeon judged it ne-
cessary to make an opening in the floor, in order by that means
to aftord an outlet to the air of the infected ward by the roof.
Thirty hours afterwards, three patients, who lay next to the
opening, were attacked by the disease, which soon spread
through the whole ward.

" In the preceding cases, the contagion was diff'used in the
atmosphere, and the miasm to all appearance, applied directly
to the surface of the ulcers. The following cases give rise to
the suspicion that this disease may be produced by the inspira-
tion of the deleterious matter.

" In the month of August 1805, I saw in one of the wards of
an hospital at Amsterdam, four patients whose wounds showed
unequivocal symptoms of gangrene. The disease did not exist
in any of the other wards. The patients in the above men-
tioned ward were removed, and the necessary precautions
taken ; none were left in the apartment but the four gangrenous
patients before noticed. The number of wounded, however,
became so considerable, that, on the following day, it was ab-
solutely necessary to place two men in this ward ; these patients
had each a benign ulcer situated, in one, above the malleolus
of the left leg, in the other on the internal side of the thigh ;
they were dressed out of the ward almost in the open air, and
the dressings covered with a wet bladder, so that the air of the
ward could exert no direct influence on the ulcers ; the dress-

236 HOSPITAL GANGRENE.

ings were carefully removed twice in twenty-four honrs. Not-
withstanding these precautions, the fever which precedes hos-
pital gangrene appeared in the first patient, twenty or twenty-
two hours after his admission into the ward, in the second
nearly thirty hours later, and both were attacked by the
disease.

" All the surgeons who have described this disease observe,
that it is communicated by the pus of the ulcers which are af-
fected by it, and by every thing which can be impregnated
with that pus, as charpie, linen mattrasses, woollen coverlets,
blankets, &c. ; this has been confirmed but too often by my own
experience. The ordinary methods of purifying linens are not
sufficient to destroying the power of the contagious matter. In
the year 1797, a quantity of charpie was bought in France,
and distributed to the different hospitals in Holland. In evei'y
place where ulcers were dressed with it, a very violent hos-
pital gangrene broke out. The circumstances were inquired
into, and it was discovered that the persons from whom the
charpie was purchased had been in the habit of washing and
bleaching that which had been used for dressings in the great
hospitals, (and which is commonly impregnated with pus,) then
arranging, and selling it as new. This proves that simple wash-
ing is not sufficient to destroy the miasm. The celebrated Pel-
letan has seen hospital gangrene produced by the employment
of charpie, which had been for several years shut up in chests
at the Hotel Dieu. Many scientific persons have remarked,
that hospital gangrene has often appeared after the use of in-
struments which had touched ulcers infected with this disease.
Pouteau also has made this remark." pp. 22 — 25.

Of the la.st fact mentioned by Pouteau no one now doubts,
and I think, after reading what is stated by the Lcyden pro-
fessor from his own knowledge, few will be disposed to ques-
tion that the disease is communicable by the atmosphere, and
that the fever often appears before the local symptoms.

On line occasion, 1 have seen chronic gangrene prevalent in

HOSPITAL GANGRENE. 238

a military hospital, but it was at its termination, and when it
had ceased to be infectious. Twelve subjects were handed
over to me by the late Staff-surgeon Bell, at Abrantes, in Sep-
tember 1812, reported to have had the disease very violently,
and it was said to have carried off vast numbers previously.
The hospital was situated upon the southern, or Alemtejo bank
of the Tagus, in a low, flat, moist olive-ground, occasionally
o\^rtlowed by the river. In its neighbourhood was the great
commissariat depot, where vast quantities of cattle were daily
slaughtered, and where, from the number of carts, oxen, and
mules hourly traversing the adjacent fields, the soil, intermixed
with their food and ordure, and occasionally with damaged bis-
cuit, was trodden down info a thick, tenacious, offensive com-
post, on which a burning sun acted almost constantly. On the
northern bank, the hill on which the town of Abrantes was
built, rose to a considerable height, and intercepted the cur-
rents of the winds, forming, by following the natural bent of
the river, nearly a quarter circle round the hospital grounds.
This stagnation of air was most obvious in the morning, when
the inhabitants of Rosgio (as the little village was called) were
enveloped in dense fog, which was seen rolling languidly along
the plain, by the inhabitants of the higher ground. The sick
were here, for the most part, accommodated in tents during
the short time of their stay ; for it was principally a passing
station, to collect them from the southern line of hospitals, and
forward them to Santarem and Lisbon by water. The natives
were universally aflFected with remittents and obstinate inter-
mittents in the autumnal mouths, and their general sickly
aspect sufficiently betrayed the unhealthiness of the situation.*
All the subjects of the hospital gangrene had either remittent
or intermittent fever, complicated with dysentery, which they
had brought with them, or contracted in camp. The sores had
been originally wounds, but when I saw them they had no re-

* Even children at the breast were affected with intermitlents-

238 HOSPITAL GANGRENE.

gularly defined shape nor figure, but had precisely what Mr.
Bell notices, " the appearance of a half putrid neglected limb,
lying on a dissecting table." The mode of cure I adopted, and
which my predecessor had instituted, was as follows : — After
putting the patients into separate tents, cleaning their wounds
and persons, destroying all the former dressings, and removing
every thing to which the slightest suspicion of being imbued
with the poison could attach, I administered the bark, with
large doses of opium, camphor, and ammonia, and a liberal
allowance of wine and nutriment. The parts were covered with
powdered charcoal, and over that a fermenting poultice ; the
dressing was confided to an able assistant, Mr. Goodrich, now
of the Gth infantry, and no hospital servant was ever allowed
even to touch the dressings, during the application of which the
gases from nitre and common salt were extricated by the usual
means. Under this treatment, these cases improved ; and
although shortly afterwards the system of separation was
changed, and syphilis, dysentery, and gangrene, were brought
under one roof, the contagion did not spread, and I lost only
three of those very unpromising patients.

I had occasion to observe some cases of hospital gangrene,
in the year 1815, at Brussels. The city of Brussels is divided
into the low and high town; the former iy built on the declivity
of a hill, at the foot of which the river Senne flows. The pre-
vailing winds are west and south-west and northerly, and blow
from one or other of these points the greater j)art of the year.
The northerly and westerly winds carry with them the vapours
from the Dutch coast and the north sea; the easterlv and
north-easterly winds are impregnated with the humid vapours
from the Grainl Canal, which is situated in the centre of the
low town, and from the extensive forest and marsh lands in the
neighbourhood tA' .Soignics. The prevailing diseases of Brus-
sels are catarrhal c(inij)lainf.s and interinittents, but, above all,
phthisis [)ulnioiialis. I'mrn IIh' (jjisorvations of the Superin-
tendent of f ho Military IJospitals, it appears that all the most

HOSPITAL GANGRENE. 23i)

troublesome cases of intermiltent treated in them, occurred
amona^ the soldiers quartered in a barrack called the " Petit
Chateau," situated among the stagnant waters and the filth of
the town, while, at the same time, all the cases of fever of the
typhoid type which came from these barracks were of a much
more severe nature than those which occurred among the sol-
diers quartered in the barracks of the Jesuits and the Annon-
<;iade, which were so much higher situated.*

At Brussels, the few suspicious cases that occurred at the
Jesuits' Hospital, the highest situated and best aired of any
establishment in that city, and which came under my charge,
all terminated successfully, by separation, the application of
the carrot poultice, free venesection in the commencement, and
steady purging afterwards. It principally affected robust and
dissipated subjects, sent in from the convalescent hospital, or
from quarters in the town, and presented the circular sore,
with the accompanying fever of the inflammatory type. Any
cases that originated in the hospital were from the lowest and
worst aired wards, and those where the patients lay on low
hospital stretchers.

In another hospital at Brussels, the Gensdarmerie, which lay
very low, and had been originally a sort of police barracks,
filthy in the extreme before its occupation as an hospital, and,
from the circumstance of its having been the last establishment
which had been opened, filled with prisoners of war, the dis-
persed remains of the various actions, who could not be moved
off the ground by the ordinary means, incapable of assisting
themselves, and depressed and maddened by defeat :f the

* Every Medical scholar knows the Medical Topography of Brussels, by
Lommius. A very interesting paper upon the subject will be found in the
•" Actes de la Societ6 de Medicine de Bruxelles," tome i. parte ii. p. 127, by
Pollart.

f Three hundred men were collected in this hospital, the majority desperately,
not to say incurably, wounded. Among them were one hundred and forty com-
pound fractures, viz, 86 of the thigh, 48 of the leg, and 6 of the arm. They had

240 HOSPITAL GANGRENE.

gangrene showed itself by a most rapidly spreading and de-
structive sloughing of the stumps, of the true circular form,
with a deep red border all round, acutely painful, and accom-
panied with violent fever, which commenced with shivering,
succeeded by a hot stage, but seldom followed up by sweat-
ino-. The skin was dry and parched, and towards the close
of the disease of a yellow tinge; the tongue foul and loaded
with a yellowish sordes; the pulse hard, full, and bounding;
the bowels universally constipated ; occasionally severe pain
in the head, and in some instances delirium. The fever was
constantly present with the sloughing. I have reason to
suppose that the sloughing in some cases preceded the fever ;
but in all the others, as nearly as could be traced by atten-
tive inspection of the sores, particularly some weeks after the
establishment of the hospital, both appeared at the same
time. In eight or ten days the violence of the fever abated ;
but often for three weeks it continued to harass the patients,
though less violent in its effects. An emetic and purgatives
at the commencement generally relieved all the symptoms ; the
cases were separated as speedily as possible on the first ap-
pearance of the complaint, and the state of the bowels was
particularly looked to throughout its duration ; a variety of local
remedies were tried, but no decided advantage accrued from
any so long as the febrile symptoms continued unabated. A
favourite external application was a liniment composed of equal
parts of balsam of copaiba and tincture of myrrh; it seemed
on its first application to sootli the pain ; poultices, from their

been collected all over the country by the peasantry, and dragged from barn to
bam, often without food or dressings, and did not arrive at Brussels until various
periods, from the Klh to the 13th day after they were wounded! It must have
been to some of these nun recently t)rou!^ht in that Mr. <'lmrles Bell alludes at
I>. SIU, of his Quarterly Report, Part ill. where he describis the state «)f a wound
*^J'ourtccn dayu iijtcr Us injliction, nhcn nothing ha* been donr." Assuredly no
body of men ever laboured harder in the cause of humanity than the British sur-
geons after the battle of Waterloo,

HOSPITAL GANGRENE. 241

weight and the uneasiness they occasioned, were early discon-
tinued.

Xot having served in the Gensdarmerie Hospital T have given
the above state of symptoms irom the report of a gentleman
(Dr. Knox) who most assiduously attended to the patients. Ey
the liberality of Dr. Theodore Gordon, who was also for some
time stationed at that hospital, and whose account sufficiently
speaks for its own accuracy, I have been favoured with per-
mission to copy his statement of the symptoms as witnessed by
himself.

" The patient becomes restless and uneasy ; he has a sense
of pricking, shooting, and lancinating pain in the stump, — it
cannot be called spasm ; he becomes hot and thirsty; his pulse
is jarring, and the whole arterial system in a very tumultuary
state ; a rigor, and regular paroxysm of intermittent has in one
or two cases about this time intervened. A small dark-coloured
spot is observable, not always confined to the edge of the sore;
its circumference is very tender; the centre itself is by no
means so, — the very reverse ; it spreads, the whole face of the
stump becomes gangrenous. The constitutional symptoms keep
pace with the local ones. The tongue becomes furred ; de-
lirium, with the greatest prostration of strength, and a yellow
suffusion of the skin, generally closes the scene."

The 7th, 8th, and i)th days were the periods when the stump
began to assume these appearances.

In the Elizabeth Hospital at Brussels, a building which lay
low, but was clean and well ventilated, some cases of gangrene
appeared, but originally and principally in the lowest wards.
The sloughing was almost universally preceded by fever, and
the remedies employed were the diluted nitric acid and poul-
tices externally, with purgatives, and occasional emetics.

In an hospital in the neighbourhood of Brussels, situated at
about two miles from the city, on a swampy flat covered with
trees, through which the great Antwerp canal was cut, and the
Dyle and several tributary branches crept along, the Bruns-

242 HOSPITAL GANGRENE.

wickers had their hospital establishment. Their wounded lay
on the floors, and were much crowded. Gangrene raged there ;
it frequently seized a stump three hours after amputation, and,
when I visited that hospital, twenty-eight days after the battle,
one solitary survivor alone marked the performance of a suc-
cessful amputation. Bark internally, and external stimulants,
appeared to have been the plan of treatment adopted. The
nature of the accompanying fever was typhoid.

Dr. Pockels, Surgeon-in-chief of the Brunswick troops, who
served at that hospital, has, while I was engaged in preparing
these sheets for the press, given me some farther information
on the subject. He says, " Almost all the amputations which
we performed in the hospital at Laecken, immediately after the
battle, terminated fatally. Some hours after the operation, the
patient was seized with fever strongly resembling the yellow
fever; a violent rigor was soon succeeded by heat and sweat-
ing, coma, yellow skin, and gangi-enous spots on the stump.
The accession continued for an hour or two, and returned
in live, or eight hours after. Almost all those who had suf-
fered amputation died of it the first or second day after the
operation.

" These fatal symptoms naturally induced us to leave many
of the great wounds to nature, and the more as we observed
that by thus leaving them, the trumatic fever was not excessive.
This circumstance enabled us to ell'ect the cure of some of the
most serious injuries, cases which, according to the rules of
military surgery, would have demanded anjputation."

Tt was the dread of this fever which induced Ur. Pockels to
defer amputation in the case of Major B. mentioned at p. 153.
The progress of the fever was so cjuick, that there was no time
for ascertaining the eflect of remedies. The stimulant and the
antiphlogistic plans were equally unsuccessful : dissection
adorded no explanation of the nature of the disease. In two
cases the blood was found much dissolved, and the liver and
spleen preternaturally soft. In all the other cases, nothing ap-

HOSPITAL GANGRENE. 243

peared to account for the mortality. Besides the gangrenous
affections which were accompanied or combined with this fatal
fever. Dr. Pockels recognized the ordinai'y hospital gangrene,
but it appeared principally in hospitals higher situated, and
prevailed for a much longer period than the former, the malig-
nity of which abated considerably after the first fortnight. A
fever of a similar kind, accompanied with rapid gangrene, is
described by M. Larrey as having attacked the French wounded
in Egypt.*

The practical conclusion which I would draw from all that I
have seen or heard of this formidable disease, is, that although,
by discriminating the type of the accompanying fever, we may
arrest the progress of the disease, or although a modification
of gangrene (which has occurred to others) should arise in which
local remedies alone, or with very little constitutional assistance,
as a purge or emetic, are sufficient to put a period to its pro-
gress ; yet that many valuable lives may be sacrificed before
the propriety of these means, whether general or local, are sa-
tisfactorily confirmed ; and that it is therefore a duty of the
most urgent kind, at once to break up an establishment where
any suspicious sores may occur. In civil life, a multiplicity of
causes may tend to obstruct this measure, but in military hos-
pitals no such objections can possibly prevail. Tents, huts, and
other temporary accommodations, which the experience of a
campaign sufficiently points out, are always within our reach.

Before dismissing the subject of hospital gangrene, I may
observe, that by an analysis of the air in wards affected with
this contagion, M. Brugmans has clearly ascertained that there
exists in it a peculiar animal matter, highly disposed to putre-
faction; that the oxygen gas is considerably diminshed, and the
azote and carbonic acid gas augmented ; and that by the tests
of nitrate of silver, acetate of lead, and oxygenated muriatic
acid gas, the presence of sulphuretted hydrogen gas is detected.

* Memoires, vol. ii. p. 18, or Waller's Translation, p. 76^^,

R 2

244 MORTIFICATION.

See his most interesting- paper, " De I'Etat et de la Compo-
sition de TAtmosphere," already referred to.

OF MORTIFICATION.

Another morbid state, which very frequently accompanies
those accidents so peculiarly the object of the military surgeon's
attention, is the gangrene or mortification to which all gunshot
wounds are more or less iuclined, and which is unconnected
with contagion. My object is not at preset)t to enter into the
general history of gangrene, which is well understood, but
merely to state the (juestion respecting the practice to be fol-
lowed in cases where the removal of a limb becomes the olyect.
The line of separation has long and universally been regarded
as exclusively leading to the formation of a correct opinion of
the particular spot to be operated upon, and the precise period
to ultempt the operation : and where mortification has been
produced from causes existing only in the constitution, or
where, by sympathy, it has been originally led to suffer, and
has at last become completely implicated, w^e can have no
better guide. Could we set bounds to this constitutional
affection, and prevent it from degenerating into an action by
which the safety of the whole system is threatened, we need
never seek any other; but, unfortunately, we too frequently
meet with cases, and particularly in military surgery, where
this sa\ing constitutional effort is never made, or not made
until too late, and where to wait f<ir it, is therefore to expose
tlie |)atient to certain death.

The division of mortification int(» Irauuiatic and spontaneous,
as laid down by .M . Larrey,* is one of great practical impor-
tance; it has bt'cn drMJnccd from long and attentive observation ;

• MiMiiiiircs (li- Cliirur^iu Mililairt-, torn, iii. ]>. I |'i, cl aniuent. Guthrie on
Ain|iuUti<ii), p. (i.'i.

MORTIFICATION. 245

it is consistent with what the practice of every military surgeon
must have suggested, and it fully justifies the adoption of the
rule of conduct announced by him, viz. "that when mortification
is the result of a mechanical cause, and puts tht* jiatient's life
in danger, we need not wait until the disorder has ceased to
spread."

By the adoption of amputation upon the field, or as soon after
as possible, the cases of this nature will be much diminished in
number; but still occasional instances will occur, where to wait
for the line of separation is to risk the life of the patient.

The practice has been frequently followed by British surgeons
of both the naval and military services, and their testimonies in
its favour are the more valuable, that they have been given, not
in support of any favourite plan or theory, or in the quality of
institutors of a new system, or promulgators of a new discovery,
but simply as the result of their own practical experience. T
cannot omit quoting the testimony of one of them on this sub-
ject, — a subject, for the introduction of which to the notice of
army surgeons, in a special dissertation, we are exclusively, I
believe, obliged to M. Larrey, and to the justice of whose re-
marks the dispersed and insulated observations of others, both
before and since his publication, will bear ample evidence. In
a work which appeared in 1807, giving an account of the
practice adopted so far back as 1782, by Mr. Curtis, a naval
surgeon, some very satisfactory observations occur on this
point.* " Some patients," he observes, (p. 229,) " with spread-
ing gangrenous sores of the legs and feet, were probably lost
from an idea that was entertained that gangrene and mortifica-
tion depends always on a disease of the system, and on a morbid
condition of the solids and fluids, which must be corrected
before any operation can succeed. And it must be confessed,
that the directions in books of surgery generally run in this

* An Account of the Diseases of India, as they appeared in the English fleet,
and hi the Naval Hospital at Madras, &c. 8vo. Edin. 1807.

24G MORTIFICATION.

way^ at least they commonly direct that we should wait till
nature makes an attempt to separate the dead from the living-
parts ; but this opinion, so far at least as affects Indian practice,
and the hospital gangrene of Ihat country, is not well-founded,
nor, perhaps, with respect to sucli mortification as is the imme-
diate consequence of external injury in general.

Mr. Curtis then gives a case of amputation after fracture
near the ancle joint, from the fail of a mast, which, though un-
successful, is valuable on two accounts: first, that the gangrene
which led to the operation did not spread to the stump; and,
secondly, that the dissection, though brief, demonstrates the
improved state of the parts, and the actual removal of some
of the diseaised appearances. The symptoms which preceded
death, in this case, had evidently no analogy to those arising
from gangrene, but the dissection is still more clear: — "On
inspecting the stump immediately after death, the swelling of
the thigh was so much reduced as to loosen all the bandages;
a fine suppuration was beginning to appear, and the skin laid
over it was adhering ; the ecchymosis left above the incision at
one spot was now cjuite gone oil", and the skin had returned to
its natural colour." This gen f Ionian also adopted the plan as
preventive of hectic fever or absorption of putrid matter, and
he gives one instance where it was successfully performed while
gangrene was rapidly spreading from improper bandaging.

I met some years ago with a case very similar to this : the
injury was effected by repeated and severe blows of a stone,
producing no less than three distinct fractures of both bones of
Iho fore-arm ; mortification set in, and, without Mailing for any
line of separation, 1 removed the linili, and the stump nearly
iiealed by tlic first intention. My friend, Deputy-Inspector
Pitcairn, of the lri-.li slafi', favoured me with his assistance on
this occasion. I had also, in some insUmces, operated after
gunshot injuries beforr I saw M . Larrey's book. Emboldened
l»y his observations, and fidlowing his rules, 1 have since re-
peatedly done so without waiting for the line of separation ; and

MORTIFICATION. 247

aithougli T certainly was not uniformly successful, I have no
reason to imagine that death was occasioned by a departure
from the rule so generally laid down by authors.

Among the great number who have written upon gangrene,
many valuable observations are to be found. Kirkland and Sharp
in England, and O'Halloran in the sister island, have dedicated
a part of their labours to the investigation. In Mr. Hunter's
invaluable work on inflammation, every line of which is of im-
portance, much interesting matter will be found ; but, perhaps,
we owe to France the most perfect account that has ever ap-
peared. I allude to the " Traite de la Gangrene" of Quesnay.
Many scattered notices, together with the majority of the special
treatises on the subject, have been analyzed by Dr. Thomson,
and their matter condensed in his Lectures on Inflammation,
under the head " Mortification."

248

CHAPTER XIV.

OF TETANUS.

The last and most fatal general affection incident to wounded
soldiers is Tetanus. Happy should I be could I aiford any
thins- satisfactory on this dreadful complaint; but, in truth, my
observations have tended more to show me what I could not
trust to, than what I could place the smallest reliance on, when
the disease was once fully formed. Was it my object to ofier
plausible theories or unsupported conjectures, 1 could with ease
accumulate references to authors, both ancient and contempo-
rary, but it must be confessed, notwithstanding all that has at
various times been ^vritten on the subject, that we have not ar-
rived at any certain conclusions, nor perhaps have we yet fallen
upon the path of investigation which is to lead us to them.
The theories of the disease, and the remedies proposed for its
cure, are numerous; and while (he opposite natures of the
latter will at once lead an unprejudiced judge to hesitate as
to Iheir value, the caiulid avowals of almost every surgeon's
conscience; will ctjntirm their ineflicacy. The facts, the de-
ductions from thi'in, and the remedies employed in conse-
fjuence, all rt^juire arrangement; and it may still occupy years
(if impaiti il investigation, and of jninulo in(juiries in morbid
anatomy, before we can be able to emerge from our splendid
poverty, and from the apparent multitude of our stores select a
few of stiflicient value, on which to found a solid structure of
practical ntilitv.

TETANUS. 249

I have never been fortunate enough to cure a case of the
Acute Symptomatic Tetanus : in some instances of the Chronic
species I have effected or witnessed relief. I shall not take up
the reader's time by detailing- my disappointments ; they em-
brace almost, if not altogether, every remedy that has come
within the knowledge of practitioners. It will be seen by a
reference to Sir James M'Grigor's paper in the sixth volume of
the Medico-Chirurgical Transactions, upon the diseases of the
army in Spain, how little dependence could be placed upon
any of the remedies employed in the disease ; and what I shall
briefly state, upon my own evidence, will, I fear, tend in no
degree to enhance our confidence in their general usefulness,
or their applicability.

In one instance, I have known a cure effected by the in-
unction of the unguent, hydrargyri ; but several weeks after
its use, the patient expired of mercurial marasmus. In another,
amputation of the wounded limb relieved all the symptoms, but
the patient died of a fever, which hung upon him during the
whole period of the complaint, and carried him off in the sixth
week. In my last case, venesection and the use of the tobacco
injection, (which brought away enormous quantities of hardened
feces,) after five days perseverance relieved all the symptoms,
and the employment of jether, and the tincture of opium in
frequent small doses, removed the occasional spasm that oc-
curred, the bowels being carefully watched. The disease lasted
for seven weeks. But in another case, precisely similar, treated
in the same ward, at the same time, on the same plan, and by
the same medical assistant, the usual termination occurred on
the 15th day.

The period of invasion, and of the time which may elapse
before an immunity from attack can be with confidence looked
for, are quite uncertain ; and it is a fact, not a little curious,
that patients, under similar circumstances, in every respect, of
age, diet, nature, and period of infliction of wounds as well as
accommodation for their cure, shall become liable to it in one

250 TETANUS.

hospital or district of a town, and be free from it in another.
This was very obvious after the battle of Thoulouse. Passion
or terror after wounds and operations has beeu known to pro-
duce the disease in some; and sympathy, though a rare cause,
has occasionally given rise to it in others.

In this disease, at least, the warmest advocates for the sa-
native powers of nature have nothing to bring forward in
favour of spontaneous cure. One case is alluded to by a recent
French writer,* but without throwing much light upon the
subject ; indeed, nature seems to be very much at variance
with herself in many points connected with this dreadful inter-
ruption to her economy. Exposure to different temperatures
appears equally to predispose to it, and the various forms
of the disease are produced indiscriminately by similar causes.
Although the Emprosthotonos is an occurrence so rare, that
I have only seen one case which approached to it, yet that
case was observed at the same time, and in the same hospital,
with the various degrees of trismus, rigid spasms of almost
every muscle of the body, and violent periodical convul-
sions, all from similar injuries to that in which it was pro-
duced. From the state of the pulse, 1 have derived no clue
to either the proper treatment or the probable event ; it has,
in the cases I have met with, been astonishingly unaflected.
From the state of the skin, I have been left equally in the
dark. Sweating which some have imagined critical, I have
seen excessive during the whole course of the disease, and
attended with a most pungent and peculiar smell, while in
others it has never appeared at all ; and suppuration, which is
generally interrupted, I have seen continue unaffected by the
spasms. Even the process of healing, which, it would be
reasonable to conclude, should be altogether put a stop to,
has gone on apparently uniuiluenccd by the disease; and

* Rriot, llistoirc de I'Etat vt dos Progres de la Chirurgic Militaire en France,
pendant Icsgucrrcs dc la Revolution, Bro, Bcsan^on, 1817.

TETANUS. 251

in the most severe case I ever saw, which occurred after a
shoulder-joint amputation, sent in to Elvas from before the
hues of Badajos, the life of the patient and the perfect healing
of the wound were terminated on the same day. I have, in
short, observed no symptom, among- the great numbers de-
tailed by writers on this disease, invariably present, except ob-
stinate costiveness. Neither are the species of injuries which
produce the disease uniform in their effects. Wounds below
the elbow and knee have been those which I have seen most
frequently followed by it, but by no means to the exclusion of
injuries nearer the trunk, of the trunk itself, and of the head.
In almost all the instances that I have seen, the patients
have been exposed to a stream of air directly blowing upon
them; this has been sometimes cold, and at others of a high
temperature.

In the dissections which I have made of cases of this dis-
ease I have been much disappointed. I never found any pe-
culiar appearance of the wounds themselves except in one,
where the radial nerve was somewhat thickened, and a small
splinter of bone was sticking in it; the man lived six weeks :
and one where, after amputation of the fore arm very high up,
I found the muscles a good deal injected with a serous effusion,
and an effusion of the same kind surrounding the vessels ; the
nerve which I suspected had been included in the ligature,
seemed perfectly sound, but the vein was ulcerated for two
inches from the ligature, and its coats thickened to nearly the
extent of a quarter of an inch, the inflammation spreading
on to the heart. This man, who was treated by a German
surgeon, was seized on the fifth day from the amputation, and
bled very copiously ; he died on the 8th. The dissection, which
was performed by my friends Mr. Crofton and Mr. Dobson,
was extremely embarassed by a thick crust of bark, which
surrounded the wound, and penetrated into and stained all the
parts in the vicinity.

252 TETANUS.

I have never been able to trace the peculiar appearance and
effervescence of the intestinal contents, as mentioned by M.
Larrev, repeated by his English translator Mr. W^aller, and
confirmed by my friend Dr. Dickson; nor any other pecu-
liarity which did not appear to me to be fairly attributable to
the remedies used ; and any inflamed or lacerated appearances
on the stomach or abdominal muscles, the fauces, larynx, &c.
which are frequently observable, appeared to have been more
from the effects of an increased flow of blood to them con-
sequent on their increased action, than from any other cause.

Among; the great mass of authorities on this point, I would
strongly recommend to the perusal of the junior army surgeons,
the Memoires of M. Larrey, the Observations of Mr. Aber-
nethy, the paper of Dr. Dickson, in the 2d part of 7th vol. of
the Medico-Chirurgical Transactions; the cases of Dr. Parry,
Bath, 1814, and a small probationary Surgical Essay by Dr.
Maclagan, Physician to the Forces, Edinimrgh, ISIO, which
contains an interesting summary of our present knowledge upon
this subject.

The host of authors referred to by Ploncquet, and indeed
all other authorities upon tetanus, lose much of their interest
if unaccompanied by dissections. Some recent occurrences,
and particularly a case detailed by my friend Mr. Webster,
surgeon of the 51st regiment, in the Medico-Chirurgical
Journal for October, 1817, have determined me to lose no
opportunity i>( minutely examining the spinal cord and the
theca vertebralis, in all future cases of acute tetanus, or of a
disease in many points very analogous to it, hydrophobia : —
a determination, in which 1 am strengthened by the opinion
of the author of the excellent paper in the Medico-Chirur-
gical Transactions, above referred 1(». J have already had
many communications on the subject, and while some of my in-
formants assert that they have found the vessels of the spinal
marrow in a state ot congestion; others of equal accuracy

TETANUS. 253

assure me that they could detect no change whatever upon
them. From some of my correspondents I have obtained in-
formation, by which I am perfectly satisfied that some of the
changes described as morbid were natural to the parts, and
that others were the consequence of a rude use of the saw and
chisel. The point may therefore be considered as requiring
much more accurate observations, and more accurate dissec-
tions than have hitherto been made; although of the frequent
existence of congestion in the vessels of the spine, and of con-
sequent effusion into the canal in tetanic cases, there can be no
rational doubt.

An anonymous writer in the London Medical Repository,
vol. ix. p. 300, has given a much more favourable view of the
comparative mortality in tetanus, as it occurs in the East
Indies, than I have ventured to contemplate ; as his observa-
tions appear to be derived from actual practice, I shall avail
myself of them. " It is pretty generally known," he says,
" that in the symptomatic tetanus from wounds which occur
in the East Indies, about one in four recover; and the usual
practice which is followed there, is the use of mercury, both
internally and locally, with the exhibition of large quantities of
opium, spirits, or wine. Some have found the warm bath
useful ; and in the hands of others, the effusion of water of the
temperature of the surrounding atmosphere (which is generally
about 80° of Fahrenheit) has proved a powerful auxiliary in
the treatment of the disease. It generally proves fatal before

the seventh day." " At first, the spasmodic affection is

generally confined to the parts immediately above the wound ;
but the whole side of the body is soon afterwards thrown into
violent spasmodic contractions ; and if a tourniquet or tight
ligature is placed above the wounded part, so as to compress
the nerves, the spasms will be relieved, and very generally pre-
vented recurring. This measure is frequently of great use in
enabling the patient to take a little sustenance, or to swallow
his medicine."

254 TETANUS.

In a disease like letanas every hint is valuable; from good
authority 1 have been informed that digitalis has been re-
cently tried with success; but from a laborious investigation
into all that has been attempted in the mode of treatment, I
am satisfied that the use of opium, with the interposition of
purgatives and warm bathing, has been more successful than
anv other remedy.

255

CHAPTER XV.

OF AMPUTATION.

It is an excellent observation, founded in the purest huma-
nity, and justified by the soundest professional principles,
that to save one limb is infinitely more honourable to the sur-
geon than to have performed numerous amputations, however
successful ; but it is a remark, notwithstanding its quaintness,
fully as true, that is much better for a man " to live with three
limbs than to die v/ith four." How many wretches have dragged
on a miserable existence, trailing after them a deformed, irri-
table, useless leg, or vainly attempting to wield an inert, con-
tracted and cumbrous arm, may be estimated by a perusal of
the work of the Prussian advocate for those distorted masses of
disease, in which, even from his own words, it is obvious that
M. Bilguer inflicted a tenfold proportion of pain, and exposed
his patients to an incalculably greater degree of danger, than
if he had removed their limbs at once. Fortunately for the
contending armies of modern times, this specious inhumanity
has now nearly passed away ; surgeons no longer hesitate, and
even patients appreciate their motives justly, and attribute the
loss of limbs to the fire of the enemy rather than to the incision
knife of their friends. This very confidence increases the na-
tural desire of a conscientious man to save his patient's limb,
and he will persevere in his endeavours until further forbearance
would degenerate into criminality. '

The circumstances which lead to consecutive amputation art
very numerous ; and the influence of existing or preceding

256 AMPUTATION.

disease, natural or acquired irritability, the diflferences of season,
climate, aud food, but, above all, the crowded state of the
sedentary hospitals, will at an earlier or later period, fix the
time of operation. For the precise moment, no delinite limits
can be laid down, but the judgment of the surgeon must alone
be his guide, and this judgment can be acquired solely from a
perusal of the ^ olume of nature, aud the impressive instructions
to be gained in the cliuical wards, by a diligent attendance on
disease, and by becoming acquainted even with its physiog-
nomy. The most superficial perusal of surgical works will point
out the diflerences of opinion which exist as to the propriety of
operation, between those who have practised among robust
peasants and in the smaller establishments, and those whose
patients have been taken from among artizaus and inhabitants
of large manufacturing towns and cities, or treated in large,
confined and ill-aired hospitals.

The military surgeon anticipates all the consequences of de-
layed operation, not only from the particular effects it may have
upon individuals, but the great influence which protracted sup-
purations, hemorrhages, diarrhoeas, febrile exacerbations, and
hectic sweatings, must have upon those who live within an at-
mosphere constantly impregnated with the eflluvia arising from
patients suflering under them. To lessen an evil which we
cannot altogether avoid, we must lose no time in effectually
preventing that deterioration of the hospital atmosphere, to
which these diseased processes so materially contribute. On
the very day that a subsidence of fever is effectually announced
by a free and healthy suppuration ; by the abatement of local
inflammation i by a restoration of the skin to its functions, de-
monstrated by returning coolness and elasticity, particularly on
the afiected liiidj, we should proceed to perform our amputation
on those patients in whom no hope of an ultimate recovery
without it can be entertained. We thus do them the strictest
justice, and we hold out to the cases reserved for trial the
i^reatest possible chance of recovery. To prepare the patients

AMPUTATION. 257

for this state, much may be done by attention to their bowels ;
costiveness is a source of great irritation, and not an unfre-
quent cause of the commencement of the diarrhoeas which so
often hurry off these poor sufferers. Dryness of the skin, and
febrile heat, often depend on this state of the bowels, and a re-
laxation of the one is best promoted by producing that state in
the other. The day before an operation, the administration of
a purgative is very important ; serious inconveniences and
among them hemorrhage, are frequently owing to the irritation
and repeated strainings to stool, occasioned by costiveness. I
scarcely recollect a situation in which bleeding vessels occur
more frequently than in the act of passing accumulated feces
after an amputation, particularly of the lower extremity.

But the grand source of safety to the individual is removal
to a distant and separate ward, and, if possible, to another
hospital appropriated to the cases operated upon, as soon as
his removal is at all practicable. To those who have not had
experience on this point, it may appear a very useless, if not
a very injurious measure, thus to remove the stump patients ;
but I hold it as one of the best established facts in military
surgery, that a cautious and well regulated shifting of those
cases from the hospitals, or, if possible, from 'the towns in
which they have been established, is one of the most certain
means of insuring ultimate recovery. I hav6 witnessed hun-
dreds of cases in confirmation of this ; I have seen the men,
who, on the first day of a transfer from one hospital to another,
have been obliged to be assisted into the boats or wao-^ons, or
held on mules ; enjoy a sound night's repose, awake with a
craving appetite, have a free copious and natural alvine dis-
charge, and proceed on rapidly towards convalescence or a
cure, which has been only interrupted by their arrival at an
hospital station. When I reflect, on the other hand, on the
poor sallow dejected beings that have pined in the hospitals;
the flabby non-adhering inanimate stumps, lined with a dis-

258 AMPUTATION.

coloured half digestecj sanies, which have disappointed my
most sanguine hopes — I shudder at the contrast.*

If the effects of Gestation have been such as I have now
described, when circumstances called for an evacuation of tlte
different hospitals, one upon another, and where the movement
was dependent, .in a great measure, upon casual transport over
execrable roads, and with bad accommodation of every kind ;
what must it be, if this moveable hospital had its own appro-
priate mode of transport, bedding, stores, and provisions, with
proper servants and medical attendants, on selected roads, and
with sufficient hospital accommodation ? Without being enthu-
siastic, or even sanguine, I may be allowed to anticipate most
favourable results, and to press such an establishment upon the
consideration of those in command. The spare forage wagg-ons
of the army might easily be made available for this purpose,
and a few hours exercise might be daily given to the wounded ;
and, under favourable circumstances, they might be kept in
movement within a small circle for several days, encamping at
night, and leaving all their filth behind them, while, in the in-
terim, purification of the diflerent hospitals was eilecting in
succession.

But, to return. — The first class of consecutive operations
having been performed, and the subjects of them removed, our
unembarrassed attention can be turned to the cases for trial.
Ofthc.se, the joint cases and the compound fractures are the
principal. Mr. Hunter, among the numberless valuable facts

• On tliis highly imjiortanl subject, see Jackson's Outline of tho Jlislory and
Cure of Fever, 1798, p. 287. Jackson's Constitution of the Medical Ueparl-
ment of the Army, 1803, p. 200. Dr Wake's Dissertalio Mcdica Inauguralis de
Typhi Uemc<liiH, Edinburgh, Jutm 1807; and Dr. Woolaston's Croonian Lecture,
rxtracted from tin- l'hilr»s<>|)hi(al Transactions in I'.din. Med. and .Surg. Journal,
vol. ^ii. p. &H. But tiic must iiitrri-sting observations to an army surgeon, upon
this subject will be found in Larroy's IVlemoires, vol. iii. p. .38, r/ ttcqurnt. In
the battle subsequent to tho rclnai from Russia, many Trench ."ioldiers began a
march inimcdialely after amputation ul thehhoulder joint. Larrcy, vol. i\, passim.

AMPUTATION. 259

which he has pressed upon our attention, points out the much
greater clanger in the injuries of parts far from the source of
circulation, than when near it, even when these parts are simi-
lar both in texture and use, as in the extremities. Military
surgeons are now in the habit of dividing injuries into those
affecting the articulating extremities of a bone, and those affect-
ing its middle portion, which is subdivided into three parts ; but
the observation of Hunter, so just as applied to the entire
limb, does not hold in the parts ; for, in the thigh, the in-
juries of its head and neck are, beyond comparison, more
dangerous than those of any other part ; next, those towards
the middle of the bone, proceeding downwards ; then the ar-
ticulating extremity at the knee ; and, lastly, the portion from
the condyles to the centre of the bone upwards. In the legs,
on the contrary, the injuries of the tibia, near the ankle joint,
are much more dangerous than those immediately below the
knee, supposing the joint not to be implicated ; and, in the
arm, many injuries of the head of the bone and its vicinity
may be got over with due attention, while those at the elbow
joint most commonly lead to the loss of the limb. In the fore-
arm, again, the order of safely becomes reversed, and the
injuries near the carpal articulation are less dangerous than
those near the humeral. In all cases, the injury from a musket
ball is less than from grape-shot, and in these less than from
round. The state of the soft parts also must be taken se-
riously into consideration, particularly the blood-vessels. From
deliberately weighing all these circumstances, together with
the peculiar constitution of the patient, and the general healthy
state of the hospital, our period of secondary amputation must
be determined. In some hospitals, and at certain periods, no
operation succeeds well. In some subjects, also, the constitu-
tion seems to have lost all its energies ; the parts may be
retained in apposition by straps and bandages, but their
approximation is mechanical, and not seconded by any healthful
effort of nature, while men in the same ward recover fast ;

2tK) AMPUTATION.

obviouslv demonstrating that localities have no influence on
them, although it must be confessed, that generally, when one
sore goes wrong, great numbers follow the example; removal
then affords the only security for success.

Could we always follow our own wishes, as we sometimes
may in the case of officers, or insulated individuals, we would
defer amputation until fever of every kind and degree was
subdued. This is out of the question in a large military
hospital. Where we are at all liable to contagion, we must
content ourselves with moderating instead of removing febrile
affections. Had a surgeon his choice, he would perhaps wait
for an amendment in the sharp, quick, small pulse of hectic,
a restoration of appetite, a regularity of the bowels, and a
diminution of the sweating tendency, and of the cough. But
it is most satisfactory to know, that the removal of the local
injurv often rapidly affects the mitigation of these sympathetic
consequences.

I have very little to add to the numerous excellent works on
the operative part of the subject; but, as I think I have
derived much benefit from attention to a few simple particulars,
I shall briefly state them.

First, Where the tourniquet is used to command the flow of
blood, I would advise, that whatever confidence we may have
in our assistants, or those around us, the application of this
instrument should never be entrusted to any individual; nor
should we proceed to operate until we have personally ascer-
tained our perfect command of the circulation. Secondly,
Where the circulation is to be commanded by the pressure
from the hand of an assistant, particularly in the operation at
the shoulder joint, there is not only no necessity for the appli-
cation of the key, boot-hook, or tourni(juet handle, usually
enjployed, previous to beginning the operation ; but it is
actually hurtful. The long-continued pressure is excruciating
lo the patient, and is often more the subject of his complaint,
than any other step ol" the business ; it is also particularly

AMPUTATION. 261

fatiguing to the assistant, wiio, by this means, begins to flag at
the moment his strength and dexterity are most required.
Pott well knew the advantages of husbanding the strength of
his assistants, (indeed, what of practical utility did he not
know?) and thought it not unworthy to remark upon their tired
state ;* but in the operation I am speaking of, the assistant has
by far the most serious part of it to manage ; and if his ma-
nagement is proper, a more bloodless one, for its magnitude, is
iiot in surgery. J abstain from all comment upon the opinion
of Mr. John Bell on the possibility Lof commanding the sub-
clavian artery ; neither is it my object to enter into a competi-
tion of sarcasm with those who make this exhausted subject a
vehicle of groundless insinuations against the military surgeons.
The point is incontrovertibly settled ; the vessel can be com-
pressed as it runs over the first rib, with the greatest certainty,
and, by an expert assistant, with the utmost ease. I have per-
formed the operation seven times, — twice out of the number by
candle light ; I have been the compressor of the artery repeat-
edly, and I have been witness to its being commanded on nu-
merous occasions ; but I have never seen the most remote
approach to dangerous hemorrhage.^ When a large majority
of the British hospital staff operated in concert for several
successive days at Vittoria, the loss of a wine glassful of
arterial blood, when this operation has been performed, was an
unusual occurrence ; much oflener half the quantity ; and in
one amputation performed upon an heroic soldier of the Chas-
seurs Britanniques by Staff-Surgeon Dease, assisted by Staff-
Surgeon M'Lean and myself, the amount of arterial blood lost
from the principal artery was no more than the quantity
contained between the point of pressure and the point of

• Remarks on Fractures and Dislocations.

t I have not the least objection to the counter security of pressure in the axilla ;
but if the patient is properly supported in a chair, or laid along on a table, which
I much prefer, his yielding to the pressure over the rib is completely prevented.
See Mr. C. Bell's Quarterly Report, p. 226, part ii.

262 A>fPUTATION.

incision through the vessels. These operations were all per-
formed bjefore numerous spectators ; and I can assure my
junior readers, that, without any peculiar dexterity, the same
result is within their own attainment. Let the assistant first
try his power of compression before the operation has com-
menced, and let him with his eye mark the precise spot well ;
during^ the external incisions the pressure need not in the
smallest degree approach to violence. When the surgeon is
about to make his dismembering cut, or that which, in removing
the bone from the socket, divides the artery, firm, steady, and
even powerful pressure will be required for the fourth of a
minute ; within that time the ligature should be secured on the
vessel, for it almost always protrudes into the surgeon's fingers ;
and if it should not it cannot be mistaken, and the tenaculum
will readily draw it forth; the smaller branches are soon
secured, and 1 have never seen them troublesome if the pres-
sure is correct. This operation was actually performed at an
hospital in the town of Bilboa, by a young hospital mate, on a
very urgent occasion, with the assistance of an orderly man
only ! This fact is curious ; but the following sacrifice of
prejudice to vanity, which has come to my knowledge, is per-
haps still more so : — A strenuous protester against the efficacy
of pressure performed the operation with one hand, while he
compressed the artery with the other ! !

To perform Amputation at the Shoulder-joint, I have for
some time exclusively employed the mode by a flap formed
from the acromion to the centre of the axilla on each side by a
gentle curve, first through the skin and cellular substance on
the outside of the arm, then on the inner, so as to mark the
flajjs and guide the future strokes of the knife; then, with a
middle sized amputating knife I cut nearly down to the bone on
each side. 1 then, taking the pointed slip of deltoid which re-
mains attached to the acromion, lay it down quickly with a
scalpel, so as to expose the head of the bone, which I now
proceed to luxate ; this is done with the greatest ease and

AMPUTATION. 263

certainty by throwing the shattered remains of the arm back-
ward, and thus exposing- the long head of the tendon of the
biceps ; by dividing this tendon, and running the scalpel fairly
forward along the groove, its back lying in it as in a director,
we are at once conducted into the joint. I have witnessed
considerable difficulty in hitting^ the articulation bv the omission
of this simple step, which will be entirely avoided if it is
adopted ; and, indeed, will enable the surgeon to enter the
joint blindfolded. By carrying the scalpel fairly round, the
capsular ligament is divided from the bone. Resuming the
amputating knife, with one sweep in the axilla the two lateral
flaps are united, the limb removed, and the flaps brought
together with adhesive straps and bandage. This I have
found the easiest and simplest mode of performing the amputa-
tion, although the dexterity of many of my brother surgeons in
the Peninsula and on the Continent was so great, that almost
every individual had a peculiar plan, and they finished their
operations in as short a space of time as they would have
required to describe the differences of their modes from those
of others.*

In whatever form we may be disposed to make our flap, we
must be guided by tbe state of the soft parts. If, as very often
happens, a round shot has grazed along the top and external
parts of the shoulder, laying open the joint, there the flap, by
laying back the deltoid, cannot possibly be made. If a musket
ball, or a piece of shell, has struck the centre of that muscle
and penetrated to tbe joint, or comminuted the head and neck
of the bone, it would be highly imprudent to make a flap of a
wounded muscle, ever liable to sloughing. If the shot-holes
are lateral, our semilunar incisions may be so contrived as to
pass through them and remove all lacerated parts ; but if it
cannot be so managed, and that they must necessarily remain

♦ This plan may also be advantageously adopted where we mean only to re-
move the head of the bone.

2t>4 AVtPLTATlON.

iD one or both oar flaps, we most, with the tiuger aud spouge,
clear away all splinters, ^with which I have sometimes found
them full, as if they had been stnffed bj art with coarsely
pounded bone,) and bring them as nearly together as we can.
Wherever the Scapnla and Clavicle are involved, which gene-
rally implies an extensive destroclion of the soft parts, after
removing all splinters, the wound mast be lightly dressed, and
its fatore covering left to adhesive straps aud bandage, which,
if judiciously employed, will very soon efiect this purpose,
without the ose of ligatures or satares. I have never met with
a case where the removal of any part of the scapula by the
saw, or even the paring of the cartilage of the glenoid cavity,
was at all necessary, if extensive fracture did not exist.

If the head of the humerus is the only part injured, or if the
injury does not spread to any extent along the shaft, it cer-
tainly becomes the duty of the surgeon to attempt to save the
limb. The following inquiries and considerations, however,
appear to me well worthy of being seriously weighed before we
proceed to remove the head of the bone. 1. That the splin-
tering of the shaft of the bone may not be so extensive as to
reach much beyond the point where a removal of its head could
be useful; and here it is to be remarked, that experience
almitsl universally shows that splintering, or splitting of the
bone, extends downwards towards the condyles instead of to-
wards the head, and the same holds good in the femur, and in
the tibia. 2. That the head of the bone being removed, tlie
process of necrosis may not go on lower down, in consequence
of an iatlamed state of the periosteum, injury of the medulla,
or disease of the bone, from other causes not cognizable in the
early period of the injury, and to the progress of which no
limits can a priori be assigned. -J. Trom these considerations,
would it not be most prudent to let the removal of the head of
the bone be always a secondary operation .' Where .splinters
stick out from a wound in or close to the shoulder joint, or are
loose, and within safe and easy reach, and the surgeon supposes

AMPUTATION. 265

the limb is not irretrievably injured, let them be removed, and
the edges that might irritate be pared or sawed off: let the
original inflammation and fever subside; and then, if the
diseased state of the bone and soft parts becomes evidently
defined in its extent, let the operation for sawing off the head
and unsound parts be attempted.* But where there is not
perfect soundness of constitution to bear up against fever,
formation of matter, and repeated exfoliations, life may often
be lost in the attempt to save the limb.

The history of the Hip-joint operation has been ably stated
by Professor Thomson, in his " Report ;" and Messrs. Larrey
and Guthrie have detailed the necessary steps for its perform-
ance. I have myself, on two late occasions, performed ampu-
tation of the thigh so very high up, nearly embracing the
trochanter, and consequently the capsular ligament of the
joint, that a very few strokes of the scalpel would have effected
the dislocation ; more especially, if the head and neck of
the bone had been split to pieces, as they very often are. My
incision was the common circular one ; and I did not, as I
once before had done, make the taking up of the femoral ar-
tery a necessary preliminary measure ; I tied the arteries in
succession as they were cut, an able assistant pressing on that
in the groin. In the last case I was favoured by the assistance
of those excellent surgeons, Messrs. Guthrie and Brownrig-g,
and the hemorrhage was not at all greater than when the
tourniquet is applied higher up. In Mr. Guthrie's hip-joint
case, at Brussels, Staff-surgeon Collier and myself compressed
the vessels, and the hemorrhage was very little more than in
the common amputation with a tourniquet; indeed, the state
of the vessels presented nothing difTicult to the operator,
whose coolness and dexterity were unrivalled. The deaths,
as far as my enquiries have gone, have been generally depen-

* See a case by Deputy-Inspector Morell, Medicc-Chirurgical Transactions,
vol. vii. p. 161,

266 AMPUTATION.

dent upon other causes than hemorrhage. The great violence of
the injary itself which requires the operation, and the severe
shock, are quite sufficient to account for the fatal event. In
much less serious operations than that of hip-joint amputation,
I have seen death occur on the moment, in men of the most
determined courage, and without the smallest excess of hemor-
rhage. Upon the whole, I believe that we may as safely divest
ourselves of all fears of hemorrhage in operations properly
conducted on the lower extremities, as we do in those on
the upper.

An ingenious naval surgeon, Mr. Veitcb, has published a
paper upon this operation, in which he proposes to make the
6rst step of it in no respect difl'erent from the high circular
one, except by leaving an inch or two of the bone projecting,
which may be done without the slightest pain or trouble, by
dissecting off the soft parts towards the knee, and sawing the
bone low down. This projecting piece of bone, he proposes
to use as a sort of lever, to assist in the complete dislocation
of the head from tlie acetabulum, which he next proceeds to
do, and which is certainly much accelerated by the removal
of the unwieldy mass of limb, which was all but separated be-
fore the application of the saw.* Were I called upon to
perform the operation, I should certainly proceed upon the
principle of Mr. Veitch in my first incision, and then cut di-
rectly upon the joint, securing the blood-vessels as I proceed-
ed : although 1 should promise myself little, if any assistance,
from the part of the bone remaining in the socket, as, in the
injnries requiring the operation, the bone is generally so shat-
tered, as to possess little or no cohesion of parts, and conse-
quently cannot be employed as a lever. I have seen the head
and neck of the femur comminuted into portions, not much
larger than a mu.sket-ball, the only adhering part being the
fragment into which the round ligament was inserted, and

* Edinburgh Mtd. and Surg. Journal, vol. iii, p. 129.

AMPUTATION. 267

consequently, bad an operation been attempted, tbe surgeon
could not bave availed biuiself of any guidance or assistance
wbicb might be afforded by the bone in a sound state.

The cases which call for amputation of the hip-joint are
either primary or secondary. The first principally arise from
grape or cannon shot, or from the explosion of shells, by
which the bones in the immediate vicinity of the joint are
severely fractured, or the soft parts and blood-vessels ex-
tremely lacerated. The second may also proceed from the
sequelae of the above named injuries, or from long and tedious
suppuration and exfoliations, occasioned by injury from musket
shot, or from the lodgement of balls, &c. in or near the joint.
Many other cases may occur where this operation may be
deemed necessary, but no prudent surgeon will ever attempt it,
except where he can avail himself of the opinions and assist-
ance of others.

In commencing an amputation below a joint, and particu-
larly in a large lower limb, I would recommend placing the
right hand under the limb, and carrying it to some extent
round, in the position meant to commence the incision, and
then dropping the knife into the hand, instead of running the
hand ready armed with the knife beneath the part. By neg-
lecting this very simple preliminary measure, I have seen some
most awkward scratches iutlicled on the patient and assistants.

By cutting the first third, or nearly so, of the circle, prin-
cipally with the heel of the knife, we shall always be enabled
to complete the external incision with one sweep of the instru-
ment, a matter of some relief to the patient in point of pain,
and of increased facility to the operator, in forming a smooth
even edged line. In amputating, I have, in a great measure,
followed Alauson's plan, and have given an oblique direction
to all the incisions through the muscles, (the first having fairly
divided the integuments and fascia,) as much upwards and
inwards as possible. This saves a vast deal of dissection of
teguments from the muscles, and is a powerful guard against

268 AMPUTATION.

leavinfj an overhanging and useless pouch of skin. If the
incisions are made perpendicularly down towards the bone, a
long dissection of skin is necessary ; this is recommended and
depicted in some of the modern systems of surgery, to an
extent which I conceive entirely unnecessary under any cir-
cumstances, and which I know to be highly improper in most.
In a small limb, I have repeatedly performed the operation
with one sweep of the knife, cutting obliquely inwards and
upwards, at once to the bone. The only objection that strikes
me to operating in this mode is, that the arteries are sliced
obliquely like a writing pen instead of being cut fairly across,
and that if this is not kept in remembrance, secondary hemor-
rhage may take place after the vigour of circulation is restored,
in consequence of the whole circumference of the vessel not
being included in the ligature. By drawing the vessel fairly
out, and placing the ligature beyond the commencement of
the oblique cut, this accident will be effectually prevented. In
many subjects, however well the tourniquet may have been
originally placed, we find a general oozing from the face of the
incision, and sometimes the arteries themselves still discharging
small jets of blood. When the discharge, from whatever
cause, is large, and particularly in very weakly subjects, where
a single jet of arterial blood is of vital consequence, I never
hesitate in tying the vessels before proceeding any farther,
giving the ends of the ligatures to an assistant until the bone
is sawed through. This may, to some, appear a very informal
proceeding ; and 1 have heard it criticised as not being accord-
ing to the rules of the schools ; but a considt>ration of the
safety of our patient should l)e our only direction, and in no
particular should we sacrifice what tlie dictates of common
sense and experience point out as necessary to ensure it, to the
rigid formality of rules, or to tlie pitiful pedantry of never
deviating from them.* On llic same principle, if we find the

• Where the great veins bleed, I have never hesitated about tying them also, iu
debilllateU subjccls, 1 Law niV't >Yilh vnly o«ic case of venous hemorrhage to bo

AMPUTATION. 2()9

bone much splintered, or diseased, or protruding after the limb
is removed, or even if, by the retraction of the muscles, or a
false calculation of the necessary quantity to be left, a protru-
sion is probable, we should never hesitate to take up the saw
again and remove the necessary portion ; by doing it on the spot,
much after pain and misei'y is avoided.

In the Fore-arm almost every possible error of projecting
bone or insufficient covering is effectually obviated by the flap
operation. This is best performed with tlie fore arm extended,
the thumb and little finger in a perpendicular line, and forming
the guiding points to the formation of two neat semilunar
flaps, which are to be cut oat either by the catlin from within
outwards, or the middle-sized incision knife in the opposite
direction.

Cases will occur where the Hand or Foot are only partially
injured. By taking advantage of the joints and of the sound
teguments, we very often succeed in saving the limb by the loss
of some part, and making a tolerable stump, by throwing the
cicatrix out of the line of pressure; but no general rule can
be laid dosvn for these cases, almost every one of which will
require some peculiar management. Where a finger or toe only
are injured, they should always be removed at the joint.

In putting up stumps, I have constantly practised the per-
pendicular cicatrix, supporting the parts after the application
of the usual adhesive straps with intervals of an inch left be-
tween them, by a band of plaster about three fingers' breadth,
put moderately tight round the whole, so as gently but steadily
to compress all the parts, particularly those that are concerned
in the process of adhesion around the end of the stump, and,
together with the roller, to moderate or prevent muscular re-

fairly traced to contraction of the integuments, as observed by Mr. Hey in his
Chapter on Amputation ; nor did it require an incision of the integuments, as
practised by him, but was relieved by loosening the bandages, and moistening the
dressings with cold water.

270 AMPUTATION.

traction.* But if circumstances of diseased skin or muscle,
wasting or distortion of the limb, accidental irregularities in the
sawing of the bone, or intentional removal of a |ydrt of it, (as
the spine of the tibia,) do not admit of the perpendicular line, 1
always place the lips of the wound in that position which most
favours the perfect cushioning of the bone, without rigidly ad-
hering to any particular line of cicatrix.

To perform amputation a second time may appear a bar-
barous, and certainly is a very severe operation ; it sometimes,
however, becomes necessary, from osteo-sarcoma, extensive ne-
crosis, abscesses of the medulla, unsuspected fissures, phage*
dena, or great protrusion of bone, with an extensively diseased
periosteum, where the powers of nature are inadequate to the
cure. It must be confessed, that although the former causes
are frequently productive of this most unpleasant result, yet an
awkward operation in the first instance, and subsequent im-
proper dressing, have but too often a full share in occasioning
the mischief.

If the general health is not impaired, and the flesh does not
peel off from the bone as if it were boiled, the efforts of nature
may be trusted to, aided by proper bandaging, and, in some
cases by the employment of the saw ; but when restless nights,
intense pain, flushings, and irregular bowels, with great tume-
faction and hardness of the stump take place, indicating ap-
proaching hectic, and there is evidence of an irregular action
of the parts, osseous matter becoming deposited and forming a
distinct tumour around the stump, our best plan will be to
operate again nearer the trunk. In cases of long standing, no
partial removal of bone will supersede this necessity, for the
soft parts in the vicinity of the bone take on a diseased action
from which they never recover. A generous diet, and removal

• Jitha?ii)g the parts is often neglected, and gives rise to great irritation iu re-
moving the ntraps. It is wortli whilo to recollect, that the hair grows much faster
on ail InHamed, than on a sound jiiccc of skin.

AMPUTATION. 271

to a pare air, if possible distant from an hospital, will be indis-
pensable to recovery after operation.

On the subject of this class of diseased bones, which is so
highly important to the hospital surgeon, Bonn, " Thesaurus
Ossium Morbosorum," Amstelodami, 1788, and Weidmann,
'• De Necrosi Ossium," Fraucofurti, 1798, are excellent; and
the Tliesis of Macdonald, " De Necrosi ac Callo," Edinburgh,
1799, is highly interesting. Louis has given some excellent
papers in the 2d and 4th volumes of the Memoirs of the French
Academy, on bone projecting after amputation. Leveille has
published a memoir, " Sur les INIaladies des os apres Ampu-
tation," in the Mem. de la Soc. d'Emulation, torn. i. p. 148. A
comprehensive inaugural dissertation, with some good plates,
was published at Leyden in 1803, by Van Hoorn, on the same
subject; and Roux published a prize essay, " De la Resection
d'os Malades," at Paris, in 1812. The " Memoires de Phy-
siologie," published at Paris in 1804, under the joint names of
Scarpa and Leveille, are also well worthy consulting.

The causes of death after amputation are various. Fever,
whether symptomatic or endemic, and mortification seizing the
stump, often cut off our patients. Sometimes the febrile af-
fection is of a chronic nature, and soon degenerates into hectic,
with cough, and every symptom of phthisis ; and often the
patient sinks, arrested, as it were, at once by the hand of death,
without running through any of the intermediate stages between
the attack of disease and dissolution.

Dissection throws some light upon this interesting subject,
and the results may be classed under the following heads.

1. Inflammation of the vessels. In some cases the veins, in
others the arteries, and in others again both the veins and ar-
teries, will be found inflamed, from the point of the stump to
the very auricle or ventricle, and in many parts, either lined
with coagulable lymph, or filled with purulent matter to various
distances. In the dissections conducted by Messrs. Dobson,
Bingham, and Crofton, after the battle of Waterloo, we met

272 AMPUTATION.

■Nvith no less than twelve cases where the veins were iuflaraed,
and where, at the same time, purulent matter was found in the
arteries, with a considerable thickening of their coats. In one
case we found the brachial artery alone affected. For three
inches from its cut extremity it was very much thickened and
filled with pus. In another case, dissected by Hospital-Assistant
Dobson, the amputation had been performed low on the femur;
— dealh ensued on the 17th day. The artery was not diseased,
but the vein was inflamed from the point of the stump to the
very auricle, and of a very bright pink ; when both iliac veins
were taken from the body, the contrast was most remarkable ;
that on the sound side preserved its natural appearance, which,
however, at the junction of the veins terminated abruptly, as it
were by a regular line. In those cases, although after the first
discovery of inflamed vessels, they were closely watched, the
symptoms were not of such a highly inflammatory nature as to
demand bleeding to any great extent ; and in some, symptoms
of a typhoid character appeared. External cold applications,
leeches to the parts, and the administration of the mass of blue
pill, succeeded by saline purges, were the measures we adopted.
I am not aware of any distinctive marks between the arterial
and the venous inflammation in these obscure cases.*

2. Metastasis to some of the yreat cavities, or organs. —
Large quantities of purulent matter are sometimes found in fatal

• Much information on this point will be derived from the papers of Mr. Hunter
in the 1st volume of the Medical and Chirurgicul Transactions; of Mr. Car-
michael, in the yd volume of the Transactions of the College of Physicians in
Ireland; and from an Essay by Mr. Travcrs, in the first part of the Surgical
Essays by him and INIr. ("nopor. From some observations in this last paj)or, it
might be supposed, that in the army wo ulivui/s tied the veins, and that ligatures
were necessarily fatal ; neither of these suppositions are correct; we put a fine
ligature on a vein, when dangerous hemorrhage proceeds from it ; and this I have
done repeatedly, without any unfavourable results, M'hero the vessel has been
tound. I have also tied tht; veins in sloughini:; gangrenous sores, without any in-
convenience; indeed, were they so constantly aftected by intlammalion, venesec-
tion itself would be a very dangerous operation.

AMPUTATION. 273

cases of* amputation, in tlie thorax, either in the substance of
the lungs themselves, or floating loose in the cavity; or serous
effosious, and great congestion of blood in the body of the
lungs, with conversion of them into a substance resembling
liver, designated by the appropriate appellation of hepatization,
by the French surgeons. In the abdomen abscesses are often
discovered, particularly in the liver, and at a very short period
from the removal of the limbs. In the adjacent joints also,
matter is frequently found. I have met with it in three cases
in the hip-joint, where the operation had been performed in the
thigh, and two in the shoulder-joint, where the arm was carried
off by cannon-shot ; and even in parts still more distant from
the original injury, diseased actions, apparently sympathizing
with the state of the stump, have also been discovered. Mr.
Guthrie has met with the thyroid gland almost totally suppu-
rated. I know of no particular set of symptoms that peculiarly
characterize these instances of metastasis. Great irritative
fever has been present in some cases ; hectic and topical affec-
tions of the chest, as dyspnoea, cough, and sense of suflbcation,
have been found in those where metastasis to the thorax has
taken place ; and the usual symptoms of deranged biliary func-
tions have appeared before death, where the liver has been its
seat. Of the cure of cases of this nature I can say nothing
satisfactory.

3. Diseases of the bones, or of the joint close to the amputated
part. — These admit of the easiest recognition in the living sub-
ject, and are various in extent and degree, and when not pro-
ceeding to the last stage, or not having superinduced great
general debility, they may be in some measure alleviated.
They are always attended with inflammation, and separation of
the periosteum, although in some cases the cicatrix remains
sound over the end of the stump ; and it is only after a separa-
tion of the soft parts, in consequence of an abscess or ulcera-
tion, that the bone is found denuded for various lengths, some-
times close up to a joint, and lying an extraneous body in the

274: AMPUTATION.

centre of the muscular mass, excitiog and keeping up a degree
of irritative fever, which but too ofteu proves fatal. Nature
makes great exertions to remove the diseased bone; and,
aided by gentle means, often succeeds if the constitution is
sound. The absorption is always made in irregular lines, the
division of the bone is never completely circular, but has the
appearance of being splintered ; sometimes this denticulation
takes place all round the shaft, at others only partially; but in
all, absorption seems to have been as powerfully exerted within
the canal of the bone, as on its external surface, giving both
surfaces a worm-eaten or perforated appearance. I have re-
moved pieces of bone of six or eight inches long thus eroded,
and smaller pieces of a ring-like form are very common. The
contrast between them and the bone of a sound stump is curious;
in the latter the bone is plump, exquisitely rounded, and the
hole leading to the medullary canal small, and covered with a
fine pellicle ; the cancelli beneath entire. In the other, the bone
is wasted and discoloured; the sawed end flat as when the in-
instrument was first applied ; the orifice wide, and without any
membranous covering, and the cancelli destroyed. The same
contrasted appearances take place where there are two bones
in the limb. These in the sound state of the stump are united
by callus, and rounded oil' by the action of the absorbents. In
some instances, the original diseased bone is sheathed in a new
formed osseous sponge, extending considerably beyond it in
all directions, and producing a foul, painful and irritable sore.
This luxuriant bony growth is almost peculiar to man; in the
accidental injuries of brutes it is scarcely to be seen; and it is
therefore reasonable to attribute much of its production to the
irijutlicious a|iplicati(jn of bandages and pressure. After these
exfoliations are removed from the ends of the bones, the absorb-
ents again commence their modelling action, and the extremity
is smoothed and rounded, and the medullary canal is closed, as
has been already mentioned, but the end of the bone does not
acfjtiire any enlargement of size. In sound habits, this process

AMPUTATION. 275

of exfoliation is not renewed, bat in diseased persons, and in
crowded hospitals, it is occasionally repeated. Death, how-
ever, but too often puts a period to the efforts of nature, the
patient sinking under the severity of his pain, and the violent
hectic and night sweats.

I shall conclude this interesting subject by some striking
cases, selected from a large number of a similar kind.

Case XXXIV.

Death after Amputation Jro7n Disease of the Lungs.

Chatelot, a French soldier, was admitted into hospital on
the 20th April 1815, with an inflamed and gleetiug stump
below the knee; the general health was greatly affected. He
complained of a short tickling cough, attended with the ex-
pectoration of gross matter; his breathing was hurried; and,
on taking a full inspiration, pain was excited in the breast ;
the pulse quick, with increased heat of surface ; the tongue
white, but moist ; the appetite good ; the bowels loose. About
eight days before his death, the symptoms became much ag-
gravated, particularly the difficulty of breathing and cough,
which was hard and distressing ; the pulse was increased in ra-
pidity and hardness, with great heat of surface. To relieve
these symptoms, he was bled, and a large blister was applied
to his breast ; these, however, procured very slight if any
relief; he got gradually worse, and he fell a victim on the
morning of the 13th September. On opening the cavity of
the thorax, a considerable quantity of fetid gas issued from
both sacs of the pleura with great force. The lungs were
found very much collapsed, and almost floating in serum. In
the right cavity the effused fluid amounted to nearly a pint. It
was turbid, and there floated on it a great number of yellow
flakes, resembling those which are discharged from scrofulous
abscesses. There were no preternatural adhesions between

276 AMPUTATION.

the luDg on this side and the pleura: its colour was very dark,
and its whole substance was crowded with small tubercles
about the size of garden peas. These bodies were of a grey
colour and firm consistence, nearly resembling indurated
lymphatic glands. The lower part of the left lung both to the
touch and to the eye, appeared quite healthy ; towards its root
a number of tubercles were felt, on cutting into which yellow
pus was found. Between this lung and the pleura there ex-
isted a few slight adhesions. The quantity of fluid in this side
of the thorax was about three-fourths of a pint. It was more
transparent than that in the other, and n<> flakes of matter
floated in it. Three or four ounces of efl'used serum were
found in the pericardium ; it was quite transparent, and con-
tained a considerable quantity of gelatinous matter, yellowish in
colour, transparent, and of the consistence of the coagulum of
healthy blood. The internal surface of the pericardium was
rather more vascular than usual ; there existed no preternatural
adhesions between it and the heart. The heart itself was natural
in size and appearance, excepting that its veins were rather
turgid. No other peculiar symptoms were observed.

Case XXXV.

Death after Amputation from Disease of the Liver.

"Captain C , 12th Ptirtuguese infantry, had his left

thigh amputated to rescue him from the consequences of hectic
fever and profuse suppuration, from a c()m[)ound fracture of
both bones of the leg by gunshot, received at the battle of
Toulouse. Tiie hectic was arrested, and every thing went on
well for nine days after the operation, when he was seized with
violent diflic ulty of breathing, and fre(|uent irregular attacks of
rig(mr, without being able to refer to any particular part as the
Heat of pain. On the4th day from this attack, he unexpectedly
expired. Some illiberal rtflections having been thrown out

AMPUTATION. 277

against the operator in this case, I examined the stump minutely
after death, and found every thing connected with the operation
perfectly right. There was a remarkable fulness observable in
the right hypochondriura, which was accounted for on opening
the abdomen, by the appearance of an immense abscess, occupy-
ing all the superior part of the great lobe of the liver, which
bad discharged a portion of its contained pus through the

diaphragm into the thorax. Captain C never complained

of pain in this region, and for nine days subsequent to the
operation seemed only to labour under rapidly increasing de-
bility. He was a healthy man, and of regularly temperate
habits."*

Case XXXVI.

Death after Amputation from Disease of the Lungs, and a
Collection of Matter in the Hip-joint.

Michael M , 3d regiment of guards, had the right

lower extremity amputated below the knee, on the 11th of July,
1815, in the Jesuits' Hospital, at Brussels. On the 18th the
stump became very painful, and his bowels were costive. On
the 27th, inflammatory fever set in, which assumed a remittent
form, but by the 29th became continued and much aggravated
in violence. Bark, which had previously been employed, was
now left off, and the heat of skin being great, he was sponged
with vinegar and cold water, which soon lowered its tempera-
ture. During these appearances of general disease, the stump
assumed an unhealthy appearance; and on one day slight
hemorrhage took place — a bed sore also formed on his back.
By the 1st of August, the febrile symptoms became very severe.
Delirium took place, attended with great prostration of
strength, and he died on the 3d. The body was inspected on

* Cumuiuuicated by StaflF-Surgcon Huglies.

278 AMPUTATION.

the afternoon of his death, and the following appearances were
reported to me by Hospital- Assistant Nichol. In the thorax,
extensive adhesions were observed between the pleura costalis
and pulmonalis. The right lung- seemed perfectly sound ; but
on the posterior part of the left lobe, several tubercles were
observable in a state of suppuration, and a greater than usual
quantity of fluid was found within the pericardium. The
abdominal viscera all appeared sound. On making an incision
over the hip-joint of the right side, a considerable collection of
matter was discovered around the trochanter major, chiefly
external to the capsular ligament. The trochanter at one point
was denuded of its periosteum. The synovia of the joint was
changed in appearance, having a dark yellowish tinge. These
diseased appearances had no communication whatever with
the stump.

Nature sometimes effects a cure by the discharge of this
matter, collected in or near the joints, but it frequently re-
mains unnoticed until death, although, in some cases, an ob-
scure difl'used kind of swelling gives room to suspect its for-
mation, and suggests the propriety of topical blistering and
venesection.

The following case, furnished me by Assistant Staff-Surgeon
Blackadder, is very illustrative of some of the circumstances
attending field amputation, and the combination of causes,
tending to produce the fatal event.

Case XXXVII.

Death after Amputation from InJIamed Veins, where no Liga-
tures were applied.

" B. J. aged twenty, was wounded on the 18th June 1815,
and admitted into the (jlens d'armerie hospital on the 30th.
A cannon-ball had carried away the loft leg, and the stump
bad been amputated on the field. He slated, that, at the

AMPUTATION. 279

moment of the operation, the French were obliged to retreat,
and that the surgeon, on that account, not taking time to secure
the blood-vessels by ligatures, merely applied a large cushion
of charpie, along with a bandage, and then left him to his fate.
He also stated, that for several days he had nothing to eat or
drink, and that the stump had not been dressed till ten days
after the operation had been performed. When admitted into
the hospital, the granulations had a clear but somewhat
bleached or boiled appearance. The bone protruded about an
inch, and had become black at its extremity, and he com-
plained of increased sensibility and pain in the stump, par-
ticularly on moving or touching it in the operation of dressing.
His pulse was quick, small, and sharp ; his skin hot and dry ;
his appetite bad ; his belly costive ; and his tongue covered
with a white mucus, somewhat yellow towards the base.

" Laxatives, followed by diaphoretics, were administered,
and the latter persevered in for several days without any mi-
tigation of the febrile symptoms; the stump became daily more
painful, but without swelling or inflammation ; the granulations
retaining their peculiar white glistening and indolent appear-
ance. At length, the skin became moist, and his pulse softer
and less frequent, but the irritability of the system was
evidently increased, accompanied by a disposition to spasmodic
action in the muscles, particularly those of the face. On the
22d July, he became suddenly very uneasy and restless, and
died on the morning of the 23d. Upon examination after
death, the femoral vein was found ulcerated at its cut ex-
tremity ; all the large veins of the stump were found to have
been inflamed ; they were remarkably vascular, and their coats
very much thickened. Unfortunately, from the great pressure
of duty, the state of the vena cava was not examined. There
could be little doubt, however, that the inflammation had ex-
tended to the heart.

" There was a small collection of matter on the outer surface
of the femur, and also in the substance of the bone near its

280 AMPUTATION.

cut extremity, where there was a considerable deposition of
bone in the form of sharp spicula, pointing toward the trunk
of the body, but no marks of commencing- separation of the
dead from the sound parts.

After a successful amputation the parts gradually close over
the end of the stump ; after some time, the end of the bone is
found to be somewhat enlarged, and is finely rounded off by the
action of the absorbents. The cavity of the medullary canal
is somewhat contracted, and is covered over with a delicate
membranous expansion, from which the medulla is a little
withdrawn ; in process of time the orifice is more firmly closed
with a cartilaginous matter, — and in some cases it is entirely
obliterated by perfectly formed bone. Where two bones are
divided, they are generally cemented together by osseous
matter thrown out from each, and the two being thus formed
into one, become rounded off as if they had been originally but
one bone ; but they never present the same smooth appear-
ance as the stump of a limb, where only one bone has been
sawn through. In some cases the junction is formed by carti-
laginous matter, and the bones are separately rounded off, and
become as smooth as where one bone only is divided.

281

CHAPTER XVI.

INJURIES OF PARTICULAR PARTS.

WOUNDS OF THE HEAD.

If the complications in the symptoms of injuries of the head,
as they occur in civil life, are of a nature so serious as to have
employed the attention and the pens of some of the greatest
ornaments of our profession ; it may well be imagined how in-
finitely aggravated they become, when they happen on the field
of battle, when the projectile force of the inflicting body is so
vastly greater than on ordinary occasions, and the aid of sur-
gery so much later in its application. Fortunately, however,
injuries of this description form by far the smallest number of
the cases which a great battle produces. It may be stated ge-
nerally, that one half of the injuries of the head are left dead
on the field, or die before assistance can be afforded ; but all
correct calculations on this subject are totally impossible. In
sieges, where the troops are exposed in the trenches to the fire
of the enemy placed several feet above them, the number of
wounds of the head will naturally be increased; and in cavalry
attacks, where the weapon hitherto most generally used, the
sabre, is so particularly directed against the head, they will also
more frequently appear, though certainly under a less aggra-
vated form than in infantry encounters.

The young surgeon, who, for the first time, witnesses a series ,'
of injuries of this description, will at every step have some- /

282 WOUNDS OF THE HEAD.

thing to unlearn; he will find symptoms so complicated, con-
1 tradictory, and insufficient to give any rational clue to their
' causes; diagnostics, of the truth of which he had read himself
into a conviction, so totally unsupported by the results of prac-
tice ; and tbe sympathies he was led to look for as infallible
accompaniments of certain states of disease, so often wanting
altogether, that he will prubably be inclined to relinquish the
hope of ever arriving at a correct theory, or, at least, he will
enter the clinical ward with the pride of science considerably
subdued.

I offer the few following observations, merely as illustrative
of some leading points of the general doctrine in a class of in-
juries, exceeded by none in the extensive range of the profession
for interest and importance, and on which volumes might be
composed without exhausting the subject, or fully elucidating
it. I do not question the propriety of the ordinary division of
injuries of the head into those of the containing parts and those
of the parts contained ; into the effects of concussion and the
effects of compression; — but excessive refinements in distin-
guishing these injuries and their varieties, I conceive to be
very unnecessary to the practical surgeon; they often, nay,
most frequently, are coexistent; and if, in the treatment, the
surgeon makes the prevention or subduing of inflammation his
great end and aim, he does nearly all in the first stages that is
within the reach of his art.

To effect this desirable object, nothing should be omitted in
serious injuries of the parts, (and who has not seen apparently
the nwjst simple terminate seriously .') to remove every source
of irritation. We now-a-days, it is true, do not cut away the
injured scalp, or procure artificial exfoliation of the uncovered
bone; but I certainly think we but too often omit making our-
selves perfectly accjuainted with their state, by being content
with a superficial incision, and clip[)ing the hair surrounding an
injury, instead of a free opening, and shaving to a sufficient
extent, as practised by our forcfalhers. Independent of the

WOUNDS OF THE HEAD. 283

more accurate view we procure by these means, we facilitate
the application of leeches, if they may be found necessary, and
of a most excellent adjuvant on all occasions, viz. cold applica-
tions, which are ever soothing to the patient, and often mate-
rially assistant to bis recovery. The formula recommended by
Schmucker is nitre sixteen ounces, muriate of ammonia eight
ounces, dissolved in forty pounds of cold water, with the
addition of eight pounds of vinegar. To avail ourselves of the
full frigorific effects of this mixture, it should be prepared in
small quantities, and used immediately before its temperature,
(which is greatly depressed by the act of solution,) has risen
to that of the surrounding atmosphere. Snow, or pounded
ice, or ice water, applied to the parts in a half filled bladder,
or cloths simply dipped in cold water, will often answer every
purpose.

I think also that I have observed a much less frequent use
of the very powerful auxiliary of nauseating doses of antimonials
than their utility warrants ; and, although I would not go so far
as Desault and other French surgeons have done in the recom-
mendation of them, I certainly am of opinion that, in the British
military hospitals, they have not generally met the attention
they are entitled to. By the employment of these external and
internal means ; by the use of mild saline purgatives, preceded
by the common blue pill ; by quiet, and by abstinence, we will
often prevent altogether those troublesome puffy enlargements
and erysipelatous affections of the scalp, which so often succeed
to bruises. And 1 may here observe, that those extensive and
formidable erysipelcrtous affections, so common formerly, are
rare and mild at present in military hospitals, where the eva-
cuant plan is duly observed, and cleanliness and ventilation
properly attended to; while in the civil establishments, the
affections of the skin in acute diseases are also most remarkably
diminished.*

* See Willan on Cutaneous Diseases, Ord. 3, Genus Purpura, p. 468.

284 WOUNDS OF THE HEAD.

The injuries of the head, which more commonly come under
the notice of the military surgeon, may be conveniently divided
into, Isf, Simple bayonet and pike thrusts, and sabre cuts ; 2d,
The same, complicated with fractures; Sd, Simple gunshot
wounds and contusions, without fracture ; 4th, The same, com-
plicated with fracture, and with the lodgment of extraneous
bodies. In all these cases, the general principles of surgery are
equally applicable as in the accidents of civil life, and, except
the fourth, present little unusual ; on this, therefore, I shall
principally enlarge, first making a few remarks on the preceding-
classes.

In bayonet thrusts of the integuments, which frequently are
extensive, judicious incisions, so as to leave a free space for
the tumefaction of the scalp that almost always succeeds,
should be employed along with the general means just men-
tioned. Perforations of the bone from bayonet thrusts are rare,
and generally fatal, but whenever the patient survives, their
mechanical treatment will consist merely in extracting spicula
of bone, and elevating any depression that may occur. Where
bayonet or pike thrusts take place in the orbits, temples, or
through the roof of the mouth, or the occipital foramen,* into
the base of the brain, they are most generally fatal ; indeed,
those through the orbit and base of the cranium are almost
invariably so. While arrows formed one of the principal
weapons of warfare, these accidents were much more common
than at present, but now the thrust of the bayonet, or pike, is
generally made at the breast or belly, in a straight forward
direction, and those which take place in the head are obliquely
upwards, as in the wounds inllicted by infantry upon cavalry,
or directly downwards, as in infantry or lancers thrusting
at a prostrate enemy. Ambrose Pare gives us the case of
Francis of Lorraine, Duke of Guise, who was wounded be-
fore Boulogne by a lance, which struck him above the right

* Ravatoii gives a cnsr of tliis latter kinil, j). 421.

WOUNDS OF THE HEAD. 285

eye inclining- towards the nose, and which entered and passed
through on the other side between the neck and the ear, with
such violence, that the head of the lance and a great part
of the wood were broken, and remained in, and could not be
removed without the aid of a farrier's pincers. " Notwithstand-
ing all this violence," says Pare, " which was not done without
breaking of bones, nerves, and arteries, and other parts, my
said Lord, by the help of God, was cured."*

In cases where the instrument breaks, the trephine is often
had recourse to with advantage, of which we have two very
striking instances in writers on military surgery, one by Des-
portes, where a pointed piece of wood was thus removed with
perfect success ;f the other in the excellent little work of
Baron Percy, in which the blade of a knife was extracted in
the same manner, and with equal success.;]: But the most re-
markable wound from a sharp pointed instrument with which I
am acquainted is one quoted by Briot ; § it is as follows : At
the battle of Pultuska, in Poland, a soldier was wounded by a
bayonet, which had been fixed, but was dismounted and pro-
pelled forward by a ball. The bayonet entered the right temple,
two inches above the orbit, it inclined backwards and down-
wards, and traversed the maxillary sinus of the opposite side,
where it passed out, and projected about five inches, having
penetrated to the hilt. The patient and two of his comrades
tried in vain to extract the instrument. The surgeon-major,
M. Fardeau, repeated the same attempts on the field, but
without success. A soldier, who assisted, thought himself
stronger than the others, and seating the patient on the ground,
placed one foot against his head, and with both hands disen-

* Lib. 29. The Voyage of Boulogne, 1515.

+ Traite des Plaies d'Armes a feu, Paris, 1749, p. 374. Obs. 25.

% Manuel du Chirurgien d'Arme, p. 101.

§ Histoire de I'Etat et des Progres de la Chirurgie Militaire en France, pendant
les Guerres de la Revolution, Svo. a Besan^on, 1S17. The case is quoted from
Ihe Journ. Gen. deMed. tom. xxxv. p. 387.

286 WOUNDS OP THE HEAD.

gaged and extracted the bayonet. A considerable hemorrhage
followed, and the patient fainted. M. Fardeau, who believed
him dead, or dying, left him to attend to others of the
wounded ; he revived, however, the wound was dressed, and
he travelled partly on foot, and partly on horseback and in
waggons, to Warsaw, twenty leagues from the field of battle.
Three months after M. Fardeau saw him perfectly cured, but
with the loss of the right eye, the pupil of which was im-
moveable, and much dilated.

Sabre cuts admit frequently of being at once replaced, and
in many instances with the aid of a few stitches, and proper
supporting bandage, they adhere without further trouble. In
some, inflicted by our own and the French dragoons in Spain
and Belgium, sections of the scalp, cranium, and even of the
brain, were frequently made, and in many instances were suc-
cessfully treated by simply laying the parts together.

Where a large portion of bone is removed from the cranium
by a wound or operation, nature supplies its place by a tough
ligamentous membrane, and if the teguments have been pre-
served, and judiciously applied over the wound, the vital or-
gan beneath is sufliciently protected. Osseous matter is also
thrown out from the edges of the wounded bone, and if these
edges come in contact, a perfect union is ellected ; thus we
often meet with a slice of bone overlapping the vault of the
cranium, and firmly adhering to it; in these cases the separated
portion had not been properly replaced in its original situation,
or it may have been dragged irom it by the action of the mus-
cular fibres attached to it.

It is worthy of remark, that the sabre wounds on the top of
the head are not by any means so dangerous as those on the
sides ; this I have often had occasion to observe in my own
practice, as well as from the reports of others. In some sabre
wounds which divide the skull across the sagittal suture, the
longitudinal sinus has been occasionally o[)encd and bled

WOUNDS OP THE HEAD. 287

profusely,* but without inducing fatal consequences. I have
seen this sinus opened by splinters, but never saw any thing
approaching- to dangerous hemorrhage from it, in truth, the
bleeding from wounds of the head is one principal source of the
patient's safety. No ligature is required to the arteries of the
integuments of the head, pressure against the bone being
quite sufficient to command the hemorrhage from them ; and
indeed, ligatures and sutures of all kinds should be used as
sparingly as possible to the scalp, as they are frequently found
to induce erysipelatous inflammation and sloughing of the
parts.

In simple gunshot wounds not penetrating the cranium, the
sloughs are sometimes very tedious in throwing ofl", and will
require a warm emollient poultice or two, instead of the cold
applications. I have known numerous instances where no
serious injury has followed them, although they grazed the
bone ; but it must be admitted that they often give rise to
subsequent inflammation, suppuration, and all the dangers of
compression ; to obviate this, the French surgeons are much in
the habit of making an incision down to the bone in all cases of
gunshot wound of the integuments of the head, in order to
ascertain the state of the pericranium ; if this membrane is
either detached or discoloured, they immediately trepan. That
many soldiers have survived the trepan thus applied, 1 have no
doubt ; but I am equally certain that it is quite unnecessary in
the first instance, however urgently it may be called for, if
symptoms of compression from purulent depositions should
subsequently occur; but proper treatment may frequently
obviate these depositions ; and it can never be too often re-
peated to the young surgeon, that by the lancet, purgatives,
cold applications to the part, and rigid abstinence, he may

* Ravaton, p. 545. Lamotte gives a case where, by the stroke of a dragoon's
sabre, the skull was deeply cleft, the right parietal bone to the depth of two
inches, and the left to between three and four nearly down to the ear. This
seTere wound was cured in less than three months.

288 WOUNDS OF THE HEAD.

prevent infinitely more fatal events, than he ever can by the
most dexterous application of the trephine or the saw.

Fractures from gunshot are almost universally of the com-
pound kind, and are rarely unaccompanied with great depres-
sion ofthe skull. The difficulties of elevating or extracting
the depressed portions of bone beat in upon the brain by gun-
shot, or the extraneous matter carried into its substance, are
often very embarrassing ; the ball, from the projectile force
communicated to it, not only fracturing the bone, but hurrying
in with it the detached piece or pieces, and jamming them
under or amongst the sound parts : frequently, also, it lodges
among the fractured portions ; frequently it imbeds itself be-
tween the more solid osseous plates, and forms a kind of nidus
in the dipliJe ; and sometimes it drives forward into the brain
itself, eluding the search of the surgeon, and subverting the
theories of the physiologist. In the majority of cases, a
leaden ball is either flattened against the bone, or, if it has
struck obli([uely, it is cut against the unshattered edge of the
cranium ; and is either simply jagged; or is divided into two or
more distinct parts, forming with each other various angles,
influenced in their acuteness by the projectile force, the dis-
tance, obliquity, &:c. &c.

It not unfrequently happens, that a perfect division of the
ball takes place; and the two distinct masses lodge, or one
lodges and the other flies olf, or else it takes its course through
a diflerent set of parts, or imbeds itself in a dillerent spot
from that where it originally strui k. In all these cases, the
removal of extraneous matters, the extraction of the fractured
portions, if they lie loose, and the elevation of the depressions,
where it can be done without the infliction of additional
violence, are, of course, the lirst steps to be taken; but
instances (particularly on the field) will occur, where this can-
not be done. The grand and leading point to be kept in view,
in all cases, is the great tendency f>f the brain and its mem-
Ijranes to inflammation ; the uncertain period at which it may

WOUNDS OF TEiE HEAD. 269

occur ; and the very doubtful consequences which may succeed
its occurrence. So irregular, however, and as it were so ca-
pricious is nature, that, while the slightest causes produce
inflammation in its most violent and ag-gravated forms, exten-
sive injuries, fracture, depression, and even permanent com-
pression from lodgment of balls, have been followed by no such
consequences. In the following case, the injury to the brain,
and the extinction of existence, were contemporaneous.

Case XXXVIII.

Instant Death from Injury of the Brain.

In May 1804, in a squabble between two soldiers, one of
them, who was sitting on the side of his bed cleaning the bar-
rel of his musket with his ramrod, was struck at by the other.
He raised the ramrod to deter the man from prosecuting his
blow. The unfortunate fellow, however, slipt in the act of
striking, and received the point of the ramrod just above the
root of the nasal process of the frontal bone, and instantly
dropped dead. Staff-surgeon Hughes, who examined the
head in the presence of a coroner's inquest, found, that the
iron had entered obliquely, running a little towards the left
side, slanting upward, and penetrating the anterior lobe of the
left hemisphere of the cerebrum to the depth of an inch.
There was no effusion of any kind, nor any unnatural appear-
ance, except the hole made by the weapon.

With this case, it may be well to compare that very remark-
able one mentioned by M. Larrey,* in which the patient sur-

* See Memoires, vol. iii. with a Plate. Compare also a case by Cuitis, on
the Diseases of India, p. 254, where a boy ran on an iron spike, and lived for
twenty-six days without much apparent injury. See a remarkable case in the
13th vol. of the Medico-Chirurgical Transactions, by Dr. Rogers, where the
breach pin of a gun was removed from the brain ; it was three inches in length,
and weighed exactly three ounces.

290 WOUNDS OP THE HEAD.

vived to the second day, where a ramrod liad actually passed
through the os frontis ; between the hemispheres of the cere-
brum ; through the thick part of the sphenoidal bone ; and
through the condyloid foramen of the occipital bone, with-
out injuring any important organ. The preservation of this
skull in the collection of the Faculty of Paris places the fact
beyond question.

The instances of death, after the setting in of inflammation
from very trifling causes, are of almost daily occurrence, and
would induce us to anticipate its certainty after all violent in-
juries ; but it is a great mistake, now acknowledged by the
best surgeons, to suppose that every depression requires an
elevator, and every fracture the interference of art; although
it is a common one, fallen into by the juniors; and even among
the older class I have seen operations attempted on very un-
necessary occasions. The following case illustrates this point:

Casr XXXIX.

Fracture, with Depression, not Trepanned.

Corporal J. Cockeyne, Ji3d regiment, received a wound from
a musket ball at Waterloo, which struck the right parietal bone
at its junction with the occipital, close upon the union of the
lambdoidal and sagittal sutures, and fractured the bone to an
extent exactly corresponding with its own size. The ball was
split into two portions, forming nearly right angles. It was
easily removed, but from the narrowness of the passage, and
from the depth to which the fractured portion of bone had been
driven into the brain, (being exactly an inch and one-fourth
from the surface of the scalp,) no operation was performed on
the field; and, as no one bad symptom occurred in tlie hospital,
I did not allow the wound to be meddled with there, although
much and frequently solicited by some of my medical friends.
1 trusted to venesection, a most rigid abstinence, open bowels.

WOUNDS OF THE HEAD. ^1

and mild easy dressings. On the 14th July, or 2(ith day, the
wound was neariy closed, without any one untoward symptom,
and the functions were in every respect natural. In a few
weeks after, the man was discharged cured.

In a similar case, where the man survived thirteen years,
with no other inconvenience than occasional determination to
the head on hard drinking, a funnel-like depression, to the
depth of an inch and half, was formed in the vertex, I am in
possession of several other instances of a similar kind.

We have here sufficient proof that there is no absolute ne-
cessity fur trepanning merely for depressed bones from gun-
shot, although few would be so hardy as not to remove all
fragments that came easily and readily away. We would also
naturally remove all extraneous bodies within view or reach ;
but before we commence any unguided search after them, we
ought seriously to balance the injury that we may inflict. I by
no means wish to be understood to say, that we ought not to
endeavour cautiously to follow the course of a ball, when
unfortunately it has got within the cavity of the cranium.
M. Larrey asserts, that it can be done with safety and with
effect. He informs us, that he traced a ball which entered the
frontal sinus of a soldier during the insurrection at Cairo, by
means of an elastic bougie, from the ori6ce to the occipital
suture, in the direct course of the longitudinal sinus ; and by a
corresponding measurement externally, he was enabled suc-
cessfully to apply a trepan over it and extract it. The patient
recovered. M. Percy, on the other hand, gives us a fatal in-
stance where a ball was absolutely within reach of the forceps,
and yet for want of a sufficient opening, and manual dexterity
in the operator, it slipped into the brain ; and although the
opening was enlarged by the trepan, it could not be recovered-
In the works of some of the older authors, we meet with cases
where epilepsy and various other bad symptoms bave followed
the attempts at extracting arrows and other missiles sticking in
the brain ; and in more modern practice there are many

292 WOUNDS OF THE HEAD.

instances where patients Lave lain in a stale of apoplectic
starter, with a ball lodged in the brain for some time, but have
expired on its removal. One instance of this kind has been
reported to me, where a soldier died in the very moment that
the ball was extracted. A modern surgeon would be severely
and justly censured for not at least making a trial ; but we are
encouraged to look for the eventual safety of our patients, when
the course or actual site of the ball or other body is unknown,
by recorded and well-authenticated instances of life being
preserved, when they either have not been looked after, or their
existence has not been suspected.

The records of surgery furnish us with many proofs of me-
tallic and other bodies lying for long periods between the
cranium and dura mater; but experience shows, that the ex-
traneous bodies may lie even in the brain itself without pro-
ducing: death.* I have seen no less tban five cases where a
ball has lodged in the substance of the cerebrum, without im-
mediately producing a fatal event. The following curious and
instructive case was furnished me by Assistant Staff-Surgeon
Blackadder :

Case XL.
Ball extracted from the Brain.

" D. M. aged 27, a soldier in the service of Buonaparte, was
wounded on the 18th June, 1815. After lying three days on the
field without tasting food of any description, he was taken to a
village, and afterwards to one of the churches of Brussels,

• In the " Memoires de I'Acadcniie Roynle de Chinirgie," torn. i. p. 310, folio
edition, is a most interesting paper by M. Quesnay, on wounds of tlie brain, ex-
tremely well worth consulting, in which he has amassed a number of cases of this
description. The catalogue might be very easily enlarged, an<l may be seen at
great hnglh in the references of Ploncquet, in liis learned and laborious " Lile-
ralura Mtdicn Digosla,'* &c. Tubingen, 1809.

WOUNDS OF THE HEAD. 293

without any thing having been done for his wound. On the
30th, I sent him, with many others, to the Gens d'armerie
Hospital, and on the 4th July, he was placed under my imme-
diate care.

" A musket ball had entered at the anterior portion of the
squamous suture of the right temporal bone, and, passing back-
wards and downwards, fractured in its course the parietal bone,
and lodged itself iu the substance of the brain. There was a
considerable degree of tumefaction of the soft parts surround-
ing the wound, but, with the exception of a slight headach,
and partial deafness of the right ear, he seemed to enjoy per-
fect health. He slept well, his appetite was good, his belly
open, his tongue clean, his skin cool, and his pulse 72 of natural
strength.

•• On the morning of the 5lh, the wound was laid freely open,
when three large and several small pieces of bone were re-
moved ; and the ball which was found lodged in the posterior
lobe of the right hemisphere of the brain, where it rests on the
tentorium, was extracted without difficulty, and with small por-
tions of the substance of the brain adhering to it.

" After the wound had been carefully cleared of blood and
small pieces of the brain, its lips were brought together and
retained by two ligatures, along with adhesive straps, com-
press, and bandage. His whole head was kept constantly wet
with cold water, a brisk purgative was administered, and he
was placed on a very spare diet, with a small allowance of ripe
fruit.

" Under this management (a laxative being daily adminis-
tered) he continued free from pain, or any derangement of the
system, until the 16th, when he complained of lancinating pains
through the back part of his head, of uneasiness from the light
of a candle, and from noise. The wound looked remarkably
healthy, with only a small discharge of healthy pus, and all that
part which had been laid open by the knife was united. The
pulsation of the brain could be readily discovered at two dif-

2[)4 WOUNDS OF THE HEAD.

ferent points, where the large pieces of bone had been ex-
tracted. A brisk cathartic speedily removed these untoward
symptoms, which there was reason to believe, had been pro-
duced by some of his fellow patients having indulged him with
part of their allowance of food, the impropriety of which was
distinctly explained, and means used to prevent the repetition
of a similar irregularity. This, however, was no easy matter,
as his appetite was keen, and he was confined to a very spare
diet, vfz. a small allowance of bread, with water whitened with
milk, and sweetened with sugar.

" He now continued to eojoy his former good health, and

nothing particular occurred till the 24th, when, on going my

usual rounds, betwixt 10 and 12 o'clock, p. M. he called me,

and said he was not well; the expression of his eyes was new

and peculiar; and, along with the fulness of his countenance,

evidently indicated a great and general irritation of the system.

His pulse was, for tbe first time, i)G, and hard ; his skin

hot and dry; along with a degree of stupor, and disposition to

sleep. Upon making inquiry, I found that the medical officer

(a young gentleman who had recently entered the service)

under whose care he had been placed for the last four days,

had omitted to give him his usual laxative, and instead

thereof, had that day allowed him wine, an egg, and other ex^ra

articles.

" A brisk cathartic was again imn)ediately had recourse to,
and after its operation a diaphoretic mixture, which, with a rigid
adherence to his former mode of treatment, soon restored him
to his previous state of convalescence.

" On the 5th of August, when I saw him for the last time,
his wound was cicatrized. The pulsation of the brain was
still visible, but, with fhe exception of a slight degree of
giddiness on stooping, he enjoyed perfect health. This he ex-
pressed, by saying, that froni his sensations he could not know
that he had ever been woiiiided. ft is proper to add, that,
durinj? fhe lime of the above, cure, he was allowed to smoke

WOUNDS OF THE HEAD. 295

tobacco whenever he felt inclined, and which was almost con-
stantly. It was never observed to produce any bad effect, and
he argued the necessity of using it, by saying, that it mitigated
the otherwise almost irresistible urgency of his appetite, and
thereby enabled him the more easily to comply with the very
restricted regimen that was enjoined him, and which, as he was
at length convinced, was essential to his recovery."

In the following case, the heads of which I received from
Staff-Surgeon Halkett, it is difficult to say to what period life
might have been protracted.

Case XLT.
Ball lodged in the Brain.

A soldier of the 8th regiment of infantry was shot in the head
during the late Canadian campaign. A fracture was the con-
sequence, with a depression of not less than an inch and half,
but, as no untoward symptom occurred, no operation was had
recourse to. This man recovered, and went to the rear, where,
at a distance of several weeks afterwards he got an attack of
phrenitis from excessive drinking, and died. As the existence
of the ball in the brain was strongly suspected, an inquiry was
made after death, and, on dissection, it was found lodged in the
corpus callosum.

A very curious and interesting observation of this kind is
given us by Quesnay: — A Brigadier, in the service of the
French King, received a musket shot above the eye-brow ; he
was sufficiently recovered to return to his duty in the field the
ensuing year, where he died, as it was supposed, of a coup de
soleil. On opening his head, however, the ball was found to
have penetrated two fingers' breadth into the brain, where it
lodged without giving rise to any morbid symptoms. M. Anel
gives another case, quoted by M. Quesnay, in which a ball had

21)G WOUNDS OF THE HKAD.

fractured the frontal bone, and lodged in the brain. The
wounded man was cured, and the ball remained for many years
in his head, wilhout giving him any inconvenience. At last he
died suddenly, while playing a game of cards. The surgeons
who had attended him opened his head, and found the ball lying
upon the pineal gland, along with some recently eifused coagu-
lated blood.

M. Martiniere presented to the French Academy of Surgery
an Invalid, in whom a small fistulous sinous existed in the
lower part of the frontal bone, occasioned by a wound from a
musket ball which had not been extracted. During the cure
of this wound, many exfoliations were detached from the internal
table of the bone ; the route of the ball could be easily traced
with the probe along the sinus, but its exact site could not be
discovered ; and at length, after a variety of accidents, as
fever, stupor, delirium, &c. on the 27th day, the patient ap-
pearing out of danger, the Mound was allowed to heal, the ball
still remaining within, and a small sinus alone marking the seat
of the injury.

The following rase is one of more recent occurrence, and the
indi>idual may probably be alive at this moment :

Case XLII.
Ball lodged in the Bruin.

Favre, a Chasseur of the im[)erial Guard of Napoleon, who
had I'ought at Dorodina, distinguished himself most gallantly
on the field of Waterloo. No mounted British soldier was
enabled to unhorse him on that day; but he at length fell,
amid a shower of musket-balls, one of which penetrated his
left teu)ple, at the junction of the three sutures. With the
symptoms which immediately folh)Wcd I am not acquainted,
but, from the history given by Favrc himself to the medical

WOUNDS OF THE HEAD. 297

officers in attendance, Staff-Surgeon Laisne, and my friend
Dr. Knox, who favoured me with the heads of the case, it was
obvious that he had lain insensible for three days and nights,
and that violent inflammation had taken place before he was
brought into the British hospital.* The entrance of the ball,
and its course within the brain, were very evident to the eye
and probe. In October, four months after the battle, this
man was alive, and, without any constitutional injury, or dis-
turbance of any one function, was performing the part of an
assistant and orderly to his less fortunate comrades. A small
suppurating sore, but discharging moderately, then remained
in the site of the wound, and he felt occasionally some giddi-
ness and headach. Favre, like many other people, was not
content with his good fortune, but wished something to he
done for him, and prevailed upon a young man to apply a bit
of caustic to his wound, to remove a small papilla of fungous
flesh, and dry up the discharge. Severe pain and corded
feeling of the head, with hot and dry skin, bounding pulse,
suppression of discharge from the wound, and, in short, every
symptom of alarming fever, soon made their appearance, and
this at a period when low fever and erysipelatous inflamma-
tion spread over every wound in the hospital, and rendered
the use of the lancet questionable, if not hopeless. However,
by means of steady purging, and other active measures he re-
covered in four days, leaving an impressive example of the
danger of ijinorant interferen&e. He returned to France with
his recovered comrades shortly afterwards. Before he left the
hospital, the vision of the eye on the wounded side began to
fail, and, to an accurate observer, the power of the muscles of
the eye and of its lid, particularly the levator, appeared to be
impaired. In expressing his gratitude to his attendants for
their humanity, and for the perfect cure he owed to their
attention, he observed, " so little inconvenience did he feel,

• The Geus d'armerie at Brussels, Division 1.

298 WOUNDS OF THE HEAD.

that, could it benefit the Emperor, he would willingly receive a
ball in the other side ! !"* ,

This lodgment of balls does not destroy the restorative
powers of nature, as the fractured and separated pieces of
bone often make a considerable progress towards perfect re-
union in the same way as we have already seen them do after
sabre cuts, Mr. Hammick, surgeon of Plymouth Royal
Naval Hospital, has a very remarkable preparation illustrative
of this fact. A large part of the frontal bone, nearly four
inches in circumference, including the superciliary ridge and
subjacent frontal sinus, is carried outward and overlaps the
temporal fossa; the bony union is nearly complete; while a
musket-ball is lodged deep in the anterior lobe of the brain.
The man from whom the preparation was taken was wounded
in Spain, and died at the distance of two months after in
Plymouth,

Lodgment of balls, and great depression of the bones, will
often exist unsuspected and unnoticed for days, until an in-
flammatory disposition is excited by some errors of diet, or
other accidental occurrence, when all the symptoms burs
forth at once. The following case illustrates this :

Cask XLIII.

Extensive Fracture, Ball lodged.

A soldier of the light company of Ibe 79th regiment was
wdunded at the battle of Quatre Bras, on the IGth June, 1815,

• A very int(rcstiii(^ rase of this kind is given by .Mr. Kirby in tlio Dublin
Hospital Reports, vol. ji. p. 303. In llii> Hulletin de la Faculty de Medccine,
No. 10, for 1812, M. Langlet gives n case where a seven drachm ball remained for
18 monthH in the brain, a fact the more curious, that a sort of membranous
envelope connected with the dura mater was thrown around it ; by this singular
disposition, the ball was in soim,- uu-asure susjendod in the purulent matter
T^hich surrounded it.

WOUNDS OF THE HEAD. 299

on the poslerior part of the occipital bone, incliniog towards
the right side. He could not tell by what weapon, nor did he
immediately perceive the accident; it was only after retiring
about an hundred paces, that, on the information of his com-
rafle, he discovered he was at all injured ; and presently after
hfi got faint from the loss of blood, and experienced great
sickness of stomach. He lay on the field that nig'.t, vomiting
occasionally, but without being able to sleep. He was re-
moved by the peasants next morning to an adjoining barn, but
was neither bled nor purged ; a dressing being simply applied
to the part. The succeeding day he was removed six miles on
the road to Brussels, and placed in a barn with other wounded,
where he was attended by a Prussian surgeon, who did no more
than apply some lint and a roller. Here he remained for nine
days, till he was removed to Brussels, during which period he
felt excessive pain in his head, with great dimness of sight
and loss of memory. The vomiting, however, had ceased,
but he had had no stool for twelve davs. He went to his old
billet, and was for five days attended regularly there by two
civil practitioners, who dressed the wound, and administered
occasional purgatives. He improved in strength, but still
complained of vertigo and giddiness: his appetite declined,
(notwithstanding that his kind host gave him what he called
slrengtheniny articles of diet;) his thirst was urgent, but he
drank no wine from the evening of his wound, except about a
pint given him in the barn by the country people.

On the 7th of July, or the nineteenth day, he was received
into hospital at Brussels, and placed under the care of Staff-
Surgeon Hill, with whom I had frequent opportunities of
witnessing the progress of the case. The injury in the scalp
was almost perfectly healed, and looked more like a bayonet
thrust than a gunshot wound. He walked about the ward
apparently in good health, and only complained of slight
he-adach. Two or three days after his admission, a very co-

300 WOUNDS OF THE HEAD.

pious purulent discharge took place, together with an occur-
rence not unfrequent in injuries of the head, viz. a sympathe-
tic swelling of the parotid gland of the right side, which
seemed to be connected with the wound by a narrow fistulous
opening. A probe entered without the smallest resistance,
and to such an extent as to render it improper to push it fur-
ther ; but suspicion was excited in the mind of the dres^ser,
who, on examination, detected a fracture with depression of
that part of the occiput opposite the internal transverse ridge
on the right side. The man's countenance had become flushed,
the thirst was urgent, and languor excessive ; there was no
shivering, however, nor was there any puffy tumour or sur-
rounding inflammation.

On the 15th July, a free dilatation of the part was made,
and the surface of a ball was discovered firmly impacted into
the bone ; when extracted, it presented a very ragged appear-
ance, having been cut against the sound part of the bone, and
one portion of it was very much elongated. The trephine was
now applied by Staff-Surgeon Hill, and two large pieces of
bone were extracted, together with five lesser fragments, from
an inch to the fourtli of an inch in size. The largest portion
was completely beaten into the brain, the lesser was forcibly
depressed on it. The patient sat upon his bedside during the
operation, his head supported on the breast of an assistant. A
small (juanlity of blood which seemed to spring from the basis
of the skull, followed the extraction ; and his pulse, which had
previously been scarcely perceptible, immediately rose and felt
soft, while a pain, of which he coinplaineil in the anterior part
of the head, disappeared. He evinced no loss of muscular
power, or paralysis, on the visit at seven o'clock in the
evening. Next morning his skin was cool, his pulse .00 and
soft, his thirst diminslied, Itiil lie had not slept. During the
<lay he had some slight nausea, wliit h was relieved by lemonade.
Jlis bowels not being free, he had a solution of Epsoui salts,

WOUNDS OF THE HEAD. 301

and an allowance of some ripe fruit with his spoon diet. He
slept two hours during the next night, and had some free
evacuations of the bowels, with a slight degree of epistaxis.
On dressing the sore, a small discharge of reddish grey serum
took place, and his pulse was harder and more frequent than
before. Eighteen ounces of blood were abstracted from the
arm; and as the pulse, which after the bleeding had sunk, rose
again about three o'clock on that day, (the third from the
operation, and thirty-first from the infliction of the wound,)
venesection was repeated to the same extent. On tying up
the arm he had a slight rigor, and at ten at night he had
another more considerable, which pained his head severely.
On the succeeding day it was found that he had had another
rigor in the night, with severe pain of the head, a quick but
soft pulse, but no derangement of the stomach ; belly costive.
From this period, up to the 28th of July, he improved imper-
ceptibly. He had some occasional irregular rigors, succeeded
by profuse sweats, now and then costiveness, and sometimei
severe pain in the head, all which were relieved by purgatives ;
but the wound went on gradually towards a cure, and only on
one day did a dilatation of the pupil give any indication of the
injury of the head which afterwards appeared.

On the 29fh day of July, or forty-third day from the injury,
a regular intermittent fever attacked him, which was treated in
the usual manner. This lasted for five days, when it degene_
rated into a remittent form, thea prevalent in the city, which
also yielded to the remedies employed, and he proceeded
rapidly towards convalescence, his appetite being particularly
craving, until, on the sixty-third day from the wound, and
forty-fourth from the operation, a fungus of the cerebrum was
observed divided into two parts by a deep fissure, so as to re-
semble the nates ; and at the same time a large tumour ap-
peared, extending from the axilla across the inferior angle of
the scapula, filled with a quantity of extremely fetid matter.

302 WOUNDS OF THE HIiAD.

No relief followed Ihe evacuation of this ; and the tumour of
the brain went on increasing in size, and with strong pulsation
on the surface, but with great depression, fluttering, and inter-
mission in the pulse at the wrist, till it burst on the third day
after its discovery, discharging a quantity of fluid during the
night. The succeeding day he was attacked with tenesmus
and occasional vomiting, and some of the cerebral substance
was discharged by the wound. The day following the senses
were much impaired, and he became delirious. The stools
were now involuntary, and the '.'rain continued to be discharged
at the wound. He got progressively worse; his mouth became
distorted towards the right, (on which side he was wounded ;)
his countenance was expressive of deep anguish ; the dis-
charge of the brain increased ; and he expired in strong
convulsions on the morning of the 23d August, the ninety-
eighth day from the injury.

The dissection showed much thickening and inflammation
of the dura mater; and an extensive attachment had taken
place between that membrane and the cerebellum. The dura
mater, all around the neighbourhood of the injury, was covered
with a yellow ish brown coagulablo lymph, and much thickened ;
the pia mater did not partake much of the inflammation.
About two ounces of water flowed from between the pia and
durti mater, and, on cutting into the ventricle, the plexus cho-
roidos appeared much diminished in size. The fungus was
formed ol' the inferior and back part of the cerebrum. Two
large (issures extended to the foramen magnum. In the
thorax, a large collection of ma.Uer was found in the sac of the
pleura, and a large abscess in the upper part of the lung of the
right side. lioth the lungs adhered extensively to the pleura
costalis ; but the external abscess in the axilla had no con-
nection with the purulent formation ,'n them : it contained much
fetid matter, but had no regular cyst. The heart was souud ;
so were the abdominal contents, except the liver, whose lower
surface presented a blackish marbled appearance.

WOUNDS OF THE HEAD. 303

Vast quantities of the bone, and of the brain itself, are
often destroyed without immediate, or even eventual, death. I
have met with some cases where the upper and lateral parts of
the cranium, embracinof nearly the whole of the parietal bone
of one side, and part of its fellow, with a portion of the frontal
bone, have been fractured, and afterwards picked away, so as
to expose a large share of one of the hemispheres. A soldier
of the corps of Brunswick Oels met with an accident of this
kind, in which nearly half the roof of the skull was blown off
from the bursting of a shell, and had no untoward symptom
until the lOth day, when the brain became in a fungous state,
and protruded to a great extent. He died comatose, with all
the symptoms of compression. In an officer of the ■ ■ —
regiment, wounded in the same action, the frontal bone was
fractured by a shell, and nearly one-third of it was removed,
laying bare both frontal sinuses. By the judicious treatment of
Staff-Surgeon Hill, although the inflammatory symptoms ran
high, and temporary insanity took place, this gentleman's life
was preserved. It is wonderful what efforts nature will make
to cover the exposed brain or its dura mater, if not prevented
by preposterous dressings. Now-a-days the scalp is never re-
moved, but I am sure it is not always brought so far over the
deficiencies in the bones of the cranium, caused by operations,
or accidents, as it ought to be.

On some occasions the functions are primarily, in others only
secondarily, affected. The removal of the depressed portion
of bone, or of extraneous matter, is sometimes almost imme-
diately succeeded by a relief of all the symptoms, and re-
storation of all the functions ; in others, the restoration is more
gradual, but not less effectual and permanent ; while, in some,
perfect relief never takes place. I have met with various in-
stances, in which the sudden restoration has soon been suc-
ceeded by a relapse and death, while the more slow, in which
no such event had been contemplated, terminated in perfect
recovery. During the progress of these and various other

304 WOUNDS OF THE HEAD.

symptoms consequent to wounds and injuries of the head, the
skin, the tongue, the ear, the eye, the motions and sensations of
the limbs, and the actions of the heart itself, are variously and
oppositely aftectecl. In the eye, particularly, I have remarked
the pupils contracted in some instances, and in others dilated,
where the injury seemed to be nearly of a similar nature and
degree ; and I have seen one pupil dilated, and the other much
contracted, in the same person.

Although we can with much probability say that paralysis or
convulsion will take place on the side of the body opposite to
the wound,* yet that occurrence (which is uncertain in its
period of attack) will frequently take place either in the upper
or the lower extremity, or in the entire of the opposite side,
and be either partial or general, from causes which are alto-
gether beyond our research. The opinion, that paralysis
took place on one side, (that corresponding to the injury,) and
convulsion on the opposite, I have never seen verified by
experience. I have seen some cases of general nervous affec-
tion of both sides after violent injury, where one has been
more affected than the other ; and in those general affections, I
have observed that convulsions have been a more frequent
occurrence than paralysis, when the fore and side parts of the
head have been wounded. Paralysis has occurred propor-
tionally oftener in my practice, where the wound or injury
approached nearer to the cerebellum. I have, however, seen

* See an admirable paper on this subject in the Medico-Chiriirgical Trans-
actions, by Dr. Yelloly, vol. i. p, 183; and some valuable cases by Mr. Anderson,
intheTransactions of the Royal Society of Edinbiirgli, vol. ii. p. 17. These cases
arc refirre<l to l)y Dr. natcman in the Kdin. Med. Journal for April 1805. The
conclusions drawn from thctn am, — I. One hemisphere of the brain being affected,
morbid symptoms generally ujipear on the other side of the body : 2. When both
are affected, the whole body suffers: 'A. If only one is riolcnily affected, the
whole body suffers : 4. Though the cerebrum alone is hurt, it produces morbid
symptoms in all the muscles of vohinlary molion, from w lialever point their nerves
may arise : 5. In cases of external accident, tin; progntisis is most favourable
where one side only Is affecle<i.

WOUNDS OP THE HEAD. 305

paralysis of one side and convulsion of another, take place
when the blow has been upon the forehead, and the same when
it has been on the occiput. Before entirely dismissing this
subject, I would offer one caution to the junior surgeons,
suggested not by what may happen, but by what I have known
actually to occur, viz. not to forget the effects of a blow on the
head, and attribute the inability of motion in the limbs to other
causes. I shall give the heads of an instructive case, which
will be sufficient to illustrate this point.

Case XLIV.

Paralysis mistaken for Dislocation.

A stout young fellow had the right parietal bone fractured by
a fragment of shell, and the fractured part was much de-
pressed. On recovery from the first stunning of the blow, he
iound he had lost to a certain degree the power of the opposite
side ; and the arm, partibsjlarly, was almost useless. By
removing the depressed portion of bone, the paralytic affection
w^s totally relieved in the other parts, and partially in the arm.
This man passed through several liospitals, and was treated by
different surgeons. He ultimately recovered the use of the
arm also, but not without various, and, as it may well be
supposed, ineffectual attempts at reducing a supposed disloca-
tion of that limb.

On the last examination of out-pensioners in Edinburgh
Castle, Assistant Staff-Surgeon Hill detected one case of pa-
raplegia, and one of hemiplegia, of the left side, produced
by a wound in the lower part of the occipital bone, and one
case of paraplegia, and six of hemiplegia, from wounds
affecting the parietal and other bones forming the sides of
the head.

Much information may hereafter be derived as to the func-
tions of paiticular parts of the brain, by a more minute ex-

306 WOUNDS OF THE HEAD.

amination than has hitherto been made into the effects of in-
juries.

Loss of the generative faculty, and atrophy of the organs
connected with it, have been attributed to blows on the back
of the head. The fact is certain; but whether the antiphro-
disiac effects proceed from injury to the organs of sexual love,
or to a general loss of power, is a subject for future inquiry.
M. Larrey gives a case, in which the blow of a sabre had cut
off the external protuberances of the occipital bone, and divided
the extensor muscles down to the sixth cervical vertebra, the
spinous process of which was also cu{ ofl'. This patient, after
his cure, in answer to an inquiry on the subject, acknowledged
that he had ever since been deprived of the generative faculty.
He also gives another, where the testes wasted, and the
" membre viril" became shrunk and inert. In the following-
case, the confession was not elicited by inquiry, but was the
subject of spontaneous complaint to Staff-Surgeon Hughes, in
whose words I give it:

Case XLV.
Affection of the Genital Organs from Wound of the Occiput.

" Gaetano, a soldier of the Oth Portuguese Ca9adores, was
struck by a piece of shell at Salamanca, in June 1813. It
shattered the superior part of the occipital bone from within
hall an inch of the great knob on the left side, to the lambdoid
suture. An irregular angular portion of the left parietal bone,
nearly an inch in length and about an inch in breadth, was also
fractured and beaten inwards. He laboured under most alarm-
ing symptoms, total insensibility, involuntary discharge of feces,
laborious breathing, iuirrifabilify of pupil, and weak low pulse,
with occasional convulsive twitchings. The removal of the
depressed portions of bone, and about an ounce of coaguluni

WOUNDS OF THE HEAD. 307

from the surface of the dura mater, on the second day after the
wound, was attended with a diminution of most of the symp-
toms; and, with two copious bleedinj^s, (which were employed
to arrest approaching inflammation,) his recovery was perfected
by the November following; except that even then, the catheter
was occasionally necessary to draw off his urine, the bladder
not having recovered from a paralysis, which, for the first three
weeks, was so complete as to prevent any evacuation without the
use of an instrument.. Of this, however, he ultimately recovered.
This man was subsequently attached to the mule with my me-
dical stores, and repeatedly consulted me on the means of
recovering his virility, which, he said, the shell had completely
carried away with it."

It becomes an object of inquiry, on which Mr. Hughes could
not satisfy me, Did Gaetano lose any other function, the organ
of which was injured I The organ of parental affection, accord-
ing to the position assigned it by Gall and Spurzheim, must
have been implicated. Was he as good a father as ever, or
did he cease to love children when he lost the power of beget-
ting them ?

Priapism is occasionally observed to occur in wounds of the
head. In a case which lately occurred in the Cavalry Hospital,
near Edinburgh, this symptom was particularly remarked in an
hussar, who had suffered severe injury by a fall from his horse.
The penis was in a state of priapism during the greater part of
the two first days after the accident, and towards the close of
Iif« he frequently rubbed the genitals violently with his hand.
On dissection, the dura mater was found extensively separated
all over the head. This separation included the " tentorium
cerebelli," and beneath its edge about four drachms of coagu-
lated blood were found, the principal part of which lay on the
cerebellum.*

♦ In dislocations of ihe lumbar vertebrae, the penis is generally erect. See Sir
A. Cooper on Dislocations and Fractures, 4to. 3d. edition, p. 4Si.

308 WOUNDS OF THE HEAD.

Some of the functions, particularly of the mind, are often
severely and permanently affected, while others are not propor-
tionally impaired, and the loss is but of temporary duration.
The recollection of recent events is abolished in some cases,
that of more distant occurrences is abolished in others, while
in other instances the memory of certain classes of circum-
stances only, is impaired ; thus, Baron Larrey states some in-
stances where the patient could never recollect proper names,
although on other points his memory was not defective. I know
of an officer who retired from his corps in consequence of a
gunshot wound, which injured a part of the frontal and left
parietal bones, and produced loss of memory, confusion of
ideas, and at length a general derangement of his mental facul-
ties, with a paralytic affection of the right arm and leg. I
had occasion to become acquainted with his situation in four-
teen years after the receipt of his wound, when his state was as
follows : There was a manifest depression in the site of the
wound; debility of the whole body, with a sensation of cold
even when the perspiration flowed copiously; involuntary bursts
of laughter frequently came on ; his memory was so defective
that he was unable to recollect the name of his surgeon, or the
day or month on which he last visited him. To these symptoms
was added a constant giddiness of the head, so much increased
at times that he fell senseless to the ground.

The powers of speech are often lost while those of memory
remain, and the sight is impaired while the hearing is perfect,
and vice versa. I have met numerous instances of this, and
have had patients who told me that they could hear distinctly
what I said, and distinguish my voice from that of others, — and
have repeated my words as a proof both of this fact and of their
retention of memory, while they could not distinguish my person
or give utterance to their thoughts. The following case, in which
I was deeply interested, illustrates this point:

WOUNDS OF THE HEAD. 309

Case XLVI.

Severe Injury of the Head, with Loss of Speech, and other

Nervous Affections.

Captain B , a particular friend of mine, was wounded

by a musket-ball in the head at Waterloo, on the I8th of June,
1815. On the 19th, he was brought into the city of Brussels in
charge of a medical officer, who gave me a most melancholy
account of his case. On approaching the waggon in which he
was conveyed, I was insensibly attracted to that part of it
where he was stretched, by a low protracted moan, as of a per-
son in extreme pain, but very weak. On calling him by name,
he sat up, caught me by the hand, which he kissed most fer-
vently, pointed to his head, and then to the site of a former
wound which he had received at the storming of Badajos, in
1812, from the effects of which I had the good fortune to relieve
him. He then burst into tears, but without having the power
of uttering a distinct word. His countenance was pale and
ghastly, and his mouth somewhat distorted ; his eye languid,
and suffused with blood ; his skin dry, but cool ; his pulse
about 90, soft and compressible. As I found that he had been
bled on the field, I contented myself with providing him a
billet, and giving him in charge of his medical attendant, with
directions to examine the wound most particularly ; to enlarge
it if fracture to any extent appeared ; to administer a brisk
purge, and to watch most carefully the approach of inflamma-
tion. The wounded being now pouring in by hundreds, I was
unable to see him before the 21st ; his, case, however, was re-
ported to me daily. Much coagulated blood, and some particles
of sand on which he had fallen, together with a thin scale of
lead, obviously a bit of a split musket-ball, had been removed.
His pulse had risen on the night of his arrival to about 100,

310 WOUNDS OF THE HEAD.

hard and bounding-, and he had been copiously bled in conse-
quence. A cruciform enlargement of the wound had been
made, which bled copiously, and gave a view of an extensive
fracture of tlie left parietal bone. On my visit I found him
nearly as follows: — Countenance pale, expressive of great
pain, referable more to mental than corporeal suffering ; mouth
still distorted ; eye sunk, but its pupil dilatable ; the power of
articulating any distinct sound lost, but the desire obviously
strong; pulse bO, soft: tongue clean, bowels open, (by saline
purgatives;) urine copious, and with a rose-coloured sediment;
skin moderately warm, and at the region of the liver bathed in
sweat; the liver itself obviously projecting, and giving a painful
sensation when pressed upon, evinced by his wincing from the
touch.

On examining the wound of the head, I found an extensive
radiated fracture, occupying almost the whole of the left pa-
rietal bone ; at the centre there was a piece of bone, apparently
the size of a musket- ball, heat in through the membranes of
the brain, and bedded in its substance, but considerably more
toward the frontal region than the occipital. The unequal pres-
sure I found to proceed from a musket ball which was wedged
in l)etween the displaced pieces of bone and the portion, which,
though cracked, preserved its situation. The separated piece
was obviously much more extensive on its internal face than
externally, and could not possibly be extracted without the
operation of trephining, to which I proceeded. The leaden
wedge, and several loose splinters which jammed it in, were
easily removed ; and on making one perforation with a large
sized trephine, I removed the depressed portion of bone, which
was forced into the brain nearly an inch and a half from the
surface of the scalp. It was of an irregularly oval shape, about
one inch long by half an inch broad, and fractured in such a
manner, that the internal table formed a much larger part of its
circumference than the cxternul.

WOUNDS OF THE HEAD. 311

No relief followed the operation ; he passed an extremely
restless night, and the pulse rose so rapidly and so high, that
the abstraction of IG ounces of blood became necessary. His
breathing during this momentous night became, for the first
time, permanently stertorous; and, when I saw him in the
morning, his whole appearance indicated the most extreme
danger. He lay coiled up in the bottom of his bed; the right
arm stretched out, and occasionally convulsed ; no exertion
could get a sight of his eyes, or his tongue ; the mouth was
more distorted than usual ; the skin was nearly as on the day of
the operation, except that the partial sweating over the hepatic
region was increased in profuseness, and he seemed to wince
more on pressure at that part ; indeed, all the sympathies
seemed to be entirely merged in those connecting the brain
and liver. The stomach participated remarkably little, for he
had scarcely any vomiting. His pulse alone gave me some
hopes; it was nearly natural. On addressing him, he made
an effort to rouse himself, but almost immediately relapsed into
his former state. I directed a strict watch to be kept over him;
and as my duties called me again to that part of the city where
he was lodged, I visited him about midnight, and found that a
spontaneous bilious diarrhoea had come on, and that he was
much more sensible. He made an attempt to articulate, and
pronounced audibly the letter T once or twice. The next morn-
ing, being the 5th from the receipt of his wound, his general
appearance was amazingly altered for the better ; the diarrhoea
still remained, and his efforts to speak were continual. On the
sixth day he grasped my hand with great fervour, looked pite-
ously in my face, and, to my inquiries as to his feelings, he
uttered audibly, though with much labour, the monosyllable
" THER," to which, in the course of the day, he added " O;"
and for the three next days, whenever addressed, be slowly,
distinctly, and in a most pathetic tone, repeated the words,
" o; THER: o; THER:" as if to prove his powers of pro-
nunciation. His general appearance, during all this time,

312 WOUNDS OF THE HEAD.

amended considerably, and my hopes now began to revive. I
therefore resolved to write to his family, and, before doing so,
I printed in large characters on a sheet of paper the following
words, " SHALL I WRITE TO YOUR MOTHER?" that being
the wish which it appeared to me he so long and ardently had
laboured to utter. It is impossible to describe the illumination
of his countenance on reading these talismanio words ; he
grasped and pressed my hand with warmth, burst into tears,
and gave every demonstration of having obtained the boon
which he had endeavoured to solicit.

From this period his mental faculties gradually developed
themselves; he regained a consciousness of the circumstances
immediately preceding his wound, and, in succession, of those
of a more remote period. The power of speech was the last
which he perfectly regained, and for which he usually substi-
tuted the communication of his thoughts and wishes in writing.
Throuo-hout the whole of his convalescent state, melancholy
ideas constantly predominated, although, previous to the acci-
dent, he had been remarkable for his flow of spirits. He returned
to England, nearly recovered, on the 29th September, or l03d
day from the wound.

I have omitted the minor details of surgical treatment after
the operation, as they are not essentially connected with the
point I wish to illustrate by the case; and, indeed, I have it
not in my power to give them day by day, as, after he had made
some progress towards recovery, I gave him over to another
surgeon. I was assisted in the operation by Mr. Jeyes of the
15th Hussars; my friend Mr. Lindsay, Surgeon to the Forces,
was very constant in his assistance and advice; Professor
Thomson often visited Captain B, ; and Statl-Surgeon Bakers
was indefatigable in his after treatment.

This case may be advantageously compared with one given by
M. Larrev,* in which a soldier, wounded in the head, formed a

• Mcinniirs, vfl. iii. |>. A'Ji!.

WOUNDS OF THE HEAD, 313

new language for himself. He expressed affirmation not by
•' Oui," but by the word " Baba." Negatives he gave by
" Lala;" and bis wants he made known by the terms " Dada"
and " Tata." These sounds bore no analogy to the words pro-
perly expressive of his ideas. Captain B., on the contrary,
strenuously laboured to combine all the simple sounds which
composed the words that he wished to express.

In the foregoing case, the sympathy between the brain and
liver was strongly marked, and took place at a very early pe-
riod ; but it is by no means such an universal occurrence as
some practitioners imagine; nor does the affection of the liver,
I suspect, so very often depend upon the direct injury of the
head, as upon certain circumstances connected with it. A class
of men more peculiarly liable to hepatic affections than others,
are the most frequent subjects of fractured skulls. I mean
quarrelsome and habitual drunkards, particularly those who
indulge in ardent spirits; and we often find that the liver has
been diseased long before the infliction of the injury of the
head. It is scarcely necessary to say, that it will very often
occur in men of the most temperate habits, and totally uncon-
nected with the affections of the organ from habitual drinking,

as was the case with Captain B . I have known it take

place within thirty-six hours from an accident, in a temperate
female. It often happens, however, that neither the liver nor
any other organ seems to sympathize with the injuries of the
head, while, in other cases, almost every viscus will appear to
suffer more or less. These sympathetic affections vary in the
organs which they attack, and in the degree of violence. In
the thorax they appear from simple increased secretion from
the lungs, to tubercles and extensive purulent formation in their
substance.* Serum is also often found in the cavity, and very

* See Morgagni, Epistle 51, Articles 17, 18, 19, 20, from Valsalva ; and Arti-
cle 21, from Nicolaus Massa and Marchctti, a case with abscess in the heart and
water in tlie iiericardiuin,

.314 WOUNDS OF THE HEAD.

frequently in the pericardium; and even in tlie heart itself ab-
scesses have been discovered. In the liver, morbid appear-
ances are found throughout every shade of affection of its mem-
branes or its secretion ; either pain and tumefaction, with bilious
diarrhoea, or the same with a perfect torpor of its functions ;
and inflammatory affections, from increased vascularity to the
formation of extensive collections of matter. In the spleen,
pain, tumefaction, hardness, and abscess, are occasionally ob-
served. The stomach sutlers more frequently than any other
organ; but it appears to be more from general nervous sympathy
than from any organic affection, which is seldom discoverable on
dissection. Bertrandi, who, in the Memoires of the French
Academy, vol. iii. p. 484 of the 4to. edition, has given a memoir
upon the Abscesses of the Liver, which form after wounds of
the head, asserts that they are most frequent when the patient
vomits a green bile shortly after the receipt of the injury; when
delirium and convulsions supervene; v/lien blood flows from
the mouth, nose, and ears; when the face tumefies, the vessels
of the throat palpitate, and the hypochondria heave convul-
sively; and, as he says himself, " 2>our ne pas ])arottre avoir
rien jyasse sous silence," when the patient lies comatose, stupid,
and delirious, when the neck tumefies and grows livid, and the
hypochondria are tense and painful. These abscesses, he
asserts, are more frequent on the convex than the concave side
of the liver, and more generally deep-seated than superficial.
My experience does not confirm any of the observations of the
academician. His theory is, that in concussion a greater quan-
tity of blood being sent to the head, a greater quantity is of
course brought to the right auricle, presses on the inferior cava,
and gives rise to accumulation in the liver. Poutoau thought,
that, instead of a greater determination to the head, there was
an obstruction there, and a congestion in the liver. Desault
attributes it entirely to sympathy. Richerand accounts for it
mechanically, and adduces proofs drawn from the effects of
firecipitaling dead bodies into a deep pit meant for their recep-

WOUNDS OF THE HEAD. 315

tion at the hospital of St. Louis, in which the liver has beeo
torn to a considerable extent; but I conceive that the circum-
stance of the liver being affected by a blow on the head, where
the patient has not fallen, militates much against this explana-
tion, and that we are still at a loss to trace the cause. The
connection, we know, exists, but we are ignorant of the extent.
It exists, though not uniformly, both in slight injuries of the
scalp and severe fractures, and shows itself from the bilious
erysipelatous tinge produced by a scratch on the teguments, to
a deep-seated abscess. Of this, however, we are assured, that
it is in the primEe vias alone we can encounter those symptoms
in their various shapes and degrees.*

Protrusions of the brain, in many instances which I have seen
succeeding' to gunshot and sabre injuries, have not appeared to
me to proceed solely and exclusively from any one cause, but to
depend on several, sometimes acting singly, and often in com-
bination. The first and most simple canse has proceeded from
actual violence, which has partially separated a portion of the
cerebral mass, and has been obvious at the first dressing of the
wound. The second has succeeded the removal of the support
of the bony case, or the membranes, either by the original
wound, by operation, or by subsequent inflammation and
sloughing. The third class has been the effect of contusion,
producing a morbid alteration of the brain itself,f which either
comes forth unaltered in appearance, or shoots out a bloody
coagulum, arising from a ruptured vessel, or else pushes forth

* Klein, a German surgeon, asserts, that the liver sympathizes much oftener
with wounds of the slioulder-joint and thorax than with those of the head. —
*' Chirurgische Bemerkungen." A paper of much interest on this subject will be
found in the 1st volume of the " Actes de la Soci6te de Medecine " of Brussels,
by M, Curtot.

+ The disposition may exist without a fracture, as has been observed by Dr.
Thomson. See his Report, p. 57. Schmucker also notices this alteration of
the brain ; and it is not unfreqiiently met with after death in cases of gunshot
injuries.

316 WOUNDS OF THE HEAD.

a new product, easily and safely separable by the knife, and
quickly renewed, like fungus growth, in other parts ; or, lastly,
it proceeds from a gradual but often extensive breaking down
of the brain into a bloody pulpy mass, which appears to issue
forth by its own fluidity, unconnected with any propelling
action of the blood-vessels.

Examinations after death (which is the general result of
these cases) give ample proofs of the existence of protrusions
from coagulated blood ; and that proceeding from the sub-
stance of the brain itself is obvious, both during life, from the
appearance of the substance protruded, and from the exami-
nations j^ost mortem, when the loss can be detected in the
cerebral mass within the skull, and the protruding parts is
observed to correspond with the deficiency in quantity and
consistence. That a true and rapidly increasing fungus
product is thrown out, is also evident by external inspection,
and by observation on the dead subject, where the cerebral
mass is found undiminished in size, notwithstanding the great
quantities of fungus that have been cut off, torn away by the
patient in fits of delirium, or spontaneously removed with the
dressings.

The following is a curious and instructive case, in as much
as it shows a combination of the different causes; it illustrates
the violent injury which the part is capable of suffering from
the accident, and from the escharotics and the knife of the
surgeon ; and it exhibits a depressed state of the circulation,
which I have not had an opportunity of witnessing in any
other instance.

Case XLVII.

Severe fnjurj/ of the Ihtiin, with Fungus.

Francis Wilde, 1st battalinn .O.jlh regimrnt, aged 28, was
woiindc<l by a musket-ball in the action of the Kith .Tunc 1815,

WOUNDS OF THE HEAD. 317

at Qualre Bras. The ball struck the frontal bone, about an
inch above the right eyebrow, and passed in a direction to-
wards the squamose suture of the temporal bone. He walked
from the field of battle to Brussels by the help of two of his
comrades. He was first seen by a native surgeon, who cleaned
and dilated the wound, and then sent bira to the Jesuits'
Hospital, where a longitudinal fracture was discovered, of an
inch and a half long, and one broad, but no depression. The
fractured bone was divided into four small pieces which were
easily picked away, leaving the surface of the dura mater
uncovered. In dressing him on the third day, fully a dessert
spoonful of the brain, and some loose splinters, were dis-
charged, but he did not appear to suffer the slightest inconve-
Bience. Indeed, after the most minute inquiries, both by
Staff-Surgeon Boggie and myself, we could detect no morbid
symptoms, nor the smallest difference in his system from that
of a man in perfect health, except that his pulse was reduced
to the very extraordinary lowuess of thirtij-six heats in a mi-
nute, and had been by report, so low as thirty. This exemption
from existing disease did not lull us into security as to its
eventual occurrence; and a most rigid abstinence was enjoined,
with occasional purgings, and a direction that bleeding should
be had again recourse to (he had been bled three times before
I saw him) on the appearance of any threatening symptoms.
On the 10th day, I found Wilde in his general health and
appearance the same as before, with the exception of his
pulse, which had risen to 46 beats. At this rate it continued
for several days ; and, on the 2Sth day, it had got up, by a very
gradual and progressive range, to 72.* From this period he
was observed to sleep a great deal, and he became very uneasy

* The erect, or horizontal position, had no effect in altering the rate and
number of the beats, whicli were always ascertained by two persons, one w ith a
stop-watch, the other with a minute-glass. Mr. Burn states a case where the
pulse sunk to eleven beats, and even to ten, but it was a case of organic disease
of the heart. See his " Observations on Diseases of the Heart," pp. 42 — Mi.

3IS WOUNDS OF THE ElEAD.

on being' moved. No particular change occurred until tlio
38th day, when a greyish-coloured spongy fungus, containing
much coagulated blood, was observed to protrude from the
wound, strangulated, as I may say, by the edges of the frac-
ture, which had fairly formed a groove in it. He now com-
plained of severe pains darting from ear to ear ; both the
pupils were dilated with a slight degree of strabismus in each
eye; skin natural; tongue whitish; thirst urgent; appetite
impaired; and there was occasional nausea and vomiting on
taking his saline purgative draught, which he frequently
used, to keep his bowels regular. The fungus, on the 40th
day, notwithstanding the use of the red o\.ide of mercury,
which had been employed to destroy it, had increased; the
edges of the wound got puffy ; he lay nearly comatose ; the
strabismus was greater than before; the left angle of the mouth
was drawn upwards ; the bowels were constipated, and the
tongue was covered with a dry black crust; pulse 76, and soft.
Some spicula of bone came away with the dressing, and the
fungus poured out a quantity of blood. Towards the evening,
the symptoms became aggravated ; he moaned incessantly ; and
on the dressing of the next day the protrusion was found to be
to a very large size, nearly tliat of an egg. It pulsated very
strongly. It was now determined to remove it by a stroke
of the scalpel; this was done, both on that day and the next,
with very little consequent hemorrhage, and the part was after-
wards dressed with dry lint, and a small pasteboard compress.
On examining the fungus, it was not as expected, and as it
originally appeared to be, chielly coagulum, but from the feel
and appearance, obviously brain itself. On the evening visit
it was found necessary to tie his hands, to prevent him from
tearing off the dressings, which he had done in the intervals of
the visits, and had dragged away with them a large piece of
fungus which had rapidly protruded, although its removal by
the knife was again tried. His general appearance, however,
viiis belter ; he was sensible to external impressions, and

WOUNDS OF THE HEAD. 319

answered questions rationally, but complained of great pain on
touching the wound. On the 42d day, although he tore off
more of the fungus, he complained less of pain, and was quite
sensible, knowing and conversing with the bystanders ; he had
not that great appearance of anxiety as before. From this to
the 45th day he got progressively worse ; the cerebral mass
continued to flow out at each dressing, more fluid and bloody
in appearance than before, and with obvious masses of coagu-
lum ; and at four o'clock P. M. he expired in the greatest
apparent agony. I was naturally anxious to inspect the body,
but a very few hours after death it became highly offensive ;
and the young gentlemen were so much afraid that it would
spoil altogether before my avocations permitted me to examine
it, that they removed the head with the intention of throwing in
an injection to trace the state of the vessels, and discover, if
possible, the ruptured one, which we all along suspected. But
before the necessary apparatus could be got, putrefaction
advanced so rapidly, that it was determined to saw off" the
skull-cap, and place the brain in a basin of water for inspection.
Professor Thomson and Dr. Somerville assisted us. We found
that the right hemisphere of the cerebral mass was reduced to
a sort of bloody pulp, still retaining some shape of what it had
been, but much diminished in size, and rendering it absolutely
impossible to trace its organization. The left hemisphere,
although obviously suffering from disease, was not so much
aff"ected, but was covered with a net work of turgid vessels.*

The mildest dressings, the cautious employment of pressure,
supporting the parts as much as possible by the approximation
of the edges of the scalp, and avoiding every species of
stimulus, are the means that I would recommend in these

* The remarkably rapid putrefaction of dead bodies after injuries of the head
has been long since observed, particularly by Hildanus, Cent. II. Obs. 25, 26,
and by Morgagni, Epist. 51, Art. 67, and Epist. 52, Art. 15. I have had re-
peated opportunities of witnessing it. The same rapid putrefaction takes place
in animals killed by lightning and in electrical experiments.

320 WOUNDS OF THE HEAD.

cases, in which, independent of the protrusion, there is oiten a
serious injury of the entire mass of the cerebrum. Some
surgeons have ventured on the use of escharotics ; but I have
generally seen their employment succeeded by a great aggrava-
tion of the symptoms. They have been employed to a greater
extent by the late Mr. Hill of Dumfries, than perhaps by
any other British Surgeon; his experience on this subject
will be found well worth consulting, and is to be met with in
his '• Cases in Surgery."

Mr. Abernethy has thrown a brilliant and steady light upon
this, as he has done upon every subject which he has enlarged
on. An interesting paper by Crell, and another by Sand,
" De Fungo Cerebri," is to be met with in the 1st vol. of the
" Disputationes Chirurgicae of Haller," and an inaugural dis-
sertation of great merit has recently been published by Dr.
Abraham Solomons, " De Cerebri Tumoribus," Edinburgh,
1810. But perhaps the greatest mass of information that has
ever been collected upon the point, is to be found in the ad-
mirable memoir of M. Louis, " Sur les Tumeurs fongueuses
de la Dure Mere," in the 5th vol. of the Memoirs of the
Royal Academy of Surgery.

Concussion, as well as compression, is a very fre(|uent effect
of fracture from shot or sabre wounds, and also from grazing
round shot, and fragments of shell, earth, or stones. The
diseases are frequently coexistent, and so often run into each
other, or dider merely in degree, as to render it impossible
in every case to lay down accurate distinctive marks between
them. Neither the state of the pulse, the eye, the breathing,
nor the skin, are infallible guides ; we have an unerring one,
however, in our most powerful remedy, if not to the precise
nature of the case, at least to its most proper treatment, — I
mean venesection ; and (he younger surgeon who allows himself
to be seduced by representations of the impropriety of copious
bleeding in soldiers, will deprive himself of a most important
and usL'ful auxiliary when judiciously employed. No well

WOUNDS OF THE HEAD. 321

informed man now-a-days, it is true, flies to the lancet the
moment he hears of a wound of the head. He examines the
case, and, from appearances, decides on the immediate necessity
of abstracting that blood which he well knows he must ulti-
viately have recourse to when reaction takes place. If the
concussion is so violent that the powers of life are absolutely
sinking-, to bleed instantly would be to destroy the patient. A.
glass of wine or of spirits poured down his throat will be the
proper remedy. If the wound is not attended with great '
sinking, which is often fatal, then indeed the lancet and a
brisk purgative are the appropriate remedies, whether we call
the affection concussion or not.

In the field, and throughout the whole practice of military
surgery, venesection becomes, if possible, more necessary,
because all the operations which may be ultimately called for,
cannot, under the urgency and confusion of existing circum-
stances, be immediately performed ; and the judicious use of
blood-letting renders the deferring them less dangerous, and
may even supersede the necessity of operation at all ; an object
the value of which those will best appreciate, who know the
frequent results of surgical operations in crowded hospitals.

The cordial and the depleting plans have each had their
advocates, and some of our most able surgeons have be endi-
vided in their opinions. It has fallen to my lot, on several
occasions, to see the plans contrasted on a large scale, where
foreign and British surgeons have practised under the same
roof; and the balance of success was so very decidedly in
favour of the latter, as to confirm me in the propriety of ab-
staining fi-om internal stimulants. But if the depressed state
of the system, which immediately succeeds violent concussion,
continues beyond its usual period, or is great in degree, and
particularly if the pulse sinks on a cautious trial of the lancet,
I have derived great benefit from applying a blister, using
the warm bath, and administering guarded doses of pulv.
ipec. compositus. If leeches can be procured, local bleeding

322 WOUNDS OF THE HEAD.

on or near the site of the wound should never be omitted.
In some cases of concussion general bleeding may be com-
bined with the use of antispasmodics ; and there is a recent
case where the use of an enema (which, from my own expe-
rience, I can recommend as powerful) of assafoetida, dissolved
in water, had a most remarkable and instantaneous effect, pre-
ceded and accompanied by bleeding from the arm and tem-
poral artery.* But in no case should we lose sight of the
necessity of guarding against inflammation, and watching its
insidious approach with the most jealous caution.

A very curious example of pure concussion is given us by
Schmucker,f in which a cannon-ball took away the queue from
the nape of a soldier's neck without injuring the integuments in
any sensible degree. He continued in a complete state of
stupor for many days, during which he was bled at least twenty
times. Twenty-four grains of emetic tartar, given at short
intervals, produced some stools, but no apparent inclination to
vomit, after having suffered a relapse from having been moved
prematurely on a march with the army. In the case of my
friend Colonel T., although the neck of his hussar jacket was
cut by a round shot at Waterloo, the shirt torn, and the skin of
tlie nape of the neck grazed, no one unfavourable symptom
appeared, and he complained only of very acute pain and
stiffness of the parts,

Wounds of the head, which are not productive of the dread-
ful symptoms of concussion or compression, often lay the foun-
dation of very troublesome spongy sores and indolent exfolia-
tions, attended with extreme headachs, and sometimes amount-
ing to inflammation of the brain or its meninges, and even to
the formation of matter on or between these parts. Tiie ge-
neral principles applicable to inflamed parts, and to exfoliating

• See a case by Dr. Thomson of Halifax, in Edinburgh Medical and Surgical
Journal, vol. x. p. 12.
+ In his thirurgische Wahrnchmungen, BerlUi, 1759, case 3d, p. 393.

WOUNDS OF THE HEAD. 323

bones, are applicable here, but requiring a promptness pro-
portioned to the importance of the organ concerned. Exfolia-
tion is more rapid, and a granulating surface of new growth,
succeeds more frequently upon the bones of the skull after an
injury, than on other bones ; but if the symptoms do not soon
yield, it would be manifestly improper to wait for exfoliation,
when, by the simple application of the crown of the trephine,
we can at once remove the source of irritation. On this point,
as well as on the entire class of injuries, I cannot too ofteu
refer to the excellent Pott.

The tendency to relapse, left after injuries of the head have
been got safely over, is very great, and demands for its pre-
vention a rigorous system of abstinence of all kinds, little
palatable to military patients. Slow as the brain is, in some
instances, to take on a diseased action, it is amazingly irritable
in others. Among a great variety of accidents of this kind, I
was most particularly struck by the following case, of which,
by the kindness of Staff-Surgeon Dease, T acquired the his-
tory. Although by no means unusual, it is valuable, in as
much as it shows the dangers of excess in the patient, and the
great probability of relief from puncturing, not the investing
membranes of the brain only, but even the brain itself.

Case XLVIII.

Fatal Relapse, with Abscess in the Brain.

A young officer of the regiment had his os frontis

fractured, and a part of it removed at one of the decisive
battles in the neighbourhood of the Pyrenees. The skill of
his medical attendants carried him throuffh the immediate
effects of the injury, but his own social disposition led him,
with the wound still open, to the society which frequented
the coffee rooms and the brothels of the city where our general
hospital was at the time established. A return of all his

Y 2

324 WOUNDS OF THE HEAD.

symptoms, in a most aggravated form, was the speedy conse-
quence, and death very shortly ensued. From the antecedent
symptoms, the formation of an abscess in the brain was con-
fidently predicted by Mr. Dease, and the spot where it would
most probably point was even indicated by the appearance of
the wound. A difference of opinion, springing no doubt from
most laudable anxiety for the patient's welfare, prevented the
performance of any operation ; although all acknowledged the
safety of the measure on some occasions ; and it was only after
examination of the body, at which I was present, and the
detection of a large abscess filled with purulent matter, mixed
with some clots of blood, to the amount of four ounces, and
within one-tenth of an inch of the surface of the brain, that
the probable good effect of puncturing was demonstrated.

Schmucker gives a most interesting case, his 29th, p. 297,
illustrative of this point, where a ball stuck in the os frontis
of a soldier ; the inner table was forced in on the dura mater ;
it was removed by the trepan, and some coagulated blood
brought away; he did well until the nineteenth day, when the
pulse began to intermit, the dura mater became raised, and
seemed to have a fluid under it. Tie made a small puncture,
and two ounces of a whitish lymph were immediately dis-
charged by tlie opening. The puncture closed, and three
days after, the membrane being again raised, he made a crucial
incision, through which an ounce of whitish fluid was evacuated.
He kept this open with sindons dipt in a stimulating balsam,
and the patient recovered speedily.

It is not the casual escape of a few that should betray us
into the most remote encouragement of a deviation from rigid
regimen in our patitnts, Jlundreds of soldiers have lost their
lives by a childish facility of the younger surgeons in allowing
them extras, (as they are technically called,) that bane of
health, and source of endless aljuses in hospitals. I doubt
much whether, upon tlu; whole, the service would not be
benefited by striking them ofl" from the diet rolls altogether,

WOUNDS OF THE HEAD. 325

and issuing them as medicines. But independent of the abuse
of food, daily experience shows, that even its moderate use
may prove highly injurious in injuries of the head; and it is
not an unfrequent occurrence that men who have suffered
long- privations in that respect, combined with exposure to
cold, have manifested no dangerous symptoms, until taken
into hospitals where their wants have been supplied. The
employment also of female servants is a measure, the utility
of which is very questionable, particularly of that class that
usually follows camps and hospitals. These persons are not
only far less efficient than men, and less amenable to the lules
of police, but sexually they are often extremely hurtful.*

Whenever the symptoms of formation of matter, or effu-
sion of blood, and consequent compression of the brain occur,
if we hesitate as to the application of the trephine, we deprive
ourselves of our only resource. That it has been often unne-
cessarily employed is very obvious ; the numerous instances
of escape, however, show clearly, that uncovering the brain
is not so very dangerous as has been argued by some, especi-
ally at the part where an injury has been inflicted, and where
there is a probable separation of the dura mater. But if due
attention is paid in the first stages (which it has been my
object principally to enlarge on,) the number of these second-
ary, and but too often fatal cases, will be most materially
diminished. Directions, as the eminent Pott observes, " to be
given on these subjects can be only and truly general ; all
the rest must be left to the judgment of the surgeon, which
judgment must be formed from the peculiar nature of each
individual case."

Tlie cases which absolutely require the trephine may be
reduced to the two following : First, where a fracture exists,
and a depressed or diseased portion of bone, a ball, or other

* For a very remarkable case illustrative of tliis, see Hildauus, Cent I.

obs. m.

326 WOUNDS OF THli HEAD.

extraneous matter cannot be otherwise removed. Secondly,
where no fracture exists, but urgent symptoms of compression
occur. In the first case, which is by far the most common in
military surgery, there can be no hesitation as to the spot to
which tbe instrument is to be applied. In the second case, if
tliere is a wound in the integuments, and if it loses its healthy
appearance, and a separation of tbe periosteum takes place, all
surgeons are agreed upon the propriety of applying the trepan
at that point. But, where there is no wound, the case becomes
much more dubious, and we are reduced to act upon proba-
bility, founded upon accompanying circumstances, — as the
gestures of the patient, or his sensibility to pain on pressing on
a particular spot, or we may be guided by what the French
surgeons place much dependence on, viz. the existence of pa-
ralysis, which is most commonly on the side of the body oppo-
site to the compressed portion of brain. This last, however, is
the most doubtful of all our guides, for although the pressure
may exist on the side indicated, it may be situated beyond the
reach of an operation. Upon tbe whole, we may say with the
eminent surgeon above quoted, " Ko man, who is at ^11 ac-
quainted with this subject, will ever venture to pronounce or
promise success from the use of the trephine, even in the most
apparently islight cases; he knows that honestly he cannot ; it is
enough that it has often been successful where and when every
other means have failed." With regard to the precise spot (tn
which the instrument is to be applied, I believe, that, in steady
and judicious hands, it may be used on almost any accessible
point of the skull, but if we have to choose, the least dangerous
spots will be found above an horizontal line drawn at an e(jual
distance from the sagilliil suture and the root of the mastoid
process.

I have already given a case (Case XLVI.) where the trephine
was successfully aj)j)lied t(j lh(^ fractured parts for the removal
• •f depressed bone, and a musket ball. A case occurred in the
practice of Stall-Surgeon Cooper at Waterloo, whore there was

WOUNDS OF THE HEAD. 327

no fracture, but where the success was very remarkable. The
patient had been struck, as stated by Mr. C, with a musket
ball on the right parietal bone, which was exposed, and had no
appearance of being fractured; as, however, the symptoms of
compression were urgent, and the patient was in nearly a lifeless
state, he conceived it right to apply the trephine to the part on
which the violence had acted. He had not sawn long before
the external table came away in the hollow of the trephine,
leaving the inner table behind, which was not only splintcfred,
but driven at one point more than half an inch into the mem-
branes, and substance of the brain. No sooner were the frag-
ments taken out with a pair of forceps, than the man instantly
sat up in his bed, looked around, and began to speak with the
utmost rationality. It is a most extraordinary fact, that this
patient got up and dressed himself the same day, without leave
from the medical officers, and never had a bad symptom after-
wards.

T have been favoured by my friend Dr. Stewart, surgeon of
the 71st regiment, with a case which appears to me extremely
valuable to military surgeons, and which illustrates the applica-
tion of the trephine under circumstances of a still more iwnbi-
guous nature, where scarcely any clue to the existence of the
mischief existed.

Case XLIX.

Successful application of the Trephine for the removal of

Coagulated Blood.

" Michael Cavenagh, about 36 years of age, of rather a robust
habit, and sanguine temperament, and much addicted to drink-
ing, was brought from the guard room of a neighbouring village,
where he had been lying for 24 hours, under the supposition
that he was in a state of intoxication, on the evening of the

328 WOUNDS OF THE HEAD.

31st of December, 1815. His eyes appeared blackened all
aroQDd, and tbere was some degree of stupor, wbich was treated
as the effect of debauchery. He was ordered a strong cathartic,
and I expected to turn him out of the hospital on the following
morning.

" On the 1st of January, 181G, he appeared in a state of ex-
treme torpor, with partial abolition of the senses ; the weather
was extremely cold, he lay with his feet exposed and uncovered ;
he felt quite cold, and had a livid appearance ; pulse about 65,
and regular; countenance pale. On examining the head, the
whole scalp appeared puffy, and oedematous, but no mark of
particular injury; the cathartic ordered on the preceding even-
ing had produced one dark and fetid stool. Warmth was directed
to be applied to the feet, and the carthartic was ordered to be
repeated.

"In the evening the natural heat had returned in tiie extre-
mities, but he continued in a comatose state, answered questions
incoherently, and only when roused ; he expressed a degree of
sensibility on pressing on any part of the scalp, which was ge-
nerally much thickened, and pitted on pressure; this diseased
state of the scalp was most prominent on the right side, and
there was somewhat more ofecchymosis about the right eye than
the left, but no particular point to mark the existence of injury
underneath ; pulse still slower than natural, but more full than
in the morning; one free stool from the cathartic. Thirty
ounces of blood were drawn from his arm ; cold lotions were
applied to his head, and the cathartic pills were repeated.

'* January 2(1. — Appeared more collected, and less comatose;
state of the scalp much the same ; pulse about 84, and by no
means strong or full; no cdcct from the cathartic pills; they
were repeated, and the lotion was continued. In the evenin*"-
the intellectual faculties continued much the same; the pulse
was increased in fre(|uency, and there was more heat of skin ;
no evacuation from the bowds. The bloodletting was repealed,
and the cathartic pills were continued every two hours, aided

WOUNDS OF THE HEAD. 329

by a stimulating injection, until the bowels were freely open;
the cold applications were also continued.

" 3d. — Very copious evacuations from the bowels in the
course of the night, of a dark colour, and highly fetid ; frequent
horripilation in the morning; countenance pale and sallow;
oedema of the scalp diminished, and there appeared something
like irregularity on the surface of the right parietal bone,
towards its anterior and upper part ; the pupils were much di-
lated, and insensible to the stimulus of light, which had not
previously been the case; pulse 116, and small. The cranium
was examined at the most suspicious point; no fissure or frac-
ture could be detected ; the trephine, however, was applied on
the part, and thick coagula of blood appeared upon the surface
of the dura mater. Six applications of the trephine were ne-
cessary in order to make such an opening as was considered
sufficienlly large effectually to relieve the patient; * the effusion
was of great extent, and the coagulated mass of incredible
thickness and density ; as much as possible was scooped from
under the bones all around, and the distance to which the dura
mater was removed from the cranium admitted of this being
done with much freedom. The parts were dressed with simple
ointment, and the cold applications were continued.

" 4th. — The patient appeared relieved in so far that he was
more collected, with a diminution of the frequency of the pulse,
and less dilatation of the pupils ; free discharge of greenish-
coloured matter by stool in the course of the night ; heat of
skin rather below the standard of health ; during the operation
on the preceding day, there was a free discharge of blood
from branches of the temporal artery. Cold applications were
still continued to the head, and cold drink was freely allowed
him.

* It is not to be supposed that a perfect circle of bone was removed by each
succeeding apidication, (although more than half a circle became necessary,) the
object being to make the ojjcning as large as required, at The same time avoiding
as far as possible the formation of angles.

330 WOUNDS OF THE HEAD.

" 5^7i.— Disposition to fever; face flushed ; no horripilation ;
state of intellect much the same ; pulse about 100, and sharp
in the stroke; no stool for 24 hours. A cathartic was adminis-
tered ; venesection was repeated to deliquium, and the cold ap-
plications were still continued.

" Gth. — Thirty ounces of blood were taken away on the
preceding, and sixteen on the morning of this day, to check
the inflammatory symptoms which threatened ; after the last
bleeding he continued very low for some time; bowels opened
in the course of the night ; considerable thirst ; no discharge
from the wound, except serous matter, mixed with coagulated
blood ; pulse about 90; he appeared altogether more collected.

" 7th. — Passed a very uneasy and restless night, with much
fever. On examining the head, the scalp was found to be de-
tached from the cranium on both sides, in the line of the coronal
suture, with an evident fluctuation underneath. By an incision
in the line of the suture, vent was given to a considerable quan-
tity ot ill-condititmed matter, which flowed from under the
pericranium in the direction of the suture, and also through the
exposed part of the suture, which was quite open : — the parts
being in a sensible and irritable state, an emollient poultice was
applied over them.

" 8th — There was a free discharge from the head, and the
patient was much easier. Pulse 8G, regular, and moderate in
strength ; more collected and rational than before, but the
extent to which the cranium was separated from its covering,
a.s well external as internal, rendered the issue more than
doubtful. Up to this date has taken nothing in the way of
nourishment except rice water and tea. JJowels not perfectly
free; in conseciucnco of which, he was ordered a solution of
Epsom salts.

" 12//!. — From the date of last report, a free discharge con-
tinued from the licad, coming from under the scalp, and also
from within the cranium; the latter mixed with the remains of
the coagulated blood orij^iiially efluscd, and tlif former with

WOUNDS OF THE HEAD. 331

portions of slough. The divided edges of the scalp appeared
pretty healthy, although the nature of the discharge was still
indifferent. He now gave perfectly rational answers lo all
questions, though he was somewhat volatile when allowed to
indulge in conversation. Had a violent desire for tobacco,
which he was in the habit of using freely when in health.
Bowels regular; very weak, and much reduced in strength.
Pulse from 90 to 100 in the morning, and from 100 to 110 in
the evening. Allowed weak broth, bread, and a few potatoes
at his earnest desire.

" From the date of last report until the 22d January, the
state of the patient continued to improve, in so far that the
discharge diminished in quantity and became better conditioned,
and granulations began to shoot on the bone that had been
deprived of its covering. For some time the discharge of
matter from within the cranium was very copious ; it appeared to
come principally from the direction of the longitudinal sinus
and left side of the head. In consequence of the discharge
which was kept up from under the scalp on the left side of the
head, it became necessary to make a counter-opening over the
suture on that side, to give direct issue to the matter. The
man's senses appeared almost perfectly restored ; his appetite
greater than could be prudently indulged. Pulse very quick
and small; strength reduced much, but improving; in which
state, on account of the march of the regiment, it became
necessary to send him to General Hospital at St. Denis, near
Paris.

" From all that I could learn concerning this man, it ap-
peared that he must have received the injury on the night be-
tween the 27th and 28th of December, as on the morning of
the 28th he was picked up in the market-place at Versailles, as
was supposed, in a state of intoxication, as the troops were
marching off, and was placed on the baggage- waggon of another
regiment, which, coming in contact with the baggage of the
regiment to whit h \iv belonged, on the following day's march,

332 WOUNDS OF THE HEAD.

he was transferred to it, and arrived in the village in which his
company was quartered that night, when, being supposed still
to labour under tbe effects of drink, he was confined, as he was
a notorious subject for irregularities of the kind. Not recover-
ing, as men usually do, he was conveyed to the hospital at head
quarters, in the state that has been already noticed. On ad-
mission, from the account which was then given, and the habits
of the patient, he appeared to labour more under the effects of
long exposure to cold after a debauch, than of particular injury
of the head, and it was not till nearly twenty-four hours after
his admission that 1 was fully convinced of the existence of
some serious effusion on the brain ; when this was presump-
tively settled, it remained still uncertain at what point an at-
tempt was to be made to relieve the symptoms. The urgency
of the case soon demanded a trial, and it so far succeeded.
Here was no external wound, — no puffy tumour, — no evident
depression, — no fissure or fracture on cutting down upon the
bone. Tie patient appeared so low, and his feet so livid and
cold on the morning after he was received into hospital, that I
even ordered him some spirits and water, until, after a little re-
flection and re-examination, I began to suspect the true nature
of the case, and counter-ordered it. The quantity of blood
effused was great; the solidity of the coagulum unusual; the
extent to which it spread such that it was considered that no
effectual relief was likely to follow from a small opening. Even
after the instrument was applied, as has been mentioned, and
the coagulated blood scooped out all around with much dili-
gence, yet a great deal remained.

" The appearance of the puffy swelling over the suture, on
the second day after the operation, made me suspect that I
might have overlooked the real seat of the injury: on making
an incision to discharge the matter, nothing was found under-
neath but an open suture.

" By subsecjuent intpiiry, I was kindly informed by my friend
Staff-Surgeon Murray, thai the man recovered wilhout anv

WOUNDS OF THB HEAD. 333

exfoliation, or tiie occurrence of any remarkable circumstance
during- the rest of tbe cure. Some months afterwards I signed
his discharge from the regiment as unfit for service.

" While be was under my care, the discharge of matter from
within the cranium was such, that, for some time, at each dres-
sing, I cautiously pressed the dura mater inwards, changing the
position of the head, and it flowed freely over my fingers. The
separation of the soft parts from the bones externally, I conceive,
indicated a corresponding separation of the dura mater within,
yet no exfoliation followed."

1 have twice seen the trephine applied in private practice,
where there was no other indication for the point of its applica-
tion than the existence of paralysis on the opposite side of the
body; the symptoms of compression certainly justified the at-
tempt, but they were both unsuccessful; neither blood, nor
matter, nor counter-fracture were found on the side trepanned ;
no dissections were made to elucidate the real point of injury.

Counter-fractures are not by any means so frequent from gun-
shot or sabre wounds, as in tlie accidents of civil life occasioned
by falls from heights, &c. so common among workmen ; they
are sometimes met with, however, and are among the most
dangerous and unmanageable of the class. The two following
cases exhibit the effects of very extensive injury from falls. In
the first there was a counter-fracture diametrically opposite to
the point where the injury was inflicted, and it affords one of
the most complete specimens I ever met of fracture of the base
/ of the cranium. In the second case, the combined effects
of concussion, compression, and fracture, to a very great ex-
tent, are exhibited. Both the cases and dissection reports are
drawn up by Mr. Johnston, surgeon of the 88th regiment,
to whose zeal and accuracy I have been indebted on numerous
occasions.

334 wounds of the head.

Case L.
Of Coiinter-fraclure at the Base of the Cranium.

'* December 6th, 1818. — Last night, G. R. being very much
intoxicated, fell from the top of the stair leading to his barrack
room, consisting of seventeen stone steps. He is in a state of
complete coma, from which he cannot be roused by any means
that are used. The breathing is rather quicker than natural,
and in some degree stertorous ; it is performed, as is frequently
done in sleep, through the nose, but with the mouth open ; the
passage from tbe glottis through the cavity of the mouth being-
shut by the retraction of the tongue, and the root of that organ
being pressed against the velum and palate. Tbe pulse is
slow, (05,) full, and strong, but very irregular. He moans
frequently, and is restless, often lifting his hands to his head,
as if to remove something inconvenient or painful. He evinces
sensibility to pain, by groaning and by writhing his limbs when
bis head is pressed on to discover the seat of tlie injury. The
eyelids are shut, but when lifted up the eyes appear natural,
with this exception, that he does not seem capable of directing
them to any object ; nor do they afford any expression of
consciousness of the impression of objects that are presented
to them. The pupils are of their natural size, and the irides
appear to possess tlieir natural susceptibility of the stimulus of
light. There is a small lacerated wound in the integuments
covering the superior and posterior portion of the right pari-
etal bone, but witliout any tumefaction to prevent the most
accurate examination of the subjacent bone. Neither at this
point nor any other can any fracture or depression be disco-
vered in the bone- 'J'here is some bleeding from the nose, and
also a little from the right ear, but there is no appearance of
any cerebral substance with it.

WOUNDS OF TFIE HEAD. 335

" 1, P.M. — Thirty ounces of blood were taken from the
arm, in the morning. He has had no alvine evacuation since
he came in. General symptoms as last described. He was
now ordered a -large dose of calomel, and a purgative injec-
tion was administered.

" 4, P. 31. — The pulse is still full and sti'ong. There is
more restlessness and jactitation. The other symptoms remain
as before. The bleeding was repeated.

" 12, P. M. — About 20 ounces of blood were taken at 4
o'clock, when the pulse became smaller, and rather more fre-
quent. At present he seems to be in articulo mortis. The
breathing is feeble and difficult, several efforts being made to
inspire before an expiration is performed. The pulse is small,
indistinct, and tremulous. The pupils of both eyes dilated
to their utmost extent, and totally immoveable on the approach
of a strong light.

" lih. — -Died shortly after the visit last night.

" Appearances on Dissection. — As mentioned in the history
of the case, the only mark of violence which appeared exter-
nally was a small lacerated wound of the integuments over the
posterior and superior portion of the right parietal bone, with
some bleeding from the nose and right ear.

" On removing the soft parts covering the cranium, the right
temporal muscle was observed to be much bruised ; and un-
derneath it, the temporal and parietal bones were found to be
fractured in various directions, the fissures divereiner some-
what in a radiated form from a point a little above the meatus
auditorius. At this point a portion of bone was insulated by
the fracture, and loose, but no part of the bone was in any
degree depressed. The most extensive fissure ran in a di-
rection backwards and upwards, to near the middle of the
occiput. There was no fracture in the immediate neighbour-
hood of the wound in the interments.

" The upper part of the cranium being removed in the usual
manner, discovered that portion of the dura mater lining the

33C WOUNDS WF THE HEAD.

left half of the frontal bone, and which was diametricalh/
opposite to that in wliich the wound in the external integuments
was situated, tensely distended, and of a deep purple colour,
from the blood effused underneath it. The upper portion of
the dura mater being removed by a circular section corres-
ponding with that of the bone, a very considerable quantity of
coagulated blood was found upon this part of the surface of the
brain, and part of the cerebral substance itself appeared dis-
organized, and blended with this grumous mass.

" Having removed the cerebrum and cerebellum from the
cranium, that portion of the dura mater which lined the right
temporal bone, but more particularly the part of it at which
the various fissures converged, was separated from the bone by
a considerable quantity of blood effused between their sur-
faces. That part of the petrous portion of the temporal bone
which forms the roof of the tympanum was fractured in an
irregular manner ;* and from thence a fissure proceeded along
the basis of the cranium obliquely, inwards and forwards,
crossing the ala of the sphenoid bone, and terminating in the
cribriform plate of the ethmoid bone. No tumour or derange-
ment of parts was to be discovered in the internal structure of
the cerebrum or cerebellum."

Case LI.

Of Severe Concussion, Compression, and Fracture.

" Nov. 11 //i. — W. C, aged 30, having fallen over the rock,
endeavouring to escape from the garrison of Eilinimrgh Castle,
in a state of intoxication, was brought into hospital (II r. M.)
in a state of perfect coma, the breathing irregular, sometimes

• A small portion seemed depressed, the fracture running round it, so as com-
pletely to insulate it.

WOUNDS OP THE HEAD. 337

carried on with apparent ease, and then, without any obvious
cause, suddenly becoming laborious and stertorous ; the circu-
lation irregular, both in point of frequency and strength. He
has a wound in the integuments of the head, covering the
upper and posterior part of the right parietal bone. On
examining the bone, however, after dilating the wound suffi-
ciently for that purpose, it is found not to be injured. There
is a contusion of the superciliary arch of the right eye, by
which the eyelids of that side are livid, swelled, and closed.
No injury appears to be done to the ball of the eye. No
fracture nor depression of the bone can be discovered at this
or any other part of the cranium, on the most careful exami-
nation. A feeling of crepitation can be indistinctly felt in the
neck in the situation of the fourth and fifth cervical vertebrae.
No important injury appears to have been sustained by the
trunk or extremities.

" The pupil is capable of dilatation and contraction on ex-
posure to different shades of light, but its relations to that sti-
mulus seem to differ essentially from those of the healthy
state. Its contraction is not uniformly the consequence of an
increased intensity of light, but frequently dilatation occurs,
when we would expect its contraction, and vice versa. Nor is
this inverted order of things uniform in its occurrence, but
sometimes the one effect, and sometimes the other, is produced
by the approach of a candle to the eye. He has every five
minutes a slight spasmodic affection of the arms and hands,
extending them with a moderate degree of rigidity, and
bringing them obliquely over the sides and abdomen; this
terminates in a few seconds, and the muscles become relaxed
and motionless, till a similar spasm recurs. He seems very
sensible to the impression of cold, and shivers when the surface
is exposed to the air. He is sensible of some of the objects
of touch, as he not only moans on handling the bruised parts,
but is apt to have the stertorous breathing and spasmodic
affection of the arms excited by the slightest impressions ; as

338 WOUNDS OF THE HEAD.

applying the finger to feel the state of the pulse or the tem-
perature.

" 12</t, 2, A. M. — Every symptom continues in the state
described above. The pulse, though irregular, beats 115 in
the minute, and is considered to be sufficiently firm to warrant
the employment of venesection, or arteriotomy. About 16
ounces of blood were taken from the temporal artery, and the
pulse has since become slower, but more irregular. There is
less stertor of breathing, or spasm of the upper extremities.

" 4, A. M. — The state of coma continues, and the pulse at
the wrist is only felt as an obscure vibration, without any dis-
tinct beat. The stertor recurs at intervals as formerly ; the
extremities are warm, and the whole surface covered with a
gentle diaphoresis.

** 10, A. M. — No change in the symptoms since last report.
There is the same indistinct tremulous motion in the pulse at
the wrist; has frequently since admitted passed urine, but has
had no stool. Eight ounces more blood now taken from the
temporal artery, with the eflect of rendering the pulse per-
fectly distinct, though weak and unequal. There is also less
stertor in the breathing.

"\,P.M. — Kreathing continues calmer and easier, the
spasmodic alfection of the arms is less observable, and the
beat of the pulse is indistinct, though weak and irregular ; has
had no stool. A purgative enema was administered.

" 4, P. M. — The pulse continues very weak, but distinct;
surface soft and rather moist ; enema has been retained ;
breathing som(!times i)erformcd by the diaphragm and abdo-
minal muscles only, without any motion of the parietes of the
thorax ; at other times, the ribs are alternately elevated and
depressed, but without the appearance of much exertion. The
purgative enema was ordered to be repeated.

" 7, P. M. — The pulse more feeble, but still distinct; feet
and ankles cold, Tho pupil insensible lo the stimulus of
light, remaining fixed (tn the approach of a candle. The

WOUNDS OF THE HEAD. 339

enema was not repeated, as he had a plentiful stool, shortly
after the last report. Bottles of warm water were applied to
his feet.

" 10, P. 3/.— Pulse not to be felt, respiration performed
feebly, but in the manner formerly described.

" 13?A. — Died at 1 o'clock this mornins:.

" Appearances on Dissection. — On separating the integu-
ments and tendon of the occipito-frontalis muscle from the
cranium, they were fouud to be discoloured by effused blood,
particularly in that part covering the occipital and parietal
bones, indicating the parts on which the injuries had been
inflicted. When the top of the cranium was removed in the
usual manner, leaving the brain invested by its membranes, a
very small quantity of venous blood was found extravasated
upon the external surface of the dura mater, immediately
under that part where the external integuments had been lace-
rated by the violence ; the quantity was only sufficient to
spread over a surface of about an inch in diameter; it was
immediately in the course of one of the branches of the pos-
terior meningeal artery, going to a glandular-looking body
lodged in a small pit formed in tLe internal table of the cra-
nium, and was probably poured out by the vein accompanying
that artery. The dura mater was found to be separated from
the bone for a very considerable extent, from above the line
where the section of the cranium was made downwards on the
hind part of the head, to near the margin of the foramen
magnum ; and laterally on both sides to the petrous portions of
the temporal bones. The superior longitudinal sinus was
laid open, and only a small quantity of coagulated blood was
found in its posterior extremity. The dura mater was now
divided by a circular incision corresponding with the section of
the cranium, the falx separated from its anterior attachments,
and the upper part of the membrane turned backwards, ex-
hibiting the two hemispheres of the cerebrum covered by the
arachnoid coat and pia mater. The general appearance pre-

340 WOUNDS OF THE HEAD.

sented by tbis surface was a bright crimson blush uuiformly
diftused over the anterior and middle portions of both hemis-
pheres. This uniformity, however, was interrupted in the
lateral and posterior parts by the effusion of dark purple-
coloured venous blood, which, in the more anterior parts,
occupied only the spaces between the convolutions of the
brain, following; the processes of the pia mater to the bottom of
their sulci, while more posteriorly the surface partook generally
of this eflTusion of purple-coloured blood. On making a hori-
zontal section of the hemispheres, parallel with the plane of
the corpus callosum, the effused blood was found to have in-
sinuated itself into almost all the sulci, and in one part of the
anterior lobe of the right hemisphere, a small quantity of
venoDS blood was found effused into the medullary substance.
About one ounce of bloody serum was found in the right
lateral ventricle, and in the left a small clot of coagulated blood
was entangled in the plexus choroides. On turning back the
corpus callosum, the inferior surface of that body was ragged
and unequal, as if it had been torn from the subjacent parts by
some very sudden and violent shock. The fourth and fifth
cervical vertebraj were found to move on each other more
extensively than any of the others ; and in pressing these
strongly together, during the time the motion was performed, a
sensation of roughness was communicated to the hand ; on re-
moving the soft parts, however, over these vertebrae, no fracture
could be found of any of their processes, or connecting sur-
faces. Tlie interior of the spinal canal was not examined. It
is proper to add, that, previous to dissection, the arteries had
been tilled by an injection of wax and verraillion, which may
have contributed to, or even altogether produced, the fine
crimsoned appearance presented by the pia mater, on the ante-
rior and middle parts of the cerebrum."

Jn some cases of violent concussion of the brain from a fall,
as where a dragoon is unhorsed in a charge, we find that the
dura mater is very extensively detached from the bone, in the

WOUNDS OF THE HEAD. 341

immediate vicinity of the point which has first struck the
ground ; and that throughout its whole extent it can be se-
parated with the greatest ease, as if the head had been mace-
rated. No surgical aid can be of any avail in such cases.

Schmucker very particularly dwells upon the appearance
of pulsation in the uncovered brain, in all cases of fractures
or operations ; and has observed that it rose and fell more on
some days than on others ; and this state of pulsation regu-
lated his employment of the lancet. In the British army we
have been guided more by other circumstances ; but the ob-
servation of the Prussian surgeon should not be forgotten, as
it is indicative of the increased action not only of the more
superficial arteries on the surface of the brain, but also of
those at its base, on the pulsation of which the alternate
rising and falling of the cerebral mass depends ; neither should
it be lost sight of, that position may have a great effect on the
appearance of the brain, if the dura mater is removed ; for
the depending posture, favourable to the accumulation of blood
in its veins, oflen gives an appearance of turgescence in the
living subject, and misleads as to the existence of inflamma-
tion, in our examination of the dead.

While I have given so many striking instances of either no
ill effects whatever, or else a very slow approach of danger,
and a remarkable delay of its ac t ual occurrence after sabre
and musket wounds, I must not omit to mention some of the
more numerous instances where death occurs from these
accidents ; but I should very much deceive the inexperienced
reader, did I lay down separate or invariable characteristic
symptoms of each of those causes of fatality, which all seem
to have a combined share in the event: — rigors, fever, stupor,
derangement of the alimentary canal, affection of the organs
of sight, hearing, and speech, and general affection of the
whole nervous system, — come on either in succession or to-
gether, and cut off the sufferer. On dissection, the rupture
of blood-vessels, which can be traced bv the knife or injection ;

342 WOUNDS OF THE HEAD.

general oozing, not referable to any set of vessels ; the effusion
of purulent matter ; the throwing out of layers of coagulable
Ivmph ; — all afford instances of pressure from fluids; while
fractures and depressions ; separation of the inner table,
without any displacement of the outer ; and a variety of ex-
traneous bodies, — form the sources of pressure from solid
matters. Besides these, abscesses, and even gangrene, are
often detected making very extensive ravages in the substance
of the brain itself; while sometimes it must be confessed that
dissection fails in pointing out the immediate cause of the fatal
event. Examinations after death have also frequently shown
effusions of blood, fissures, and fractures, the existence of
which had never been suspected during life ; but which, if
affecting the basis of the cranium, are universally fatal. The
symptoms of these cases are extremely equivocal, and I am
not aware of any which characterize them more than any other
serious injury of the same kind differently situated, ex-
cept the effusion of brain from the external ear. The effusion
of blood I have observed in several instances, but I have not
found it necessarily fatal, which that of brain is.*

The brain is not unfrequently injured, and some of its
functions destroyed or impaired, by bullets passing below or
close to its basis, and inflicting wounds belonging to the class
of those of the face, though often supposed to be of the cra-
nium itself. In all these cases, the prevention of inflammation
and its consequences is the only rational attempt which we can
make at care.

Wounds of the head have attracted the attention of philo-
sophers and physicians from the time of Hippocrates. His
book on the subject is among the most interesting of his
writings, and has greatly occupied the commentators, from

• See an account of Dr. Thomson's communications upon this subject to
the ChirurRical Society of Edioburgli, in the Edin. .Med. and Surg. Journal,
Tol. TlH. p. 2fl0.

WOUNDS OP THE HEAD. 343

Vidus Vidius, who puhlished upon it at Paris, in 1544, down
to Bernardini Falciuelli, whose commentary appeared at Flo-
rence in 1658. The authors of the Arabian school were not
behind the Greeks in their investigations, and Lanfranc, Guy
de Khauliac, and de Vigo, followed in their steps. But an
author, in whose work all the knowledge of his predecessors
will be found concentrated, is Jacobus Berengarius, whose
treatise, " De Fractura Cranii," was published at Bologna in
1513, and has since gone through a variety of editions.
Another author who has written a most interesting work on the
subject, and whose memory has been rescued from oblivion by
the learned and ingenious Scarpa, is Carcanus, or Carcano
Leone : an epitome of his work is annexed to Scarpa's Memoir
on the Cutting Gorget, translated by Mr. Wishart, Edinburgh,
1816. It is to the moderns, however ; to Pott, Dease, O'Hal-
loran, and Abernethy, in these islands ; and to Petit, Quesnay,
and Desault in France, that we owe by far the most valuable
parts of our knowledge ; nor is the work of Schmucker, his
" Chirurgische Wahrnemungen," to be omitted. The cases
and observations contained in it are the results of long prac-
tice with the Prussian army, and a perfect acquaintance with
shot and sabre wounds, acquired in the field and at sieges.
Many interesting cases of these injuries will also be found in
a valuable paper by M. Bordenave, in the 2d volume of the
Memoirs of the French Academy of Surgery, and in the dif-
ferent volumes of the " Journal de Medecine Militaire," edited
by Dehorne, Paris, 1782, et ann. seq. and the " Recueil
D'Observations de Medecine Militaire," edited by Richard de
Hautesierck, Paris, 1766, et ann. seq. M. Larrey and all
the other French military writers abound in cases and obser-
vations on this important subject.*

• A very valuable paper on " Injuries of the Brain," by Mr. Brodie, will be
found in the 14th volume of the Medico-Chirurgical Transactions ; and another
by Mr. Rose, in the same volume, on the " Depositions of Pus and Lymph
occurring in the Lungs and other Viscera, after injuries of different parts of the
Body."

344

CHAPTER XVII.

OF INJURIES OF THE EYE, EAR, FACE, AND NECK.

The incised wounds of these parts require no peculiarity
of treatment, except that the antiphlogistic treatment in
wounds of the Eye must be most rigidly enforced, and that in
wounds of the Ear and Face, increased attention will naturally
be paid to prevent irregular union and consequent deformity.
In general, all the sabre wounds of these parts heal kindly.

The eyes suffer in various ways by gunshot wounds and
explosions. The natural mobility of the organ, the frequent
use which the soldier is obliged to make of it, without varying
the position (»f his body, and the different attitudes in which he
is placed in the loading, discharging, or aiming his piece,
occasion a great variety in the angles at which the ball strikes
the eye and passes along its orbit. After an action we meet
with one or both eyes partially injured, or blown completely
out; or the ball passing through the upper part of the nose,
and leaving an arch ; or removing it altogether; sometimes the
ball passes behind Ihem, destroying their power, either by
cutting the optic nerves at once, or causing their subsequent
inflammation and thickening. An additional proof of the de-
cussation of these nerves is afforded by the effects of gunshot
wounds of the eye; f^r in many instances an injury by a ball
inflicted in the neighbourhood of one, produces paralysis of the
other. Sometimes the ball enters straight forward, destroys
the organization of tlir <'y<-, and lodges in a variety of parts, in
the br.iiii, {\iv orbit, under the zygoma, or in the soft parts, and

INJURIES OF THE EYE, &C. 34&

sometimes its course cannot be ascertained during life. Pierre
Roussillier, of the 26th regiment of the line, in the service of
Napoleon, was wounded on the I8th of June at Waterloo. The
ball entered the right eye ; the left, though not in the
slightest degree injured to appearance, was completely blind.
Rare, however, are the cases where death does not follow all
wounds, particularly small punctured ones, going directly for-
ward into the orbit, as this did. I felt under the zygoma and
all along the neighbourhood of this poor fellow's wound, but in
the puffy state of the parts could not detect the course of the
ball; he himself was confident it had gone into his brain; he
returned to France convalescent. Garangeot (Traite des
Operations, vol. iii. Obs. 20.) gives us an interesting case from
the lectures of Petit, in which a soldier received a wound
towards the great angle of the eye ; it was deemed but of little
consequence, and healed under the common hospital treatment.
The man expressed a wish (o leave the hospital, although
cautioned by the surgeon, and had scarcely reached the door,
when he was seized with rigors, obliged to return, and died in
two days. On dissection, the ball was found lodged under the
sphenoid cells and the hole of the optic nerve. The effect on
this man's sight is not mentioned.

In some cases the ball passes into the orbit without bursting
the eye-ball, although the power of vision is totally lost. Of
this I had a case at Elvas, which occurred during the siege of
Badajoz, in 1812. It struck me at the time, as illustrative of
the mode in which, by the resilience of their coats distended
with fluid, the blood-vessels often escape injury when balls
pass close to them. A soldier of the 52d regiment was brought
into the operation room at Elvas, some weeks after being
wounded, for the purpose of having a ball extracted which
gave him excessive pain, impeded his respiration, and ob-
structed his deglutition; it prevented his speaking distinctly,
and kept up an irritation in his fauces, attended with constant
fiow of saliva, and a very frequent inclination to vomit. On ex-

346 INJURIES OF THE EYE, &C.

amination, it was found to be lodged in the posterior part of
the fauces, forming- a tumour beiiiud and nearly in contact with
the velum pendulum. It had passed in at the internal canthus
of the eye, fracturing the bone ; and, although blindness was
the instant consequence, the globe of the eye was not de-
stroyed ; and the remaining cicatrix and very inflamed state of
the organ were the only proofs that an- extraneous body had
passed near it.

In some cases much less injury is done to the eye than might
be supposed : of this the following case, which occurred to
Dr. Burton, then of the 36th regiment, now surgeon of the
66tb, is an example:

Case LII.

Of Musket-hall lodged under the Eye, without impairing

Vision.

December 1809. — During the retreat of Sir John Moore's
army towards Corunna, the 36th regiment having been engaged
skirmishing with the enemy in front of the town of Lugo, a
soldier of the regiment, who was left to cook the conpany's
dinners, whilst employed in that ofBce, at the distance of
about twenty yards in rear of a loose wall, of from two to
three feet in height, suddenly fell backwards, and as I chanced
at the moment to be employed near him, says Dr. B. I imme-
diately ran to him, and found that he had received a wound
running in a horizontal direction, under the left eye, above the
orbital margin of the superior maxillary bone, as if made with
a rough cutting instrument ; very considerable ecchymosis took
place, which was got rid of by pressure. I introduced a
probe, — plainly felt a foreign body lodged in the socket, which
was easily extracted by means of the common forceps. I found
it to be a musket-ball, llatlcncd so much as to resemble a

INJURIES OF THE EYE, &C. 347

piece of money, the cause of which evidently was, its having
first struck against a stone of the wall in front of the man. The
eye did not suffer in the least, although he underwent a very
distressing march that night in the direction of Corunna.

The followiug case, received from Dr. Pockells, is very in-
teresting.

Case LIII.
Injury of the Eye succeeded by Mental Derangement.

A hussar was wounded on the 18th of June, 1815, by a
musket ball, which penetrated by the left temple into the orbit,
and tore the globe of the eye from its cavity. The ball could
not be found. The eye hung from the eye-lid, and appeared
to be easily separated from the surrounding parts. The patient
was insensible for the first few days, but recovered on being
copiously bled. The wounds were simply dressed, and were
cured in three months. The patient has, in part, lost the
hearing of his left ear, and is constantly in a state of men-
tal derangement, without being entirely idiotic. He has be-
come very corpulent, an occurrence frequently observed after
wounds.

Balls occasionally take their course through the superciliary
ridge, and often penetrate through the lower part of the orbi-
tar process, and go out under the zygomatic arch, or lodge in
the antrum of Highmore, or in the nares ; or, finally, pass out
through the palate and into the mouth, or externally at the
throat. Of this kind seems to have been a case which made a
great noise many years ago, and obtained insertion in the Phi-
losophical Transactions. The ball entered by the right orbit,
and passed inwards. After a variety of exfoliations from the
wound, nose, and mouth, and the formation of several tumours
about the jaw, it was at last cut out (after thirty years' residence

348 INJURIES OF THE EYE, &C.

in the parts) near the pomum Adami.* Strabismus is not an
unfrequent occurrence from wounds of this kind so close to the
neighbourhood of the eye, and from the passage of balls from
one zygoma to another. I have observed also, but particularly
in a French prisoner, Joseph Fleche, of the 51st regiment of
the line, a fixed state of the eye-balls of both eyes, indicating
a paralytic affection of their muscles, with a dilatation of their
pupils; the dilatation was permanent; but on some occasions,
(not apparently connected with any external cause,) the globes
of the eyes evinced a considerable share of motion; the sense
of smell was entirely lost. No symptoms of injured brain fol-
lowed this wound. But in a soldier of the 28th regiment,
wounded in the same action, June, 1815, and same manner, but
more below the zygoma, the head was violently affected ; the
smell was instantly and permanently lost ; the hearing was im-
paired ; but the sight of the eyes remained perfect throughout
the cure, and so continued. A French prisoner, of the 63d
regiment of the line, had a ball passed through the right eye
in a direction straight inwards and lodged, site unknown. A
total paralysis, both of the pupil and muscles of the left eye,
ensued. In another, Dupre, of the 51st regiment of the line,
the ball entered the right temple, at the upper part of the
zygoma, and lodged. The sight of the eye was utterly destroyed,
although the globe appeared quite perfect to a superficial ob-
server. On looking carefully into it, the lower half of the
pupil seemed to be separated from the upper by a transverse
line formed by the edge of a floating mass, apparently coagu-
lated blood, The upper half appeared as if occupied by an
exudation of lymph. The pupil was so dilated, that scarce a
trace of iris was to be seen; it was barely marked by a coloured
circular line.

• See Phil. Trans, abridged, vol. v. p. '204, or vol. iv. p. 14, Part II. new
abridgment. For a case of a ball lodgi-d in llu- nares for 25 \ ear.<», see Ephem.
Nat. Curios. Cent. 10. Observat. 300.

INJURIES OF THE EYE, &C. 349

Diplopia sometimes, though rarely, takes place from gunshot
wounds in the neighbourhood of the eye. The following case
occurred in a soldier of the 33d regiment at Waterloo :

Case LIV.
Of Diplopia,

A. B. received a wound from a musket ball, which brushed
along the root of the nose, and onwards towards the right
eye-brow, but without producing any injury to the bone, and
so little general derangement, that the wound healed in a very
few days. Immediately on being struck by the ball, double
vision took place. I did not see him until the wound was nearly
healed. He then saw the double objects at the same moment,
and both with equal distinctness. Nor did his shutting his
eyes, and then suddenly opening and fixing them on the object,
or viewing it in an oblique direction, occasion any variation in
the appearance. He had been, I believe, a very dissipated sub-
ject, and abstinence, with occasional emetics, and cold collyria,
were recommended. In about two months the disease was
removed, but on running into some excess in drinking, it re-
turned again, and the wound burst out afresh; a recurrence to
a more rigid regimen perfected the cure in a fortnight, and he
was discharged entirely from hospital.

Diplopia, and other derangements of vision, also take place
in injuries of the head, where the eyes themselves are not at all
originally affected. I have seen it in many cases of injuries
of the head in various points, with and without depression of
the bones, or inflammation of the brain, or meninges. In Mr.
Hill's cases, we have a very curious, though short account of
it.* — A man had been under his care for some time with a

* Hill's Cases in Surgery, Case v. p. 108,

850 INJURIES OF THE EYE, &C.

severe injury, affecting the head generally, but his friends,
despairing of the possibility of saving his life, brought him
home. Repeated attacks of fever, iuflammation, and suppura-
tion of the brain, took place. " When the inflammation was in
the fore part, the candle appeared double ; when backward,
with a circle about it, but after the free eruption of the matter,
the candle appeared single and distinct."

1 have met with one or two cases of amaurosis from wounds
of the supraorbital nerve ; the perfect division of the nerve
produced no alleviation of the complaint, but, after some time,
the eye partially recovered. Scarpa doubts of the possibility
of the cure of amaurosis from this cause, and mentions Val-
salva's case as the only one on record. Mr. Hey, however,
states another in the Medical Observations and Inquiries, vol.
V. M. Larrey mentions another, vol. iv. p. 181 of his Memoirs.
Vicq d'Azyr, who gives a case of amaurosis from a wound of
this nerve, in the " Histoire de la Societe Royale de Medecine,"
Annee 1776, says, that he has since divided this nerve, in qua-
drupeds, but without producing any such effect.

In the unfortunate injuries of this delicate organ, very painful
consequences ensue, and fungi to a great size, and of a most
irritable nature, occasionally protrude. I have seen many
gallant men driven almost to desperation by the agony they
suffered, which nothing but large and frequently repeated doses
of laudanum could subdue. The means which I would recom-
mend are: First, if the globe of the eye is irreparably injured,
as in almost every case it is, at once to evacuate the accumula-
ted humours by a free and deep igcisioii. By this means, we
sometimes are enabled to extract the bullet, if it lies in or near
the orbit. The parts should then be covered with the lightest
and mildest possible dressings, and with cold applications,
although sometimes we find that warm fomentations, and some-
times cloths dipped in spirituous lotious, give most relief,
Fiuoly scraped lint, applied dry, will, in the lesser degrees of
fungous excrescences, serve to repress them; but if they become

INJURIES OF THE EYE, &C. 351

tronblesome, we must have recourse to a strong solution of
nitrate of silver. If inflammation runs very high after one co-
pious general bleeding, leeches should be applied, and conti-
nued, if the abstraction of more blood is necessary. I am con-
vinced that mischief, rather than good, has been often done in
the inflammatory afl'ections of this insulated organ, by profuse
general blood-letting.

In some instances the iris is disorganized by a blow, and
sometimes it is partially torn away from the ciliary ligament,
leaving a small chink, or artificial pupil, through which the
light is admitted to the bottom of the eye. Often also small
points of the sclerotica are absorbed, and appear as if detached
grains of gunpowder were strewed over the globe of the eye;
these accidents admit of no remedy; with them is to be classed
a tremulous motion of the humours seen through the pupil at
each motion of the globe of the eye, and which proceeds from a
dissolution of the humours, and a flimsy ragged state of the iris
itself. The pigmentum nigrum is sometimes forced ofl'in small
masses, and lodged in the anterior chamber, where their
presence gives rise to the sensation of " muscee volitantes;" by
time they are absorbed, and this sensation is removed. Cataract
also often follows wounds of the eye.

The bony circle, forming the exterior part of the orbit, is
often the seat of gunshot injuries, particularly the superciliary
ridges, the frontal sinuses, and generally the whole of the bone
in which they lie; and, I may here take occasion to confirm an
observation made bv the accurate Pott, as far as has come
within my own experience, that the injuries of " this bone
are, by no means, so cpmmonly dangerous or fatal as those
afliecting other bones of the cranium." Universal experience
has now pointed out the safety and facility of trepanning every
part of it, including the sinuses, in which balls are frequently
seen completely buried, with extensive depressions of the inner
table, which nothing short of the operation can remove.

352 INJURIES OF THE EAR, &C.

Almost all the systematic writers treat on the wounds of the
eve incidenlally. Pare has dedicated a chapter to them in his
10th Book. Casar Magatus, in his valuable work, " De Rara
Medicatione Vulnerum," also treats on them ; but Bohn, in his
very useful little volume, '• De Renunciatione Vulnerum," has
not mentioned them ; although in this work, and that of 3Ia-
gatus, already referred to, information on the injuries of almost
every organ and part of the body may be met with. Ravaton
and Percy give some observations upon the wounds of the eye ;
and a variety are accurately enumerated by Dr. Thomson, in
his " Report." I am not aware of any monograph upon the
subject.

INJURIES OF THE EAR.

The Ear is the subject of gunshot wounds as various as the
eye, in their course and in their eti'ects. The mastoid process
is injured sometimes in its whole extent, and sometimes only
partially brushed ; the balls, passing about it in every possible
angle, and sometimes appearing even to enter the external mea-
tus itself. At all events, injuring the bony circle primarily, and
in its conse(jueuces implicating the more internal bony sides of
the auditory canal, and small bones of the organ, in suppura-
tion and caries. These cases are attended with more or less
deafness, great pain, frequent spasmodic affections of the
face, and an intolerable fetor in the discharge ; and are some-
times followed by death from inflammation spreading to the
brain. Open bowels, abstinence, and strict attention to clean-
liness by tepid injections, are particularly called for on these
occasions.

The function of hearing is sometimes greatly impaired by the
passage of balls near the head, but I have met a case where the
external ear was com[)litely removed by a cannon ball, and yet
the sense of hearing is us acute as ever.

INJURIES OF THE FACE, &C. 853

Pare gives a very short chapter in his 10th book on the
incised wounds of the ear ; Hildauus gives some observations
on the deafness produced by the explosion of ordnance ; and
Sennertus dedicates the 5th chapter of his first book to the
-wounds of this organ. I am not aware of any special treatise
on the subject.

The sabre injuries of the external ear are very simple; even
when almost separated, this organ has adhered again by
proper treatment.

As a measure of safety, which prudence dictates, and expe-
rience fully justifies, in every wound connected so nearly with
the brain as those which I have been speaking of, a mild course
of mercurial physic should never be omitted, with the rational
view of completing the absorption of any effused fluids or
depressed bony points, that may still remain within the cavity of
the skull, and lay the foundation of future mischief; and also
to relieve the sympathizing viscera, particularly the liver, on
the discharge of the functions of which so much of the health
of our patient depends.*

INJURIES OF THE FACE.

Wounds of the Face attract our attention more' particularly
from the deformity with which they are attended, than from
any peculiar danger consequent on them, the great vascu-
larity of the parts favouring their union as soon as the danger
of hemorrhage is over. Those from sabre cuts, although the
most horrible on first appearance, yet, by the judicious use of
adhesive straps and sutures, and by the proper application of
supporting bandages, are frequently healed witbout much dis-
figuring the patient, especially where the parotid duct is not
divided.

• See some valuable remarks on this subject, in 2d Tolume of Transactions of
a Society for the Improvement of Medical and Chirurgical Knowledge, by Sir
Gilbert Blane ; and Cases in the 4th volume of the Medico-Chirurgical Trans-
actions, by Dr. Hutchinson.

2 A

354 INJURIES OF THE FACE, &C.

Case LV.

Severe Sabre Wound of the Face.

A most remarkable instance of this occurred to Captain

De H at the battle of Waterloo. My friend Stafl-

Snrgeon Dease dressed him on the field, and sent him into
Brussels to my care. The wound was from a sabre, which
struck him nearly across the eyes, one of which it destroyed,
and cut obliquely inwards and outwards, so as to admit of a
view of the pharynx. In the multiplicity of engagements, I
did not see him for several days, and not before a Belgian
barber had cut out the ligatures and removed the straps by
which the lower portion of his face was kept in position, and
had stuffed the parts with charpie. This officer recovered,
granulations spouting up at all points, and the deformity is by
no means so great as it was natural to apprehend it would
have been, the parts having been again brought into apposition
by straps and bandages, but with great pain to the patient, and
consequent delirium. The hiatus was so great, that Mr.
Dease was on this occasion obliged to sui>port the upper jaw
by morsels of cork put into the mouth, in such a way as to act
as fulcra, but admitting of the passage of liquid nourishment.
The cicatrix now forms one right line from ear to ear, the soft
parts united, but the bones not. This soft union occurs also
Hometimes in the lower jaw.

Injuries from musket-balls, although at first of little ap-
parent conse(jiience, arc eventually productive of great and
distrusting incorjveniences ; and those from fragments of shell
or round slutt often communicate their eflects to the brain,
particularly if they fracture the Jiialar prominence and parts
adjacent, while, if they injure the lower parts, the organs of
speech and of mastication are seriously and sometimes irre-

INJURIES OF THE TONGUE. 355

tjoverably affected. Great secondary injury is produced by
the frequent exfoliations of bone, and deep-seated formations
of matter, occasioned by a musket-ball passing through or
shaking the bones of the nose, or penetrating the maxillary
sinuses, the effect of which may be felt for years. The balls
often get partially split and entangled among the irregular
shaped bones forming the face and upper jaw, resisting all at-
tempts at removing them for years, until they have produced
by their irritation large puffy tumours, extensive ulceration,
and caries in the bones, and sloughing of the mucous mem-
branes which invest them. In all cases where it is at all
possible, the extraction should be made internally, to obviate
deformity. Spicula of bone will long remain after the ball is
extracted, which give rise to great irritation in the fauces
and nostrils, through both of which they for months continue
to be discharged, affecting the organs of taste and smell in a
very unpleasant manner.* Loosened teeth also form a great
source of irritation, and should be removed as soon as possible.
I have never seen the attempt to save them productive of any
ultimate good. In some cases, the ball has passed obliquely
downwards through the antrum, and has driven the tooth
before it, or has lain upon, and subsequently loosened it, and
has itself been readily extracted afterwards.

The Tongue often suffers from the passage of balls through
the mouth, or from bayonet thrusts, and will often heal with-
out any bad consequence, if not too much interfered with by
art. Indeed, it is astonishing how little beyond simple dressing,
quiet, and abstinence, is required in the most serious-looking
penetrating wounds about tlie mouth and cheeks. The elastic
nature of the soft parts forming the cheeks, admit of their
being brought into close apposition by art, even where there is
a large destruction of them ; but it becomes a very different

* In the case of a general officer, in which I was consulted for a circumstance
of this kind, I recommended the use of prepared charcoal snuff, which was em-
ployed with considerable relief.

2a2

356 INJURIES OF THE TONGUE,

matter if the bone, particularly the lower jaw, is either simply
fractured, or has sustained a loss of substance throughout.
The powerful, opposite, and frequently excited action of the
muscles inserted into it, render it difficult, if not impossible, to
prevent great deformity.

Wounds of the Tongue often heal with great rapidity. Its
functions are found, on after examination, to be injured in
proportion as the nerves which form the organ of taste, or
those which supply its muscles, are injured. Thus, I have
seen some cases where, after a gunshot wound had been long
healed, the patient has lost the sense of feeling and of taste
on one side of his tongue, and occasionally on both, while he
could speak, and masticate, and perform other motions with
that organ nearly as well as before his accident.

The following case occurred to my observation while ex-
amining the invalids who presented themselves at Edinburgh
on a levy of out-pensioners.

Case LVI.

Injury of the Tongue and singular Course of a Bali.

William Fulton, of the 1st regiment of Foot Guards, re-
ceived a wound from a musket-ball in his upper lip, at the siege
of Bergen-op-zoom in the year 1814; it struck him nearly
under the centre of the colunnui nasi, as he was ascending a
scaling ladder. The ball carried away six teeth of the upper
jaw, penetrated the tip of his tongue, and passed out exactly
above the tipper part of the thyroid cartilage of the left side;
it then, in its farllu-r pr(»gress, re-entered at his neck, pene-
trated the sternal portion of the left sterno-cleido-mastoideus
muscle, passing under the skin in a course directly downwards,
and lodging in the st«.'rnum at the distance of about three
inches from the point where it last entered ; — it was cut out
almost immediatelv.

LOWER JAW, &C. 357

On receiving this wound, the man immediately fell from
the ladder, with a sense of excruciating pain in, and loss of
motion of his tongue, at the same time a violent hemorrhage
occurred from the orifice over the thyroid cartilage. It was
five months before his wounds wei*e perfectly healed.

I examined Fulton in December 1819. He then complained
of a constant sense of coldness in the left half of his tongue,
which is drawn to the right side of the mouth ; his lower jaw
was very powerless ; in other respects, he was in good health,
and the sense of taste was not at all impaired.

In some horrid cases, where the Lower Jaw is swept away
by a cannon-shot, life has been preserved by the endeavours of
art, aided by a sound constitution ; but, in general, the patient
sinks under the accumulated tortures of his situation.* It is
still, however, our duty to try every expedient; and, after the
ragged parts and splinters of bone are removed, the vessels
within reach secured, and the suppurating process fairly estab-
lished, we may endeavour to assist nature, faithfully following
any effort she may make to fill up the chasm, but without
allowing ourselves to count upon a showy or complete cure.
By strict attention in this way, I saw a horrid-looking case,
where nearly one half of the face was carried away by a round
shot at Waterloo, in very fair progress of contraction, under
the care of my friend Staff- Surgeon Roach.

In injuries of the Lower Jaw-bone, if the fracture is not
complete, little more need or can be done, than removing the
splinters and loose teeth, and taking away exfoliations, to
which it is particularly liable. If the bone is fairly divided
into two portions, the best chance of avoiding great deformity
is to apply the lower jaw closely in contact with the upper,

* M. Larrcy's case of Louis Vaute is so curious, and so amjilj' illustrative
of the powers of nature, seconded by art, that I beg to refer to his book, now
translated by Mr. Waller, surgeon of the navy, p. 130, where the ingenious ,
mode of feeding the patient through an elastic tube, and of covering his de-
formity afterwards, by a metallic mask, are fully shown.

358 INJURIES OF THE PAROTID DUCT,

which, in this case, must be viewed in the light of a fixed
splint, supporting the part by a properly adapted roller, with
a compress over the fractured points, and giving the patient
the strictest injunctions to keep his mouth closed. His food
must be altogether fluid, and his wants and wishes conveyed on
paper, or by signs.

The various nerves that may be injured in wounds of the
face, give rise to a great variety of paralytic and spasmodic
affections and distortions, which do not come within the power
of art to remedy. I have seldom met hemorrhages about the
face that were not very readily relieved by the ligature of the
small vessels, or graduated pressure applied either to the
Wound or along the artery implicated ; still less have I ob-
served any requiring the experiment of tying the carotid trunk,
although such necessity has occurred to others.* In simple
incised injuries of the parotid duct I have in a few instances
derived advantage from making the division complete by a
clean incision across and into the mouth, and closely bringing
together the edges of the wound on the outside of the cheek.
The natural flow of the saliva into the mouth has rendered
the wouud on that side (with the occasional aid of a little lunar
caustic) indisposed to All up. We are, however, often disap-
pointed in this fortunate result, particularly after gunshot
wounds, and a constant dribbling, with depositions of tartar
around the wound, succeeds. Pressure upon the duct, so as to
obliterate it, or at least to obliterate its point, has been pro-
posed, but the practice is very dubious ; excruciating pain and
imuxense swelling of the parotid gland, with a general oedema
of the neighbouring parts, almost constantly succeeding. An
ingenious proposal ha.s been stated and practised by the French
surgeons to prevent the uncleanly dribbling cif saliva, viz. the

• Sec Mudico-Lliirurgifiil TranMiclioiis, vcl. vii. papi-r hy Staff-Surfffoii
Collier. I wiUiCbhcU the euro, lliougli not ijic optration. Il aiipeand i)cr-
r«;ctly <:oinplcU.

NOSE, FAUCES, &C. 359

obliteration of the secreting gland altogether, by compression.
This, it is said, is done with perfect safety, and the other ghind
completely supplies its place by an increased secretion. I have
never tried the experiment ; but I doubt the fortitude of pa-
tients in g-eneral to bear the necessary pressure.* The opera-
tion of the seton, usually recommended in systems of surgery, I
have not employed.

Wounds of the Nose by sabre cuts should be placed in as
favourable a situation as possible for adhesion; or if the car-
tilage is much injured, the nostrils should be kept properly
dilated with a canula, sponge, or charpie, so as to preserve the
rotundity of the passage, while the parts are compressed in-
wards by proper bandages, &c. I must refer to Mr. Carpue's
work on the subject of the formation of a new nose, in cases
where the original one has been cut off, for details as to the
practice to be adopted ; but I may remark, that I served in the
same corps with one of his patients, who lost his nose from the
employment of enormous quantities of mercury, administered
for an affection of his liver, without the smallest reason to sus-
pect the existence of a venereal taint.

Fragments of bone and teeth are sometimes driven far into
the soflnd parts ; and if the fauces or tonsils are engaged, great
irritation follows. A very curious case of this kind is now
before me, which I hope my friend Staff-Surgeon M'Leod of the
York Hospital will give more at large. An officer had the
lower jaw fractured, and several teeth knocked out, at the
storm of St. Sebastian. After a variety of sufferings, he is now
in perfect health, and serving in the army ; but in the posterior

* See Desaultpar Bichal, torn. ii. p. 218, and Gariot, Traite des Maladies de
la Bouchc, Svo. Paris, 1S05. The gland itself has been operated upon by Dr.
Palmer. Medico-Chirurgical Journal, vol. i. p. 457 ; and by Mr. Gooillad. Me-
dico-Chirurg. Trans, vol. vii. Part i. p. 112, See also a paper by Mr. Percy,
Bulletin de la Faculte de Medeciiie, ISll, No. 3. For some valuable observations
on the subject, I vyould particularly recommend the study ol" Burns on the Surgical
\natoniy of the Head and Neck, Edinburgh, ISH,

360 INJURIES OF THE NECK,

part of his fauces there is lodged a substance, whether a frag-
ment of jaw-bone, or a tooth, cannot be now determined,
around which an extensive osseous mass, perceptible to the
eve, and to the probe, is thrown out. A recollection of Mr.
Hunter's experiments on the transplantation of teeth incline
me to the supposition, that a tooth is the nucleus of this depo-
sition.

Pare gives a few short notices on wounds of the face, and its

different parts, in his 10th book ; and Wiseman treats of them

in his 5th. Ravaton gives some instances of external injuries

cured ; and Deschamps, in the 3d vol. of the Journal de Mede-

cine Militaire ; and Bouillard, in the 4th vol. of the same work,

give two remarkable cases ; the first of a transverse sabre

wound, opening the frontal sinus and lachrymal canal ; the other

of a longitudinal wound, from the same weapon splitting the

face from the root of the nose to the bottom of the chin. 13oth

these extensive wounds were healed by proper bandages, and

adhesive straps, without the use of sutures. Simon published

at Paris, in 17G5, upon the diseases of the tongue, in which he

gives an instance of gunshot injury of il. Pibrac, in the 3d

vol. of the Memoirs of the Academy of Surgery, proposes a

species of pocket bandage for the wounds of the tongue,

more curious than useful. In the same vol. Duphenix, Morand,

and Louis give some excellent observations on the fistuhe of

the salivary canals; and in the 5th vol. of that great work,

Bordcnavc has aflorded several instructive instances of injuries.

of these parts.

INJURIES OF THE NECK.

It is only from a consideration of llu; parts of the Neck, as
Ihey form one complete and synipatliizing whoh', ihat we can
deprive any rational views of the syn)pt«>ins that may occur from
its injuries, or any satisfactory explanation of them after they

INJURIES OF THE NECK. * 361

have taken place. The close and intimate connection of the
great vessels and nerves, and of the canals leading to the thorax
and abdomen, are such, that separate views of their affections,
however they may carry the appearance of minute accuracy
along with them, are more the objects of speculative calculation
in the closet, than the results of actual experience, and can
seldom be of any practical utility in the field or hospital.

Simple incised wounds on the back of the neck, although
sometimes penetrating to a great depth, and even uncovering
the vertebral arteries, are not beyond the reach of simple ban-
dage, and retention by adhesive straps and sutures ; feebleness
of the extremities, particularly the lower, are a more frequent
source of complaint in these cases than hemorrhage.

In the simple superficial gunshot injuries, no peculiarity of
treatment is required ; wounds which penetrate are, however,
productive of great distress, and very high degrees of inflam-
mation, the immediate or consequent effects of which spread
far and deep, and, besides the immediate lesion, draw into
sympathetic action all the adjacent parts. Hence arise rest-
lessness, oppressed breathing, cough, nausea, and great irrita-
bility of stomach, with various nervous affections, as aphonia,
hiccup, globus hystericus, and spasmodic twitchings of all the
neighbouring parts, from general affection of the complicated
and communicating nervous distributions throughout the cervi-
cal isthmus. Loss of power of the arm of the affected side is
also a very common occurrence in those cases, either instanta-
neously, or at a more remote period, as the cervical nerves
going down to form the axillary plexus may be affected prima-
rily, or at some time after the infliction of the wound; and all
these symptoms are accompanied by severe hemorrhages, which
are always violent, and but too often fatal, life being generally
extinguished in one or two pulsations of the heart, if the great
vessels are injured; but if the secondary, or still smaller class,
pour forth their blood, their natural refraction, or the fainting
of the patient, admits of surgical aid, or so far subdues the

362 WOUNDS OF THE THROAT.

disposition to subsequent inflammation, that life may be saved.
I omit saying any thing on the wounds of the jugulars, or ca-
rotids ; gunshot openings of tbem I hold to be so universally
fatal, that any exceptions may be looked upon as merely serving
to confirm tbe general rule.

The principles already laid down when speaking of first
dressings, and treatment of wounds in general, are equally ap-
plicable in the cases we are now considering ; it is unnecessary
to recapitulate them, or to enter at large into all the varieties
of injuries of the neck ; but as the following case exhibits a
combination of most of the circumstances tbat occur in severe
gunshot wounds of that part, I shall oiler it as illustrative of the
general doctrine, and the practice in those cases.

Case LVII.

Of Severe Gunshot [Vound of the Throat.

My friend, Lieut.-Col. A. C received a wound from a mus-
ket ball on the evening of the 18th June, at Waterloo. The
man who fired at him was so close, that he could perfectly well
see him, the distance probably about 70 yards. On receiving
the shot he instantly dropped, not, however, perfectly senseless,
but very much stunned. He felt as if he had received three
distinct wounds, the most severe of which he referred to tbe
arm of the wounded side, — the two others, of nearly similar se-
verity, to his throat and stomach, Jle was carried to the rear,
where a light dressing was applied by an hospital assistant, and
a very copious bleeding employed. He was then sent into the
city of Brussels, where ho arrived at two in the morning. On
bis arrival I was called to see him expire; and, truly, I did not
suppose he could possibly survive till daylight. The ball had
entered the sternal portion of the sterno-clcido-mastoideus of
tbe left sidf, about an iiu b :ibov<' its origin, lunl had passed in-

WOUNDS OF THE THROAT. 363

wards towards the thorax ; but no trace of its route could be
discovered. The wound had obviously discharged an enormous
quantity of blood, which also gushed copiously from it at every
effort to cough or vomit; symptoms which recurred at intervals
of ten minutes, and distressed him most severely; and which
had, as I afterwards found, taken place almost on the instant
of his wound. His left arm hung nearly lifeless, with a pulse
scarcely perceptible; that at the sound arm was excessively
quick, 120 in a minute, and feeble. I did not judge it prudent
to do any thing for him that night; and one of the assistant-
surgeons of his own corps arriving next morning, in whom the
greatest confidence could be placed, he was left in special
charge of him, with directions, on any appearance of rising in-
flammation, to bleed copiously, and to keep his bowels open,
and the skin perspirable.

' On the second day, when the bustle, consequent on the ar-
rival of the wounded, had subsided, I called upon him, and,
much to my surprise, found him comparatively calm, sensible,
and free from any pain in the wound; but, with such an op-
pression about the scrobiculus cordis, and, indeed, all along the
course of the diaphragm, that he urged me to cut for the ball,
as he was certain, he said, it was the source of his pain. He
even laid his finger upon a spot below the right scapula; but
after examining the part minutely, I could see no justifiable
motive for hazarding an incision. He spat up a florid frothy
blood very copiously, and the same issued occasionally from
the wound. The efforts to vomit, and spasmodic catchings
of the throat, with globus and hiccup, were very severe. He
had passed frequently and copiously, during my absence, a
pale, limpid, inodorous urine; his pulse, however, and his
general appearance, were improved. During the course of
this night, the pulse rose so high, and dyspnoea came on to
such an extent, that twenty-four ounces of blood were taken
from the arm.

364 WOUNDS OF THE THROAT.

Third day, symptoms as before, the belly did not answer suf-
ficiently to the enemas ordered, and he had, in consequence, a
saline purgative draught, which operated moderately; but
towards evening the pulse rose, the pain became torturing, the
dyspnoea almost sufTocating, the nervous symptoms ran very
high, and another copious bleeding of twenty-four ounces was
had recourse to, with relief.

On the fourth day, a new symptom was superadded ; his
voice, which we had directed him not to employ, except on the
most urgent occasions, was now lost altogether, and when ad-
dressed he pointed constantly to the course of the recurrent
nerves, so as to convince us that an affection of them was the
cause of this privation. His other symptoms, if not better, were
certainly not worse. As he had not closed his eyes in sleep since
the receipt of his wound, he had an anodyne this evening of
tinct. opii gtt. xxv. vin. antim. gtt. xv. from which he had some
refreshing slumber. On the fifth day, the cough and spitting
of blood lessened much, and the retchings were less frequent;
urine copious, and limpid; bowels free.

On the morning visit of the sixth day, I found the hfemop-
tysis altogether gone; but on the night of that day his suffer-
ings were dreadful, the vomiting, dyspnoea, globus, and uni-
versal uneasiness and restlessness, rose to a pitch almost in-
tolerable. His face was extremely (lushed, and almost purple.
His pulse got up to 130, hard, and bounding; carotids throb-
bing violently. Thirty ounces of blood were taken during the
ni<,'ht, but with little relief till towards morning, when I found
him Ijathcd in perspiration, which was encouraged by acid
diluents, and tlu; occasional exhibition of the li(|. amnion, acet.,
with a few drojis of vin. antim. He continued rather easier for
the two succeeding days, when the symptoms becoming again
violent, he was copiously bled to twenty-four ounces, from which
Im» derived inimediato ease. The blood on this, as on all the
loriner occasions, exhibited a thick huffy coat. From this day

WOUNDS OF THE THROAT. 365

his recovery of voice, strength, and appetite, and tlie removal
of all his painful symptoms, became progressive, and only
interrupted by occasional costiveness, or some trivial symptom,
easily removed. His regimen v^^as most rigidly abstemious,
and his drinks diluent, and moderately acidulated.

On the thirtieth clay, while asleep, he was seized with a
violent vomiting, which came on in convulsive jerks, by which
such quantities of acrid bilious matter were thrown up, that
he was nearly suffocated. His speech again became suddenly
affected, and he uttered several incoherencies, of which, how-
ever, he was sensible; and, as he himself expressed it, after
his paroxysm was relieved, (by a draught of ether and tincture
of opium in some aqua pioiento,) " his tongue would not obey
his reason." His arm, which had, after the first twenty-four
hours, given him occasional uneasiness, and in which he felt a
prickling sensation on the inner side, was particularly painful
at the period of this spasmodic attack. It had been wrapped
in flannel, and gentle friction had been employed to it; but,
upon examining it more particularly, it was found somewhat
shrank, and the fingers cold, and nearly insensible to pres-
sure. At this period, the wound, which was simply covered
with an emollient ointment, was perfectly healed ; but no trace
of the ball could be discovered, although the Colonel positively
averred that it was below the scapula. On the thirty-first day,
the arm was not so painful; his spirits were excellent; his
appetite craving, and he began to move about. In a fev/ days
he was able to visit his wounded brother officers in the neigh-
bourhood ; and, before the expiration of July, he received leave
of absence to proceed to England. By a subsequent personal
communication with him, I found that his health had gone on
progressively improving.

M. Larrey recommends immediate free scarification as a
means of preventing the paralytic nervous affections consequent
on wounds of the neck, which be conceives prevents irregular
adhesions of the lacerated nerves to the cicatrix. In such

366 WOUNDS OF THE THROAT.

cases as I have related, the nervous affection evidently pro-
ceeded from sympathy of the cervical nerves which form the
axillary plexus, of the phrenic, and, perhaps, of the par
vat^um, where no operation could be attempted.

The dressings on those occasions ought to be light, and the
approach of inflammation most assiduously watched; but I
would recommend great caution in the employment of antimo-
nials, which we find so useful in other cases, where the rigid
antiphlogistic plan is to be enforced. Their emetic or nau-
seating effects render their use at least ambiguous; and,
although they had no unpleasant effect in Colonel C.'s case, 1
confess I should not use them again in such another.

Cases have occurred where balls have passed between the
trachea and the carotid artery, and where an aneurism has been
formed. Acrel, in his cases,* mentions an instance of the kind,
where the cure was completely effected by pressure in the
course of six months.

Wounds of the Larynx and Trachea, if unconnected with
any of the neighbouring parts, or not attended with much
hemorrhage, are not peculiarly dangerous, although they are
very slow at times in healing. In the upper part of the tube
the cartilages sometimes become ulcerated, and throw out large
fungous excrescences, and hoarseness amounting almost to
complete aphonia, takes place. Emphysema is also a fre-
(juent, though not a dangerous symptom of wounds of this
description ; indeed, I have met with it oftener in wounds of
the larnyx and trachea than in those of the lungs, probably
because the action of the muscles subservient to respiration is
exerted in such a manner, as to send a current of air through
the larynx, whence it is driven forcibly iuto the cellular sub-
stance. Simple puncture is, in these cases, the best remedy.

In some cases of injuries of the Trachea, inflanunatiou takes
place in such u high degree as to spread by continuous sym-

• Chirurgiiickc Iliindvliicr, tivo. •S'tocklKilin, 177b,

WOUNDS OF THE THROAT. 367

pathy to the lungs themselves, and produce very aggravated
forms of pneumonic affection, and is often succeeded by a slow,
wasting, and painful disease, in many points and symptoms
strongly resembling phthisis pulmonalis. Dissection, in these
cases, shows inflammation, thickening, ulceration, and erosion
of the cartilages, frequently with concretions resembling spongy
bone thrown out on their surface. In a successful case of
tracheotomy, performed at Portsmouth by Drs. Denmark and
Johnson, a large mass of this nature was ejected by coughing,
and several of a similar kind were removed from the wound.
Instances also have occurred where, from a severe blow, some
of the rings of the trachea have been burst, and fatal emphysema
has been produced.

In dressing and examining these patients, we often find, when
great delicacy is employed, that the irritation is invariably
greater than when less ceremony is used ; and it would be well
always to keep this in view on applying remedies to the irritable
internal parts about the throat. A moderate sized morsel of
sponge immersed in our caustic solution, or whatever else we
may use to the sore, will give infinitely less irritation than the
more gentle, but more titillating camel hair pencil; and on the
same principle, a lump of food, conveyed by a tube or funnel,
will be more easily sent into the stomach than a more delicate
fluid injected by a siphon. The use of opiates is of great use
in these cases to allay the irritation of coughing, &c.

Wounds of the (Esophagus in themselves are not peculiarly
fatal; but, in common with all other wounds about the throat,
the connection of that part with many other important organs,
makes them highly dangerous; I have met with but a very small
number, and I proposed treating them on the same principles
as I would those of injuries of the intestinal canal. AH were
from gunshot, and all died from hemorrhage and severe irrita-
tion, long before I could try the use of the flexible tube, in
supplying them with food. Emphysema took place in one of
these cases.

368 WOUNDS OF THE LARYNX AND (ESOPHAGUS.

The following highly interesting case of severed larynx and
wounded resophagus was communicated to me by my friend,
Dr. Johnson of Portsmouth, now of London.

Case LVIII.

Of Wounded Larynx and CEsophayiis.

^' In the year 1805, while in sick quarters at Prince of
Wales's Island, in the East Indies, Mr. Stewart, an army-sur-
geon, and myself, were called up in the night to a man in the
suburbs of George Town, who had just been wounded in a
dreadful manner in the neck. On arriving at the spot, we
found the poor fellow weltering in blood, with an extensive
wound across the throat. Having secured two or three ar-
teries, which were still throwing out blood every time that the
man recruited a little, we examined the injury more accurately,
and found, to our surprise, that the larynx was completely
severed between the thyroid and cricoid cartilages; and, more-
over, that the oesophagus was laid open throughout half its
calibre. We learned that this man, who was a Malay, had
been playing at a game of hazard till late at night with another
Malay, from whom he had won several dollars. This so
provoked his comrade's ire, that following him to his abode,
and marking the place where he lay down to sleep, which was
before the door, in the open air, he first swallowed some glasses
of arrack, and tlien leisurely cut his comrade's throat in the
shocking manner related, with a large knife.

'* I confess we were at a loss what to do; for, when we
attempted to close the wound, he couUI not breathe at all. We
therefore left it open, keeping his head reclining forward, and
expecting that he would soon bo suflTocated. This did not
happen, however, for he breathed very well through the wound;
but his greatest suffering proceeded from thirst, as every thing
he attempted to swallow came through the opening. Wc tried

WOUNDS OF THE LARYNX AND (ESOPHAGUS. 3G9

to introduce liquids tiirougli a flexible lube, but we succeeded
very badly, ori account of the great irritability of the fauces,
trachea, and oesophagus. As there was great abundance of milk
to be had, he was put into a bath of this fluid several times
a day ; and glysters of various nutritious liquids were assidu-
ously thrown up. By these means, he was entirely supported,
during the space of eighteen days, and nothing but common
dressings were applied to the wound. At the end of this
period, the oesophagus became retentive when liquids were
taken ; and the breathing was beginning to be partly carried on
through the mouth. From this time he rapidly recovered,
excepting a considerable loss of voice, and power of articu-
lation."

A curious case is recorded by the learned and accurate Mr.
Percy, Manuel de Chir. d'Armee, p. 118, which occurred at
the Battle of Fontenoy, where a ball had entered the oesopha-
gus close to the thyroid cartilage. No search after it was
ventured upon, but on the 16th day it was passed by stool.

I am not acquainted with any monograph upon wounds of
the neck. Pare employs the 29th chapter of his lOth book upon
them. Wiseman gives only one case, and that of little interest;
and Mr. John Bell confines his observations to wounds, volun-
tarily inflicted and penetrating into the mouth. An interesting
case of wound of the neck, succeeded by hemiplegia, and.
another of gunshot wound of the throat, succeeded by paralysis
and convulsions, is given by Forestus in his Surgical Observa-
tions. Another, with loss of motion in the arm from a wound
of the neck, is to be found in the Edin. Med. Essays, vol. 1.
And in the Med. Commentaries by Dr. Duncan, vol, iv. p. 434,
and vol. viii. p. 356, are two very interesting cases. Mur-
sinna, one of Schmucker's successors, in his " Medic. Chirurg.
Beobachtungen," relates a case of removal of the thyroid gland
by a cannon ball ; the patient survived fourteen days, and died
of dysentery. Richard de Hautesierck gives an interesting
case in the " Recueil d'Observations," &c. vol. i. p. 48, where

2 b

370 WOUNDS OF THE LARYNX AND (ESOPHAGUS.

several nervous symptoms followed exposure to cold after a
woond of the neck ; and Verdrier, in the 3d vol. of the Me-
moirs of the Academy, p. 67, gives a very curious case of a
wound of the throat, and another of the abdomen, in the same
subject. Wounds of the oesophagus, as well as of the stomach
and bowels, often remain open for indeterminate periods. I
shall have to give some instances of the latter, when I come to
observe upon Wounds of the Abdomen. Trioen, in his " Fas-
ciculus Observationum," Leyden, 1745, p. 40, gives us an
instance of the oesophagus remaining open after a severe gun-
shot wound, in which also the larynx and trachea were
implicated. Staff-Surgeon Bruce gives a very interesting case
of a wound of the oesophagus in the Medico-Chirurgical Jour-
nal, vol. i. p. 369. The Essay on CEsophagotomy, by Guattani,
in the 3d vol. of the Memoirs of the Royal Academy of Surgery,
4to. edition, is very well worth consulting. A work of great
value on the subject has been published in German by Eckholdt.

371

CHAPTER XVIIT.

OF WOUNDS OF THE THORAX.

The obscurity which attends wounds of the head, and
renders their pathology so ambiguous, does not exist in an
equal degree in those of the Thorax. Its injuries are more
cognizable to the senses; the operations required for their re-
lief have nothing peculiarly dangerous in them, and the ne-
cessity for performing them is often clearly indicated by the
symptoms ; yet, with all these circumstances in favour of the
patient, and in aid of the surgeon, the wounds of this division
of the body are frequently as fatal as those of the head itself.
Like them, too, they naturally divide themselves into those of
the investing parts, and those of the parts contained ; but the
leading point to be attended to, is the great and dangerous
hemorrhages that may arise from them. Another point of
resemblance between wounds of the thorax and head, is the
lodgment of extraneous matters within their respective cavi-
ties, without producing immediate or eventual ill consequences.
In the examinations of the bodies of soldiers who have died
from those injuries, I have frequently found pieces of wadding,
of clothes, spicula of bone, and balls, (and, in one case, some
charpie used as a dressing,) either loose in various parts of the
lungs, or lying in sacs, which the exertions of the constitution
to free itself, had thrown round them by the medium of coagu-
lating lymph. In the more fortunate few who have recovered,
these matters have been discharged from the wounds, or ex-

2b 2

372 WOUNDS OF THE THORAX.

tracted from them by the surgeon. In some lucky cases, they
have been ejected by the convulsive efforts to cough, which
their irritation has occasioned.

In speaking of extraneous bodies generally, I have shown
how often a ball, striking the body, or a limb, will run round
under the skin, and appear to penetrate right across the mem-
ber or the cavity. By the deep-seated course which balls
sometimes take, the deception is rendered still greater. Thus
I have traced a ball by dissection, passing into the cavity of
the thorax, making the circuit of the lungs, penetrating nearly
opposite the point of entrance, and giving the appearance of the
man having been shot fairly across, while bloody sputa seemed
to prove the fact, and, in reality, rendered the same measures,
to a certain extent, as necessary as if the case had been
literally as suspected. The bloody sputa, however, were only
secondary, and neither so active nor alarming as those which
pour at once from the lungs when wounded. There is also
another source of deception, as to the actual penetration of
balls into the cavities or the limbs ; this is, where they strike
against a handkerchief, linen, cloth, &c. and are drawn out
unperceived in their folds, a peculiarity which has not escaped
M. Larrey, who gives an interesting notice on it in the
" Bulletin de la Faculte de Medecine," Paris, 1815, No. 2.
I have also given an instance in the preceding pages, (p. 3G.)
The following case proves, that a much larger mass than a
bullet will pass even through the lungs, without producing
death ;

Case LIX.

Extraneous Body passed through the Tliorax.

A soldier of the guards was wounded through the thorax at
Waterloo, between the J3d and 4th ribs of the right side. On
hitj arrival at Brussels, he was placed ii>an hospital and dressed

. WOUNDS OF THE THORAX. 373

by Assistant-Surgeon Reid of the 25th regiment, who has
favoured me with the case. Nothing remarkable occurred for
the first five days ; and the only singularity in the appearance
of the veound was its large size, capable of admitting three
fingers conically placed. Blood and air were freely discharged
from it. On turning the man to examine him and renew the
dressings, a tumour was discovered on the scapula, from which
was extracted his breastplate, about two-thirds of it rolled up
by the force of the blow into a figure somewhat resembling a
candle extinguisher, with the musket bullet contained within
it; the other third was broken off, but had also passed through
the wound and was extracted. This man survived for three
weeks, with great hopes of his perfect recovery; but on some
sudden gust of passion, to which he was very liable, he tore
the dressings off" his wound one night, and was found dead the
next morning.*

Balls have been found in the substance of the lungs after a
residence of twenty years there, the patient preserving a per-
fect state of health, and no peculiarity of symptoms denoting
their site.f There are on record, instances where the ball has
rolled about in the cavity on every motion of the body. These
cases are briefly stated by Mr. Percy, whose work is one of
vast interest on the subject of extraneous bodies, and may be
seen at large in Mangetus.;}: But it must be observed, that
these are deviations from the usual course of nature; for the
irritation of an extraneous body either leads to adhesive inflam-
mation or thickening of the parts around it, and it is thus shut
out, as it were, from the system ; or an involucrum of coagu-
lable lymph is thrown out, vessels shoot into it, and a sac is
formed. Where balls have lodged in the cavity of the thorax,

» He was carried to the dead-house, and Mr. Reid had no opportunity of
inspecting the body. Drs, Thomson and Somerville were shown tlie breastplate,
but the uian would not part with it, and after his death it was not to be found.

+ See Percy " Manuel," p. 125, and the aulhorities quoted by him,

* Bibliotheca Chirurgica, folio, (ieneva, 17-il.

374 WOUNDS OF THE THORAX.

Larrey recommends removing a portion of the upper edge of
a rib, with the lenticular, so as to avoid the intercostal artery,
and thus to make room for the extraction of the foreign body ;
this operation he has performed with success. (Memoires^
vol. iv. p. 259.) The ball, however, generally fractures the
rib so extensively, as to admit of its being removed by the
orifice through which it entered, which may, if necessary, be
enlarged ; in the 3d vol. of the Medical and Surgical Journal,
p. 353, an interesting case is given where an iron ball of 3^ oz.
was removed in this manner.

Balls or bayonets passing along or through the muscles
covering the chest and its vicinity, demand a peculiarity of
attention, solely from the danger of inflammation spreading to
the pleura, or the lungs and heart, or of troublesome abscesses
forming. In tliis view the very slightest are interesting, and
sometimes highly dangerous, particularly in persons disposed to
pulmonic affections. When a ball has fractured one or more
ribs, we must not be contented by enforcing a strict diet, but
we must call in the lancet to our aid, and keep the bowels
freely open with mild purgatives, and the skin in a perspirable
state by antimonials and diluents, aiding our endeavours wilh
a supporting bandage, and picking away any spicula of bone
which are within our reach. Balls sometimes lodge between
two ribs, but this is not a very common case, and by a proper
use of the forceps, occasionally employing one of its blades as
a lever, they can be easily removed. In every injury of the
chest, a firm elastic bandage is an indispensable assistant
in the cure; the motions of the ribs arc not only restrained,
but the parts are powerfully su|)portod l)y its application ; if
fracture has taken place in any of the bones, we have no other
m(;ans so perfect of retaining them in their place ; if a slight
degree of emphysema has occurred before we see the patient,
wc thus prevent its farther ilidusion ; and if we are called on
before it takes place, we may prevent the occurrence alto-
gether. The extent and tightness (if this bandage should be

WOUNDS OF THE THORAX. 375

such as to oblige the patient to perform respiration, as much
as possible, by the aid of the diaphragm and of the abdomi-
nal muscles; if there is a wound, an opening ought to be left
so as to permit of the usual dressings without removing the
bandage. These, however, are our most favourable cases.

Next in order, though not in frequency, are wounds opening
the cavity, but not injuring its contents, which is comparatively
a rare occurrence ;* for a ball or bayonet that has passed
through or between the resisting intercostal muscles or ribs, is
rarely prevented from penetrating farther, particularly if it
strikes in the intervals of the bone, and is driven directly
forward. To discover whether the wound has injured the
lungs or not, is a point which has given to the older surgeons
great room for the employment of their ingenuity in devising
possible cases, and has occasioned no small waste of time and
wax tapers in ascertaining the exit of air through the passage.
A practical surgeon will require but little investigation ; bloody
expectoration immediately on receiving the wound, and the
terrible symptomL' of dyspnoea, sense of stricture and suffoca-
tion, insupportable anxiety, and faintness, which succeed, soon
enough discover the fact ; and if by good fortune no intimation
is given in this way, happy is the surgeon, and thrice fortunate
the patient.

The immediate danger in wounds of the lungs is either from
debility from hemorrhage, or suffocation from the blood flowing
into the air cells and cavity of the thorax. The effusion of
air forming emphysema is also a troublesome, but taking it ab-
stractedly, is not a dangerous symptom of these injuries;
neither is it by any means so frequent as has been supposed.
The symptoms that I have now enumerated, whether single or
in combination, may be deemed the primary effects of wounds

* Among the exUaoidinary instances of recovery, there is a recent case where
the shaft of a gig passed between the sternum and lungs. See " An Accouut of
a Case of Recovery after an extraordinary accident," by William Maiden, 4lo.
London, 181*. Venesection to I'ilb. in ten days, saved the patient.

37G WOUNDS OF THE THORAX.

of the thorax ; violent inflammatory aflFections of the longs and
the membranes, ever subject to relapse ; long- and tedious sup-
purations, and exfoliations of the bones, are the secondary, and
though not so rapidly fatal, are often as certainly so as the
others. Diseases which, although we cannot strictly call them
pulmonary consumptions, agree with thetn in many points,
particularly in cough, emaciation, debility, and hectic^ are
often the consequences.

In whatever part of the thorax a ball, bayonet, or sabre strikes,
our first object is to diminish the quantity of circulating blood,
so vast a proportion of wliich passes through the contents ot
the cavity. On this the very existence of our patient depends ;
and we cannot from reasoning a priori fix any bounds to the
quantity to be taken, or determine the intervals at which it is
to flow ; our practice in both respects must be governed by the
effects. There lies a man with a wound of his chest ; the
blood is oozing from the external orifice in a constant, though
slow florid track ; in his frequent and painful efforts to cough,
it is thrown up in frothy arterial mouthfuls, mixed with occa-
sional clots ; his breathing is oppressed almost to suffocation ;
his pulse (juick, weak and fluttering; his eyes are starting from
their sockets ; his nostrils are distended in his efl'orts at relief
by inspiration ; and his extremities are cold, and often tossed
about in fruitless anguish. This wretched being must as-
suredly die if surgical aid is not promptly afl'orded him. The
mode which should instantly be adopted in such a case is as
follows. Without searching after balls or fragments of bone,
or attempting to ascertain the precise track of the bayonet or
the pike, or evpatiating (as I have seen done by some young
gentlemen fresh from their studies) upon the particular vessels
or their branches which may be injured ; let the man lay quietly
along, and lose from thirty Ui forty ounces of blood from his
arm, by a large orifice. This d(jne, we should remove the
cloths or handkerchief which may have been hurriedly put over
the wound to staunch the blood. If he has fainted during the

WOUNDS OF THE THORAX, 377

bleeding, or if we find bim in that state when we arrive, instead
of administering any cordials to him, we should put our finger
into the wound, and extract every thing within reach, whether
cloth, ball, iron, wood, splinters of bone, or clots of blood. If
the orifice is not sufficiently large, we must not be afraid of
making it moderately larger, by a cautious use of the probe-
pointed bistoury, or the sharp one with a small morsel of wax
on the end of it ; by this means we make way for the removal
of extraneous bodies, and may possibly discover the bleeding
orifice of one of the intercostal arteries, which sometimes are
cut, but ?iot at all so often as speculative writers would lead us
to believe. We now proceed to dress the wound itself. If it
is gunshot, a light mild dressing will be sufficient ; but if
incised, the lips should be closed at once; and this treatment
will be found to afford the most certain preventive to ernphy-
sema, future hemorrhage, or collections of matter. I scarcely
recollect an instance where it was necessary to remove the
adhesive straps, or (where it was gunshot) the usual dressings.
We now lay the man down, and let him remain as quiet as
possible, and in as cool and airy a spot of the barn, church, or
hospital, as we can find. He will often require no further aid ;
but if the case is very severe, he will possibly lie for some
hours in a state of comparative ease, till the vessels again pour
forth their contents, and induce fresh spitting of bloody froth,
and a repetition of all the symptoms of approaching suffocation.
The lancet must again be had recourse to ; and if, by this
management, repeated as often as circumstances demand, the
patient survives the first twelve hours, hopes may begin to be
entertained of his recovering the immediate effects of hemor-
rhage. In the after treatment of a wound of the nature here
described, we shall be considerably assisted by the aid of
medicine ; but until the danger of immediate death from
hemorrhage is over, we must not think of employing any thing
except depletion by the lancet; it, and it only, can save the
life of the wounded man.

378 WOUNDS OF TIJI-; thorax.

This immediate closure of the wound has been recently

adopted by M. Larrey with success. The practice is not novel.

John de Vigo, in the tenth chapter of his third book, has given

an account of it ; and Pare says that the practice is founded on

reason and truth, if there is little or no blood poured forth into

the cavity of the chest ; he, however, does not close the wound

for the first two or three days, to prevent accumulation of blood.

La Motte closed all wounds of the chest most accurately with

a tent; hence, perhaps, it is, that, in the whole course of his

work, he scarcely mentions emphysema. His history of the

secret dressing, which consisted in sucking out the blood, and

then closing the wound, is highly worthy of notice, and is given

with great fidelity in his " Traile Complet de Chirurgie,"

vol. iii. p. 20, Paris edition of 1732. But Belloste seems to

have done more practical good in this way than any other

French surgeon. He argues strenuously and successfully

against keeping the injuries of the chest open, in his " Chirur-

gien d'Hopital," and he sets a very valuable example to writers

of a more modern date; for, in a letter in explanation of Sau-

cassani's Italian translation of his work, he acknowledges his

obligations to honest old Magatus, who wrote nearly ono

hundred years before him.

When the paroxysms of pain, the sense of sufi'ocation, and
the return of hemorrhage, have become more moderate, and
occur at longer intervals, we may have recourse to means of
less immediate influence, and spare the lancet. In this view,
the most powerful medicine that we can administer is Digitalis,
in such form as may best agree with the patient; and if the
pain and efl'orls to cough are severe and spasmodic, we must
liave recourse to tiie ai»l of opiates. To this course of meiiicine
should be added Q rigour of diet, amounting to the total pro-
hibition of every thing solid, and admitting (j1 fluids only of
the mildest nature and least irritating quality; and even these
in small f[nantities and duly atitlnlattMl. Should we be for-
tunate enough to preserve our patient during the. first six or

WOUNDS OF THE THORAX. 379

seven days, a relaxation in this rif^our may be cautiously
admitted ; but a departure from the g^eneral plan, or an omission
of bleeding on the rising of the symptoms, can only tend to
accelerate the event that our efforts are designed to counteract.
Mild saline purges, and an emollient enema, should be occa-
sionally administered if required, and the patient kept in a
state of the utmost quiet and seclusion from all external im-
pressions, and in a cool atmosphere. Blisters are recommended
by Cooper, article Wounds, Rees' Cyclopedia, when much
cough and pain in the breast continue, after bleeding has been
fully practised.

In incised or punctured wounds, hemorrhage takes place
instantaneously and profusely ; in gunshot wounds, if the inter-
costal artery or lungs are only brushed, or some of the more
minute vessels opened, it is not so violent ; and we have rather
to prepare for what may occur on the separation of the eschars,
than to combat any existing symptoms, the general tendency
to pneumonic inflammation excepted. In the event of se-
condary bleeding from the lungs themselves, we are in possession
of no external means for remedying it ; but whenever the
tenaculum can be used to an injured intercostal artery, it should
at once be applied, and the vessel secured by ligature.* Un-
fortunately, however, we but too often are disappointed in
finding the source of hemorrhage; and here judicious pressure
is our only resource. In some very slight injuries I have used

* I have never met a case requiring the tenaculum, although such have been
reported by others. See Bell's Discourses on Wounds, pp.263, 264, 3d edition.
Plenck carried a needle round the rib of an injured intercostal artery, and
putting a tent under it, tightened the ligature so as to compress the vessel. The-
den, the Prussian Surgeon-General, tried the plan, but fatal consequences
ensued ; he, therefore, in future, trusted to pressure on the vertebral portion of
the vessel, first having cut it across, and then pressing it backwards with a tent
of agaric. The hemorrhage from these vessels is, in some irritable habits, and
where their bony covering is removed, much more profuse than could be supposed
from their si/e ; a general officer nearly lost his life in Spain from an accident
this kind.

380 WOUNDS OF THE THORAX.

the graduated compress with success; but if the sloughing is
extensive, nothing but the finger of an assistant, relieved as
often as occasion may require, and pressing direct upon a com-
press along the course of the vessel, or so disposed as to
operate upon its bleeding orifice, will be of any avail. In the
advanced stages of this and all other hemorrhages, when the
most imminent danger is impending, the face becomes pallid and
cadaverous, and bedewed with a cold clammy sweat, spreading
down the neck and chest, and giving the parts a soiled greasy
appearance; the lips are pale and quivering; the eyes glazed
and inanimate ; and the lachrymal caruncles remarkably sunk ;
as the danger increases, spasmodic twitches pass across the
face and the angles of the mouth ; the larynx is convulsively
elevated and depressed ; efforts of vomiting come on, and
general convulsion, or a sudden relaxation of the sphincters of
the anus and bladder, announce the approach of immediate
dissolution.

When I first entered on the practice of military surgery, the
fear of Emphysema actually haunted my hours of repose.
This fear I have often since witnessed in young men fresh from
their studies, and in their search after, and treatment of this
accident, they have been hewildered and embarrassed beyond
measure; the plain fact is, that it does not occur perhaps in one
case of fifty, and that in a great proportion of those where it
does lake place, under judicious treatment it is trifling. Some-
times, however, it is indeed tremendous in appearance, and
most distressing in reality.

In confined punctured wounds this crackling tumour is of
more frequent occurrence than in the free and open, and
spreads with great rapidity throughout all parts of the cellular
texture, the palms of the hands and soles of the feet excepted.
I have seen a case from a bayonet thrust in the breast, where
all distinction of chin, neck, and chest, were confounded in
one general and unbroken surface; and it has been found that
the air has cnfcrrd the more condensed crlbilar substance, form-

WOUNDS OF THE THORAX; 381

ing the envelopes of the different organs, and even into the
substance of the viscera themselves — one proper application of
the scalpel would have prevented it all.

The treatment of general diffusion of air has been supposed
to have remained in obscurity until the time of Dr. William
Hunter, who has given a description of emphysema, like every
thing else he has touched upon, of great elegance and correct-
ness ; and who has performed and recommended the only and
very natural remedy of letting the air escape by incision.*
But to go no farther back, the father of British military surgery
says,-|- " A footman was wounded in the left side; he coughed
blood, and discharged much by the wound. Some few days
after a tumour arising about the wound, I gave him a visit, and
felt the swelled part crackle under my fingers. Concluding it
wind got out from the cavity within the thorax, I made an
incision into the swelling about an inch long, by which the
wind was discharged."

In the case of effusion of air into one side of the thorax, or
into one sac of the pleura, the quantity must depend upon the
greater or less adhesion of the wounded lungs to the costal
surface, — a circumstance which is so frequent as to be scarcely
looked upon as morbid ; in whatever proportion the effusion
may be, the wounded lung is incapable of perfectly performing
its functions; did it dilate and contract by the inhalation and
expiration of air, it never could heal at all. Fortunately it lies
for the most part sunk, and always quiescent; and when the
wound, in its parenchymatous substance, coalesces, it gradually
extends so as to fill, as it originally did, the side of the thorax
to which it belongs. Whenever the orifice in the teguments is
open, the air has a free passage through it, and continues to be
forced out at every attempt at expiration, until the process of

* Medical ObserTations and Enquiries, vol. ii.

+ Wiseman's Eight Chirurgical Treatises, fol. ed. London, 1705, p. 349,
Observat. 4th.

382 WOUNDS OF THE THORAX.

adhesion has taken place, if not prevented by art. If the lung
lies collapsed at the bottom of the thoracic cavity, and that the
external wound is healed up before it has resumed its natural
inflated state, any small portion of air that may remain within
is soon decomposed or absorbed. In many cases, however,
where adhesion exists, or has subsequently taken place between
the wounded lung and the thoracic pleura, air in small quanti-
ties continues to be discharged through the external orifice,
(whenever the dressings are removed,) until it is perfectly
healed, without any serious inconvenience to the patient.

The sinking of the lung is not an uniform consequence of a
penetrating wound of the thorax. We have sometimes ocular
proof of this, not only by the close contact in which the lungs
lie to the wound, discoverable at first sight, but by protrusions
which occasionally happen, and which, in the bauds of the
older surgeons, were removed by the knife, — a practice now
rejected, and gentle pressure substituted. These facts are still
farther illustrated and confirmed by the observjitions of Mr.
Abernethy on the subject,* and the experiments of Messrs.
Hewson and Littre in the respective Memoirs of the Academy
of Surgery at Paris, and of the Medical Society of London.
When this sunk state of the lung occurs, it obviously reduces
a man to half his usual allowance of air ; it is, therefore,
(though not necessarily fatal,) a very hardy act of a surgeon,
who deliberately runs the risk of depriving him of the other,
by puncturing the sound side of the thorax. That the opening
both sides of the thorax at once has been fatal in man, ex-
perience has j»roved, and this when the o|)ening was made, both
by accident and with a curative intention; it must be confessed,
however, that, with all the experiments and facts before us,
there is still an ambiguity in the " philosophy of cni()liysenia,"
to use a term oi' Mr. John IJell's, hitherto uiiravcllod, notwith-

• Works, vol. ii. on Kin;ihyscimi, In Ricliitrund'ii lalu celebrated ctise of
KxciHioii of a porlion of tlio l{il)s, llic lung was forced towards theo|>ening.

WOUNDS op' THE THORAX. 383

standing hi^illustiations of the point. From experiments on
brutes we derive no satisfactory elucidation, for in some, where
incisions on each side have been made through the intercostal
muscles, much greater than the natural passage of the air, the
lungs, so far from collapsing, have puffed out, the animal has
lived, and in ten days ran about as well as ever ; and in our own
species, the recoveries from sword and gunshot wounds of the
thorax on both sides, larger than the orifice of the glottis, dan-
gerous as they are, are not a few.*

The distressing state of the respiration consequent on general
emphysema has led to a great anxiety on the part of surgeons
to remove it, and, where it has not been allowed to proceed too
far, incision or punctures, cautiously employed, will effectually
produce the evacuation of the air, and afford great relief to the
patient. The accident, however, can seldom proceed to any
great length with the proper use of the preventing bandage, and
the closing of the wound at once, as already recommended,
together with a free incision of the puffy tumour on its first ap-
pearance, as practised by Wiseman.

A still greater anxiety has existed on the subject of the air
contained within the sac of the pleura, and numberless means
have been proposed and adopted for its removal ; it was long
customary to take advantage of the interval between the termi-
nation of the expiration, and the commencement of the effort
to inspire, and then to form a valve of the teguments, as recom-
mended by the writers of systems of surgery ; but I have met
with so many instances in which the patient did well, by closing
the wound at once, and without ceremony, by a bit of adhesive
plaster and the preventing bandage, that I have long left all

* See Ravaton and Van Swieten's Commentaries on Wounds of the Thorax.
Forestus, Schmucker, Hemraan, and Schlichting, all concur ia testifying the fact.
Consult also " Hoadly's Lectures on Respiration, read before the College of
Physicians of London as a Gulstonian Lecture, Anno 1737. London, 4to. 1740;
where some curious plans and diagrams are given, illustrative of the effects of
opening both sides of the thorax.

384 WOUNDS OF THE THORAX.

attempts at extracting air entirely aside. Someti^jes, indeed,
it occurs, that an ofticer has some confused notions of respiration
and of the supposed state of the lungs from wounds ; and having
unfortunately heard of their being compared to a pair of bel-
lows, insists upon the necessity of great nicety and caution in pre-
venting the accumulation, and iu effecting the expulsion, of air,
by the application of air-pumps, &c. &c. I know one instance
•where death had very nearly ensued from gratifying the wishes of
a philosophic General in a whim of this kind ; but if cautiously
done, and that it amuses the patient or his friends, I would by no
means rigorously forbid it. Mr. Abernethy shows, that the air-
pump may be employed without harm, if not with advantage ; but
the blowing wind instruments, by way of puffing out the lungs
and forcing the air before them, is worse than useless; the
attempts are highly hurtful. Fortunately they are now scarcely
recollected, and the army surgeons of the present day are quite
convinced, that when their patients are capable of performing
such feats, they may discontinue their attendance.

Emphysema, on some occasions, is of a secondary nature, and
very obscure in its history and progress. A case, curious, dif-
ficult, and important in all its details, occurred in the military
hospital in Edinburgh Castle some short time since, with which
Dr. Thomson has furnished me, and which I shall briefly state.

Case LX.
Seco nda ry Emph i/sema.

George Gunn, i)3i\ regiment, was wounded at the attack of
New Orleans, on January 8, 1815, by a rifle bullet, while in
the act of firing his musket. The bullet entered on the left side
a little above and behind the articulation of the clavicle with
the scapula, and, anterior to the edge of the trapezius muscle
passed apparently across the back, and was cutout about 48 hours

WOUNDS OF THE TPIORAX. 385

afterwards from below and behind the acromion process of the
right side, havings attached to it a splinter of bone about an inch
in length. About ten minutes after receiving the wound, blood
flowed copiously from the mouth on turning from side to side,
and was occasionally brought up by hawking or coughing
slightly. Haemoptysis and acute pain of the left side of the
chest supervened, which continued about three weeks, and for
which he was twice copiously bled. Immediately, or soon after
the wound was received, air was discharged from the orifice,
and continued to be so while it remained open, with so much
force as to drive off the dressings. In about two months the
constitutional symptoms which supervened had abated, and he
gained flesh and strength ; and although, while the orifice of
the wound continued open, and allowed the air to escape, his
respiration was comparatively easy, yet, on exerting himself, he
was always affected with oppression and difticulty in breathing-.
During this time he continued under the care of the American
surgeons, but afterwards returned to England, and was received
into Chatham hospital in the beginning of June. The external
wounds, which had discharged, while open, several small spicula
of bone, had healed up a short time before his arrival. Some
time after, on using the dumb bells for the removal of a stiff"ness
in the shoulder, air was forced from the chest among the soft
parts on the left side of the neck, and the posterior part of the
shoulder, and was easily recognized by the emphysematous
crepitus. This spread considerably, became painful on pressure,
and his breathing was difficult, and attended with great pain in
the left side of his chest. He was bled copiously and repeatedly
during the peiuod of this affection, which occurred in November,
and an incision was made into the swelling, a little behind the
entrance of the ball, by which a large quantity of air and pu-
rulent matter were discharged, and the patient was almost
instantaneously relieved. The incision continued to discharge
air and pus for about two months, when it healed, and his health

3S(> WOUNDS OF THE THORAX.

being much improved he was discharged. At the expiration of
a month, air again began to be forced among the soft parts,
with the same crepitus as before, and a recurrence of dyspnoea
and pain. He was taking into the Edinburgh Infirmary for
these complaints, and, being relieved, went to the Highlands ;
but his complaint again returning, he was,, in the beginning of
July, admitted into the Depot Hospital.

Thus far the account is derived from himself, and from in-
quiries among the medical gentlemen who attended him. Tbe
following is the sum of the reports made upon him in the Depot
Hospital: — When he coughs or shuts the glottis,* and makes an
eflbrt to expire, a sudden croaking noise is produced, which
can be heard at a considerable distance, and, on placing the
hand at the root of the neck at these times, the soft parts are
felt to be suddenly distended, and to communicate a feeling of
crepitation, which continues at all times to a greater or less
degree in the neighbourhood of the wound. This noise and
the accompanying escape of air can be prevented by pressure
with the point of the finger in the course of the first rib, a little
above and nearer to the spine than the cicatrix of the original
wound. He has laboured under dyspnoea, with severe cough
and expectoration of mucus, streaked with blood. The dyspnoea
is much aggravated by the slightest exertion, and he frequently
complains of pain in the left side, as if produced by a cord
drawn tight from the shoulder to the lowermost rib of that side.
The position in which he lies easiest is on his back, with his
head and shoulders a little raised. The left side of the chest
appears enlarged, and emits, on being struck, a sound distinctly
more hollow than the right. His pectoral symptoms are always
aggravated in damp foggy weather. His llesh, since his ad-

• It is from this i)ower of sliutting tlie glottis, as explained by Dr. T. in his
Iccturi's on tliifi niul similnr niscs, tliat cniiiliyspma is so oftt'ii sprcail witli such
force and rnpidily ; the patient, catching his breath, forces the air still further into
the cellular substance.

WOUNDS OF THE THORAX. 387

mission, has wasted, bis strength has decayed, and he has been
in a state approaching to hectic fever. Opiates have been ad-
ministered, and occasional blisters applied, with temporary
relief. An incision into the swelling has also been made at the
root of the neck, but only a small quantity of air was discharged,
and little relief obtained.

Under all these unfavourable circumstances, Gunn sunk apace,
and died hectic. The following were the appearances on dis-
section : — On opening the chest, that cavity appeared to be
considerably diminished, and the lungs on both sides were found
adhering very firmly to the pleura costalis. The consistence of
those organs was firmer than usual; and when cut intoj their
air cells appeared to be almost obliterated. The ramifications
of the bronchiee appeared to be filled with puriform mucus. At
the upper and posterior part of the left side of the thorax, a ca-
vity was found existing between the surfaces of the pleura pul-
monalis and costalis, capable of containing from 10 to 12 cubic
inches of air. The inner surface of this cavity was lined with a
thick firm membrane of coagulable lymph, particularly strong
in the place where the lungs adhered to the parietes of the
chest; it contained only a small quantity of pus, which seemed
to have been secreted chiefly from the ulcerated surface of the
lungs, forming the parietes of this cavity. Two small openings
were observable at the upper part of the cavity, penetrating
through the pleura costalis, between the second and third ribs,
and communicating with an abscess which existed in the upper
and back part of the shoulder. It was obvious that the second
rib, a small portion of which was found bare, had been frac-
tured by the bullet which inflicted the wound, and that a con-
siderable quantity of callus had been thrown out on the re-
union of the fracture. The abscess over the shoulder was
immediately under the skin and cellular membrane, and ex-
tended several inches backwards and downwards from the
external wound. No distinct marks could be seen of the coarse
of the ball.

2c2

388 WOUNDS OF THE THORAX.

After the extraction of extraneous matters, and the cessatioa
of hemorrhage, it is still a question, among some surgeons,
whether wounds of the thorax should be dressed simply and
lightly, or kept artificially open by the introduction of lint in
the form of tents, &c. and of metallic canulas for allowing the
exit of putrid blood, matter, and air. From my own experi-
ence, I have no hesitation in giving the preference to mild
easy dressings, where it becomes necessary, from the formation
of extensive collections of purulent matter, or bloody sanies, to
keep the wound at all open. If the patient is placed in a proper
position, that is, with the wound in a dependant posture, (and,
in general, he lies by choice on the affected side,) the exit of
effused fluids is not necessarily impeded ; if they exist in large
quantity, the wound is effectually prevented from closing, by the
slate of general irritation in which the system is kept by tbeir
effusion, and by their pressure on the lungs ; if the flow is so
minute as to admit of the union of the wound, the quantity
effused is within the power of the absorbents to remove, and
will produce no constitutional effects. I have seen, among
foreign surgeons, tents and canulas so long continued as to give
rise to the very symptoms they were meant to remove, and to
become absolutely necessary to the patient's constitution; while,
in our own hospitals, where they are very little employed, I
have never seen the closing of the wounds followed by ill effects.
The case, however, becomes very different, when, from unab-
sorbed blood, or a wide spread pulmonic or pleuritic inflamma-
tion, a true empyema, or fluid collection, is secondarily formed;
or when, after all the dangers of the first stage are happily
subdued, irregular thills, succeeded by great oppression of
breathing, difficulty of lying on the opposite side, restlessness,
'jL'dema, and distortion of the chest, take place, and the pro-
priety and strong necessity of performing the paracentesis is
obvious. But even here, keeping the wound open for any
len^fth of time by a canula, is a practice so little followed by
tlie generality of British surgeons, that I am inclined to hesitate

WOUNDS OP THE THORAX. 389

upon its necessity. 1 have contented myself with the applica-
tion of a little lint, not so closely pressed in as to confine the
discharge forcibly, and gradually diminished as the discharge
has lessened.

If the symptoms of effusion of purulent matter succeed the
original wound within a short period, the site of the injury, as
chosen by some surgeons, is the most proper point of puncture.
If the Empyema is formed at a more distant period, the spot
of election, as it is called, or between the 6th and 7th true ribs,
is preferred. I should recommend a point considerably below
the original wound, as adhesions, either general or partial, are
apt to form in its neighbourhood. I have observed great relief
to follow this operation ; but I have also seen a removal of all
the pulmonic symptoms take place, and death very frequently
ensue shortly after the puncture. In the examination of some
of the bodies, I have met with abscesses in the very substance
of the lungs, completely out of the reach of any operation,
and not indicated by any peculiarity of symptoms during life.

Nature sometimes makes an effort for the removal of the
fluids effused in cases of Empyema, by distant channels, but
the instances are rare, and not often successful. M. Richard
De Hautesierck, in the Collection of Cases from the French
military hospitals, edited by him, (vol. i. p. 343,) gives an
highly interesting instance where the evacuation of a large
quantity of purulent matter, by expectoration, by stool, and by
urine, relieved an extensive empyema, which had succeeded a
wound of the breast. A case somewhat analogous occurred at
Brussels, where a French prisoner was wounded by a musket-
ball, which entered the thorax between the 8th and 9th. ribs,
at the distance of two inches from the vertebrae, and lodged in-
ternally, but in what situation was never afterwards known,
although some pains were taken to discover its course, which
was conjectured to have been through the diaphragm, for the
dissection showed an hernia of the stomach, through that
septum »Ato the thoracic cavity. This man lived from the 18th

390 JVOUNDS OF THE THORAX.

of June, the day of his wound, until the 1st of November, when
he died hectic. He had a discharge of about a pint of puru-
lent matter daily from the external wound, but it suddenly
ceased, and the stools became very frequent, with a large com-
mixture of pus, some time before his death. The thoracic
cavity exhibited only a slight ulceration on the surface of the
lungs, at the entrance of the ball, and a small sac, containing
a very little matter, similar to what was mixed with his stools
during life.

I have never had an opportunity of examining the lungs
after recovery from a severe wound. Where death has oc-
curred after recent slight wounds, thickenings, adhesions, and
the other usual consequences of inflammation are observed ;
but Sir Everard Home has given us the appearances on dis-
section, after a lapse of 32 years, in a paper in the 2d vol. of
the " Transactions of a Society for the Improvement of Me-
dical and Chirurgical Knowledge," p. 169, which is highly in-
teresting. An induration of the substance of the lungs was
formed wherever the ball had passed, its entrance was readily
discovered by a cicatrix, the membrane at that part being
thinner than usual, and having a puckered appearance, which
terminated in a central point. This part of the lungs had
not the slightest adhesion to tiie pleura, but was in its natural
detached state. The portion of lungs above the course of the
ball contained serum, and not air : it sunk in water, but was
not contracted in size : it had no communication with the
bronchia, the adhesive inflammation having consolidated all the
p^rts above the line through which it passed.

I should be unwilling to lull either a patient or a surgeon
into a false security, or to underrate the real dangers of any
case ; but I have seen so many wounds of the thorax, both from
pike and sabre thrusts, and from gunshot, do well ultimately,
lliat I cannot but hold out great hopes where the third day has
been safely got over; jor, though occasional hainoptysis may
come on, at almost any period during a cure, and its approach

WOUNDS OF THE THORAX. 391

can neither be entirely prevented nor anticipated, the more
deadly hemorrhages are usually within the first 48 hours ; and
yet, to this alarming symptom, when within moderate bounds,
the safety of the sufferer is often due.* I have met with many
cases, where, no surgeon being within reach, the spontaneous
and unchecked hemorrhage has saved the patient's life ; no at-
tempt at surgical treatment, except a very clumsy one, of
applying rags or handkerchiefs to the wound, by the patient or
his brother soldiers, having ever been made ; the bleeding has
ceased spontaneously, the wound has closed, and any extrava-
sation of either blood or air within the thorax has been absorbed.
I could produce a great mass of evidence upon this subject;
but I shall confine myself to one case, which will sufficiently
illustrate the point.^

Case LXI.

Penetrating Sabre Thrust.

" George Harman, aged 33, now hospital-serjeant of the
1 0th Hussars, received a wound through the lungs from the
thrust of a sword, in an affair with some French cavalry near
Morales, in Spain, on the 2d of June 1813, The sword entered
the thorax behind, close to the basis of the right scapula,
about the middle of its margin, and the point came out on the
edge of the sternum, betwixt the articulations of the 3d and
4th ribs of the same side. He immediately fell from his
horse, and soon fainted from loss of blood. In a short time he
recovered, and had power to raise himself, and to sit upon
the side of the road where he fell. In his removal to the village
of Morales, about one hour and a half afterwards, he again

* Dr. Gregory of Edinburgh, was in the liabit of stating in his Lectures, that
of twenty-six wounds of the thorax received at tlie battle near Quebec, two
only were fatal.

392 WOUNDS OF THE THORAX.

fainted from returning hemorrhage. When he had remained
qniet a short time the hemorrhage nearly ceased.

" I examined the wounds, (says Assistant-Surgeon Rogers,
who has favoured me with the case,) and found that situated
near the scapula rather more than an inch in extent ; that in
front was scarcely half an inch. On inspiration, the blood was
thrown out from the posterior wound to the distance of several
inches, in drops, so as to sprinkle my face when examining it ;
it was also forced out of the anterior wound in a frothy state.
Blood was thrown up by coughing ; the pulse was barely per-
ceptible ; a cold sweat had broken out : he was extremely faint,
felt great anxiety, and complained of much pain in the chest ;
no appearance of emphysema at either wound. The edges of
the wounds were united with adhesive plaster, and covered
with a compress of lint, and a bandage applied. This was
about three o'clock. At six in the evening the pulse had risen
a little, the pain in the chest had increased, but no further
hemorrhage had occurred. At nine o'clock, there had been a
return of hemorrhage, not very great, and it had now stopped ;
the pulse continued much the same. At six in the morning of
the 3d, I found he had passed a very restless night, but without
any return of hemorrhage ; his pulse was quick and small;
pain in the chest remained the same ; respiration more diflicult.
At nine o'clock no change of symptoms ; the bandage and
dressings had become loosened ; no emphysema round the
larger wound ; the edges of the smaller one were rather pulled ;
but tlu; little tumefaction which appeared proceeded chielly
from blood extravasated. The wounds were again dressed,
and I left him in charge of Mr. Pulsford, Assistant-Surgeon of
the 18th Hussars, to be removed to the general hospital at
Toro. He now (January I'^l?) feels no inconvenience on
moderate exercise ; but running or any violent exertion, causes
quick and painful respiration. 1 have one other remark to
make on his [)resent state. If the (ing(;r be applied to the site
of the j)05terior wound, a singular vibration is very perceptible

WOUNDS OF THE THORAX. 393

when be speaks, confined immediately to the spot. If it be
argued that the sword did not penetrate through the chest, but
that the wounds were by separate thrusts, I can speak posi-
tively to the contrary. This being the first time we met the
French cavalry, curiosity led me forward with the squadron
which charged. I was close in their rear, and saw this man
wounded after the enemy were broken, being scarcely twenty
vards from him at the time." So far Mr. Roofers : and I am
myself enabled to add the following fact. When I took
charge of the hospital at Toro, on the 9th of the month, seven
days after the action, I found Harman who was an active acute
man, giving every possible assistance to the other wounded,
both English and French, and performing the duties of an
hospital Serjeant ; no other dressing had been applied to the
wound but a slip of adhesive plaster ; and no morbid appear-
ance whatever had taken place. He had suffered a convulsive
fit of vomiting on two occasions after the wound was healed,
without any apparent cause, in which he had ejected a large
quantity of bile. He had another of these attacks some months
after, when the diaphragm was severely affected with spasm ;
but his general health when 1 saw him a few months ago was
excellent.

Injuries of a most serious nature are inflicted by wounds in
the upper and back part of the thorax without entering its
cavity ; but which produce dreadful laceration of the muscles,
splintered fractures of the clavicles and scapulae, and profuse
hemorrhage from the arteries running along these bones, The
sternum is often injured by gunshot, and fractures accompanied
with severe cough and enormous collections of matter are the
consequence. The patients often die hectic, but in good con-
stitutions, where the purulent matter is duly evacuated, and
all extraneous substances removed from the wound, life is fre-
quently preserved to a lengthened period. In some of these
cases, very large splinters of the sternum have been successfully
removed.

394 WOUNDS OF THE THORAX.

The injuries of the Scapula itself are not of a very serious
nature. Balls make a clean passage through its broad plate,
and the splinters occasioned by them are easily removed; nor
are the simple fractures of the Clavicle of great consequence
abstractedly ; but I have seen some of the most tremendous
wounds in which they have been implicated, and the inflamma-
tion and sloughing disposition spreading from them to the
thoracic viscera and to the shoulder-joint, have been produc-
tive of protracted tortures to the sufferer, rendering life a very
dubious blessing indeed.* The immediate preservation of
existence has, in the fortunate cases, certainly depended on
the profuse loss of blood ; and the antiphlogistic regimen,
with the utmost simplicity of dressing, has perfected the re-
covery.

The following appears to me an instructive and interesting
case :

Case LXII.
Severe Wound of the Lungs.

Lieut. -Colonel H. received a grape-shot of eight ounces
weight on the day of Waterloo, just as the action was decided.
The ball entered precisely under the centre of the clavicle of
the left side ; raised the periosteum into a few small flocculi,
and passed through the spine of the scajjula close to its neck,
lodging between the skin and his flannel waistcoat. Profuse
liemorrhage, incalculable as to quantity, but designated by his
servant and the surrounding soldiers, who had seen many hard
fought days, as " enormous beyond example,'^ instantly took

• A very remarkable case is noticed in the Edin. Med. Jour. vol. xi. p. I4<),
rommunicated by Dr. Malliday, surgeon to the forces, wlu-ru a 24 jiound shot
frarturud the bone extensively, exjiosing the lungs and perieardium, yet the
patienl-reeovcred.

WOUNDS OF THE THORAX. ^95

place. He lay for dead for some time. On bis recovery he
found himself in the hands of a foreign surgeon at a village ad-
jacent to the 6eld, faint, but collected ; his arm numbed and
immoveable, but very sensible to pain when touched. I
need scarcely say that he had been in extreme danger, when
the assistant-surgeon of his regiment joined him, shortly after
his wound. When he was placed under my superintendence,
on the 9th day, suppuration was fully established; and, on re-
moving the dressings, some few splinters appeared around both
the sternal and dorsal aspects of the wound. I was very curious
to see the state of the artez-y ; it lay awfully pulsating in situ,
(which uncovered arteries are not always observed to do,) bare
for about two inches in length, or I should rather say uncon-
nected, for its surface was studded with healthy granulations of
unequal size, from a pin's head to that of a pea; the plexus of
nerves was bedded in granulations ; the arm was stiff, and all
voluntary influence over it gone ; and the slightest motion in
dressing the parts was attended with exquisite torture. The
posterior wound was somewhat puffy, and a triangular piece of
the scapula, easily removable by the fingers, lay in it. No ac-
cident or interruption to the cure occurred till the 14th day,
when a most acute pain in the region of the kidneys, and fre-
quent ineffectual calls to make water, attacked him during the
night.* By warm fomentations, and the use of mucilaginous
drinks, this accidental symptom was removed. His cure then,
went on uninterrupted for some days; granulations of a healthy
appearance sprouted rapidly up in all directions; and the
discharge, though copious, was of a very bland nature, and
inoffensive in smell, until, in an unguarded moment, he was in-
duced to allow of the removal of the supporting bandage ia

* This affection of the kidnej', which the older surgeons imagined was a pro-
cess of nature, to carry off peccant matters, and for which they, therefore, pre-
scribed diuretic vuhierary decoctions, was here, I believe, entirely accidental; they
supposed there was a direct passage from the vena azygos to the kidney.

396 AVOUNDS OF THE THORAX.

which his arm had hung since the receipt of the wonntl. Im-
mediately after this the pain in the joint and all around became
almost insupportable; the whole upper extremity, and particu-
larly the fingers, became oedematous, numb, and tormented with
an occasional prickly sensation ; and the discharge was very
profuse and gleeting, with large drops of an oily nature floating
on it, which, both from appearance and from the spot whence
they flowed, there was every reason to suppose were synovial.
By restoring the arm to its former situation, and applying
emollient cataplasms, these symptoms were relieved ; and in a
few days, as this increased discharge had very much debilitated
him, he was allowed a more nutritive diet, with some English
porter. The healing process was soon re-established ; and, by
the use of adhesive straps, the edges of this great wound were
brought together, and a partial use of the arm was admitted of,
with every hope of its regaining its full powers. His general
health was completely restored ; and he returned to England in
the third month from the accident.

In another case, which occurred in the same action, a nine-
ounce grape-shot passed nearly in the same direction, and was
cut out beneath the clavicle ; the patient recovered. How the
arteries and nerves escaped in these cases, I cannot pretend to
explain.

There is a class of wounds in the neighbourhood of the Sca-
pula, which, though not of a threatening nature at first, yet
often and unexpectedly have a fatal termination. These are
principally occasioned by gunshot, but sometimes by punctured
wounds, which directly open the infra-scapular vessels, or cause
them subsecjuently to slough and pour forth their contents in-
ternally ; giving to the eye the appearance of very trifling he-
morrhage, but filling the whole sub-scapular space with blood,
which makes its way down to the very loins by infiltration, and
there causes deep abscesses and even gangrene. The long and
distant range of parts through which the blood passes prevents
the deluctiun of the cause immediately; and, indeed, could wo

WOUNDS OF THE THORAX. 397

even discover it, I am not aware of any effectual mode of se-
curing the bleeding vessels. In the cases I have met, the
blood has been effused in large quantities, and has descended
nearly to the sacrum, dissecting the interstices of the muscles
completely, and giving to the posterior part of the thorax and
the loins, that appearance said by Valentin to designate san-
guineous effusions into the sac of the pleura.*

The Supra-Scapular vessels are sometimes the source of fatal
hemorrhage when wounded. I have met with one curious case
in a French dragoon, who was wounded at the action of Morales
by a deep sabre thrust. He was reduced so low by repeated
bleedings, that when Staff-Surgeon Dease and myself saw him
all hopes were at an end. The wound had been secured by
the twisted suture and by compress, which had partially
stopped the hemorrhage. On examination after death, the
Supra-Scapular artery was found to be punctured, and an
aneurismal tumour, as large as an egg, was formed at the site
of the wound.

In many cases in military practice, when great injury has been
occasioned by guns, tumbrils, &c. running over a man, the
concussion alone is so great, that the functions of the diaphragm,
heart, and lungs, are for a while impaired, and sometimes actual
death takes place, without any very satisfactory explanation of
the cause being afforded by dissection. When the patient has
recovered from the immediate shock, inflammatory symptoms
often arise to a very high pitch. I have occasionally met with
herniary protrusions of the lungs from these causes, which have
been attended with no particular inconvenience, but have sup-
purated freely, and have been punctured like cases of common
abscess. But, in general, all injuries of the thorax lay the
foundation of a strong disposition to disease, particularly in-
fluenced by the state of the atmosphere, and approaching very
close in its nature to pulmonary consumption. Of this the fol-

* Valentin, " Recherches critiques sur la Chirurgie 3Ioderne," Paris, 1772.

398 WOUNDS OF THE THORAX.

lowing are the heads of a case, and the particulars of the
dissection, communicated by Mr. Reid, Assistant-Surgeon of
the 25tli regiment :

Case LXIII.

Phthisical Tendency excited by Injury of the Thorax.

'* J. G. of the 25th regiment of infantry, received a contu-
sion on the lower part of the left side of the thorax, from the
bursting of a shell, at Ciudad Rodrigo, which produced severe
pain, and occasional diflicuity of respiration. These immediate
consequences were removed by proper remedies ; but in some
time afterwards he was seized with a violent catarrh, in conse-
quence of exposure to cold on a coasting voyage. Dyspnoea
came on, followed in succession by cough, debility, emaciation,
and copious expectoration, until, after the usual vaccillation
between degenerating and improving health, death, in about
twelve months, terminated his sufferings.

" On dissection, the whole of the right lung presented exter-
nally the natural appearance, and no adhesions were formed
between the pleura pulmonalis and costalis, but two-thirds of
its internal substance seemed to consist of small hard tubercles.
The left lung adhered throughout its whole extent to the pleura
costalis and mediastinum, from both of which it was separated
with dilliculty; the lobes also adhered (irmly to each other; the
adhesions were very strong, and of a lirm dense membranous
texture ; the whole lung was of a dark livid hue, and consisted
almost entirely of tubercles, which varied in size from that of a
grain of common sized shot to the size of a filbert. Three or
four of the largest measured one inch in length, by Ihree-fourths
of an inch in breadth ; and, when laid open by the scalpel, pre-
sented a dark cineritious appearance. They were of a firm,
hard, consistence externally ; but when prcsbed upon, or rubbed

WOUNDS OF THE THORAX. 399

by the finger, communicated a friable earthy sensation. The
whole of the tubercles were uniformly hard and dense, and no
tendency to suppuration could be discovered in any of them.
Incisions into the substance of the different lobes of both longs
were immediately followed by an oozing of mucus from the
bronchiae, but no collection of matter, or any mark of recent
inflammation, could be discovered. The trachea, particularly
the lower part of it, and the larger branches of the bronchia,
were literally filled with a glairy tenacious mueus ; the capsule
of the heart contained about eight ounces of serum, of the na-
tural colour and consistence ; the heart was perfectly sound,
but remarkably small, and the parietes of the left ventricle were
three-fourths of an inch in thickness ; the outer side of the left
ventricle adhered firmly to the pericardium ; the adhesion was
of a circular form, and was about one inch and a quarter in
diameter ; the aorta ascendens was preternaturally hard and
dense, but no actual ossification had taken plaee.

A sense of stricture in the chest, and considerable pain on
raising the body to an erect posture, with great anxiety on walk-
ing up an ascent, are very frequent consequences of wounds of
the thorax after their cure ; and, in two cases lately under my
charge, great depression of spirits, and a very impaired stale
of the digestive organs, followed wounds in which the intercostal
nervous branches were implicated.

It may be observed generally of the organs contained in the
difibrent cavities, that, after any serious wound, their disposi-
tion to disease is very much increased, and causes which, in a
state of health, would have had scarcely any effect upon them,
operate very powerfully. In the head, the tendency to conges-
tion becomes so great, that phrenitis and mania follow any ex-
citement from heat, exertion, violent emotions, and especially
excesses in drinking. In the abdomen, hernia, local pains
darting around the affected part, irregularity of the bowels and
the stomach, borborygmi, gastrodynia, &c. &c. follow its in-
juries. The lungs suffer severely in the lesions of the thorax.

400 WOUNDS OF THE THORAX.

the slightest atmospheric changes affecting them powerfully ;
this coDsequeuce is almost invariable; yet there have been re-
marked instances where a naturally delicate, or even an actually
diseased state of the lungs, has been bettered by a penetrating
wound. An instance of this kind has never come under my
notice; although I have very respectable living authority to say,
that a strong predisposition to phthisis was suspended in one
case, and spasmodic asthma remarkably relieved in another, by
penetrating wounds of the thorax. M. Larrey mentions the
case of an officer cured of a well characterized phthisis by a
wound which penetrated this cavity. Memoires, tom. iii. p. 37C.
I shall now refer to some curious particulars of wounds and
injuries of the Heart. Ambrose Pare has, in the 30th chapter
of his 15th book, given all the information upon the subject
known up to his own day, and proving that they are not in-
stantly mortal. Lamotte has given cases in support of the same
opinion. Bonetus, in his Sepulchretum, book iv. section 3d,
treats on the subject; as does also the illustrious Morgagni, who
adds some cases to those collected by Bonetus, in the 53d
Epistle, article 27. Haller gives an instance of a needle found
in the heart of an ox, in his valuable " Bibliotheca Chirurgica,"
vol. ii. p. 378; and, by the kindness of Mr. Hammick, surgeon
of the Royal Naval Hospital at Plymouth, I have lately seen a
preparation of a pin lodged in the human heart, (but without
any trace of the mode by which it got there,) of which some
cases arc to be found in the references of Ploucquet. — The
patient had complained of pain in his chest, about three months
previous to his death, and died of carditis. Immense thickening
and enlargement of the organ, with extensive cflusion of coagu-
lable lymph upon its surface, and adhesion to the pericardium,
was discovered on dissection. In the last mentioned work are
to be found references to cases of balls lodged in the heart of
a stag; in the heart of a fresh healthy dog; and in the anterior
v«'ntricle of the human heart, where it is stated to have re-
mained for years. In the 12th vol. of the Edinburgh Medical

WOUNDS OF THE TEIORAX. 401

and Surgical Journal, p. 498, there is detailed an instance of a
ball lodged in the heart of a deer. M. Fournier, the learned
author of the article " Cas Rares," in the " Dictionnaire Des
Sciences Medicales," g'ives a case where a soldier, who received
a gunshot wound of the breast, was taken up for dead, a violent
hemorrhas^e having destroyed all hopes of his surviving. By
great care, the flow of blood began to diminish about the third
day; his strength insensibly increased; suppuration came on,
and many splinters of bone exfoliated. At the distance of three
months the wound was cicatrized, and the patient's health re-
established, with no other inconvenience than frequent palpita-
tions of the heart, which continued to harass him for three
years; they then became less troublesome for three years more,
when he died of a disease unconnected with the affection of
the heart. On dissection, the cicatrix was found to be very
deep, with loss of substance of the fractured rib. On further
examination, the ball was found lodged in the right ventricle of
the heart, near to its apex, enfolded in a great measure in the
pericardium, and resting upon the septum medium.

A very curious preparation of a species of herniary protru-
sion of a pedicle springing from the heart is to be seen in the
Anatomical Collection, founded by the present Director-General
of Hospitals, lately at York Hospital, but now at Chatham.
The following account of it has been furnished me by Mr.
Blackadder, who prepared it. It occurred in an English sol-
dier, who was severely wounded in the chest with a bayonet at
the battle of Waterloo. About three months after he was cured
and discharged from hospital, he (along with several of his
comrades) was attacked with pneumonia, and died under that
disease. Upon examination after death, the following morbid
appearances were detected : " On the left side of the thorax,
two inches below the ensiform cartilage, and immediately under
the cicatrix of the wound, there was a lump formed on the
edge of the cartilage of the ribs, evidently showing that the
weapon had forcibly injured that substance when the wound

2 D

40l$ WOUNDS OF THE THORAX.

was inflicted. In the diaphragm, at that part where the peri-
cardium adheres to it, and nearly in a line with the external
wound, there was a perforation extending into the cavity of the
pericardium, and of a size readily to admit the ring- finger.
Through this perforation there protruded a fatty pedicle or
tongue, of fully an inch in length, and about two tenths of aa
inch in breadth; its anterior surface being convex and some-
what lobulated, while its posterior surface was smooth and flat.
This pedicle did not adhere to the diaphragm ; but, on opening
the pericardium, it was found to arise from the anterior surface
of the heart, about an inch and a half from its apex. The
heart was of a larger size than it is usually met with ; and its
anterior surface, from a little way above the origin of the
pedicle to the base, was attached to the pericardium by means*
of long, broad, and strong ligamentous bands, which were
evidently the eftect of an attack of acute inflammation at a
period anterior to his last illness. His heart is still preserved,
and was one of the first that I put up when employed, in 1816,
in making the anatomical preparations at York Hospital."

Dilatations of the heart are sometimes occasioned by blows
upon the back or sternum, and the disposition to aneurismal
aflectious of the great vessels are produced in a similar manner.
I shall conclude this interesting subject, which I might easily
enlarge on, by referring to Guattani, " De Aneurismatibus,"
for an instance where a patient survived a wound of the aorta
for eight years ; and to " the Medical Records and Researches,'*
London, ITJJN, for a case of a penetrating wound, in which a
bayonet passed through the colon, stomach, diaphragm, part of
the lungs, and the right ventricle of the heart, and the patient
survived the accident for upwards of nine hours ; it is com-
municated by Ur. Rabington from the records of his Majesty's
Royal Hospital of Haslar. Nor should a very interesting and
learned paper, by a TVench arn)y surgeon, be forgotten ; the
author, M. Chastenet, surgeon to the Military Hospital at Lisle,
iu i'laudors, has collected various observations on the subject,

Wounds of thK thorax. 403

bat he gives five highly interesting cases, which occurred in his
own hospital. One is particularly detailed from the papers of
his father, in which a bayonet had penetrated into the right
ventricle. Life seems to have been preserved by the occurrence
of faiutness, a state in which the wretched sufferer remained
without nourishment for five days concealed under an old
staircaise. He died the 15th day after the wound, and the 10th
after his reception into hospital, where there can be little doubt
that his death was accelerated by mortification, which had taken
place in his lower extremities, from cold and a languid circula-
tion. On dissection, M. Chastenet found cicatrization completed
in both the lungs, pericardium, and heart, and no sign of eff'usion
in the surrounding parts. " Quel triomphe," he naturally ei-
claims, " pour la Medicine expectante! " this interesting paper is
to be found in the Journal de Medecine Militaire, vol. ii. In the
14th volume of the Edinburgh Medical and Surgical Journal is
given the history of a case, illustrated with a plate, where a
transverse opening about an inch in length was discovered,
penetrating the right ventricle, near the origin of the pulmonary
artery. On removing the heart, the ball was found in the
pericardium ; on tracing its course, it became evident that it
must have remained in the right auricle, as the tricuspid valve
bad a circular lacerated opening in it, near its attachment to
the muscular structure of the ventricle. The left side of the
thorax contained about two quarts of a serous fluid tinged with
blood; the lung was shrunk and adhered to the spine; the
pleura costalis exhibited strong marks of inflammation ; the
pericardium was thickened and distended, and contained half a
pint of the same fluid as that found in the cavity of the pleura;
the heart had suffered from inflammation, a thin coat of
coagulable lymph adhered to it, and near its apex was seen a
small coagolum of blood ; the contents of the right side of the
thorax were unaffected with inflammation. The patient, a sol-
dier of the Queen's regiment of foot, was wounded in Spain,
-came to England iu a transport, and died at Plymouth on the

2d2

404 WOUNDS OF THE THORAX.

14th day after he received his wound, under the care of Mr.

Fuge.

It must be confessed, however, that all these cases are rather
objects of curiosity, and extreme instances of what nature can
bear, than cases likely often to occur.

Of lesions of the Thoracic Duct, I shall not insult my readers
by treating-; the uncomplicated injury is barely possible, but
art can do nothing towards its cure.

Although every systematic writer has treated upon wounds
of the thorax, the French surgeons have been particularly
attentive to them from Pare downwards; and, in addition to
that great man, Lamolte, Belloste, and Ravaton, as military
writers, are well worth consulting, as also several papers in the
" Journal de Medecine JNJilitaire." Bordenave and Guerin'
have ffiven some excellent observations in the Memoirs of the
Academy; and Valentin in his " Recherches ;'' Guisard in his
" Pratique de Chirurgie ;" Petit in his " Traite des Maladies
Chirurgicales," and Sebatier in his " Medecine Operatoire," are
highly worthy of attentive study. Among the Germans, Hem-
man in his " Chirurgische Aufzatze," and Schlichting in his
" Traumatologia Novantiqua," Amstelodami, 1748, give many
instances of both sides of the thorax being opened without the
accident proving fatal; Schmucker, the great Prussian army
surgeon, has some interesting cases in his " Wahrnemungen;"
but Pechlinns in his " Observationum Physico-Medicarum, libri
tres," published at Kiel in 1G82, has given perhaps the most
minute diary on record of a wound of the chest, in which the
blood lost amounted to an enormous cjuantity. In this country,
Mr. John IJell has given an animated and interesting account
of these injuries, in his Discourses on Wounds; and Dr. llalli-
day. Surgeon to the Forces, has collected and detailed nearly
all the experiments and observations of preceding authors, willi
some cases of his own, in his work on " Eoiphysema."

405

CHAPTER XIX.

WOUNDS OF THK ABDOMEN, PELVIS, &C.

These injuries are extremely severe in their nature, and
very dubious in their results; like other wounds, they divide
themselves into those which affect the containing, and those
which affect the contained parts. In their treatment, the vio-
lence of symptoms is to be combated more by general means
than by any of the mechanical aids of surgery. The search
for extraneous bodies, unless superficially situated, is altogether
out of the question, except they can be felt by the probe, as in
Ravaton's case, (Chir. D'Armee, p. 241,) or in cases of lodg-
ment in the bladder, where they may become the object of
secondary operations. Enlargement or contraction of the original
wound, as the case may require, for returning the protruded
intestine, securing the intestine itself, and promoting the adhe-
sion of the parts, are all that the surgeon has to do in the way
of operation ; and even in this the less he interferes the better.
Nature makes wonderful exertions lo relieve every injury
inflicted upon her, and they are often surprisingly successful,
if not injudiciously interfered with.

In a penetrating wound of the abdomen, whether by gun-
shot or by a cutting instrument, if no protrusion of intestine
takes place, and this, it must be observed, in musket or pistol
wounds rarely occurs, the lancet, with its powerful concomitants,
abstinence and rest, particularly in the supine posture, are
our chief dependence.' Great pain and tension, which usually
accompany these wounds, must be relieved by leeches to the

406 WOUNDS OF THE ABDOMEN, &,C.

abdomen,* if they can be procured, by the topical application
of fomentations, and the warm bath ; and if any internal
medicine is given as purgative, it must, for obvious reasons,
be of the mildest nature. The removal of the ingesta, as a
source of irritation, is best effected by frequently repealed
oleaginous glysters; indeed, on tire first infliction of a wound
of the abdomen, the contents of the intestinal canal and sto-
mach are generally evacuated spontaneously by vomiting, and
soon followed by stools which are sometimes tinged with blood ;
their accumulation must be guarded against by a rigorous diet;
for, to the general state of fulness of the vessels induced by
food, is added its local and mechanical stimulus in the undi-
gested form. By this treatment, penetrating wounds, in which
several plicae of the intestines have been necessarily implicated,
have been happily cured. Authors abound with instances of
this kind, and I have seen several ; among others, I have been
a witness to the recovery of a soldier who had been shot through
the abdomen by a ramrod, which passed in anteriorly, and
actually stuck in one of the transverse processes of the vertebrae,
from which it was not disengaged without the application of
some force; this occurrence took place before Budajos in 1812;
it is to be hoped that the gentleman under whose care the case
fell will favour the profession with an account of it. Soma
instances are on record, and among them a remarkable one by
Garcngcot, and another by Lamotte, where a sword had passed
right across tho cavity of the abdomen without injuring a single
fold of the intestines, to which jwssibly this case may be
analog(ms.

The following cane, received from Dr. I'ockels, is as despe-
rate as can well be imagined :

" Tbeir applicutioii to the unus, so as lo uiilund the hicinurrltoidal vessels, is
Hiuch ]iractiHod on tlic continent, in Uuiibiu ctipi^cially, and is oftcu aMcadcd
Ml ill) rtmarkable relief.

WOUNDS OP THE ABDOMEN, &C.' 40t

Case LXIV.

Wound from a Grape-sliol jyassing through the Ahdomm.

A soldier of the Brunswick Corps was wounded on the 16lh
of June, 1815, by a grape-shot, which struck the right arm
near the cubitus, the articulation of which was destroyed. An
English surgeon amputated the arm some hours after. The
patient remained that night at Genappes. Next morning be
observed blood flowing through the bandages, and requested
Dr. Spangeuberg, Physician-in-Chief to the Hanoverian army,
to examine the arm ; this able physician found the humerus
split as far as the joint, and informed the patient that it would
be necessary to perform a second operation ; with the consent
of the man, Dr. Spangenberg extracted the head of the
humerus. After being dressed, the patient complained of
pain in the lower belly ; on examination, the grape-shot was
found to have passed through the anterior part of the abdomen,
and at the points where it had entered, and made its escape, a
portion of intestine protruded, not wounded or inflamed, but
in the natural state. The intestine was smeared with oil, care-
fully reduced, and the openings covered with adhesive plaster.
The patient was brought to the hospital of Laecken on the lUth
of June, with moderate fever, and very little pain in the ab-
domen, or in the wound of the arm. The functions of the
intestinal canal were not disturbed. He took no medicine, but
merelv light broths. Five days after the operation, the wound
of the arm presented a favourable aspect, and in four weeks
was cicatrized. The wounds of the abdomen were cured more
slowly, they were attacked with a slight degree of hospital gan-
grene after the wound of the arm was closed', but they healed
by degrees in the space of three months. At present the
patient only complains of pain in the abdomen during a change

40S WOUNDS OF THE AHDOMEN, &C.

of weather, or when he commits any irregularity of diet. He
receives a higher pension thao a soldier who has only lost an
arm, as he ought to be very attentive to his diet.

In some instances the ball, or a part of the weapon which
has inflicted the wound, remains within the abdominal cavity,
and is afterwards evacuated by the natural passages. The
subject of the following case I saw while under cure, and I
had afterwards an opportunity of examining him again, and
taking the account from his own lips.

Case LXV.

Musket- Ball passed by Stool.

Peter Matthews, sergeant of the 28th Infantry, received a
wound from a musket-ball in the abdomen, on the evening of
the 18th of June, 1815, at Waterloo. It struck hira upon the
right side, about one inch below the navel, and three lingers
breadth to one side. Scarcely a tinge of blood followed the
wound. He did not fall, but walked about 50 yards to the
rear ; from whence in half an hour, he was carried to a large
barn in the village, where he remained for three days, before
he was conveyed to an hospital at Brussels. During this
period, he was bled three times ad deliquium ; the first vein-
was opened about 24 hours alter the receipt of the wound.
On his arrival at Brussels, his principal complaint was inces-
sant straining to stool, for which he received daily glysters.
On the Gth day from the receipt of the wound, immediately
after an enema, he had an urgent call to the cIose-sto(»l, when
he passed a small-sized rille uiusket-ball, enveloped in mucus,
and unaltered in shape, except a small groove indented in it,
probably from cutting along the bayonet or ramrod of the
piece from which it was fired. The wound was perfectly
heahd by the tiCitli August following, without anv ill accident

WOUNDS OF THE ABDOMEN, &C. 409

or uncommon occurrence from the time of receiving it, except
that, during the course of the first night, he was sensible of a
sort of watery oozing, that moistened the linen placed on his
wound, particularly whenever he drank, which he frequently
did. This circumstance he was never after sensible of. He
joined his corps at Paris, but had not been more than ten weeks
there, when severe pain again arose in the bowels ; some bits of
cloth were passed by stool ; an abscess formed externally ; and
every symptom threatened approaching peritonitis, which was
relieved by active means, uiider the charge of Staft-Surgeon
Dease.

In September 1816, while attending on the Major-Geueral
in command of the south-western district of England, this man
was brought before me for inspection, and I immediately re-
cognised him, having seen him at Brussels, and noted some
particulars of his case on the spot. I examined him with Mr.
Eyrtt, the surgeon of his corps, and found the abdominal
wound perfectly healed, but with a strong herniary disposition.
His general health was good, but if he indulged in a full
meal he felt a severe pain in the part. He was subject to
obstinate costiveness, and if he allowed the bowels to remain
for any length of time in that state, the pain produced in the
abdominal region, and particularly in the wounded part, became
very severe indeed. The motion of his limbs gave him no
pain, although for some time after receiving the wound he
was obliged to bend his body in walking, and he performed
that movement with considerable uneasiness ; but if he stooped
or drew in his breath forcibly, he experienced very severe pain.
In all other respects, his general health and appearance were in
as good a state as before the receipt of the injury.*

* Other cases of a similar nature have come to my knowledge, and many are
to be met with in Ravaton, Schenckius, Mang:etus, and Hildanus. as quoted by
Percy ; to which I would add Pare, lib. 20, chap. 19. Sandifort, who gives
three instances in his Thesaurus, vol. ii. p. 1-20, and Sennertus, lib. 5, cap. 6,
pars +. A case is quoted from iliviere by Ploucquet, where u ball had entered

410 WOUNDS OF THE ABDOMEN, &C.

Balls sometimes remain in the cavity of the abdomen during
life. Botallus gives a case of this kind which occurred to an
armourer of Bergamo, in whom the ball entered a little above
the right groin. Botallus's rule, with regard to the search after
balls in penetrating wounds of the abdomen, is admirable:
" At si inveneris educas, quod si non sinito."

It occasionally happens that the ball lodges near the course
of some of the nerves, and hence the patient often becomes
subject to pain, numbness of the thigh and leg, obstinate cos-
tireness, and other derangement of the viscera. In a case
recently examined by me, the ball entered the right groin, and
passed inwards and upwards ; although the wound was received
fourteen years ago, the patient has suifered ever since from
constipation to such a degree, that he rarely, if ever, has an
evacuation, without the use of some laxative, an enema, or a
suppository. The right lower extremity is affected with numb-
ness, which, on any change of weather, degenerates into actual
pain.

Balls very frequently pass directly through the abdomen,
evidently wounding the intestines, but without occasioning any
protrusion of them at either of the orifices. These cases, like
all others of those parts, are extremely dangerous, but are not
necessarily mortal. They require the most guarded attention,
and the utmost watchfulness of the approach of inflammation,
which often comes on most insidiously, and as often insidiously
goes off, but not before the destruction of the patient is eflec-
tually sealed. The mildest possible application should be em-
ployed to the wounds, and no plugging with tents, nor intro-
duction of medicated dressings thought of. Sometimes the
efl'usion of the contents of the intestines takes place very soon
after the receipt of a wound ; in other cases, especially of
gunshot, it docs not appear until the eschars separate. In

the frontal «iiius, and was passed by stool. At the attack on Alf,'iers, a seaman
was woimdod over the ninth rib, and j'assfd the ball by sIdoI. See DcwarV
Thrsis, " l)c Vulniribus," lidin. IHIH, and Dr. John.son'.s Journal, No. IV.

WOUNDS OF THE ABDOMEN, &C. 411

either case, excessive inflammation is what we have to dread,
and the lancet alone is onr remedy, used, not at stated inter-
vals, or for measured evacuations, but unhesitatingly employed,
whenever pain and tension call for it, and continued until the
pain is moderated, or the fainting of the patient prevents its
further use. The intestine, although not primarily penetrated,
yet sometimes sloughs from a wound of the abdominal parietes,
and sometimes from the injudicious intrusion of art, par-
ticularly the insertion of setons. In all these instances an
artificial anus is produced. In fortunate cases, this unseemly
alternative is only partial and temporary ; in some, however, it
continues through life ; and most fortunate the patient may
consider himself to escape in this way, the establishment of the
new passage, being the test of his recovery from the imme-
diate dangers of the wound, any attempt to prevent this,
beyond cleanliness and moderate pressure, during the high
inflammatory stage, is extremely reprehensible, and endangers
life for the probability of preventing! nconvenience.
The following cases are worthy of notice :

Case LXVI.

Artificial Anus.

William Jackson, -Sd battalion Royals, received a severe
contusion from a splinter of a shell at the siege of St. Sebas-
tians, on the 25th of July 1813. It struck him on the right side
of the abdomen, at a point nearly central, between the spine
of the ilium and the umbilicus. He was put on board ship, to
be conveyed to the general hospital at Bilhoa, and on the
passage the contused part sloughed off", about six days after
the injury. On the first time of going to stool, and for
four months afterwards, feces proceeded from this point, but
none passed through the regular channel. He was placed
under my care in the last week of August. The following is a

412 WOUNDS OF THE ABDOMEN, &C.

statement of the appearances then observed : — On removing
the dressings, which he always did on feeling an inclination to
evacuate the feces, a circle of reddish-coloured skin appeared,
somewhat discoloured with a bilious tinge at its edges, the
circumference of which might be about three inches. In the
centre was a small puckered protuberance, or papilla, about
the size of the point of the little finger. When the feces ap-
peared, their exit was slow and uniform ; the papilla gradually
expanding, so as to admit of their passage; and, during the
whole time of their expulsion, a gradual e version of the coats
of the intestine took place, so as to give the appearance of a
fleshy ring. On the expulsion being completed, the ring regu-
larly and slowly corrugated itself, and was withdrawn inwards,
presenting, on a small scale, precisely the same appearances as
the rectum of an horse after dunging, The treatment was of
the most simple nature ; cleanliness, moderate pressure by a
pad and bandage of his own contrivance, and a regular diet ;
while, to solicit the natural discharge, I recommended the
occasional use of a suppository of Castile soap. About two
months after being receised into hospital, he, for the first time
had a stool by the regular passage, from which period the
artificial one began gradually to close ; and in about five
mo nths.it had contracted to less than a fourth of its original
size, being scarcely perceptible, and no feces issuing from it.
The general health of this man had not suffered in the smallest
degree, which, I think, was to be attributed to the adhesion
between the intestine and the abdominal parietes having been
completed before the sloughing took place, and the parts
became more exposed, and to the very mild and unirritating
ticatmcnl thai was subsecpiently adopted.*

* Dr. Cliarlos Fi)rbps, the principal nuitlical ollicor al Bilbon, under whom I
served as .StalT-sur>?i;on, ofttni saw prior .(ii(ksnii.---.\ very instructive case*
niiuli rirsi'inblinff tliis, is given by Vatcr in Ibf I'liilosojiliical Transactions ; it
took place in a camp follower, woiinclod at the Battle of Ilamilies, and continued
for fourli Mil years. Abrid;^im!nt by I.owlliorpe. vol. iv.

wounds of the abdomen, &c. 413

Case LXVII.

Artificial Anus.

James Monagban, 40th regiment, was wounded on the 28th
of July, 1813, by a musket-ball, which struck him in an oblique
direction, and entered exactly over that part of Poupart's
ligament of the right side, under which the artery runs. Its
internal track cannot of course be ascertained, biit it went out
at a point of the left or opposite side, nearly corresponding to
that at which the sciatic nerve and posterior crural vessels
pass. He immediately lost all power of moving the right
limb, while the left was very much benumbed; and on the first
occasion of his going to stool after the receipt of the injury,
he passed a very large quantity of clotted blood, mixed with
feces, and perceived excrementitious matter and flatus issuing
from both orifices made by the ball. This discharge occurred
on each occasion of going to stool ; it continued at the posterior
orifice for five weeks, at the expiration of which period that
wound healed. The feces, however, still continued to be dis-
charged at tbe groin for six weeks longer; the posterior wound,
then broke out afresh, and the feces were discharged from it as
before. It then, after a few days, healed, and again opened ;
this happened successively for three periods, at each of which
fecal matter passed from the wound. During the early part of
the cure he had been almost constantly in a state of constipation,
and had received daily enemas. He had never suffered any
other serious inconvenience, and had not been bled from the
arm, but the hemorrhage, on his receiving the wound, he de-
scribed as very profuse from both orifices, and as reducing him
to the greatest imaginable degree of weakness. His treatment
under my direction was of the most simple and least irritating
nature possible ; by it the posterior wound became firmly

414 WOUNDS OF THE ABDOMEN, &C.

cicatrized, and tbe wound of the groin nearly so; nothing but
a small sinns which had formed on the fore part of the thigh
retarding the perfect healing, and this was very shortly after-
wards effected. Whenever this man went to stool, he felt a
sensation as if the feces and flatus passed freely along the course
of the intestine, until their arrival near the groin, about the
sigmoid flexure of the colon, at which period he was obliged to
support the hip by pressing upon the site of the posterior
wound with the palm of his hand, before he could make an
effectual effort towards the expulsion. His general health had
never suffered, and he was discharged with no other incon-
venience than a slight limp of the right limb, and the necessity
above described, whenever he went to stool. How the blood-
vessels and great nerves escaped here, I cannot pretend to
explain; that the latter were closely brushed by the ball, the
paralytic affections evidently proved.

Case LXVIII.

Severe Wound of the Thigh and Jnlestincd Canal.

Private Jonathan Carter, 2d battalion 1st Foot Guards, was
wounded at Waterloo, on the 18th of Juno, 1815, by a musket-
ball, which passed obliquely through the long head of the triceps
adductor of the left thigh, entered and passed through the
lower part of the pelvis below the bladder, wounded the intes-
tinum rectum, and [)assed out through the inferior portion of the
right OS ilium, leaving a slight degree of laceration in the
gluteus maximus muscle. In order to explain the very extra-
ordinary course of the wound, it may be necessary to state
that the patient, when wounded, was in the act of kneeling on
the right knee, in the front rank of his corps, preparatory to
their receiving a column of French cavalry, whicli was advancing
in front of them. He was brought into hospital, and had his

WOUNDS OF THE ABDOMEN, &C. 415

wounds dressed on the third day after the action. During the
first six days after his admission into hospital, his stools were
passed involuntarily through the anterior orifice of the wound
in the thigh, but no part of them was ever passed by the pos-
terior orifice in the ilium. From this day, (27th June,) they
were passed partly by the anterior orifice of the wound, and
partly naturally, at the intervals when he was usually called to
stool, until the 20th of July, when the whole of the fecal dis-
charge took the ordinary course. The posterior orifice had now
cicatrized, and the anterior, gradually assuming a more healthy
appearance, was ultimately cicatrized on the 20th August
following. The only medicine administered to the patient
during the whole of the cure was an occasional laxative,
according as the state of his bowels required it, in order to
render bis stools more liquid, and to facilitate their egress
through the wound. His general health continued invariably
good ; and, at the period of his discharge from hospital, he was
nearly equal to the performance of his military duty.*

Injuries of the abdominal parietes from shot and shell, al-
though they do not penetrate, often leave a great weakness in
the part, and a strong disposition to herniary formations,
either of the stomach, intestines, or bladder ; hence, a circular
belt should always be worn in those cases, and the same pre-
cautious used by the patient as if hernia had actually taken
place.

I have hitherto touched upon those wounds only, which
require very little mechanical aid from the surgeon. Of this
class are by far the greatest proportion that occur in military
practice. The older practitioners were very much averse from
leaving any thing to nature in cases of abdominal injuries,
although their universal employment of sutures ought to have
convinced them how much she could bear with impunity ; for
there can be very little doubt that their uniform performance of

* Communicated by Mr. Reid, Assistant-Surgeon, 23th Regiment.

410 WOUNDS OF THE ABDOMEN, &C.

the operation of Gastrorapliy was at least superfluous, if not
positively hurtful; in the course of a very extensive practice,
two cases only have come under my notice where it was
required to a wounded intestine, though frequently it may be
needed for injuries to the parietes. Indeed, the surgical world
have long since dismissed their fears about the intestine falling
inwards, and about the difficulties of distinguishing between
the right and the wrong end of it. The apprehensions of
abdominal effusions are now also pretty well subdued. The
occurrence is extremely rare, and when it does happen, we
leave the poor wretch to die in peace, without searching after
effused fluids, the nature of which cannot be known, or, if
known, the information cannot in the most remote degree lead
to recovery. I have never witnessed a case where any possible
good effects could follow the paracentesis, for peritonitis in its
most exquisite form has always preceded the symptoms which
would lead to the performance of that operation; I by no means,
however, would deny the possibility of the occurrence of effu-
sion, and its relief in this way ; for from Vacher, Petit, and other
good authorities, we know it has happened ; but in the military
hospitals, to which I have had access, eftusion has been in-
variably fatal.

The great practical point of diflerence among modern sur-
geons, in the only operation now acknowledged by them, is the
mode in which the suture should be applied. Mr. John Bell
insists on the interrupted, Mr. Travers recommends the con-
tinued. The former takes one, two, or more stitches, the latter
holds the wounded extremities of the intestine in contact in
their entire circumference. Having only practised the mode
by a single stitch to the abdominal parietes, and then closed the
wound, I can speak of it alone. The cases were simple: in
one a shoemaker's knife, in another a sabre, had obliquely cut
a small portion of the colon of about an inch in length, which
had protruded, and on returning it to the cavity of the abdomen,
the slit exactly coijfesponded to the oxlernul wound. I cut ofl'

WOUNDS OF THE ABDOMEN, &C. 417

both ends of the ligature, as recommended by Mr. Benjamin
Bell, (although tbe first step towards that improvement seems
to have originated with M. Verdrier, who, in 1731, observing
that the ligatures in gastroraphy occasioned a greater flow
of matter than all the rest of the wound, cut off one of the
threads,*) a perfect cure was effected in a few days in both
cases. Of Mr. Travers's mode, which has been found success-
ful by others who have had an opportunity of employing it, I
have no personal experience.

If tbe intestine is strangulated in a small opening, a few
cautious touches of the bistoury will be sufficient to insure their
reduction ; and if it be not highly inflamed, or evidently disor-
ganized, it may be returned unsecured.

A soldier of the 38th regiment, under my inspection, at
Gloucester, was gored by a cow; the intestines protruded, and,
although the peritoneal coat was lacerated, the bowel was
returned, the wound was retained together by straps and simple
dressings, and, when I last visited that city, I found the man
recovered, under the able care and superintendence of the
surg^eons of the county hospital.

I conceive it to be quite useless to dilate the ends of a
divided intestine in order to remove supposed stricture, as
practised by some French surgeons, because this apparent
stricture is tbe means which nature employs to produce a re-
paration of the injury ; the ends of an incised wound being
always (according to Mr. Travers) drawn asunder and everted,
with a broad and bulbous lip, from the contraction of the circu-
lar fibres behind it producing relatively to the inverted portion
the appearance of a cervix ; hence the slitting might, in this
case, be carried on as long as there remained any intestine to slit.

* Memoires de rAcadera. vol. iii. p. 69. See a very interesting case of
sewing the intestine, and drawing the ligatures out at the external wound,
performed by IVIr. Peter Travers at Lisbon, in 1757, recorded in the Philosophical
Transactions, abridged by Hutton, Shaw, and Pearson, vol. ii. p. 73. The
patient was perfectly cured on the 3oth day,

2 E

418 WOUNDS OF THE ABDOMEN, &C.

If the opening in the parietes is small, an adhesive strap
and bandage is sufficient; but the openings, particularly by
round shot, or shell, are sometimes so enormous as to admit the
protrusion of the stomach, bowels, or bladder, and to require
a very extensive use of the suture with the assistance of bandage
and adhesive straps. The introduction of sindons of linen, and
plates of lead, have also been used; and in those cases, an
ingenious French surgeon (M. Desport) has proposed, in the
3d volume of the Memoirs of the Academy of Surgery, a
peculiar mode of performing the gastroraphy, by which the
thread sufficiently supports the part, and may be loosened at
will. In a very few singularly fortunate cases of this kind, life
has been preserved ; but this event does not take place in one
case of a thousand, and almost instant death succeeds the injury.
The sudden shock, and the withdrawing their usual support
from the abdominal contents, seem quite sufficient to produce
the fatal event.

I have, however, seen two cases, where the destruction of
the patient was not immediately effected. In one, the great
arch of the colon was completely laid bare by a round shot,
and the patient was reported to me alive within a week after
the event; (indeed, I may here observe, that injuries of the
colon are by no means so dangerous as those of other parts of
the canal;) the other was a truly melancholy picture of the
dreadful effects of the explosion of a shell. An officer of infantry
was brought into the hospital of the Jesuits at Brussels in a
waggon ; he was laid on a mattress in the room used as an
operating room; and was in his turn examined by myself and the
other surgeons employed on the occasion. Surrounded though
we were by the dead and the dying, this case was pre-eminently
horrible; almost the whole anterior part of the abdominal
parietes had been blown off", with the exception of the perito-
neum, which still remained, though extensively lacerated, and
deprived of the muscles; where the umbilicus had been, there
was a large rent through which the omentum protruded, though

WOUNDS OF THE ABDOMEN, &C. 419

not to a great extent, and scarcely above the surface; spots of
the stomach, and of the arch of the colon, were visible through
smaller rents, and, what was remai'kable, no part of the intes-
tines protruded through these openings ; but the most singular
circumstance was, that this wretched remnant of life conversed
and took some refreshment, for which he repeatedly called
during the forty-eight hours that he survived. No opportunity
occurred of examining the body after death, although I was
very anxious to observe whether nature had made any efforts
towards a reparation of the injury, or had excited the parts to
any peculiar action.

For much of our knowledge of injuries of the intestines we
are unquestionably indebted to the valuable observations of
Hevin, Petit, and other writers, in the Memoirs of the Royal
Academy of Surgery of Paris, (which it is to be feared have
not been referred to, with the same freedom that they have
been made use of,) to the " Medecine Operatoire" of Sabatier,
and to the unrivalled Memoir of Scarpa, now rendered familiar
by the publication of it by Wishart in an English translation.*

To Mr. Traversf we owe a very learned and laborious work
on the subject, in which he confirms the experiments of
Professor Thomson, which show ; first, how nature disposes of
the ligatures ; and, secondly, the greater danger of stitching
longitudinal than transverse wounds : he also illustrates the
process employed by nature in the reparation of intestinal
injuries. By his experiments on brutes, Mr. T. confirms the
observations of Scarpa upon the human subject.

Mr. Astley Cooper, in his valuable work on Hernia, has
greatly increased our knowledge of the pathology of the parts,
and illustrated the practice ; as has also Mr. Lawrence, in his
excellent volume upon the same subject.

• Scarpa on Hernia, Edinb. ISU, Memoir 4th.

t An Inquiry into the Process of Nature, in repairing Injuries of the Intes-
tines. London, 1812.

2 e2

420 WOUNDS OF THE ABDOMEN, &C.

Mr, John Bell adds to his Discourse on Wounds of the
Belly, a particular illustration of the modes of securing a
wounded intestine, and by a plan of the Rahmdorian mode,
shows its probable danger; it may, however, safely be asserted,
that this proposal, which originated with the German author,
and is detailed by Heister, is in most cases absolutely imprac-
ticable. Another work which may be consulted with great
advantage, and which is rich in references to cases both
successful and fatal, is the Dissertation of Vogel on Wounds
of the Colon, to be found in Sandifort's Thesaurus, volume the
second.

The wounds of the Fixed Viscera of the Abdomen, though
highly dangerous, are not necessarily mortal ; the simple prin-
ple of avoiding or subduing inflammation must guide us in the
attempts at relief in these cases. All deep wounds of the
Spleen, Liver, or Kidney, are almost immediately fatal from
hemorrhage ; some instances, however, occur, where even
severe injuries are survived.

The slightest reflection on the situation and structure of the
Kidney, and on its various sympathies, will at once show the
desperate nature of wounds inflicted on it, even with all the
caution of a curative intention. In the excellent and learned
memoir of M. Ifevin, on Nephrotomy, this point is most amply
discussed and illustrated, and a great mass of evidence is pro-
duced on ihe subject.* The instances that I have observed
where recovery has been established are very few indeed. If
the patient has survived the first hemorrhage, the fever and
peritoneal inflammation, with incessant hiccup and vomiting
from sympathy of llio diaphragm and stomach, have generally
cut him off; and if he has for a time escaped, excruciating
pains, profuse stii)puration from iistulous sores, hectic, and

• Recliirclies IIistori(HiL' t;l ("riti<jucs sur la Ni')))irotoniie ou Taille du Rein,
par M. Hevin, Mtinoirs de L'Acudemie Hoyult; dt- Clururgic, toin. iii. p. 238,
fol. wlit.

WOUNDS OF THE ABDOMEN, &C. 421

emaciation, have terminated his existence. Where the cure
has been effected, there is reason to think that the ureter has
been but slightly brushed, and the body of the kidney itself
left untouched. The remedies consist of venesection, mild
purgatives, as manna, oil, &c., frequent emollient enemas, the
warm bath generally, and local fomentations, so as to excite
diaphoresis and moderate urinary secretion ; with a diet of the
mildest kind, but much restricted in fluids, the indulgence in
which, even in small quantity, should be avoided. Stimulants
under any form, particularly those which can at all influence
the urinary organs, as blisters, diuretics, &c. are decidedly
hurtful. The dressings should be extremely light, so as to
admit of the free percolation of the urine; the neighbouring
parts should be varnished over with some unctuous substance,
to prevent excoriation, and the bedding should be guarded by
an oil skin. By these means a few cases that have come to my
knowledge have terminated favourably.

The following case appears to me very valuable. It is per-
haps among the most singular on record, and it illustrates the
whole series of symptoms attendant on injuries of these parts.
It is told principally in the plain and unadorned language of a
soldier, who relates what he felt, without any fixed ideas of
the nature or functions of the organs the lesion of which he
describes. The authenticity of the facts is unquestionable, as,
independent of the officer's own history, they have all been
corroborated by the testimony of his medical attendants.*

* Messrs. M'Leod, Hill, and Ryan, Surgeons to the Forces, Mr. Dunn, Sur-
geon 23d Fusileers, Messrs, Thomson and Ekins, Assistant-surgeons 38th
regiment, and Mr. Mayow, surgeon, Winchester. On examination by me in
December 1816, in presence of Staff-Surgeon Hughes and Dr. Knox, at Hilsea,
the cicatrix of the wound at the entrance of the ball was found to be close to the
interval of the 9th and 10th ribs, about midway between the sternum and verte-
brse, and the ball was cut out about the point of the transverse process of the
lowermost dorsal vertebrsE the day after the receipt of tlie wound.

422 WOUNDS OF THE ABDOMEN, &C.

Case LXIX.

Complicated Wound of the Kidney.

" On the 9tli December, 1813," says this brave man, " I
received a dang-erous wound from a musket ball through the
body, which entered the right 'side. The surgeon of the re-
giment being nearly on the spot at the time I was wounded,
had me moved in a blanket to the nearest house, where he in-
stantly examined me, and was about to extract the ball ; but,
from the extreme agony in which I was, and from my imme-
diate death being apprehended, he desisted from the operation,
and in one return I was actually .stated as dead. As nearly as
I can recollect, in one hour after being wounded, the surgeon
ordered some tea to be made, and had me moved near a fire.
On this movement I expressed a desire to pass urine, which
flowed very copiously, and was a second cause of alarm, as it
had more the appearance of blood than otherwise. This
symptom put an end to all hopes of recovery on my part. On
account of the whole army retreating this evening, I was una-
voidably moved to the rear, nearly a distance of three leagues,
the pain induced by which exceeded description. In less than
an hour, while in the waggon, I again passed a quantity of
blood, far more visible than before, as it deeply stained every
thing that it touched. On my arrival at the quarter destined
for me, Assistant-Surgeon Ekins bled me, and an enema was
administered. I now began, in addition to the pain in my
wound, to feel considerable pain from inflammation in the
bowels. I soon became delirious, and cannot describe how I
was aflccted for a considerable time; but I understand I was
several times bled to keep back the inllammatioii. I recollect
tliiit, on my reason returning, I sent for a surgeon to examine
my right shoulder, as I could not \n\ persuaded, from the pain
I felt, but. that I wius wounded there also. This was not the

WOUNDS OF THE ABDOMEN, &C. 423

case. For fourteen days I understood no other nourishment
was given me but small draughts of tea. I recollect that large
blisters were applied to my belly and breast, and that I drank
several draughts, and took several pills to compose me. The
wound in my back nearly mortified by my lying so long. I
thought I should never recover the use of my arm, and I could
not stretch out my legs, particularly the right one. I also
suffered great pain between the wounds, and do so to this day,
and I must be very cautious in raising my body suddenly. In
about seven weeks I was removed farther to the rear and sent
to England."

This gentleman arrived in England, and, after passing some
time in London, proceeded to the depot of his corps. In con-
sequence of the journey fever was excited, which proceeded to
a considerable length, and peritoneal inflammation again at-
tacked him. On the second day after this attack, a tumour
formed in the site of the posterior wound, which in about a
fortnight was punctured, and discharged nearly six ounces of
purulent matter, of an urinous smell. The discharge continued
for some time, and another abscess formed lower down, which
was punctured in about three weeks, and a large quantity of
pus of the same kind was discharged from it. The discharge
varied in quality from time to time, and the abscess occasionally
healed and burst open again. In the meantime, the pain and
emaciation were very great ; and the quantity of urine dimi-
nished, with very frequent calls to pass it. In this way he con-
tinued, with little variation, and with small hopes of recovery,
until the end of July. 1 shall now resume the narrative in his
own words. " I lingered in this state, constantly using medi-
cine to enable me to pass urine, as it was supposed I had the
gravel. The passage of the urine became every day more
difficult, and I found that the extreme pain I felt moved first
from my side to my belly, and gradually on to the testicles, and
latterly to the penis. The flowing of the matter continued
great, and very much savoured of urine ; my skin was at times

424 WOUNDS OF THE ABDOMEN, &C.

exceedingly fair, and at others completely yellow ; and my
eyes glistening, and the white at all times discoloured. I at
last became so exceedingly uneasy from the frequent attempts
to pass urine, (which every day diminished in quantity so
greatly that I could not at length evacuate more than by drops,)
that I was reduced to a state of frenzy, when, about twelve
hours before the following extraordinary event took place, the
discharge from my wounds, which had been lessening for two
days before, suddenly stopped ; the pain and the pressure of
urine became so great, that I could no longer exist ; all my
efforts were vain, — nothing but drops would pass. While in
this state of agony the surgeon was sent for. Before he arrived
my desire increased, when another attempt was made, but with
less effect than before. I remained in the greatest torture for
more than three minutes, when a burst of urine took place, and
with it a lump, which struck forcibly against the chamber pot ;
the most uncommon quantity of urine followed, coloured with
blood ; and in less than an hour another discharge, having
less colour of blood than the former. On the arrival of the
surgeon the chamber pot was examined, when a lump in the
shape of a short thick shrimp, was taken out, which was that
night thought a stone, being covered with black grit, and very
hard. One side was lighter than the other, where I suppose it
was fastened to. It was placed in a glass, and in the morning
all the surgeons examined it, by which time it became dry, and
on being pressed, it clearly appeared to be cloth, which had
been driven in by the force of the ball. 1 believe, that the
great pain I felt in the side, and, as it made its approaches,
was solely occasioned by its movements ; and also, that it re-
mained some time near the bottom of the testicles and penis.
I do not hesitate to say, that it has injured the parts of the
passage, from symptoms I now feel."

This officer is now in good health. He keeps the cloth as a
relic. It is three quarters of an inch long, and tapering to a
point like a piece of the end of a bougie. Two projecting

WOUNDS OF THE ABDOMEN, &C. 425

shreds, like antennae, now gone, but which originally belonged
to it, gave it the appearance of the shrimp which he describes.

In this case, the passage of the cloth from the wound in the
breast, across the body, through the ureter into the bladder,
and thence by the urethra, can admit of no question; the dila-
tability of the ureter and urethra, is sufficiently great to admit
of the passage of much larger substances, formed within the
body, or casually introduced.

The cases on record of recoveries after wounds of the Kidney
are' not numerous. The excellent Haller gives us one in his
Opuscul. Patholog. Obs. 69; and Bourienne furnishes another
in the Journal de Medicine, tome xlii. p. 554. There is
also a case by Dr. Borthwick in Duncan's " Annals of Medi-
cine" for 1799, where a wound was inflicted by a sword, and the
patient recovered. Wounds of this part are treated of by
almost all the systematic writers. A special dissertation on
them was published by Gittler, at Leipsic, so far back as 1596,
the only monograph, with the existence of which I am ac-
quainted.

AYounds of the Bladder are dangerous, in proportion as it is
full of urine at the time of their receipt, or as the upper and
anterior, or lower and posterior part of the viscus may be
wounded. If the intestines are implicated in the wound, it is
highly dangerous; if a ball passes through the bladder when it
projects above the pubes, the case may be considered mortal.
Inflammation from wounds of these parts runs rapidly into gan--
grene, from the delicate nature of the organs wounded, and the
increased irritation proceeding from the effusion of the urine,
and its filtration through the cellular substance, which com-
pletely destroys all its natural connections. If there is a free
extensive passage externally, much of this danger will be ob-
viated ; and after the first effusion from the bladder has taken
place, the judicious use of the elastic gum catheter affords us an
admirable assistance against this accident; indeed, without this
useful instrument, our practice in wounds of this nature, and in

42& WOUNDS OF THE ABDOMEN, &C.

those afifectiug the urethra, would be merely confined to looking
on and moderating symptoms, instead of preventing them, as
we are now enabled to do. With the aid of the catheter, I
have seldom met with any cases of wounds of the bladder and
urethra, which required more than an antiphlogistic regimen,
an open state of bowels, mild dressings, and cleanliness ; to
which, if the edges of the sore have become irritable, a mild
solution of the nitrate of silver, applied with a camel's hair
pencil, has been added. I have very rarely bad occasion to
use the knife for the enlargement of the wound or to pare its
edges, when I have treated the case from the beginning, or
where the catheter and proper dressings have been employed.
A perfect cure is the general result in sound healthy constitu-
tions ; but, in habits of a different kind, and more especially if
they have been hard drinkers, the reverse is the case, and the
most distressing symptoms, as rep6ated sloughiugs, foul and
deep ulcerations, or fistulous sores, remain. — I presume it is
superfluous to speak of the stitching this organ, as a means of
remedying its injuries.

Extraneous bodies, particularly balls and morsels of bone,
are frequently carried into the bladder, either as it rises above
the pubes, or through openings in the pelvis, and they come ofl'
by the natural passages, or are removed by a surgical operation,
conducted on the same principle as that of lithotomy.

If extraneous matters carried into the bladder are of a soft
yielding nature, or of a small size, the natural flow of the urine
often carries them out. Of this the following are examples :

Case LXX.

Passof/e of Clolli hy the Urethra.

James Rowan, of the 50lh regiment, aged 44, a man of a
very robust constitution, was skirmishing in front of his corps

WOUNDS OF THE ABDOMEN, &C. 427

in the Pyrenees, on the 25th of July, 1813, when he received a
musket ball, which, passing- through the skirt of his regimental
jacket, entered a little above the tuberosity of the left ischium,
in a direction towards the sacrum, and lodg-ed, as was supposed
at the time, in the neighbourhood of that bone. The swelling
of the soft parts was so considerable, and the general inflam-
matory symptoms ran so high, that when he was carried to the
field hospital, it was deemed improper to probe much after the
ball. He was, therefore, freely bled ; his bowels were well
opened ; and emollient applications being applied to the wound,
he was sent down to the general hospital, at the convent of St.
Domingo, Vittoria.

On the subsidence of the inflammatory symptoms, several
attempts were made in search of the ball, but with no other
effect than to convince the assistant, under whose charge he was
more immediately placed, that it did not occupy the situation
originally imagined, but had passed onwards directly into the
pelvis.

The patient's general health did not suffer ; the wound was
scarcely more troublesome than a common flesh wound, and was
unattended with any peculiarity in the appearance, or in the
character of the discharge; in short, he was so far recovered in
the course of three weeks, that he was sent down to the general
hospital at Bilboa in a covered waggon, along with a numerous
escort of wounded, a distance of nineteen leagues. On his
arrival, he complained of being a good deal shaken, but the
wound was nearly healed, and, on the most minute exami-
nation, no trace of any extraneous substance could be dis-
covered in it. There was every reason, however, to suppose
that the bullet was lodged in the neighbourhood of the bladder,
for he complained of a dull sensation in the glans penis, with
numbness and coldness of the testicles, attended with great
pain in making water, and occasionally an inability to retain it;
there was, nevertheless, neither stoppage nor tortuosity of the
urinarv stream.

428 WOUNDS OF THE ABDOMEN, &C.

The wQund was perfectly healed in the first week of De-
cember, or about 130 days from its infliction, when he was
discharged to the convalescent depot, where he remained for
six days, when the uneasy sensations of the urinary organs arose
to actual pain, which he attributed to his change of bed, and
bis not living so comfortably as he did in the hospital. For this
grievance he had recourse to a soldier's remedy, and drank as
copiously of country wine as his finances would allow. After
having committed a debauch on the evening of the 8th day from
his quitting the hospital, he was seized with an irresistible
desire to make water; and, after some severe straining, in which
he was sensible of an obstruction about the neck of the bladder,
which for fully half an hour prevented the passage of a single
drop of urine, he shot out of the urethra, with a convulsive jerk,
a substance coiled up, somewhat in the shape of a fragment of
a large bougie, nine lines in length, and three in breadth, the
ejection of which was followed by a profuse flow of urine,
passed without any muscular exertion, and succeeded by in-
stantaneous relief. On examination of the ejected substance,
it proved to be two bits of cloth, consisting of his jacket and
its lining, corresponding with the size of the shot-hole. The
texture was unaltered, but the colour of the red piece was much
faded ; it had neither any urinous smell, nor was any calculous
concretion observable on it.

I had an opportunity of examining this man in February 1814 ;
the wound was perfectly cicatrized, and no disorder of the
urinary organs was present; but not the slightest trace of the
ball could be discovered, either by the sound, or the finger, in-
troduced into the anus.*

• This case I published in tlie 5lh volume of the London Medical Repository,
J). 293. The cloth is in possession of my friend, Mr. Thomson, lately one of the
editors of that work.

wounds of the abdomen, &c. 429

Case LXXI.

Passage of Bone by the Urethra.

T. D. aged 39, a soldier of a light infantry corps, was wounded
by a musket ball on the evening of the 18th of June, 1815. It
entered the pelvis at about one inch and a quarter from the
symphysis of the pubes, grazing close to the bone, and came
out, unaltered in shape, through the buttock of the same side,
about three inches from the sacrum. In this course the bladder,
which was much distended with urine, was injured ; great stupor
and pain of the part were experienced on the receipt of the
wound, and particularly affected the loins, and testicle of the
wounded side. He had a strong inclination to void his urine
immediately after the receipt of the wound, and in doing so it
passed entirely through the anterior opening over the pubes,
and not a drop by the natural channel ; the efforts to pass it
were attended with severe pain. When my attention was par-
ticularly called to him, in about four weeks after his wound, I
found that the urine still pas&ed, but in small quantities, from
the upper orifice ; the posterior one had closed, and the other
was inclined to heal. The urine had been almost constantly
carried off by means of an elastic gum-catheter, but notwith-
standing, an abscess by infiltration had formed on the inside of
the right thigh; from this abscess, some small pieces of bone,
to the amount of about twenty grains in weight, and the largest
of about the size of a grain of coarse gunpowder, had passed at
different times. The urine drawn off from the bladder was in
general turbid, and, on being allowed to deposit its sediment,
about three drachms of osseous grit had been collected from it
at different periods. After some time he began to pass the
urine partially by the natural passage, and the same osseous
grit was deposited, while a discharge of more palpable bony:

430 WOUNDS OF THE ABDOMEN, &C.

particles appeared in the stream ; these were collected from
time to time, and amounted to three drachms in weight ; the
largest piece was circular, flat like a piece of coin, and of the
size of a split pea. The man was transferred from my care and
sent home to England. I saw him eight months after; his
general health was good, but the osseous discharge still con-
tinued. He presented me with some few pieces of the bone,
rough and angular, about one- third of an inch in length, and
one-fourth broad, which had all passed by the urethra, and
weighed together about an additional drachm; and also one
piece which had passed by the wound, of about the same
size as the others, but smooth on one surface, evidently an ex-
foliation direct from the pubes, without having been acted on
by the urine.

An interesting case, in which a piece of bone nearly an inch
in length, and about the thickness of a crow's quill, was passed
by the urethra, is detailed by Mr. Douglas, late of the 8th
regiment, in the Edinburgh Medical and Surgical Journal, vol.
ifiii. p. 314.

Air is sometimes, but ver}^ rarely, passed from the bladder,
most probably from some opening in the Ureter communicating
with an external wound ; or, as in the cases mentioned by
Clamper,* from ulcerations connected with the intestines. I
saw a case of this kind at Brussels, and Dr. Theodore Gordon,
Physician to the Forces, has most obligingly favoured me with
the followinsr notes of it:

Case LXXII.

Passage nf Air hy the Urethra.

Augustus Labiche, 7th French dragoons, was wounded 18th
of June, 1815, by a musket ball, which entered the left hy-

• Demonstrat. Aiiatom. Patholog. Lib. ii. j). 10. See also a case by Dr. Fo-
thergiU — Duncan's Medical Coramcntarios, vol. ii. p. 194..

WOUNDS OF THE ABDOMEN, &C. 431

pocbondrium, directly under the 12th rib, near its anterior
extremity, and came out to the left of the 2d vertebra of the
loins, close to the spinous process. Some blood passed through
the urinary passage the first few days after receiving the wound.
Up to the 13th of July, the discharge through the wound on
the back was very copious, and mixed with thin faeces, and with
the seeds of fruit which he had swallowed ; the wound under
the rib discharged very little. On the 14th of July, he, for the
first time, had a sensation as of air passing through the urethra,
with a gurgling noise after discharging the urine. On the 16th,
the wound on the back was healing up, and the faeces ceased to
pass. On the 20th, the bed clothes and bandages betrayed a
strong urinous smell, and urine was observed to pass from the
posterior wound ; the noise formerly heard on making it now
ceased, but on passing it with the penis immersed in water,
about a cubic inch of air bubbles made their appearance. The
passage of air bubbles from the urethra, and of urine from the
wound in the back, had ceased entirely about the 8th of Au-
gust, (or the 51st day from the receipt of the injury,) and the
wounds in both the side and back were considerably diminished.
In a few days after this he complained that he wanted to pass
wind ; he felt an acute pain in the wound, as if the air had first
proceeded there, and then had passed off per anum. The pain
continued to increase, and the wound to assume a fistulous
disposition, till, on the 57th day, the air again began to pass both
from the wound and the urethra, and a slight gonorrhoea ap-
peared. He soon after began to recover fast. The change of
the medical officers, who were removed to other duties, and
the restoration of the prisoners to their native country, pre-
vented the continuation of the notes of the case; but the
impression on Dr. Gordon's mind is, that the man finally re-
covered. The external treatment of his wounds was confined
to simple dressings.

Where a ball has struck the region of the bladder, if its
force is weakened by distance, or broke by encountering the

432 WOUNDS OF THE ABDOMEN, &C.

elastic integuments and the coats of that org^an, and still farther
resisted by the presence of a quantity of urine, it sinks down
through the fluid, and often remains unnoticed ainid the other
circumstances of the wound, until it gives rise to a train of
symptoms, which ultimately call for the incision of the bladder.
This operation, which has not been unfrequently resorted tc
has lately been successfully performed at the York Hospital,
Chelsea, by !Mr. Guthrie. A similar operation was performed
at St. George's Hospital on a soldier, who was shot in the
bladder at the siege of Lisle, and operated on the spring fol-
lowing ; a view of the calculous concretion is given by Che-
selden, in his book on the High Operation, London, 1723,
plate X. Garengeot, in his Traite des Operations, vol. i. p. 17,
gives a case of an officer, cut for a stone, the nucleus of which
was a musket ball, which remained in his bladder ten years;
and Hildanus gives a case where a ball remained for thirty
years in the bladder. Cent. 3. Obs. 67.

Depositions of Calcareous matter are often formed in the
bladder after its coats have been injured by a wound. In a
case lately operated upon by Statl-Surgeon Dease, it was nearly
filled with loosely compacted urinary depositions, part without
any visible nucleus, some masses with splinters of bone for
their nuclei, and, in several points, the calcareous crust ad-
hering to the internal coat of the bladder itself. The patient
was wonnded in the anterior part of the viscns, and suffered
most severe torture during the protraction of his life for three
years. Circumstances forbad the examination of the body after
death.

A. splinter of bone is, in most cases, found to be the nu-
cleus of the deposition of calculous matter. Baron Larrey
prefers this operation in recent cases to the attempt of extract-
ing a ball by the passage through which it has entered, as the
wound in the external parts, and in the bladder, will not cor-
respond in conseqaence of the sinking of the latter organ.*

• Tom. IT. p. 385, et. seq.

WOUNDS OF THE ABDOMKN, &C. 433

Tt has been found by Dr. Marcet, who analyzed the calcu-
lus extracted by Mr. Gutbrie, which I have alluded to above,
that in all cases where depositions have been formed, or extra-
neous bodies introduced into tbe bladder, they have been of the
fusible species.*

Wherever it is probable that a ball, cloth, or large portion
of bone is lodged in the bladder, it unquestionably becomes
our duty to extract it at once by the original wound, if possible,
without the more formal operation of cystotomy. We know,
indeed, that balls have been passed by the urethra, f but no
prudent surgeon would trust to such an event. An ingenious
idea of dissolving the ball by means of crude quicksilver was
started in France; Le Dran instituted some experiments on
the subject, he effected the amalgamation of lead wifh mercury
in a vessel filled with urine, and brought to the heat of the
body ; he went a step farther, and thrusting some lead into the
bladder of an ass, conceived that it had been there dissolved
by quicksilver ; he then operated upon a West Indian Governor
by the mercurial injection, for the removal of a piece of a
leaden bougie, which had broke short in his bladder. All
France rung with his new and ingenious operation, and the con-
triver was so far deceived as to affirm that the lead was dis-
charged ; but on the Governor's death, which occurred some
time after, the identical piece of lead was found in his bladder.;;}:
The use of mercury has also been at times adopted for the
removal of leaden balls from other parts, but without success;
in some cases,, it has insinuated itself among the cancelli of the
bones, the fibres of the muscles, and the tendinous sheaths, and
produced great irritation.

Paralysis of the bladder is also a common effect from blows
of shells, &c. and an actual diminution of its cavity occasionally

* See his Essay on Calculous Disorders, 8vo. Loudon, p. 75.
t Paulinus, Cent. 3, Obs. 40. Ephemerid. Nat. Cur. Dec. 2, 3. Larr*y,
vol. iv.

t Percy, " Manuel," p. 137.

2 F

434 WOUNDS OF THE ABDOMEN, &C.

takes place, by its thickening and adhesion to the pubes and
other adjoining- parts ; rupture also sometimes occurs without
any external solution of continuity. Time and moderate exter-
nal stimuli are useful in the first case; the antiphlogistic
regimen, in all injuries, will go far to prevent the second ; but
the last is an occurrence uniformly fatal.

In addition to the observations upon the wounds of the blad-
der by the systematic writers, the military surgeon will derive
much information from Garengeot, and from Desportes, in the
" Operations de Chirurgie" of the former, and the " Traite
des Playes d'armes a feu" of the latter. Bordenave, in the
Memoirs of the Academy, 2d vol., Bourienne, in the " Journal
de Medecine, tome xxix. and Thomson, in his " Report," are
also well worth consulting. But the most instructive cases
that, I believe, are to be met with, will be found in the
" Memoires" of M. Larrey, particularly in the fourth volume.
No special treatise exists, to my knowledge, upon tlie wounds
of the bladder.

A deep wound of the Liver is as fatal as if the heart itself
was engaged ; the slighter injuries are recoverable, particularly
if the membrane alone is injured. The site of the wound at
once points out the organ alfecled, and the suppressions of some
of its functions almost invariably succeed;?.

The usual symptoms which characterize these injuries are
yellowness of the skin and urine, derangement of the stomach,
and of the alimentary canal, and cutaneous affections, particu-
larly great and distressing itching. The discharge from the
wound is generally yellow and glutinous, but I have seen it of
a serous nature, and sometimes very nearly allied to unmixed
bile. The following case will exhibit the symploms, and the
mode of treatment adopted, in a very dangerous and con»pli-
cated case :

wounds of thf abdomrn, &c. 435

Case LXXIII.

Wound of the Liver.

June 18tli, 1815. — Lieut.-Col, H. received a musket shot,
which, entering between, and partially fracturing, the 8th and
9th ribs posteriorly, at about two and a half inches distant from
the spine, passed out between the 7th and 8th anteriorly, about
four and a half inches from the sternum. The hemorrhaore.
which continued for three days from both wounds, was so ex-
cessive, that he could not be moved from the neighbourhood of
the field of battle. The 1 Ith day he was brought into Brussels,
when I saw him, with Deputy Inspector Gunning, Surgeon in
Chief, and Mr. Robinson, Surgeon of the 16th Dragoons. His
pulse was then about 90, and hard; his countenance pale, and
sunk; his eyes glazed, and with difficulty kept open; his skin
of a dusky yellow, and bedewed with a clammy sweat; the
tongue foul ; the respiration difficult, and interrupted by fre-
quent singultus. He had great sense of weight and pain in the
region of the liver, but his severest complaint was an inability
to remain in one posture, and want of sleep. He had occa-
sional, but not violent, cough, and expectorated some coagula
of blood. On examining the posterior wound, I found a copious
glairy yellowish discharge, mixed with air bubbles, and some
small streaks of blood; the anterior wound was nearly closed.
The treatment which had been adopted by Mr. Robinson had
been so judicious, that no alteration was proposed; he had bled
his patient five different times copiously, and had kept his
bowels regular daily with solution of neutral salts, and ol.
recini. The inflammatory symptoms returned on the night of
his arrival, from which time, till the morning visit at six
o'clock, he lost thirty ounces of buffy blood at three bleedings. ^
The following are the reports of the case during its progress

2 F 2

43G WOUNDS OF THE ABDOMEN, &C.

under my inspection. 12th day. — Extremely low and weak, so
as to be scarce able to answer questions ; pulse 80, weak and
fluttering-; he tosses incessantly in the bed, and speaks very
incoherently; discharge very copious, thick, and of a deep
bilious tinge; belly hard, and bowels costive; cough severe,
and he spits up a tenacious yellow mucus, of bitter taste, and
offensive smell, but with great difficulty, and in very small pro-
portions. He was ordered an emollient glyster, and to drink
of a solution of gum arabic, sweetened with capillaire. 13th
day.— Last night all the symptoms became aggravated, so that
the Assistant-Surgeon, Mr. Bingham, who sat up with him,
took 12 ounces of blood away, which immediately relieved him.
On examination of the wound this morning, the edges of it, for
about an inch round, were emphysematous, and the discbarge
of a still deeper yellow colour, and more tenacious consistence
than before. Up to the 24th day of July, or 37th of the wound,
very little hopes of his recovery were entertained ; the bilious
discharge from the posterior wound continued copious, and the
bilious expectoration the same. On pressing the edges of the
posterior wound, the air could be forced out, so as to raise the
glairy bilious discharge into a large-sized bubble, but there
was no distinct rush during respiration; the anterior wound was
nearly closed ; he complained ol a griping pain in his bowels,
and of a great sense of fulness, notwithstanding that he had
some doses of castor oil, and his nightly enema had procured
him several regular stools ; his tongue also was foul, and his
hiccup, which had left him for ten days, now returned. His
castor oil was repeated. 3Hth day. — IJis eye had very much
recovered its natural lustre; his tongue was clean, and he slept
some hours (juietly. Since the administration of the purgative
and injections, he has had 12 stools, with each of which he has
passed hardened scybala, mixed with dark bile, and a (juantity
(»f matter of the consistence of paste, like moistened pipe-clay.
Jliccup and l)ilious expectoration gone. Asked for an increase
of food, which, up to this day, has been either fruit, (straw-

WOUNDS OF THE ABDOMEN, &C. 437

berries,) or some very light gelatinous matter. 40lli day. —
During the night he was seized with a violent and universal
itching over his whole body, but more particularly over the
legs and thighs ; the skin, however, is free from any eruptive
appearance, and is nearly of a natural hue and feel. He was
now ordered a nightly warm bath. 4 1st day. — The discharge
from the wound very remarkably changed in quantity and ap-
pearance ; the quantity was not the fourth part of what it had
been, and had lost its bilious hue. Had one very copious
bilious stool, being the first without medicine which he has had
since his wound ; itching still continued unabated. From this
day he gradually improved. By the advice of Professor Thom-
son, be took an occasional squill pill, and every third night
about six grains of the mass of blue pill. A few spicula of
bone came away from the posterior wound, but without any
pain or annoyance; and on 1st of September he had recovered
almost perfect health.

The complication was still greater in the following successful
case, communicated by Mr. Hughes :

Case LXXIV.
Complicated Wound of the Liver.

Joac. Cordeiro, private in the 8th regiment of Portuguese
infantry of the line, ffit. 20, was wounded when carrying a
ladder, at the unsuccessful attempt to storm the forts at Sala-
manca, June 1812. A large ragged shot hole appeared in the
centre of his left cheek, passing obliquely inwards and down-
wards between both jaws, and fracturing the two first molares
of the under jaw; its course was followed by the finger to
about an inch and half before the angle of the jaw, on the
inside of the bone, and from this a considerable clot of blood
was removed, but no farther trace of it could be here perceived.

438 WOUNDS OF THE ABDOMEN, &C. -

His breathing was quick aud laborious ; his pulse frequent and
small, and his countenance ghastly. He said he had coughed
and vomited some blood, but his chief complaints were acute
pain in the opposite shoulder, tightness in the chest, and fre-
quent inclination to go to stool ; his evacuations consisted of
dark coloured blood and greenish mucus in small quantity, and
were attended with tenesmus. On examining with my fingers
on the outside of the neck, (no line or blush on the skin appear-
ing to guide me in tracing the ball,) a crackling feel was ob-
served about one-fourth of an inch below the bone, close to the
inner edge of the mastoid muscle, which was traced in the
direction of that edge as far as the sternum, and here it was
lost. I began to fear the lodgment of the wounding body in the
chest; but, continuing to examine carefully all about the
confines of the thorax for further guidance, I had the fortune
to come on a line of similar feel to that of the neck, which com-
menced about an inch below and to the right side of the umbi-
licus, and led my fingers to the posterior part of the right
hypochondrium ; here it stopped on a hard round substance,
which I had no doubt was the ball ; the tumefaction over it was
scarcely perceptible ; but on fixing the hard body, and cutting
on it to the depth of about half an inch, I extracted without
difficulty a four ounce grape shot; it was followed by a small
quantity of dark grumous blood, and I proceeded to take from
his arm 18 ounces more, which produced syncope. I directed
an emollient enema to be administered, and the abdomen to be
ft)mentcd ; a large quantity of grtenish fluid mixed with clotted
blood followed the enema ; his pulse rose, and became more
firm and equable about an hour after the bleeding, when I
found him in a disturbed sleep. At noon his pulse was about
112, strong and hard, |)ain in the right shoulder severe, breath-
ing diflicult, and constant inclination to go to stool, with
distressing thirst and hcadach ; evacuations bloody. Tn the act
of taking his arm to repeat the bleeding, he lost about two
ooiices of dark coloured blood Jrum llic exit of the ball, twenty

WOUNDS OF THE ABDOMEN, &C. 439

ounces of blood were extracted from his arm, and the enema
repeated, which brought oft" some clots, with a little green-
coloured feculent matter. The fomentation was continued, and
a dose of castor oil administered, which, before evening, pro-
cured three easy, copious, feculent motions, the last of which
was a little tinged with blood. At the evening visit his pulse
was 87, soft and regular ; he was free from pain, breathed easily,
and complained only of thirst. A slight return of pain in the
shoulder, and soreness over the hypochondrium, obliged me
the following morning to take away 12 ounces of blood, and
from this time he went on invariably well, and commenced the
campaign of 1813 in good health.

In this case the ball appears to have passed along the inner
surface of the chest, without injuring the lungs, and to have
entered the abdomen, where it injured a portion of the intes-
tine and implicated part of the liver.*

From experiments on rabbits lately tried by Dr. Monro,
Professor of Anatomy and Surgery at Edinburgh, it appears
that considerable portions of the liver may be removed without
injuring the health of the animal, the wounds cicatrizing as in
other parts. In Blanchard's " Anatomica Practica Rationalis,"
Amsterdam 1688, we find the case of a soldier who was
wounded by a sword in the hepatic region ; the wound was
succeeded by a profuse hemorrhage and deliquium ; on the
cessation of the hemorrhage a morsel of the substance of the
liver was removed by the forceps, and after many threatening
symptoms the patient recovered. At the end of three years
he died of fever; on dissection, a small portion of the lower
part of the wounded lobe of the liver was observed to be
wanting, where it had been removed by the cutting instrument ;
the other viscera were sound.

* Loesecke, in his Observationes Anatomic. Chirurg. Med. Berlin, 1754, p. 7,
gives a very remarkable case of a complicated wound, in which a screw exploded
from a musket, penetrated the ribs, lungs, diaphragm and abdomen, without de-
stroying the patient.

440 WOUNDS OF THE ABDOMEN, &C.

I have not had many opportunities of examining the bodies
of persons killed by wounds of the Liver, or who have survived
slight injuries and died of other diseases ; but my attention
was very particularly called to the healing of solutions of con-
tinuity in this organ, by the results of several dissections made
in India, and communicated to me by Dr. Nicol, Surgeon to
the Forces, who served for some years in that country, and who
found in many instances the marks of cicatrices on the sur-
face of the liver, which must have occurred in consequence of
abscesses bursting into the cavity of the abdomen. In some
instances, the period of the rupture was clearly indicated
during life by the cessation of pain, and the absorption of
matter was announced by subsequent rigors. I have had an
opportunity of observing the marks of cicatrices on the edge of
the right lobe of the liver, iu two subjects who belonged to Dr.
Nicol's late regiment, (the 80th,) who were affected with liver
complaints in India, and died on their return, at Gosport
Hospital.

I have never known a patient recover after a wound of the
Gall-Bladder, and, indeed, it is diflicult to imagine a case
where it could happen without an eff"usion of bile into the ab-
dominal cavity, except a previous adhesion had taken place to
the parietes ; a case, however, is mentioned iu the " Opuscules
de Chirurgie" of Paroisse, p. 255, where a leaden ball had
lodged for the space of two years. A case, I believe unique,
is reported by Dr. Thomson at page 91) of his Report, where
nature had provided against the extravasation of bile from the
substance of the liver into the cavity of the abdomen, by the
means of newly formed adhesions of considerable extent.
Waton, a French army-surgeon, gives a fatal case from the
puncture of the cyst by a ijayonet, in the Journal de Medecine
Militaire, vol. vii. p. 550, and Sabatier refers to another in his
Medecine Operatoire, vol. i. pp. ^4 and 42.

The observations upfni wounds of the Liver itself are very
frequent in authors. Murgagni, in his 53d Epistle, article 40,

WOUNDS OF THE ABDOMEN, &C. 441

gives a very interesting case; and some valuable observations
will be found in the works of Desault and Cbopart. Tbere
are few of tbe collectors that do not abound in instances, both
fatal and otherwise, and some special dissertations are to be
found on the subject, particularly one by Kaltschmidt in
Hailer's Collection, vol. v. and one by De Bergen, published at
Frankfort, 1753, and to be seen also in Schlegel's Collection,
vol. v. See also a very extraordinary case of an effusion of
bile discharged by puncture of the abdomen, Med. Chir. Trans.
vol. iv. p. 330.

Of the wounds of the Diaphragm, I have never met one un-
connected with injuries of one or both the cavities which it
divides, or in which symptoms of their being affected did not
appear ; although I have met with one instance where a
musket-ball passed along from the sternal to the vertebral con-
nection of that septum, precisely following the curvature of
the ribs ; nor have I, in those cases which have come within
my view, ever observed that peculiar spasm, (risus Sardonicus,)
described by the older authors, and lately noticed by M. Percy.
The prevention of inflammation is the leading indication of
cure ; but injuries are frequently found on dissection, which
were not at all indicated during life by any peculiar symptoms.
Sometimes the diaphragm is injured in two different points by
the same ball ; an interesting illustration of this has been fur-
nished me bv Dr. Thomson.

Cask LXXV,

Injury of the Diaphragm in two places, hy a Ball,

A lad received a wound from a musket-ball which entered
the left side between the 10th and 11th ribs posteriorly, and
passed out nearly in a direct line beneath the 8th, at the
distance of five inches from the sternum ; he died on the 5th
day. On dissection, a considerable quantity of air escaped

442 WOUNDS OF THE ABDOMEN, &C.

from the left cavity of the thorax ; it contained about three
pounds of bloody seram ; the lungs on that side were com-
pletely collapsed, though, on inflating them, they did not appear
to be wounded ; the surface of the lungs, pleura, and upper
part of the diaphragm, were covered with coagulable lymph,
which adhered very loosely; the ball broke the 11th rib, and
drove some splinters of it into the diaphragm, entered the
thorax, passed through the septum into the abdomen, grazed
the upper surface of the spleen, which was covered with
coagulated blood, returned again through the diaphragm into
the cavity of the thorax, and passed out below the 8th rib ;
none of the other viscera appeared to be wounded.

Pare gives us two cases in his 10th book, where the colon
passed through an opening of the diaphragm made by a ball,
and another, where the stomach passed through one made by a
sword. I have already mentioned a case where a hernia of the
stomach was found through a hole in the diaphragm, supposed
to have been made by a musket-ball. M. Ravier, in the
Journal de Med. Militaire, vol. i. p. 114, gives a case where
the principal viscera of the abdomen passed into the thorax,
after the receipt of a violent blow on the belly; and Mr. Boyle,
surgeon of the G2d regiment, gives a case of hernia of the
stomach through a wound in the diaphragm, in the Ed. Med.
Jour. vol. viii. p. 42. Professor Barthe of Montpelier gives
an instance where a part of the omentum passed not only
through the diaphragm, but appeared externally through a
wound which had penetrated between the Gth and 7th rib; it
separated, by the application of a ligature, on the 16th day, and
the patient, a healthy lad, recovered. See Medical and Phy-
sical Journal, vol. x. p. 250. Blancard gives a case where a
ball entered near the thyroid cartilage, and passed under the
sternum, making its exit between the 5th and Gth rib ; the colon
|)rotruded through the wound into the thorax. He gives
juiother case where the stomach protruded into the thorax, and
where there was a dibpluconicnt of I lie heart itself, which was

WOUNDS OF THE ABDOMEN, &C. 443

seen to pulsate on the right side, Observations 1, 2, Century
1st, and 9, 10, Century 2d. Morgagni, valuable on every sub-
ject, is highly so on the injuries of the Diaphragm, in his 53d
and 54th Epistle ; but the most interesting accouut that I am
acquainted with is given in the article " Diaphragme," in the
" Dictionnaire des Sciences Medicales." by M. Percy.

Wounds of the Stomach are extremely dangerous, though
not mortal. Baron Percy calculates, tbat of twenty cases, four
or five only have escaped ; tbis, however, is a most favourable
average. I have never treated an instance, nor did I see the
two reported by Dr. Thomson, which occurred at the battle
of Waterloo, one from a musket-ball, the other from a pike.
They were treated on the mild unirritating plan adopted for
wounds of the intestines, and I understand both did well.
The histories of the Bohemian, Prussian, and English " Cul-
trivores," in some of whom the knives have been cut out, and
in others discharged spontaneously thi-ough the coats of the
stomach and parietes of the abdomen, as well as many other
instances on record, are very encouraging in cases of injuries
of this organ. Mr. Hevin, in his excellent paper in the 1st
vol. of the Memoirs of the Academy of Surgery, page 144,
has collected a number of interesting instances of recovery,
both from incised and gunshot wounds. But the industrious
Ploucquet, in the articles " Ventriculus" and " Pantophagi,"
has exceeded all other authors for the vast number of cases he
has amassed. In our own Philosophical Transactions, Low-
thorpe's Abridgment, vol. vi. p. 192, or in the modern one by
Drs. Hutton, Shaw, and Pearson, vol. iv. p. 66, an instance is
given where the stomach of a horse was wounded and sewed up,
and a similar instance in the human species ; both recovered.
More recently, sutures have been applied to its wounds in Hol-
land and France, as may be seen in the " Annales de Littera-
ture," &c. b}' Kluyskens, vol. ii. and in the " Traumatologia" of
Schlichting ; and it has been again successfully done, very

444 WOUNDS OF THE ABDOMEN, &C.

lately, on tlie Continent by the French army surgeons.* Not
unfrequentlv, a wound of the stomach has become fistulous, and
remained open. Richerand gives a very curious case of this
kind, where the opening remained for nine years; Etmuller,
in the 5th vol. of Haller's " Dissertations Chirurgicae," gives
an instance where it remained open for ten years ; and Wenker,
in the same volume, relates a case where a wound of the
stomach continued open for the long space of twenty-seven
years.

Severe blows upon the stomach by spent balls, shells, &c.
often produce as certain death as similar injuries of the head ;
these cases are often supposed to afford proofs of the fatal effects
of the wind of balls.

Of wounds of the Spleen I have seen a few ; some of the
slighter recovered, the deep invariably proved fatal. Expe-
riments on the brute creation have given rise to some specula-
tions on these wounds ; but without incurring the charge of
hardened scepticism, we may be permitted to doubt if the result
of injuries, whether accidental or deliberate, on the lower
animals, can be held as perfect illustrations of similar inflictions
on the human body, although there may exist a very strong
coincidence. Diouis, a very sagacious French author, whose
work is well known in this country, has made a striking observa-
tion on this point, as applicable to the spleen. " About thirty
years ago," says he, " a certain sect of surgeons sprung up, who
took great credit to themselves for performing the extirpation
of the spleen; they looked upon this part as useless, and even
hurtful, porliaps because they did not know its functions. They
supported their theory by an analogous operation on dogs, and
because animals did not die upon t/ie spot, they extolled the
advantages it would be of to the human species ; but all the

• Sec Rulletin <lf la Fiirulli-, vol. v. p. 3S(), for a case wiiere the suture was
uh«h1 by Percy. Pumiaiinus ofti-ii stitched the stomach, in his practice with the
army. Chirurgia ('uriosa, p. IIH.

WOUNDS OF THE ABDOMEN, &C. 445

animals sabjected to it died shortly after, and no human being
was found to submit to the proposal." It would appear, from
Haller and others, that the brutes in many instances became
more fat and salacious; and there is a recent instance on record,
in which the spleen has been successfully removed from man by
Mr. O'Brien, a naval surgeon, (Medico-Chirurgical Journal,
1816, vol. i.) where it had protruded at an incised wound. This
is certainly a more favourable case than if that or^an had been
injured " in situ" where the blood from its numerous vessels
might have been extravasated into the abdominal cavity, —
a circumstance which seems to be the principal cause of dan-
ger. Dr. Home, in his " Medical Facts and Experiments,"
gives a similar case ; and another is recorded in Duncan's
Medical Commentaries, vol. ii. p. 351.

In some cases of wounds of the fixed viscera of the abdo-
men, particularly the spleen and liver, a critical hemorrhage
from the wound, or a spontaneous diarrhoea, have relieved all
the urgent symptoms, after copious purging and venesection
had been employed before without effect.

Blows upon the region of the spleen have frequently given
occasion to fatal extravasations of blood, and sometimes this
organ has been ruptured by blows inflicted at more*distant
points. The following is a case of this kind, in which the dis-
section was performed at a very short period after death :

Case LXXVI.
Rupture of the Spleen from a Blow on the Stomach.

** At a quarter before 10 o'clock on the morning of the 20th
of February 1820, I was suddenly called upon to see private
J. B. 4th Veteran Battalion, but on my reaching his room he
was dead. Assistant-Surgeon O'Donel, whom I found with the
deceased, informed me he had seen him about live minutes

440 WOUNDS OF THE ABDOMEN, &C.

previous to my coming, and that, in consequence of the alarm-
ing state in which he found him, he had sent for me. When
Mr. O'Donel saw the deceased, he was unable to speak, his
countenance of a deadly paleness, his lips livid, his pulse not
perceptible, — in fact dying. Upon inquiry, I learned that the
deceased had been fijjhting' with another soldier, bv whom he
had been knocked down, and that, while in the act of rising,
with the assistance of another man, he received a violent blow
on the stomach, which brought him a second time to the ground ;
that, upon being placed on his feet, he fell, as if he had fainted,
against the range in which the cooking-pots are set. He was
immediately assisted to his room, being unable to walk without
support, and a non-commissioned officer instantly sent for a sur-
geon, so that five minutes had not elapsed from the infliction of
the injury until he was seen by my assistant, who opened the
median basilic vein, and endeavoured to give him some aether,
but to no effect. At two o'clock P. M., I examined the body.
Upon opening the parietes of the abdomen, I was surprised by
the escape of an immense quantity of dark coloured fluid
blood, to so great an extent, as to induce me at first to think the
cava was ruptured. Having laid open the abdomen perfectlv,
I carefu4ly removed with sponges the remainder of the eflused
blood, and, from the quantity collected I was enabled to form
some estimate of the extent of the hemorrhage, which could
not be less than between six and seven pounds. My attention
was first directed to the large veins, which I found uninjured ;
the liver sound and healthy, as also the stomach, but (juite full
of liquid food, the man being just after breakfast; the intestines
were healthy, and nothing worthy of remark appeared, but that
the diameter of the sigmoid flexure of the colon was smaller
than natural. Upon raising the great curvature of the stomach,
I discovered a considerable collection of coaguhi and fluid
blood surrounding the spleen, upon the removal of which I was
enabled to ascertain the source of so fatal an hemorrhage.

WOUNDS OF THE ABDOMEN, &C. 447

'* I carefully passed ligatures round the cardiac and pyloric
orifices of the stomach, and then removed it with the spleen
attached. Upon examination, I found the latter ruptured from
its lower to its upper margin, to the extent of four inches ; the
rupture passing under the duplicature of the peritoneum, con-
necting the spleen with the stomach, close by the entrance of
the splenic artery, the large vein accompanying which was
ruptured. The spleen was perfectly healthy, not in the least
enlarged, nor any apparent tendency to disease; it was firmer
in its structure than is generally found. The contents of the
thorax were in the natural state, the coronary veins distended
with blood. So completely were the other vessels emptied of
their contents, that, on opening the superior cava, eight ounces
of blood were not effused. Rupture of the spleen is a rare
occurrence, unless when much diseased, and a great degree of
violence is offered. But this case is very peculiar when it is
considered that the part upon which the blow was struck is so
distant from the viscus injured, but particularly so, that the
spleen was not in the least enlarged, nor any apparent tendency
to disease existing. Had the stomach been empty, I think the
blow would have been borne with impunity ; or had the contents
of the stomach been less fluid, I think it probable it would not
have occurred." For this very accurate account I am indebted
to Mr. Burns, Surgeon of the 4th Veterans.

Some interesting observations on Wounds of the spleen are
to be met with in Richter's Bibliotheca, B. 8, p. 533, and
among the older authors, as in Fallopius de Vulneribus,
Chap. 87, and in Schenckius, Lib. 3, Obs. 104. A special
dissertation on them, by Pohl, is extant in Schlegel's Collec-
tion, vol. ii.

From severe blows or bruises upon the Abdomen, very
serious injuries are inflicted without the solution of external
continuity, and even instant death is no unfrequent consequence.
Dissection in some instances explains these cases, but in others
we are left entirely in the dark, and until we can affix a more

448 WOUNDS OF THE ABDOMEN, &C.

appropriate name, we may apply the term Concussion to them,
as we do to the unknown cause of death in injuries of the head.
Nor is the analogy so loose as might at first sight be supposed ;
for, independent of the lesion of the organs contained in the
two lower cavities, the spinal marrow may be affected in a way
beyond the reach of our senses to discover. Some cases of the
effect of pressure upon it from internal causes, and some of the
experiments of Le Gallois in France, and Philip and Clift in
England,* open a wide and interesting field for inquiry, which
the difficulties attendant on examining the Theca Vertebralis
ought not to deter us from pursuing. Where the powers of
life, therefore, are obviously sinking, stimulants, both general
and local, as wine, aether, warm friction, blisters, &c. may be
used, followed up, if active inflammation should show itself,
by the depleting plan.

It is from the neighbourhood of the Spinal Marrow, and the
great nerves proceeding from it, that all wounds of the bony
pyramid derive their greatest interest; extensive injuries, or
permanent lodgment of balls, give rise either to death, or to
incurable paralysis. In a sergeant of the Enniskillen Dragoons,
wounded at Waterloo, a piece of the shaft of a Polish lance
stuck fast between the spinous processes of the two last dorsal
vertebrje, completely paralyzing him until it was removed. In
some cases we have to wait for the slow operation of exfoliation,
if the spinous process be injured. Sinuses also are very apt to
form along the spine, and they often prove very troublesome;
I would never trust to pressure in these cases, but make a free,
though cautious, incision. These incisions are sometimes
rendered very necessary by the lodgment of balls, pieces of
cloth, &c. Immediate death docs not follow on all wounds of
the spinal marrow, although it may have been completely

• I.e Gallois, Kxperiencos sur Ips Priiicipt-s de la Vie, 8vo. Paris, 1812.
riift, in the Philosophical Transactions for IKIH, part i. p. S)l. Philip, in
tin; KdinburKh Medical Journal for .lanuary, 1S15. Knox, in the London
Kcpository, vol. vi. p.f7J. Moulson, in llic Mtilico-Cliirurgicnl Journal, vol.iii.

WOUNDS OF THE ABDOMEN, &C, 449

divided, nor, as we learn from an instance related by M.Boulet,
in the Parisian Chirurgical Journal, vol. ii. English translation,
are these cases always attended with paralysis ; in this case,
a gunshot wound of the chest completely divided the spinal
cord at the tenth dorsal vertebra ; the man survived twenty-six
hours ; the functions of tlie urinary organs were uninjured, but
he was incapable of disharging his feces, — he was in constant
agitation, moving the pelvis and lower extremities continually.
Balls which pass along, or strike against the different bones
of which the Pelvis is composed, if discharged from a musket,
rarely penetrate ; dreadful penetrating wounds and fractures,
however, arise from round and grape shot. I have never
witnessed a recovery from an injury of this description, nor
have I seen one, where the performance of any operation, much
less the application of a trephine, as proposed by Boucher in
the Memoirs of the French Academy for 1776, could have
been of use. The picking away of splinters, or other sources
of irritation, is all that I have ventured to do in the few cases
that have come under my care, trusting the remainder to proper
regimen and dressings, and to the sanative powers of nature.
It sometimes happens that balls lodge in or near the bones of
the pelvis, and sometimes Ihey enter the cavity through the
natural foramina, constituting wounds of a most dangerous
tendency from the nerves, blood-vessels, and important organs
which they injure. In some cases where a musket-ball has
struck at point blank range, it has fairly penetrated the bone ;
these cases are also highly dangerous, but there are some rare
exceptions, in which neither immediate death nor paralysis take
place. Mr. Hammick, Surgeon of the Royal Naval Hospital
at Plymouth, was so kind as to show me a preparation made
from a patient who had received a wound from a musket ball,
which passed through the right side of the sacrum, about three
inches above the point of the os coccygis, and penetrated
obliquely upwards. The ball was passed by stool in about
two months after the infliction of the injury. The unfortunate

450 WOUNDS OF THE ABDOMEN, &C.

man sarvived for two years, when, a discharge of feces coming
on through the orifice in the bone, he died, exhausted by
a complication of sufferings, but no paralytic affection ever ap-
peared. A case, precisely similar to this, was seen by Dr.
Thomson, in the Military Hospital at Berlin, under the care of
Dr. Reich.

In a case of an officer of the Commissariat, which occurred
at Elvas, during the siege of Badajos, a ball passed through
the sacrum, nearly in the same line of direction as in Mr.
Hammick's patient, and out over the symphysis pubis. Urine
passed after the first few hours from the posterior wound, and
almost immediately from that in front, but no feces ever ap-
peared at either, until a few hours before the patient's death :
the intestinal gases, however, escaped in great quantities, and
the smell was overpowering; no loss of motion appeared until
the third day, when he expired, labouring under symptoms of
the most violent peritonitis. On examination of the body, all
distinction of parts was so completely obliterated, that the
exact course of the ball could not be ascertained.

Dr. Thomson lately met with a case where a musket-ball had
lodged in the ilium of a military olficer, where it remained
above two years, until violent infiammation having been excited
by dancing, it was luckily discovered and extracted with con-
siderable dilliculty. A very large quantity of matter followed
the extraction, and it was obvious that the ball had perforated
the bone completely, and had been wedged into it, and con-
fined the matter. The patient, who had been hectic, gra-
dually recovered, and now enjoys perfect health. Bordenave,
in his paper so often referred to, and Andouillr, in the same
volume of the Memoirs of (he Academy, furnish some very in-
teresting cases of gunshot womuls of the pelvis and spinal
column.

Wounds of a most distressing nature, but fortunately not
very common, occur in the Perimeum, and in the Organs of
Generation. In the first class, the elastic gum catheter is of

WOUNDS OP THE ABDOMEN, &C. 451

the utmost assistance to us. In the few cases which I have
met with, a perfect cure was effected by its employment, to-
gether with that of small adhesive straps to bring- the lips of
the urethra tog^ether, and light easy dressings, particularly
finely scraped dry lint, without the aid of any scarifications
whatever ; the latter application, with an occasional emollient
poultice, has generally brought the wounds of the genitals to
a healthy state. In some instances, the Scrotum has sloughed
extensively, leaving the Testis quite uncovered ; in others, the
Testis has thrown out, with great rapidity, a fungous protru-
sion. In some of these fungous cases, I have seen the whole
tribe of escharotics employed in vain, and the ultimatum of
castration has been adopted. This is a remedy often unneces-
sary, for, by removing the fungous growth with the knife, and
cautiously dissecting away the excrescence in slices, until we
come to the sound structure, the parts frequently heal up with
the usual dressings.

It will be obvious, in the perusal of the foregoing part of
this work, how much I have trusted to Depletion ; but I
beg to remind my readers, that I have been describing the
injuries of robust young soldiers, full of life and vigour, and
fitted for all the purposes of active warfare ; living principally
in the field, enjoying few, if any, of the luxuries of domestic
society, and, consequently, exempted from many of the dis-
eases incident to the inhabitants of cities. A short absence
from the army, has, however, been often attended with a re-
markable change in their constitution ; the men who were once
in the hospitals in the rear, have almost constantly formed the
great majority of their inhabitants afterwards. It may be said
they were weakened by previous sickness, — to a certain extent
1 admit the fact ; but the same cannot be said of the officers
who, from duty or other causes, remained in the Depots, and
preserved their health there. These men could not bear the
privations of the field ; they were subject to low typhoid

2g2

452 WOUNDS OK THE ABDOMEN, &C.

febrile attacks ; they could not bear evacuations, either in their
diseases or their wounds, to any thing like the extent of those
more actively employed. The difterence of success was so
notorious, that the depot officers were consigned to certain
death when they joined the army, by their veteran brethren;
but what military men deemed moral judgments, medical men
accounted for upon physical principles.

The histories of unlooked for cures that have occasionally
been effected in wounds of the various parts of the body, and
that have from time to time been recorded, should render us
cautious in pronouncing any injuries absolutely mortal, and
should encourage us to persevere to the last in our efforts at
relief. True it is, that those histories are more numerous in
the earlier annals of our science, when miracles of surgery and
miracles of medicine shed a mystic glare around their profes-
sors, and distinguished them amidst the " palpable obscure"
of a superstitious age ; but even in the present day, when the
steady light of anatomy, of physiology, and all the collateral
sciences, has illuminated the different branches of the healing
art, — M'hen the theorist and the speculator are neglected or ri-
diculed, and the fascinating mazes of fancy are abandoned for
the more arduous path of rigid enquiry and practical deduc-
tion, facts singular and inexplicable are daily offered to our
notice. To rescue these facts from oblivion is the duty of
every man ; each reader or each witness may doubtless consi-
der them with a bias perhaps unknown to himself, and invo-
luntarily influenced by his own peculiar opinions, or by the
particular point of view in which he sees them. In the fore-
going pages f have, as far as 1 was capable, divested myself
of every prejudice, and Ix^en tht; faithful narrator of what I
have seen ; I have neither indulged in the visions of theory
nor the intricacies of criticism, nor have I strained or distorted
facts to serve a particular purpose ; and if I have contributed
to fix one wavering mind, to illustrate one point of military

WOUNDS OF THE ABDOMEN, &C. 453

surgery, or to advance in the smallest degree the interest of
that branch of my profession to which my life is dedicated, I
shall have obtained the full completion of my wishes.

I should next proceed to details in which the general prac-
titioner is deeply interested, and in which I shall endeavour
equally to divest myself of all prejudices and preconceived
opinions ; but I shall first throw into a miscellaneous chapter
some observations which at present I can only consider as
hints to my military readers, but upon which I may hereafter
have more time to enlarge.

454

CHAPTER XX.

OF MISCELLANEOUS POINTS CONNECTED WITH MILITARY

SURGERY.

Although some of the subjects of this chapter merit a
much more detailed consideration than I have space to enter
into, I could not omit them in a work professing- to treat on
Military Surgery, and the duties of the army surgeon. These
subjects are, The Examination of recruits, on their entrance
into the service ; The Examination of military persons said to
labour under various diseases, which have been assumed for
the purposes of procuring- a discharge from the service, or an
increase of pension, or temporary exemptiou from military
duty ; and, lastly, some few Heads of Inquiry on which the
medical oflicer should found his reports, on the Medical Topo-
graphy of the stations in which he may be quartered.

EXAMINATION OF RECRUITS.

In the standing orders of our army, as well as in those re-
gulations issued from lime lo time for the guidance of ollicers
connected with the recruiting depiirtment, some directions are
given on this head ; but liltU; or nothing is to be found to
guide the surgeon in dubious cases, much being left to his own
discretion. This often (xxasions very striking dilferences of
opinion between the examining oHiccrs, as to the fitness of re-
cruits or deserters for service ; and as, by a recent regulation,

EXAMINATION OF RECRUITS. 455

tbe extraordinary expences incurred for recruits, who are not
ultimately found proper subjects for the army, are paid by the
surgeon, he often finds that he is a considerable pecuniary
sufferer, by his carelessness, his ignorance, or his good na-
ture. The subordinate officers and soldiers who are employed
in this service often take advantage of him, and frequently
present men a second time, whom he had previously rejected.
The examining officer shoukl therefore always be in possession
of a register, in which should be inserted the name, age, and
description of the recruits whom he examines, the date of
their examination, and, if rejected, the cause of their unfitness.

The plan adopted for filling the ranks of the French army
by conscription, during the I'evolutionary war, occasioned many
attempts at evading the service, and induced the constituted
authorities of that very ingenious people to form a set of regu-
lations, which left few if any points on which the persons con-
nected with this branch of the service could go astray. Indeed
their " Code de la Conscription," 8vo. Paris, 1810, may, as far
as the medical officer is concerned, be considered as a perfect
model : I would strongly recommend a perusal of it to all
medical officers; and I shall avail myself of such parts of it as
are applicable to the British service, as I go along.*

It should be made a general rule never to examine a recruit
or deserter while he is in a state of intoxication ; the examina-
tion should always be made when these persons are naked ;
and that the surgeon may be assured that he has left no part of
his duty unfinished or neglected, he should form a regular
system in his own mind for his guidance, and should not trust

* This book is rather difficult to be procured in this country : an abstract of it
will be found in the Edinburgh Medical and Surgical Journal for April 1S16,
vol. vi. Mr. Marshall, Surgeon to the Forces, published in 1S2S, an 8vo. vol.
entitled Hints to Young Medical Officers of the Army, on the Examination of
Recruits, and respecting the Feigned Disabilities of Soldiers. He has annexed
to tbis useful work the French and Prussian Codes for the Inspection of
Recniits.

456 EXAMINATION OF RECRUITS.

to a desultory inspection. He should first examine the persons
submitted to him generally " a capite ad calcem," as to the ex-
ternal parts of their body, and then more particularly as to
their functions, severjll of which will have come under his view
in his first examination.

In the first examination, the shape of the head should be
ascertained ; no man with a preternaturally large cranium, or
who has the mark of extensive fracture with depression, or who
has venereal or other exostoses, can be considered as a healthy
subject. Tinea capitis is a cause which, without proceeding
any farther, is sufficient for his rejection.

All diseases, or marks of former disease in the Eye, or
lacrymal passages, are a principal cause of rejection; the ex-
amination on this point should be particularly minute, and both
the upper and lower eye-lids should be gently turned out over
a probe, to ascertain the existing state of the membrane lining
them. If it presents marks of existing inllammation or granu-
lation, or the appearance of former cicatrices, the person is
ineligible. Pohpus of the Nose, or caries, or ozena, or
extensive fractures, or distortion, are causes of rejection. In
the Mouth, au extensive deficiency of teeth, caries of the bones,
or foul ulcerations of the gums, and all chronic diseases of the
salivary passages and glands, renders the person ineligible. In
the Neck, all scrofulous tumors, enlargements of the vessels,
or rigidity or distortion of tlie muscles and joint-;, are causes of
rejection. All malconformations in the Thorax, whether in its
fore or back parts, are, without proceeding farther, causes of
rejection, as are also ail marks of punislunent or extensive
cicatrices. All preternatural tumefactions of the Abdomen, or
distortions of the lumbar vertebra', all herniary protrusions,
fistulous affections ol the rectum, or extensive hemorrhoidal or
other excrescences, render the subject unfit for service. All
diseases of the Testicle or Spermatic cord, all tendency to
a varicose state of the vessels in these parts, and all herniary
tumors, are causes for rejection without proceeding farther.

EXAMINATION OF RECRUITS. 457

All distortions of the legs, thighs, or arms, exostoses, nodes,
caries, extensive fractures, open ulcers, or extensive cicatrices,
especially on the shin and adhering to the bone, stiffness, or
contractions or dislocations of any of the muscles, tendons or
joints, varicose vessels, especially in the ham or its neighbour-
hood, wasting of the limbs, loss or contraction of the fingers,
loss of the great toe, caries of the bones of the (oes, all foul
ulcerations between them, or distortions, rendering the pressure
of a shoe or boot painful, or walking difficult, are causes of
rejection. The loss of one toe, if it have proceeded from
accident, is not perhaps a cause of actual rejection, though it
renders the person an object for strict consideration. All
Cutaneous affections of an inveterate character are a cause for
rejection ; simple itch is so frequent among the lower orders,
that it forms an exception.

This first and ^nore general examination will have enabled
the surgeon to ascertain several important points. He should
now re-examine the person submitted to him more particularly
as to their various functions. Their Intellect. — Idiots should
at once be rejected. At the commencement of a war, I have
known many instances of such persons being brought forward
for examination. Their Vision: their Hearing : their Speech:
their Smell. — All affections of the sight, deafness, dumbness,
and stammering, are causes for rejection. In examining for
Veteran Battalions, the loss of one eye is not considered a cause
of rejection, but on the late formation of these battalions, the
examining officers were furnished with printed instructions as
to the specific causes for i-ejection. On all occasions, these
specific instructions are a great assistance to the surgeon, and
should be most rigidly attended to. Loss, or great distortion
of the nose, impeding the stmse of smell, is a cause for rejection,
as well as the other diseases mentioned above. The state of
their Respiration should be specially examined into ; short
frequent dry cough, asthma, and all symptoms denoting a
phthisical tendency, form a cause for instant rejection. Ex-

438 MEDICAL TOPOGRAPHY.

tremely fetid breath is also a cause for rejection. Tlie state of
their Circulation should be particularly examined, and the
existence of all palpitations, or other affections of the heart,
aneurismal and varicose tumours, should be strictly inquired
into; they form a cause for absolute rejection. The loss of the
penis, or of both testicles, is stated as a cause of rejection in
the French code. Such a case never came before me, but if it
did, 1 should consider it a fair cause for rejection. Diseases of
the urinary passages, and stone in the bladder, are a sufficient
cause for rejection.

An aspect betokening habitual ill healtl:, without any specific
disease being present, is a sufficient cause for rejection. If
the recruit ever has had Epilepsy, however healthy he may
appear, he is at once to be rejected by the standing orders of
the army.

By adopting this systematic mode of examination, and by
making the person to be examined walk, run, or leap, move
and extend bis joints and limbs in various directions, cough
with his arms extended over his head, and with his head and
chest thrown back, it will be very rarely, indeed, that any
serious cause for rejection can escape the examining surgeon.

HEADS OF INQUIRY ON MEDICAL TOPOGRAPHY.

The study of Medical Topography is one of considerable
importance to medical men of whatever class, but the habit of
arranging his ideas on this subject, so as in the shortest possible
time to ac<juirc the most valuable information concerning the
situations in which he may be stationed, (as far as the health of
the troops is concerned,) is an essential object to the military
practitioner. Diseases, the characters of which are supposed
to be the most unalterably fixed, are greatly modified by locality.
The plague itself, the most violent and the most rapid of dis-
eases, acknowledges this inlluence. Thus we find, that, in the

MEDICAL TOPOGRAPHY. 459

expedition to Egypt, tbe cases of plague in the 6lst and 88th
regiments, whose hospitals were crowded, were, from the
commencement, attended with typhoid, or low symptoms. The
cases from the Bengal Volunteers, and other corps encamped
near marshy grounds, were all of the intermittent or remittent
type. The cases which occurred in the cold rainy months of
December and January had much of the inflammatory diathesis;
and every case admitted into hospital at one quarter, Rahama-
nie, had the symptoms of pneamonia. See " Medical Sketches
of the Expedition to Egypt from India,'' by Sir James M'Grigor.
The following heads may serve as useful memoranda to the
medical officer whereon to found his inquiries ; others will
naturally be suggested by his own ingenuity, and the pecu-
liarities of the district in which he may be stationed. These
heads are divided into three classes, as they refer to the Station
of the troops, to the Barracks, and to the Hospitals, and
are as follows :

Class I. — The Station. — 1. Its geographical position —
size — population — distance from the sea — rivers — marshes —
bogs — and its height above their level — its drainage, and state
of its canals.

2. Nature of the soil — its mineral and vegetable productions
— nature of its waters — their medicinal powers, and chemical
contents.

3. Police — morals — food — employment — cleanliness — and
general health of its inhabitants.

4. General direction of the prevailing winds, and whether
they blow over bogs, marshes, the sea, &c. — mean standard of
the thermometer, barometer, hygrometer, and mean quantity
of rain.

5. Tbe diseases of the inhabitants, and whether they appear
to be influenced by the situation — the contagious diseases
which most prevail in the town or district — in its civil hos-
pitals — prisons — poorhouses, or manufactories, and their nature

4C0 MEDICAL TOPOGRAPHY.

— llie peculiar diseases among the inhabitants, or among the
troops quartered in the town.

6. The ordinary period of duration of life among the in-
habitants, and the remarkable instances of old age, or of mor-
tality — the relative state of health of the last twelve months to
that of former years — if possible this information should be
extended to several preceding years.

7. The most unhealthful season, according to the observation
of residents and physicians who have written on the subject —
the comparative mortality according to the registers of births,
burials, &c. of the country and of the town.

8. The peculiar modes of cure adopted by the inhabitants
or their resident medical men, and an account of any particu-
lar remedies.

Class II. — The. Barracks. — 1. Their situation — the date af
their erection — their form — whether built in a square, or in
parallel lines, or in detached houses, or any other particular
manner, and whether of wood, brick, or stone.

2. The nature of the soil on which they are built, and of
that immediately around them — their state with regard to
damp, cold, exposure to particular winds, and their general
aspect.

3. Their general plan — the number of stories — the number
of rooms in each story — the state of the cellars, and whether
inhabited or not — the number of men they are calculated for
in war, and the number in peace — whether they consist of one,
or of many distinct buildings.

4. '^I'Ih- size of the rooms in feet — as to their height, length,
and breadth— the niinibor ol windows in each — ditto of doors
— ditto of fireplaces.

5. The state of ventilation — whether the upper sashes let
down, and the lower lilt up — whether any reach down to the
lloor, (jr up to the ceiling — whether there are holes or ventila-
tors over the doors, or in the walls or ceilings — whether the

MEDICAL TOPOGRAPHY. 401

fireplaces vent well, and are so placed as to sufficiently warm
the rooms, and to obviate the danger of the men sitting around
them being exposed to rude currents of air from the doors
or windows.

6. Whether the bedsteads are single or double— of one or
two tiers of sleeping places — and whether their bottoms lift in
and out, so as to admit of cleaning under them — whetber the
beddino" is sufficient.

7. Calculating the number of men in each room, and its
size, to ascertain how many cubic feet each occupant has al-
lowed him on the war, and how many on the peace establish-
ment — wbether the size of the bedsteads, or of presses or
divisions in the rooms, materially deduct from the volume of
air, or from its free circulation — whether there are any recesses
or projections which favour the accumulation of filth, or con-
ceal it when accumulated.

S. Whether the passages are well constructed for ventilation,
with cross windows, or with gratings admitting a passage of
air perpendicularly through the different stories from the ground
to the roof.

9. Whether the kitchens, wash-houses, &c. are good, and
separated from the barracks.

10. Whether the barracks and the yard are well drained,
and the latter ample in size.

11. Whether there is a sufficient supply of water, and if
furnished by rivers, pumps, springs, or cisterns.

12. Whether the privies are detached, ample, clean, well
drained, and with free access of air and light, and whether
they are placed on that front, which from the usual course of
the winds is most frequently to be leeward. Whether the
privies or common sewers emit any unpleasant exhalations in
any particular state of the wind or of the weather.

13. Whether any particular diseases have prevailed in the
barracks, and whether they have been general or confined to
particular rooms or wings.

462 MEDICAL TOPOGRAPHY.

14. Whether Ihe places of conSnement are dry, wholesome,
and airy, and whether disease has ever been traced from them.

Class III. — The Hospital. — 1. The same questions as in
Class II. to be answered as far as they are applicable to the
hospital.

2. Whether the store-rooms are sufficient for the provisions*
the clean and dirty linen, the men's packs, &c. Whether there
is a sufficient surgery, dead-house, wash house, &c.

3. The distance of the hospital from the barracks, and whe-
ther it is of easy access. Whether there is a separate airing-
ground for convalescents.

4. Whether typhus or hospital gangrene have ever made their
appearance, — or whether several patients have ever laboured
under any particular disease at the same time, which could be
fairly attributed to the locality of the hospital.

If these points of inquiry are duly attended to, a great mags
of useful information may be elicited in a very short time.

4G3

CHAPTER XXI.

OF FEIGNED DISEASES.

This is, in many instances, a subject of extreme delicacy
and importance, and on the just decision of the surgeon the
character of an individual, and the benefit of the service, are
materially interested. Upon the whole, however. Malingerers,
as they are technically called, are not now so frequently met
with as formerly.

In forming a judgment of these people, the medical officer
must be greatly influenced in his decision by his knowledge of
their previous character, habits, constitution, and former com-
plaints, and by the ostensible reasons which they may have for
feigning either for temporary or permanent purposes. The
men of bad characters, who are to be found in all corps,
especially at the beginning of a war, will be incessant in their
attempts, particularly on young surgeons; frequent exajiiina-
tions, made apparently without having any suspicions, will often,
by the contradictory replies, enable us to elicit the truth, and
they should be made in private, as the number of spectators
always increases the obstinacy of the impostor.

There ^re some diseases, the symptoms of which are so
obvious to 'a well-informed medical man who watches them
closely, and at times when he is not expected, that no artifice
of those who pretend to labour under them can deceive him ;
these diseases are principally of the acute class. One caution
I have already given at page 198, upon the subject of dis-
tinguishing between intoxication and those severe affections of

464 FEIGNED DISEASES.

the nervous system which so frequently precede fever. It has
been said, but I know not whether on good authority, that
a severe paroxysm of fever may be excited and kept up by the
introduction of a clove of garlic into the rectum. Profligates
have, to my own knowledge, boasted that they have often
received indulgences from the medical officers in consequence
of a supposed febrile attack, by presenting themselves after a
night's debauch, which they have purposely protracted, to aid
the deception. Emetics also have been taken with the same
view, or the face has been exposed to the fumes of sulphur,
and Fodere states, that paleness has been imitated by smoking
cumin, (Cuminum cyminum.) I have seen some old soldiers,
profoundly versed in the history of a paroxysm of intermittent,
and very skilful in imitating the rigors, but their detection has
never been difficult.

Mr. Hutchison mentions an instance where a French
prisoner swallowed tobacco, and covered his tongue with soap
to produce fever; the tobacco occasioned great rapidity of
pulse, but the matters ejected from the stomach were so strong-
ly impregnated with the smell, that the discovery was easily
made.

Of the diseases of the chronic class, which are often assumed,
one general remark should be attended to, viz. that it is very
rarely a disease of this description exists for any length of
time, without obviously injuring the patient's general health, or
his external appearance. Ulcers, Chronic Rheumatism, Incon-
tinence of Urine, Epilej)sy, Ophthalmia, Pectoral Complaints,
and A (lections of the Liver, and of the Intestinal Canal, arc
those most frequently assumed.

Ulcers were formerly extremely [)revalent in the army, and
were often produced by various acrid applications, pressure, &c.
but by the adoption of Mr. Baynton's practice, they are now
rendered much more manageable; where the ulcer is supposed
to be excited by unfair means, surgeons are now in the habit of
scaling the dressings, and so effectually preventing any improper

FEIGNED DISEASES. 465

tampering with them without immediate discovery. I had some
time ago a case in a recruit, reported to be " pompholyx diuti-
uus," and resembling that species of bullae in a very remarkable
degree. After several veeeks. Dr. Bartlet of the 88th regiment,
into whose charge the man was at last transferred, detected a
shining particle of the powder of cantharides adhering to an
unctuous dressing, which he had purposely applied loosely to
the limb, in order that the patient might not be prevented from
managing his case in his own way.

Pins are occasionally stuck through the ordinary dressings to
imitate ulcers ; a box will therefore be found even belter than
the sealed roller.

With regard to Chronic Rheumatism, if there is not an evi-
dent wasting of the limb, said to be affected, I should not con-
ceive it a sufficient cause for excusing from dut}', or invaliding
any class of military men. Severe rheumatic affections of the
back occasionally produce distortions from disease of the ver-
tebrae, or their ligaments, and are often a cause for invaliding.
The real rheumatic affections are all aggravated by damp ; the
impostor complains at all times.

Incontinence of Urine is frequently affected by worthless
soldiers, but is almost always detected by giving- them a full
dose of opium at night without their knowledge, and introducing
the catheter during their sleep. Or, by taking them by surprise
during the day, and introducing the same instrument, when it
will be found that the urine has not drained off guttatim as it
was secreted, but that the bladder possesses the power of re-
tention. If the bed-clothes are not found wet after a full dose
of opium, during the operation of which the patient is suddenly
awoke, we may also be satisfied that there is no incontinence,
without taking the trouble of introducing the catheter.

If a soldier can discharge his urine in a fuU stream, and in
the usual quantity, which the less hardened impostors may be
desired to attempt before the examining officer, no doubt can
be left as to the non-existence of disease. Fodere says, that
if the penis is secured by a ligature, it swells considerably it)

2 H

4GG FEIGNED DISEASES.

the real iucontiuence, in cousequence of the urine running into
the urethra; but this does not happen in the feigned. Dr. Ban-
croft, in his Essay on Yellow Fever, p. 15, has well observed,
that in most cases of injury of the spine, or disease of the blad-
der, in which that viscus loses the power of contraction, it also
soon loses its governing powers, and the urine is voided in a
putrescent state, like that voided in severe cases of fever, —
from this fact a diagnosis between real and feigned eneuresis
may be drawn.

However high coloured the urine may be, if it does not con-
tain blood, it does not give a clear red stain to a bit of linen
dipt into it, (see Howship on Diseases of the Urinary Organs,
p. 12.) We should see the patient make water, and then in-
stantly dip a rag into it, and secure it from any after addition
of blood. If blood be really evacuated in a fluid state, it soon
ibrms a coagulum on the linen cooling, a fact which may assist
us in forming our judgment.

Bloody urine is sometimes imitated by pouring real blood, or
colouring matter into the chamber-pots ; and in India the fruit
of the prickly pear, (jr Indian tig, (Cactus Opuntia,) is often
eaten, and gives to the urine a bloody appearance. Large
companies of men have been simultaneously affected in this way.
Ellicot, in the Journal of his " Travels for determining the
Boundary of the United States," 4to. informs us that his people
eat very plentifully of this substance, at an island of the
Mississipi, ( Kayo-ani,) " and were not a little surprised the
next morning, on iinding their urine appear as if it had been
Lighly tinged with cochineal." No inconvenience resulted
from it. It would ap|)ear that the juice of this plant may be
analized into a crimson dye by utlicr processes besides that of
the cochineal ins<.'ct. Beet root also has the same ctlect.

All preteud«,'d calculous concretions can be immediately de-
tected by sawing them through, and marking the absence of a
lamelluted appearance; or by applying to them the chemical
tests p(jiiited out by Dr. Marcet, in his excellent work on
Urinary Calculi. In general, we shall be enabled to recognise

FEIGNED DISEASES. 467

in these substances the common stones and sand of the high-
"ways or fields in the impostors' neighbourhood.

W^orms have been imitated by throwing vermicelli into the
vessel which contains the urine ; this clumsy deception is easily
recognised ; but the appearance of worms in the urine is occa-
sionally given by filaments of coagulable lymph, which have
really passed, and which probably have been formed in the
ureter; here disease exists.

Strictures are often feigned, especially by idle officers, the
cautious use of the catheter will soon discover their existence.

A trick, very common formerly among vagrants, but which is
now of more rare occurrence, and which I should scarcely have
mentioned here, were it not that a case of it has recently come
to my knowledge, is the puncturing the scrotum, and by means
of a straw or quill, distending it with air to an enormous size;
the detection of this deception is not so easy as may be ima-
gined, but the suddenness of the tumefaction, and the general
character of the subject, together with a close examination to
discover the orifice made in the integuments, will lead to the
detection. Emphysematous tumours in other parts of the body
may be produced in the same manner.

Some persons have the power of drawing up the testicles
into the groin, so as to resemble hernia, of this Mr. Hutchinson
gives an instance.

Injuries to the loins are also often feigned by men who have
some power over the vertebrae, and can for a time throw them-
selves into a state of distortion.

Some have the power of dislocating even the femur. (See
Sir A. Cooper, Preface, 3d edition, p. 7.) Others possess the
power of dislocating the patella at will, (see same book, p. 9,)
this occured in a female dancer. In the 7th Garrison Battalion
I met a slight of hand man who could throw his wrist, thumb,
and fingers into a state of most singular distortion.

Contracted joints, see Haddock's case, Mr. Marshall's paper.
If the arm is kept stretched out, as it occasionally is, we

2 II 2

4G8 FEIGNED DISEASES.

examine the biceps, if it is plump and vigorous we doubt the
reality of the case, if the biceps is cut through by a sabre, or
much iujured, theu the biceps keeps the arm constautly ex-
tended.

Epilepsy so rarely appears for the first time after the age of
puberty, that its reality is to be suspected whenever it comes
on, without obvious cause, in an old soldier. Those who feign
this disease select conspicuous situations, and rarely present
the appearance of bruises or injuries of the tongue. In the
real disease, the muscular contractions are preternaturally
strong and protracted, and they are simultaneous, not exerted
one after the other; and the patient, after they are over, falls
into a profound sleep. It has also been observed, that in the
real epilepsy, if the hands are forced open they remain so,
while in impostors they are immediately clenched, and the nails
are livid in the former, but retain their natural colour in the
latter. But it is from the eye that we are best enabled to form
our judgment; in the impostor it is moveable, and the iris is
sensible to the impressions of light. In the real epilepsy the
eye is fixed, and the iris does not contract on the application
of light. The sense of bearing also is lost in the real epileptic ;
the proposal of a cautery will often effect a very rapid cure on
the impostor, who is perfectly sensible to sound as well as to
pain. M. Vaidy states in the article ** Hygiene Militaire," in
the " Dictionnaire des Sciences Medicales," that he had
recently detected a recruit nvIio was reputed to be afflicted
with epilepsy, by assuring him that the real disease attacked
only in the morning, while the feigned appeareil after mid-day.
ITie next day the impostor arranged his fits according to this
information. In mendicants, who assume this disease for the
purpose of exciting charity, a small morsel of soap is moved
about in tJie month to create the appearance of froth ; a si-
milar device has, 1 brlieve, been occasionally detected among
soldiers.

Mania is Kometimes feigned, and is an in)position of very
(lifiicult detection. The feigned maniac never willingly looks

FEIGNED DISEASES. 469

his examinator in the face, and if his eye can be 6xed, the
changes on his countenance on being accused are indicative of
his real state. I have seen an instance where a person, feigning
madness, confessed that he could not support the inquiring
glauce of the physician who examined him. Real maniacs
often resist the want of sleep and the power of emetics and of
opium very remarkably.* This disease is very rarely feigned
by military persons ; we occasionally find, however, that some
of their diseases derive their character from a certain state of
mental hallucination ; this, in my opinion, was the case in an
instance which made some noise in the south-western parts of
England a few years ago. It occurred in a soldier who, as a
punishment for poaching, had been sent to a corps employed
on the coast of Africa; and was afterwards placed under my
superintendence at Hilsea Hospital, in the neighbourhoood of
which place he was known by the appellation of the " Sleeping
Man." There can be no doubt, however, that grief and terror
had also a share in the production of his disease. As no re-
gular detail of his previous history could be obtained on his
being received at Hilsea, the following experiments were ar-
ranged and carried into execution, principally under the ma-
nagement of Dr. Knox ; and my report on the subject to the
Director General of Hospital gives the following account:

Case LXXVII.

Of Somnolency combined ivifh Mental Hallucination.

The state of the patient is as follows: He is, or pretends to
be, in a state of somnolency, incapable consequently of any

* A singular case of simulated mania is given by Professor Monteggia, in the
Medical Memoirs of Dr. Giannini, for 1800, which contains some valuable hints
respecting the action of opium in real and feigned madness. See also Foder6
" Medecine Legale." Article " des Maladies Feintes."

470 FEIGNED DISEASES.

muscular motion, and lays constantly in bed, retaining that
posture in which his limbs and body may chance to be thrown,
unless the position be an awkward one, and not easily persisted
in. He aflects to be constantly asleep, though the difference
between this and real sleep may be observed on the individual
himself every evening. His great aim seems to be this, viz.
to be considered unconscious of the external world ; and with
that view he holds no converse with it in any manner. How
far this is actually the case, may be gathered from the following
experiments :

ls(, The upper eye-lid was raised, and the pupil observed to
be perfectly susceptible of the stimulus of light. The hand was
made to approach the eye suddenly, and the orbicularis palpe-
brarum contracted with a rapidity clearly indicative of a fear of
injury to the organ. Occasionally he disregards this. The ex-
periment proves him to be conscious of those impressions which
the brain receives through the medium of the eye.

2d, The pulse is generally that of a healthy person ; it be-
comes very frequent on the approach of the gentlemen who
conduct the experiments, and becamealmost insensible to the
touch when the proposal was first made to submit him to elec-
tricity; a decided proof that the organ of hearing performed its
functions; that the brain was conscious of a second set of im-
pressions ; and that the vital organs, such as the heart, sympa-
thized with it.

3d, The sense of taste and smell are excitable by the usual
stimulants, since he takes his food (milk diet, occasionally half
diet or low, with extra allowances) like one in perfect health,
and has a great dislike to any thing bitter; a piece of aloes was
put into his mouth, whic h he very soon after vomited. He
sucks and partly chews his food, but never employs his mastica-
tory organs on any thing indigestible which may happen to be
put into his mouth, as a jiiece of iron or brass, seeming to be
perfectly aware that such thiugs are neither easily chewed nor
digested.

FEIGNED DISEASES. 471

4tli, He pretends to be perfectly incapable of using his
muscles. On raising the fore arm, he retains it in that position
for some time, but not longer than a man of ordinary strength
is capable of doing. The first day also he kept bis leg elevated,
when elevated by another person, but since that time he allows
the limb to fall down immediately, apparently finding the posi-
tion inconvenient and painful. All the muscles of the body are
excitable by electricity.

5th, The sense of touch is that to which he seemingly pays
most attention, next to the general muscular debility which he
affects. The skin, however, though evidently much against his
inclination, shows abundant marks of sensibility on the ap-
proach of a hot wire,* from which he uniformly and involunta-
rily shrinks ; it is strongly affected by cold applied in the form
of a shower bath, during the use of which the muscles of his
face act involuntarily, expressive of strong dislike. The
dashing unexpectedly any liquid in his face, produces in his
countenance every mark of surprise and fear; the success of
this experiment was particularly striking, and was remarked by
all present.

The subject of these remarks is of a stout muscular form of
body, of a rather dark complexion, apparently thirty years of
age, and evidently in a state of perfect health. All his functions
are performed with the utmost regularity, and every organ of
his body is readily acted upon by its accustomed stimulus.
Even the brain itself, on which no direct experiments can be
made, seems in perfect possession of all its powers, the only
faculty which, for obvious reasons, could not be made the sub-
ject of experiment, being that of volition.

June 6th. — Has been reported by the orderly appointed to.
attend him, to have moved himself during the night. The elec-
trical machine was again employed, and a great many severe
shocks passed through different parts of his body. Common

♦ The skin was never touched in the course of these experiments.

472 FEIGNED DISEASES,

Jbarlsliorn was, as on a former occasion, injected into the nos-
trils. The employment of these stimulants either did not
affect him so much as on former trials, or he endured them with
more fortitude. Finally, the shower-bath was thrice used, and
with the same effects as yesterday. He appears, however, to
be srettino- habituated to this also : his head has been ordered
to be shaved and blistered,

Ith. — Yesterday afternoon, whilst the orderlies were em-
ployed in the ward in which the patient is placed, one of them
stole softly to his bedside, and suddenly shouted aloud in his
ear; the experiment had the desired effect, he leaped up im-
mediately and stared around. On recovering from his surprise,
he lay very quietly down, and resumed bis former appearance
of being asleep.

13//j. — Since last report, he has continued precisely Id the
same state; his complexion is clearer, and he appears, if pos-
sible, in still better health than when brought into hospital.
Small doses of calomel and antimonial powder have been given
him, which act readily on the bowels. Yesterday, in presence
of a number of military medical officers, several experiments
were repeated with the greatest success.

\st, The upper eye-lid being raised, a piece of rolled paper
was pushed directly towards the cornea; this constantly pro-
duced contraction of the muscle, in order to save the organ
from external injury. The experiment succeeded in both
eyes.

2/j</, The upper eye-lids were raised, and [iressurc made on
the forehiiul, immediately above the nose; the eyes rfmained
open. J'he j)rt>ssure was removed, and a common penknife
was laid across the forehead in such a position as in no way to
influence the action of the orbicularis palpebrarum muscle ; he
still kept liis eyes open ; the pcnkuile was removed, and he
shut Ihem immediately.

There can be but one opinion on this experiment, and one
conclusion drawn from it, viz., that he imagined his eyes ought

FEIGNED DISEASES. 473

to be kept open by pressure on the forehead ; and, not aware
that the pressure had been removed when the knife was laid
across the forehead, he still retained his eyes open until this
was removed. The shutting- the eyes is with him an act entirely
voluntary. It is now proposed to have recourse to nauseating
doses of tartar emetic.

This report was dated in June 1816. On the 18th of that
month, he was visited by the garrison chaplain, by whose ex-
hortations he was evidently much affected, that gentleman
having held out every hope of pardon to him, if he did not
obstinately persist in counterfeiting^ appearances that were not
natural to him. In two days after this, he sat up, keeping his
eyes open, and occasionally moving his hands ; this amend-
ment was prefaced by some convulsive movements, which were
reported to me as having been " so evidently an imitation, as
to be obvious to all present ;" this day he was allowed some
wine. On the 21st he employed his masticatory organs readily,
and seemed more improved than on the preceding day; he
slept naturally for several hours after having sat up in his bed
all day. \yith a little assistance, he carried a glass of wine to
his mouth, which he readily swallowed, and apparently with
relief. His progressive improvement was evidently graduated
by his own will, and considerably influenced by fear and hope.
He put out his tongue for the first time this day, on being di-
rected so todo.

The crowds of the populace, and even of the more respect-
able inhabitants of the country who came to see this man, were
very great ; and no doubt a considerable revenue might have
been drawn from showing him as a phenomenon, an intention
which I understand was at one time entertained by his friends.
The most extravagant tales were circulated about him : one was
that the surgeons of Hilsea Hospital had cut oflhis head ; a
very respectable dressed farmer requested me to admit him to
the hospital, to enable him to verify this extraordinary fact
himself; and he left us very much surprised, and apparently

474 FEIGNED DISEASES.

disappointed, at finding our patient in possession of every part
of his body, Tlie nuisance, however, at length became so
great, and the other patients in hospital were so incessantly dis-
turbed, that I applied to have the man transferred to London.
On the yth July he was embarked for York Hospital ; his pulse
regular, and about 90, his skin moist, his countenance natural,
his bowels regular; in short, his health in the best state, ex-
cept a slight iiidammatiou of his eyes. During the passage he
took his food apparently with appetite ; all the functions of his
body were perfectly natural ; the motion of the ship occasioned
no degree of nausea ; but he manifested much uneasiness in
the recumbent posture, frequently turning his body, stretching
his limbs, and endeavouring to elevate himself into the sitting
posture. During the course of the voyage he succeeded in
sitting up without any assistance, and appeared sensible to cu-
taneous titillation, being observed to have scratched various
parts of the body. Towards the conclusion of the voyage he
manifested strong symptoms of mental distress. He was ad-
mitted into York Hospital on the 17th of July. He was then
apparently in a state of stupor ; he lay without motion in bed ;
his eyes remained, during the day, immoveably open, unless
when roughly touched ; he appeared to have lost the senses of
sight and hearing, and he never attempted to speak ; he ate his
allowance of provisions, but required to be fed by an attendant;
his general health did not appear materially affected ; his bowels
were inclined to consti|)ati()n ; his skin cool, and tongue clean ;
his pulse varied from 70 to 100 in a minute.

As his case appeared to the able and judicious |)hysician.
Dr. James Forbes, who suj)frintendKd the establishment at
York Hospital, to be satisfactorily accounted for, by supposing
it to be the elfects of extreme grief and fear upon the nervous
system, he was treated in the most soothing manner ; excepting
a brisk cathartic every second morning, nothing else was at-
tempted in the sha[)e of medicine, but all was trusted to
management. JJy this mode of treatment ho gradually im-

FEIGNED DISEASES. 475

improved, and towards the end of July was able to get out of
bed unassisted, and dress himself; he walked about the garden
daily, recovered his hearing, and at length answered questions
put to him in a low whisper ; and ultimately he was discharged
from the hospital, and, 1 believe, from the service.

Whatever doubts may arise as to the existence of a systema-
tic attempt at simulation, in this and other cases, that humane
principle should never be forgotten, which leads us to consider,
that the escape of many guilty is a much less evil than the
unjust punishment of an innocent individual.

Daily experience shows us, that maniacs, or persons labour-
ing under certain states of mental hallucination, are perfectly
capable of supporting any appearances which require the com-
bined efforts of cunning and obstinacy. To this disposition
are to be referred, in a great measure, the wonderful cases so
often related of the discharge of flints or basalt from the urinary
organs, or from the vagina of women, which have always been
placed there, and often picked up from the high roads in the
neighbourhoods ; or the periodical discharges of membranous
matters, which on examination have turned out to be long
portions of the intestinal canal of the smaller animals, &c.
Pare relates an instance where a polypus of the gut was
feigned in this way ; but in his case, the villany of the impostor
was unmixed with any mental derangement.

Ophthalmia is often artificially excited by the application of
various stimulant remedies ; sometimes the efiects of these re-
medies are very easily detected. Thus lime excites a deep
slough, caustic the same ; there are several others, however,
which are not so easily discovered. Spirits of turpentine I
have found to be an application much in use, and not easily
discovered : tobacco smoke blown into the eyes is also of the
same nature. Washing in the tubs distributed in the barrack
room is a filthy practice, by which there is occasion to suppose
Ophthalmia has been kept up, and even in its gonorrhael form ;
sometimes with design. In a corps some years since under my

476 FEIGNED DISEASES.

superintendence, which was in part recruited by convicts, and

which was ordered to the West Indies, the surgeon was led in

one case to suspect the application of some acrid substance to

the eye, by the depth and the defined edges of the ulceration.

On minute examination of the person of the patient, a paper

of corrosive sublimate was found in his possession, with some

manuscript directions for its use, in which it was recommended

to put a minute portion of this substance into the eye on going

to bed, to repeat it every third night, and to be cautious not to

put too mucli, lest the eye should be destroyed. There was

also annexed to this prescription a form of receipt for removing

the artificial disease thus produced ; it consisted of a decoction

of parsnips and clover, with which the eye was to be fomented ;

and the leaves of the clover, softened by boiling, were to be

applied to the part, and continued to it during the night. On

no other individual of the corps could any deleterious substance

be discovered ; but it was not a little remarkable, that all the

leeches which were applied to him, as well as to other suspected

persons, died almost immediately, giving every reasonable

ground for the supposition that they were poisoned by the

action of the mercurial solution.

If in any suspected corps we find that the right eye is uni-
versally aftected, it gives a reasonable ground to suppose, that
the deleterious substance has been put in preference into that
eye, frem design, or perhaps from the facilities which the im-
postor derives from his right hand ; a loft-handed man will, for
the same reason, inflict the injury on the left eye.*

There are several affections of the eyes which are not disco-
verable at first sight, and (or an account of whi( h we must
occasionally trust to the patient himself. We can, from the
form of the globe, and from the mode in which the patient
views objects, often determine on the existence of near-siglit-

• See a valuable {lapcr by Dr. V'clch, Etlin. Med. and Surg. Journal, vol. jv.
|>. 167.

FEIGNED DISEASES. 477

eduess; ia some cases, it exists without any very obvioas
nialconformation of tbe eye ; in others, it is altogether affected.
The French employed a simple and ingenious mode of distin-
guishing the feigned myopes who endeavoured to escape the
conscription laws. They placed spectacles of various powers
upon the persons to be examined, and suddenly bringing before
their eyes a printed paper, the subject of which they were not
acquainted with, the facility with which the person under trial
was able to read, pointed out with considerable accuracy the
actual state and degree in the deficiency of vision. A myope,
and none but a myope, could read tluently a paper brought
close to his eyes, with concave glasses, and vice versa.

1 believe the effects of Belladonna were known to mendi-
cants, and used by them to give the appearance of Amaurosis,
Jong before it was employed by surgeons for the purpose of
dilating the pupil.

Pectoral complaints are often asserted to exist where they do
not. The general appearance of the patient will soon indicate
whether they are real or assumed ; and we should always exa-
mine the sputa, as they have been ejected before our eyes. I
have known an instance where an imposition was attempted by
a person who had procured a quantity of bullock's blood for the
purpose of covering his deception.

The action of the Heart and Arteries is often fraudulently
excited or depressed. Tobacco is used for the latter purpose,
and various stimulants for the former. For the following in-
teresting case I am obliged to Dr. Cumin of Glasgow.

Case LXXVIII.

Increased action of the Heart produced at Will.

Private F , — — regiment, was shown to me by the

assistant-surgeon soon after I joined that battalion, (March

478 FEIGNED DISEASES.

1814,) as a man proper to be discharged from the service on
account of enlargement and diseased action of the heart. On
examination the heart was seen beating violently in the epdgas-
triam with occasional intermissions ; his countenance betrayed,
at the moment of examination, a very anxious and distressed,
but fixed aspect. No doubts of the reality of the disease were
entertained by the assistant-surgeon, by myself, or, as far as I
could learn, by the staff-surgeon who had inspected this indi-
vidual. But on enquiry many weeks afterwards, I found that
his appetite and spirits were good, and that when not the object
of attention, he appeared active, and careless of his complaints.
I now determined to subject him to a strict and continued scru-
tiny. I admitted him into hospital, and after carefully ob-
serving him for some days, I made him swallow such a dose of
opium as threw him into a state of insensibility, but not of deep
sleep ; the palpitation of the heart was not now perceptible. 'I
afterwards i'ound that 1 could render it very imperfect at any
time, by throwing the patient's head well back, so as to destroy
that voluntary combination of muscular action which I believe
to have produced the palpitation. That the apparent disease
was produced by the man's own efforts, 1 had then, and I still
have, no doubt ; and the only way in which it can be accounted
for is, by supposing that he had the power of throwing the
muscles which narrow the chest into sudden and strong action,
at the moment when the apex of the heart made its stroke

upwards. After a serious admonition, I suffered F to

return to his duty, at which he remained without making any
further complaint of this alarming disease, which had very
nearly procured him his discharge from the service.*

• Cheyne, in his " Enfjlish .Malady," 8vo. London^ 1733, p. 209, gives a very
interesting case of the Honourable Colonel Townsend, who, by laying iiinisslf
gently down on his back, and remaining quiet, could influence the movements of
his heart and arteries .so far, as to become, to all appearance, dead. Dr. Cleghorn
of Glasgow, meniiODS a similar case. See " Males' Forensic Medicine," 2d.
e*l. p. 238.

FEIGNED DISEASES. 479

It is by no means an unusual occurrence for the pulse to
cease iu tbe radial artery, on taking a full inspiration, and
continuing- to retain the breath as long as possible, and the
learned and ingenious Dr. Parry, in his " Elements of Phy-
siology," states, that the pulse in these arteries has been fre-
quently suspended for several days. I have known some in-
stances where attempts were made to accelerate the pulse, and
give the appearance of fever, by violently knocking the elbow
against a wall, while the tongue was covered with powdered
chalk. Some of these attempts were the more disgusting, that
they were not exclusively confined to persons of the lower
orders.

Aft'ections of the Liver are very frequently said to exist
where they do not ; a strict examination, in general, will detect
them. Some instances have been reported to me, where an
imitation of enlargement and hardness of the abdomen, with
diseased viscera was attempted, by taking along inspiration, by
■which the diaphragm was forcibly pressed downwards, and
consequently forced the abdominal contents forwards. The
detection was simple, as it was only necessary to wait until the
effort was finished, or to surprise the patient in his sleep or
otherwise. The jaundiced colour of the skin has been imitated
by the application of dyeing materials, as the flowers of broom,
the stamina of the iris, and carthamus seeds, but the imposture
is a clumsy one, and easily detected by the appearance of the
eye, to which nothing but genuine jaundice can give the
yellow tint,

Aft'ections of the Intestinal Canal are very often feigned ; it
is impossible that these aft'ections can be of long continuance,
without very sensibly impairing the general health. If, there-
fore, a person of a ruddy countenance, and of muscular vigour,
states to us, that he has long suffered iu this way, we cannot
be accused of unreasonable scepticism if we discredit his
report. Diarrhoea was during the late war frequently excited
among the sailors, by a mixture of vinegar and burnt cork,

480 FEIGNED DISEASES.

whicb in many instances proved fatal. See Hutchison in AJed.
and Phys. Journal for Feb. 1824. In general hospitals, men
who have been admitted with Dysentery often affect its conti-
nuance, in order to evade their duty, and to enjoy the indul-
gences of the hospital. I had many opportunities of seeing
this disposition at Abrantes, while doing duty with Dr. Somers,
Physician in Chief, who paid particular attention to the
disease, and who has published a very able tract on the em-
ployment of venesection in it.* We there made it a rule
accurately to examine the dejections, but it was discovered
that the orderly men were often bribed to supply the bed-pan
which had been used by a patient in the advanced stage of the
disease, to those who were convalescent, and it was shown at
their bedsides as a specimen of their own morbid discharges.
At that station also, we found under the bed of a man, who
had been long in hospital, several loose sheets of Zimmerman's
" Treatise on Dysentery," which he had purloined from some
of the medical officers, and from which he was in the daily
habit of enumerating his changes of symptoms; notwithstanding
all the ingenuity of this person, he at last fell into a dropsical
state, and died.

In examining the stools, we should hold in mind the unna-
tural colours of which they may be tinged by various medicinal
substances. By the employment of hematoxylon and its pre-
parations, they become of a bloody red. Decoctions of senna
tinge them deep green. Calomel renders them green also, and
often streaked with yellow. By the use of the Lamego, and
other deep coloured wines of Portugal, the stools acquire a
tinge almost appr(ja<;hing to black. iVJany hypochondriacs
have been greatly terrided on observing this etlect, without
being aware of its cause, and their terrors have been increased,
by the effects which rhubarb, given to clear their bowels, has

• Medical Suggestions for the Treatment of Dysentery, &c. by Edmond
Higisraond Somers, M. D. Physician in thief lo liic Allied Annies on the I'cnin-
Kula, 9vo. London, IBIfi.

FEIGNED DISEASES. 481

had upon their urine. I have known some attempts made to
impose upon medical men, by persons who have been ac-
quainted with these facts.

It is in general Iiospitals, where soldiers are separated from
the medical officers of their own corps, who are intimately
acquainted with their character, that impositions are most
frequently attempted. But wherever such persons may be met
with, we can never go wrong, if we treat them as if the disease
they feign really existed. The most approved methods of cure
for many diseases, as incontinence of urine, for instance, and
chronic rheumatism, are sufficiently painful, if persevered in,
to shake the constancy of an impostor not very hardened in
guilt. I have seen cases, however, where blisters to the sacrum
and to the limbs, as well as the shower bath, and nauseating
doses of emetic tartar, have been borne with a constancy worthy
of a better cause. A. case has been reported to me, where a
dragoon bore very severe riding-school duty for some weeks,
secured to his horse, before he acknowledged that his chronic
rheumatism was assumed. I saw a case where the patient even
admitted of all the preparatory measures for amputation, before
he thought proper to relax his knee joint:* and another, where
he allowed himself to be all but drowned in a deep lake, into
which he was suddenly plunged from a boat, before he stretched
out his arm to save himself by swimming, an exercise in which
he was well known to excel.

The annals of civil life, as well as those of the navy and army,
durino- former wars, afford numerous instances of even more
gross impositions than any of those 1 have alluded to. I shall
not pursue the subject farther, but content myself with warning
the medical officer, who is entrusted with the examination of
military persons claiming leave of absence, exemption from
duty, or pecuniary rewards for their sufferings, to be incessantly

* See a paper by Mr. Carmichael, in the Transactions of the College of Phy.
fiicians of Dublin, vol. ii. p. 377, where a very instructive case is detailed.

2 I

482 FEIGNED DISEASES.

on his guard against imposition, or the exaggeration of acci-
dental and trifling symptoms or appearances. The cicatrices
of common ulcers have been shown as those of gunshot wounds,
and I once saw the mark of a square blister pointed out as the
effect of contusion from a cannon ball. But if the person sub-
jected to the surgeon's examination appears to him really to
merit these indulgences, he should recollect, that if he owes a
duty to the service, he owes one also tojustice and to humanity.*

♦ On Feigned Diseases see the followijig : —

Mr. Hutchison's " Practical Observations on Surgery," London, 1826.

StafiF-Surgeon Marshall in the 89th No. of the Edin. Med. and Surg. Journal.

Dr. Clieyne in Dublin Hospital Reports, vol. iv. anno. 1827.

Beck's Elements of Medical Jurisprudence, 2nd edition, by Dunlop, London,
anno 1825.

For an useful paper on this subject, see also Hutchison in Med. and Phys,
Journal for February, 1824.

An excellent article on " Simulation des Maladies," ■will be found in the 51st
volume of theDictionnaire des Sciences_Medicales, by Baron Percy and Laurent.
In that article, the following works are referred to on the subject. : —

Luther. Dissertatio de morbis simulatis ac dissimulatis, 4to. Enfordid, 1728.

Boeder. Epistola occasione fraudulento mulieris, quse per totam fere vitam
ficto monstroso ventre omnium decepit oculos, 4to. Argentorali, 1728.

Vogel. Dissertatio dc simulatis morbis, et quomodo eos dignoscere liceat,
4lo. Gottingae, 1769.

Neurrmnn. Dissertatio de morborum simulatione, 4to. Vittembergo, 1788.

Schneider. Dissertatio de morborum fictione, 4to. Francofurti ad Viailrum,
1794.
I have not met with any of them.

483

CHAPTER XXII.

ON VARIOLA AND VACCINATION.

To enlarge upon the advantages of vaccination to mankind
would be quite superfluous; — to deny that, like all other human
inventions, it is not infallible, would be both absurd and
injudicious; — vaccination possesses too many real merits to
require false or exaggerated praise. From causes which it
may, perhaps, never be permitted us to penetrate, that terrible
scourge, the ravages of which are so pre-eminently neutralized
by the happy discovery of Jenner, attacks the unprotected with
redoubled violence during certain epidemic visitations ; and
even those who have undergone the cow-pock in an unequivocal
manner, bear a share in the suffering, though rarely in the
mortality. It has fallen to my lot to have witnessed some very
interesting and important facts connected with small-pox and
with vaccination ; of these I deemed it a paramount duty to
give the earliest intelligence to the public in the 56th Number
of the Edinburgh Medical and Surgical Journal, vol. xiv. for
the more minute particulars of which I must refer to that pub-
lication, and I shall here content myself with condensing the
information into a less diffuse shape.*

* These cases have given rise to some ingenious papers and criticisms in
various periodical works, especially in the 15th and 16th volumes of the
Edinburgh Medical and Surgical Journal ; they are particularly noticed in
a valuable work by Dr. Thomson on the " Varioloid Epidemic," 8vo. London,
1820 ; and they are in part detailed in Dr. Monro's " Observations on the
different Kinds of Small-pox," 8vo. Edinburgh, 1818.

2i2

4b4 VARIOLA AND VACCINATION.

From the decided part which his Royal Highness the Com-
mander-in-Chief early took on the subject of vaccination, and
from the universality of its adoption by army practitioners,
small-pox has become a disease of very rare occurrence in
military life. It has raged around our camps and barracks,
and carried off its victims from under our very walls, and even
from the houses where our detached troops have been quar-
tered, while it has left them unmolested. In Scotland, this
exemption has been no less remarkable than in other parts of
the empire, and for the years 181G and 1817, I do not find
one case of small-pox mentioned in the records of the military
hospitals in Edinburgh ; neither did varicella occur within the
same period in these hospitals. One man, however, was
received into the depot hospital at Queensberry House froui
the Castle barracks, labouring under the latter disease, on the
14th of May, 1818. He asserted, on a general examination of
the depot some time before, that be had had small-pox. No
very decisive mark of them could, however, be traced on him,
and his name was noted in order to his being vaccinated, but
before that operation was performed, he was seized with vari-
cella, which was extremely slight, and confined him to the
hospital only four days. After his dismissal from hospital, the
vaccination was performed; but the vesicle did not satisfy
Dr. Bartlet, who was then doing the duties of the depot, nor
had the man any constitutional affection. From an examination
of all the circumstances of this man's case, it is rendered pro-
bable that his assertion with regard to bis having previously
had small-pox was perfectly correct.

In three days after the above individual had been admitted
into hospital, an unequivocal case of small-pox was received.
It occurred in a Highland soldier belonging to a recruiting
party, who hud never had the disease before, and who had
obstinately resisted all the persuasions that were enq)loyed to
procure his submission to vaccination. This man passed
through the small-pox in a manner not dissimilar from that

VAtllOLA AND VACCINATION. 485

\vhich is usually observed in adults, and was dismissed from
hospital In thirty-three days after admission.

On the 17th of May, a child of the hospital sergeant's, who
had been vaccinated in Ireland, in LSI I, and who has two very
perfect cicatrices in his arm,* was taken ill with a disease,
which I at first conceived to have been modified sma!l-pox, but
which, on consultation with Professor Thomson, Surgeon to the
Forces, in charge of the Queensberry Hospital, I afterwards
considered as varicella. His brother, a hoy of 11, who had
been vaccinated at three months old, and who has a perfect
cicatrix, escaped all complaint whatever. This boy's case was
very slight in its progress, although ushered in with smart
fever; the eruption was pustular on his face, and vesicular on
his legs ; it soon dried up, and his illness lasted upon the whole
but eight days.

On the 6th of June a recruit was admitted into the same hos-
pital, whose case Dr. Thomson, for the first two days, conceived
to have been varicella, but which he afterwards considered and
reported as affording, in its progress, maturation, and decline,
a good specimen of the modified small-pox, so well described
by Dr. Willan, and of which several interesting cases are re-
ported in the 55th number of the Ediiiburah Medical and
Surgical Journal, as having occurred in that city during the
preceding six months. The subject of this case had a cicatrix
of variolous inoculation on his arm ; from twenty to thirty pits
of small-pox were observable on his body, and he said that he
passed regularly through that disease from inoculation, before
he entered the army. This man's case was severe upon the
whole, but by no means so much so as is usual when the disease
attacks persons of adult age for the first time.

* By perfect cicatrix, I understand a permanent circular cicatrix, about five lines
in diameter, and a Utile depressed, the surface of which is marked with very minute
pits, or indentations, denoting the number of cells of which the vesicle had been
composed.

480 VARIOLA AND VACCINATION.

Ou the 9th of June, a child of my own, who had been vac-
cinated upwards of ten years before, and who went through the
disease most satisfactorily, and now has two perfect cicatrices
on his arms, took ill. This boy was vaccinated by myself when
three months old, and I had every reason to be satisfied with
the genuineness of the matter. He had often been exposed to
variolous contagion in Spain, France, and Portugal, and par-
ticularly in the year 1817, at Portsmouth. His younger
brother, who had been vaccinated eight years previously, and
exhibited one perfect cicatrix on his arm, was also ill some days
before, but so very slightly, as not at the time to have attracted
any particular attention. Both these boys, after coming from
school, had occasionally played in the hospital airing-ground,
and sergeants' rooms, and in the reading-room of the Army
Medical Society, which is held in the hospital, while all the
preceding cases were under treatment. Three older members
of my family, two of whom had been vaccinated upwards of
fourteen years before, and the other had had small-pox, escaped
all disease whatever, although the last slept in the same room,
and for some time in the same bed with the sick boy, and one
of his vaccinated sisters had been in constant attendance on
him. The eruption on this boy was vesicular, his fever before
the eruption was very smart, but declined immediately after; he
was confined for eight days to his room, after which period he
recovered rapidly. The case I at first considered as an instance
of aggravated varicella, and under that impression, I delivered
to Dr. Bartlet of the 88lh regiment, four lancets charged with
lymph from his body, for the purpose of ascertaining by ex-
periment some points in the natural history of that disease,
which are still in obscurity, notwilhstunding the observations of
the late Drs. Wilhui and llrhcrden. Mr. liryce, however, and
Dr. Monro, who saw my son after \nc lymph taken from him
had been inserted (within tiie space ol" two hours) into the arms
of six children who never had had snudl-pox, cow-pock, nor
varicella, and who were selected as the most proper subjects

VARIOLA AND VACCINATION. 487

for trying- an experiment upon, at once pronounced his case an
example of the modified small-pox, with which Dr. Monro's
children had been affected. It may well be imagined what a
strong degree of interest was excited by this circumstance.
The experiment, highly important in itself, if the disease com-
municated were purely varicella, became doubly so on the sup-
position, that it should prove to be small-pox ; for we had been
taught to believe that the modified small-pox produces the real
disease in persons who have never gone through it before, or
who have not been previously vaccinated ; but that it still re-
tains its modified character in persons who have previously un-
dergone either of these diseases. The results of these experi-
ments have been detailed with a very great degree of minute-
ness, from the Journal of Dr. Bartlet, in the paper already
alluded to; suffice it to say here, that there can be no doubt
that the disease which these children underwent was variola,
varying in violence in the different subjects, and being very
severe in one or two ; they all went happily through the disease.
Three adult soldiers, who had had communication with the
inoculated children, fell ill in succession in the course of ten
days. These three men exhibited several marks of previous
small-pox, particularly the last, on whose arm there was the
cicatrix of the inoculation, and they all recollect their having
had the disease. In these three men unequivocal variola took
place, severe in its nature, but modified by their having previ-
ously gone through the disease.

Mr. Burns, of Glasgow, appears to have been the first to
try the experiment. — See Ediu. Medical and Surgical Journal,
vol. iii. p. 158.

Besides these persons, one adult and three children who had
had free communication with the inoculated, were also taken ill
in the Castle during the early part of the month of July; the
adult so slightly, as never to have been received into hospital,
nor to have omitted his duty for a single day. He said he had
had small-pox twenty-four years before, and bore the mark of

488 VARIOLA AND VACCINATION.

iuoculatiou, as well as of several pits of that disease. A fe^
pustules, of a horuy nature, appeared on his face, breast, and
arms, preceded by a smart degree of fever of short duration,
and dried up rapidly in four or five days. Of the children, one
of eighteen months old, who had been vaccinated about fifteen
months belore, and exhibited a perfect cicatrix, had a slight
feverish attack, succeeded by a few pustules of the >anie horny
nature as the adult, which soon dried up. A second child who
Lad not been vaccinated, an infant of three weeks old, who was
nursed by the mother of an inoculated child, and who slept in
the same bed with it, had, at the same time with the adult and
the first mentioned child, an eruption of the same slii>ht cha-
racter and short duration as they had. But a third child of
twelve monih-s old, whose parents had neglected to bring it
forward for vaccination, had, at the same period, a very severe
affection resembling that of one of the inoculated children.

On the 4th of August, I received intimation from Dr Bartlet,
that a soluier who. was then, and had been for some time previ-
ously iu the Castle hospital, and on whom we were about to per-
form the operation for artificial pupil, had been siezed with a fe-
brile attack, which the doctor strongly suspected was the eruptive
fever of small-pox. This man had represented himself as having
had small-pox, and there were some marks on his body, which,
in conjunction with his assertion, were sufficient to justify the
surgeon in considering him as having passed through that
disease ; he afterwards confessed that he had been guilty of a
deception. This imprudent man was on the same (loor with the
adults alreaily mentioned, only separated from them b> a narrow
passage, and In* had even conversed with one of Iheni during
the continuance of his disease. The case terminated fatally on
the morning o( the I^Jth day of the eruption, being a very aggra-
vated form of conllnenl small-|)ox. It (d>viously would be pre-
sumptuous to assert with perfect confidence, that all these cases
sprang from one and the same source, although there is the
strongest reason to suppose that they did.

VARIOLA AND VACCINATION. 489

1 have already stated, that the inoculation was instituted
under the impression that the disease to be communicated was
Varicella. When, however, I saw the first adult take a disease
which spared neither the vaccinated nor the variolated, (although
attacking the latter in a proportion incalculably greater,) and
which I myself, and many eminent gentlemen of Edinburgh,
conceived to be decidedly a form of small-pox, I at once put a
stop to all further experiments among the troops. I tried,
however, upon myself, what I did not choose to do upon the
soldiers whose health was committed to my care. From one of
the children I inoculated myself. I had had small-pos, but
never varicella: no result followed. Dr. Bartlet, and his
brother, who had also bad small-pox, but not varicella to their
knowledge, tried the same experiment with a similar result;
these, to be sure, are negative trials. Dr. Bar'let, in order to
throw some fnriher positive light on the natural history of vari-
cella, inoculated seven children who had neither had cow-pox,
small-pox, nor chicken-pox, with lymph taken from a child of
Mr. Wisbart, surgeou, of Edinburgh, who laboured under
genuine unequivocal varicella. No disease was produced in
any of the children thus inoculated. This Dr. Bartlet conceived
might have proceeded from the virus having been collected on
glass, and afterwards liquefied by steam.

After the most mature consideration, I must explicitly avow,
that nothing has occurred in the cases I have related, which
has, in the smallest degree, shaken my opinion of the great and
pre-eminent importance of the practice of vaccination, whether
we view it as a preventive of small- pox in a vast majority of
cases, or as a most effectual neutralizer of its malignity in the
comparatively few instances in which, from some peculiarity of
constitution, or some anomaly in the process, hith rto not fully
developed, it has failed to afl'ord this permanent security. If
the more anomalous among these cases are considered as merely
aogravated instances of varicella, the value of the Jennerian
practice is in no shape affected by them, except, indeed, that it

490 VARIOLA AND VACCINATION.

is clearly shown, that the practice renders not only variola, but
varicelhi also, more mild. If, on the other hand, they are con-
sidered as the horn-pock, or the steen-pock, that disease, as I
understand from the first medical authorities, was well known
in this country before the introduction of vaccination, and fre-
quently occurred in persons who had previously gone through
the genuine small-pox, although never noticed of later years as
an objection to variolous inoculation. In this case, also, vac-
cination will be found to have manifested its neutralizing pow-
ers. But I have witnessed it still more remarkably among the
children of the lower class in the neighbourhood of Edinburgh
Castle, where, while unmitigated small-pox has raged violently
among the non-vaccinated children, many instances have oc-
curred of those who have gone through tliat process, having the
complaint in the very mildest possible form, and many of them
escaping it altogether ; a fact exhibiting the results of a more
rigid ordeal of the preventive powers of vaccination, than can
be imagined by those who have not witnessed the incredibly
crowded and confined apartments in which these compact
masses of human beings gasp for air; while, from the mutual
friction of their bodies under the same scanty covering, the
most intimate contact takes place between the sound and the
diseased, and in many instances efl'ects a complete and con-
stantly renewed inoculation.

Finally, if it be admitted that the disease in the adults was
small pox, whether genuine or modified, of which, indeed, there
can be uo doubt, it adds five more additional proofs to those
already on record, of that disease occurring a second time in
the same individual, and with this very remarkable circumstance
attending tht-in, that thty all occurred consecutively, and in all
human probability from the same source of infection.

In my paper in the Julinhurgli Medical and Surgical .Journal,
I have given references to consideraldy more than a hundred
authorities, for cases where smallpox has occurred a second
time in the same individual; many more I know have been

VARIOLA AND VACCINATION. 491

collected by others.* It is probable that still more are to be
found on record ; that many are daily occurring within the reach
of inquirers ; and that more have escaped all observation what-
ever since the time of Rhases, or in the unbounded confidence
of practitioners in the universality of the law, that the disease
can be taken but once, have been set down as cases of as:ora-
vated or confluent varicella. A suflScient number of unquestion-
able cases, however, are extant, to prove, that if vaccination
does not afford an infallible preventive of the subsequent
occurrence of small-pox in all cases, neither does the previous
existence even of small-pox itself act as an infallible preventive
of its future recurrence.

Laws which we can never develope govern the susceptibility
to variolous contagion ; and it is highly probable, as has been
observed by the ingenious Jenner, " that the susceptibility to
receive it always remains through life, but under various
modifications or gradations, from that point where it passes
silently and imperceptibly through the constitution, (as is fre-
quently the case with cow-pock,) up to that where it appears in
a confluent state, and with such violence as to destroy life."
The fact of small-pox partially affecting persons who have
already had the disease, while employed as nurses to children
labouring under it, proves this to a certain extent; but the
existence of variolous pustules on the body of the fetus, capable
of affording the genuine matter, and of communicating the
disease to others, by inoculation, while its mother has been
unaffected, places the fact in a still stronger, and in an unques-
tionable point of view.f

The observations which I have now concluded were elicited
by the diseases which appeared in the hospitals, and among the
soldiers themselves, and their children, in the year 1818. I
find one case which occurred more recently in the person of a

* See Dr. Smyth's Tliesis, De Variolis Secundariis. Edin. 1819.
t See Jenner, in the Med. Chir. Trims, vol. i. p. 271 ; and also the works of
Mead and Mauriceau.

492 VARIOLA AND VACCINATION.

soldier's wife of the 80tli regiment, very well deserving of
notice. Tt is a case in which we have every reason to suppose
that variola occurred after the most perfect vaccination that
can be conceived, inasmuch as the subject had contracted the
vaccine disease directly from the cow. In support of this fact,
we have the testimony of the woman herself, a person of good
character ; we have the fact of her having for a series of years
resisted variolous contagion ; and we have the still stronger
fact, that when, in adult life, she did take the disease, it was
extremely mild ; for the eruption was complete on the 7th, and
declined generally on the 8th day, scabs forming on every part
of the surface; the pustules were small, and not numerous,
and she had no secondary fever. Of the truth of the woman's
having had the vaccine disease, therefore, there can be no
reasonable cause of doubt, for nothing but previous vaccination
could have rendered it so mild in an adult subject. If we
wanted any further proof of the fallacy of the doctrine which
teaches that vaccination fails in Scotland and elsewhere, solely
from the want of making a certain number of punctures in
a certain manner, this fact would suffice. For I apprehend it
must be admitted, that the lymph derived direct from the cow
is at least as effectual as that which any vaccinator can employ,
however dexterously he may insert it.

Case LXXIX.
Of Sinall-jjox, after Vaccine Disease directly taken from the

Cow.

Mrs. C. ag< «l 3(), the \vif»,> of (nie of ihc band, reported her-
self to Mr. liightbody, the surs;eon of the 80th regiment, on
the 1st of December, 1819, with general symptoms of pyrexia

* Similar cases will be round in the E«lin. Med. and Surg. Journal, vol. lii.
p. 41.

VARIOLA AND VACCINATION. 493

of two days standing-; some suitable medicines were prescribed.
On the 4th an eruption made its appearance on the face, hands,
arms, and body. On the 6th, (3d day of eruption,) it had a
distinct pustular appearance, some of its apices already con-
taining a white fluid. On the lOth, (7th day of eruption,) the
process of maturation appeared to be completed; the pustules
were filled with a straw-coloured fluid, and some of them,
especially on the face, had broken, and discharged tlieir con-
tents. On the 11th, (8th day of eruption,) declination appeared
general, scabs forming on every part of the surface ; from this
time she continued to recover. The eruption was distinct and
well marked ; the pustules were not numerous ; they were in
general small; and no where did they coalesce. She had a good
deal of fever throughout, but, on the whole, the disease was
mild and favourable. She was not sensible of having been
exposed to contagion of late; but she was lodging, when
attacked, in a little filthy and confined room, in a back, street,
whence she was removed previous to the appearance of the
eruption. She got accommodation in a barrack-room in which
there was only another family, an infant belonging to which was
at the time under the process of vaccination, which proceeded
favourably, without seeming to be inOuenced by its variolous
neighbour.

It appears from Mrs. C.'s information, that when about
fourteen years of age, being a dairy maid in Norfolk, she had
a number of sores on her hands and arms, which she caught
from the cows' udders, and which were at the time said by a
doctor who was consulted, to be what was called cow-pock ;
that afterwards, when a house servant, she was, with several
others in the same family, cut in both arms for the cow-pock,
and perfectly recollects having one on the right arm, and, she
thinks, one on the left; the marks, however, are so indistinct
as to be scarcely discernible. When the examination was
made in 1817, for the discovery of persons in the regiment who
bad not had variola, or been vaccinated, " I found it remarked

41)4 VARIOLA AND VACCINATION.

in the register," says Mr. Lightbotly, " in the hand-writing of
Dr. Nicoll, " " that Mrs. C. took the cow-pock from the cow,
■when a dairy maid in Norfolk."

While these sheets are at press, I have myself seen this
woman, and am perfectly satisfied of the authenticity of the
above facts. I am here naturally led into a remark on the
employment of Mr. Bryce's test, which, did we consider it
meVely as a speculation, is, perhaps, one of the neatest and
most ingenious that has ever been proposed ; but when we
reflect on its great practical utility, we will naturally esteem it
for qualities of far greater importance; and we will be led to
class its amiable proposer as one of the ablest supporters of
vaccination, and among the greatest benefactors to the rising
generation. This test, therefore, is well worthy of adoption
universally, and I believe there are few army surgeons who do
not appreciate its value; for although epidemics may occasionally
arise, where, from causes inscrutable to human inquiry, variola
will occur among the protected, yet, upon the whole, we view
it as a most untoward occurrence, when that disease appears in
our military hospitals; and every surgeon is anxious to show,
from his register of vaccination, that, so far as he is concerned,
every human precaution has been taken.

On the medical treatment to be employed in small-pox,
whether in its ordinary or its modified forms, it is unnecssarv
to dwell. In the latter disease, the symptoms are in general so
mild as to require merely open bowels, cleanliness, and pure
air. Where they possess an unusual degree of violence, that
violence is suddenly checked, in a way as marked and decided
as if an insurmountable barrier had been opposed to its further
progress, and it had been decreed, that " thus far and no farther
should it go;" all fever ceases, and the eruption rapidly dries
up, and scales off. The period of the eruption at which this
happy and sudden transition takes place, is not the same in all
cases. From the 6th to the 7lh day is the period I have usually
marked, — sooner or later,- according to the milducs» of the

VARIOLA AND VACCINATION. 495

disease; but at whatever time it may occur, the secondary
fever, which is so frequently the fatal symptom, either never
shows itself, or is so trifling as not to attract particular notice.
In the unmodified disease, where it occurs in adult subjects,
our most powerful remedies are called for, and among- them
venesection is often necessary, and markedly beneficial. I had
an opportunity of seeing this very clearly illustrated some time
ag-o. Four adults, recruits, were seized with variola at Ports-
mouth; the determination to the head and lungs was violent to
a degree, and copious venesection was had recourse to in three
of the individuals ; these three recovered, while the fourth, in
whom venesection was not performed, after having passed
through the violence of the disease, sunk under extensive for-
mations of pus, which appeared in the form of abscesses,
dispersed almost all over his body, and affording a most dis-
gusting spectacle.

496

CHAPTER XXUI.

OBSERVATIONS ON SYPHILIS.

I DO not propose to inquire into, or rather, to recapitulate
the argaments on the origin of Syphilis, since nothing is left
to be said on that point that has not already been collected
from poets, historians, and physicians. From whatever source
it may have sprung, the army possesses the undisputed but
melancholy claim of having mainly contributed to the propa-
gation of that terrible disease, which spread over the greater
part of Europe soon after the siege of Naples. The array
surgeons could not have shut their eyes to the ravages of a
complaint in which they were so peculiarly interested; and
accordingly we find, that one of their body, Marcellus Cuma-
nus, who served with the Venetian troops under Charles VIII.
in the campaign of 1495, was the earliest author who wrote
concerning the history and cure of syphilis. Fracastorius,
another surgeon in the same army, followed him on the same
subject, and has left a poetical account of the disease, remark-
aWe both for its accuracy and its elegance. Ferrius, Vesalius,
Botallus, Pare, and many of the older arn)y surgeons, signalized
themselves in this particular department of their profession ;
and, to the same class of practitioners, at various subsequent
periods, we owe several important accessions to our knowledge
of the subject.

Indeed, the opportunities which military hospitals all'ord
for extensive observations and comparisons, are highly favour-
able to the elucidation of the natural history of this disease.

SYPHILIS^ 497

-so that it is really a greater object of surprise that more light
has not been thrown upon the subject by the officers of these
establishments, (especially considering that no interested views
could have interfered,) than that they should at length have
fallen into the fair and philosophic course of investigation.
Nothing can fully account for this, except the undoubting reli-
ance that has been placed, — justly in many instances, — on the
sanative powers of mercury. But, notwithstanding its unques-
tionable efficacy, the united experience of medical men of all
countries, and in all ages, has shown that great inconveniences
often result, even under the most judicious mode of managing
it; while, from abuses in the quantity, but especially in the
irregularity with which it has been exhibited, effects so de-
plorable have proceeded, as to leave no doubt that in these
instances it has been infinitely more destructive to health than
the diseases for the removal of which it was originally employed.
These distressing consequences were obvious to the practi-
tioners in the military hospitals, as well as to those in civil life.
To advert more particularly to those of our own country, — more
than half a century ago, when mercury was in the highest re-
pute. Dr. Brocklesby stated his conviction, that, instead of
" rubbing in such extravagant loads" of that medicine, it was
necessary only to employ as much as was sufficient to cause a
slight swelling and soreness of the gums, and a spitting not ex-
ceeding one pint in twenty-four hours.* About the same time
that Dr. Brocklesby practised in the military hospitals, the
results of some experiments instituted by Mr. Gataker, at the
regimental hospital of his Royal Highness the Duke of Cum-
berland, were also laid before the public. f These particularly
related to the use of Sarsaparilla and Corrosive Sublimate, and
contain many acute observations on the venereal disease. AU
though a very decided friend to mercury, Gataker urged the

* Economical and Medical Observations. London, 1764. p. 296.
+ Essays on Medical Subjects. By Thomas Gataker. London, 1761.

2 K

4i)8 SYPHILIS.

necessity of caution in its employment; indeed, throughout the
whole of his observations, he shows great judgment and mo-
deration, and evinces his desire to simplify the study of sy-
philis, which had been rendered so complicated by the minute
descriptions of Astruc, and the variety of symptoms assigned
bv him and others as characterizing that disease, that Gataker
was led to observe, that, from the accounts of these authors,
" it was difficult to say when a man was not poxed." Sir
William Fordyce, then a surgeon in the Guards, had previously
(in 1751) tried some interesting experiments on the use of Sar-
saparilia, to be seen in the 6rst volume of the Loudon Medical
Communications.

During the American war several experiments were tried on
the utility of Opium in syphilis, in the British military hospitals
in North America, by Mr. Grant, the senior surgeon on that
service, by Dr. North, Mr. Weir, Mr. Foster, and others;
and similar experiments were tried by the medical officers of
the auxiliary troops, by Dr. Michaelis, Physician-General to
the Hessian army, and by Dr. Schoepfff Physician to that of
Anspach. The accounts of these experiments may be seen in
the " London Medical Journal," vol. vi. and in the Medical
Communications, vol. i. During the war of the French Revo-
lution, trials of the anti-syphilitic powers of the Acids and other
substances abounding in oxygen, were instituted at the Artillery
Hospital at Woolwich by Dr. Rollo, Surgeon-General of the
Royal Artillery, and Mr. Cruickshank, chemist to the Ordnance,
and a surgeon in that service. An account of these is given by
Dr. Rollo in his Treatise on Diabetes.*

During the course of the Peninsular war. Dr. Fergusson,
Inspector of Hospitals, published a most important paper in
the 4th volume of the Medico-Chirurgical Transactions, in which
he showed very clearly that the venereal disease, as it appeared

* The plan had been tried long before in India by some of the regimental sur-
gums with f^etiX success.

SYPHILIS. 499

in Portugal, was curable without the employment of mercury.
In the 8tb volume of that work, Mr. Gullirie, Deputy Inspector
of Military Hospitals, and Mr. Rose, Surgeon of the Guards,
published two highly valuable papers on the same subject. In
the 53d number of the Edinburgh Medical and Surgical Journal
for January 1818, Professor Thomson, Surgeon to the Forces,
^ave an account of the trials which he had instituted in the
military hospitals of Edinburgh Castle for the cure of syphilis
without mercury ; and in the 54lh and 55th numbers of the
same Journal, for April and July 1818, I submitted to the
public such observations and tables as I felt myself fully war-
ranted to do by the experiments tried under my own eye in the
hospitals in North Britain.

Mr. Evans, Surgeon of the 57th regiment, has published
within the last year the first part of a work on " Ulcerations of
tlie Genitals," especially on those ulcers which are not to be con-
sidered as the primary affections of syphilis, and which do not
require mercury for their cure. Judging from what this gen-
tleman has already done, great expectations may be formed of
what he will hereafter do on this interesting point.

I shall not inquire into all that has been done in the foreign
military hospitals on this subject. The most important trials
have been those by Dr. De Coste, Physician to the French
army at the Military Hospital at Lisle, on the use of Opium,
Journal de Medecine Militaire, par De Home, tome vi. Of 26
patients, 15 were cured, 5 doubtful, and 6 failures ; those of
De Home, on the use of Corrosive Sublimate; but, above all,
those on the latter substance, by Baron Van Swieten, at the
Military Hospital at Vienna, by which he has rendered a most
important service to physic. He was aware of the injuries so
often inflicted by salivation, and he introduced the alterative
cure by the oxymuriate of mercury into general notice. Nothing
could exceed the violence of the opposition to this plan ; it wag
very generally decried, and by many it was pronounced a mon-
strous, inhuman, and unjustifiable measure. Van Swieten, who

2 K 2

500 SYPHILIS

held the highest medical station at Vienna, and had the control
of the military medical department, sent 300 soldiers to the
hospital at Saint Mark, in order to institute upon them an ex-
periment on a large scale as to the power of his new remedy.
The results of this measure are sufficiently interesting, and
strongly illustrate the difficulty of introducing any innovation in
the treatment of the venereal disease.* With the exception of
six who were affected with incurable caries of the bones pre-
vious to their admission, every one of these individuals went out
of hospital cured. In a little time afterwards, an accusation
was brought before one of the highest military tribunals, in
which Locher, tlie physician of the hospital, was charged with
dismissing from that establishment 300 soldiers not only un-
cured, but even in a far worse condition than when they entered
it. Fortunately the records of ihe hospital were in existence,
but what was still more convincing, all the soldiers were at the
very time wilhin the walls of Vienna. " The physician," says
Van Swieten, " insisted on a strict examination of the matter
by law, nor did T neglect doing it. The delays of the law were
spun out under various pretexts, and the calumniator, in the
mean time, ran away, died, and escaped his deserts. Locher
afterwards quietly continued the cure of the venereal disease in
his usual manner." Such is the original history of a remedy
which has now been received into private and hospital practice
all over the continent of Europe; and we must either suppose
that the great mass of continental surgeons are profoundly ig-
norant of their profession, or in a combination to deceive us,
or else we must admit that corrosive sublimate really possesses
those virtues attributed to it by V^an Swieten. Indeed, inde-
pendent of the details in books, innumerable opportunities have
been afforded to British surgeons since the peace, of seeing
the unquestionable efficacy of this medicine at the hospitals in
Paris, and yet a very few years since, no orthodox English

• See his Comment on the I477lh Aphorism of Boerhaare.

SYPHILIS. 501

practitioner would have trusted his patient's safety to it. It may,
indeed, be possible, that difference of climate, constitution,
and mode of life, in many cases contribute to the superior
efficacy of this remedy among- the inhabitants of the continent.
Such being the prejudices against a mercurial preparation,
we cannot wonder at the treatment which the proposals made
from time to time of curing the disease without mercury have
met with. These prejudices are now much less violent than they
were some years ago, when the idea of curing the disease in that
manner was looked upon as so absurd, that the person who
might propose it, would at best be designated as a visionary
who was himself deceived, but the more common opinion ad-
vanced was, that he wilfully deceived others. Many medical
men acted on these occasions as if they had a personal interest
n supporting the omnipotence of mercury. When a most in-
genious and ardent philosopher of this country. Dr. Beddoes,
began some years since his course of trials of the acids, he was
assailed at all quarters ; ridicule and abuse were lavishly thrown
upon him, his opinions and his supporters, and a fact, which a
common share of candour on the part of the judges, and a
little more perseverance on the part of those whose practice
was to be judged, would have completely established, was lost
to the medical world. A show of candour was indeed made,
and the results of several trials were published ; to select
any of these for animadversion would be invidious, but one com-
mon strain ran through them all, and the value of the acids, and
of other substitutes for mercury, were pronounced upon by men
who assumed, (what has since been shown to have been a most
gratuitous assumption,) that no other remedy existed, capable
of curing the venereal disease, and with this very assumption
did they come forward to the trial, and pronounce their sen-
tence. With a similar spirit of prejudication, De Blegny and
De Thiery were ranked as visionaries; and as for Fernelius
and Palmarius, they were permitted to slumber on their shelves
unnoticed, while the modest Morgagni, whose works were

502 SYPHILIS.

better known than the others in England, by a translation into
oar mother tongue, was just quoted to be rtyected, and his
account of the cure of syphilis without mercury was classed with
the useless and antiquated physiolog-y, which dims though it can
never extiniruish the lustre of his immortal work. As for the
historical notices of Leo Africanus and Le Blond, they were re-
jected with contempt.

Unfortunately for the attempts of those who were anxious to
investigate the anti-syphilitic powers of various remedies, the
smallest disappointment checked their hopes, and they were
driven by groundless fears into the immediate employment of
mercury. Indeed, many of the friends of Dr. Beddoes fell into
this very error, and, not being* aware that the secondary symp-
toms would yield with time and steadiness, they resigned many
of the advantages they had gained, — but not all, — for the
testimony in favour of the acids were so strong, and so unan-
swerable, that they were admitted into a sort of copartnership
with mercury, and their power was in part, though very reluct-
antly, acknowledged. It is a very remarkable fact, that, in a
variety of instances, whenever a rival medicine has started up
in opposition to mercury, while the blind supporters of that
mineral seemed to be confirmed in their conviction of its
exclusive power, the rival is often allowed to have " some
powers," or " under certain circumstances to be useful," or
" to be applicable where mercury has aggravated the com-
plaint," &c. &c. The roguery of the quacks in putting corro-
sive sublimate into their boasted syrups said to be composed of
vegetables alone, cannot be adduced to controvert the fact; it
only proves that the ignorant quack and the learned physician
were ecjually bigoted morctirialists. The annals of our pro-
fession unfortunately disclose a striking coincidence between
them in more points than one.

liut it has not been among professional men alone that these
prejudices have existed ; the diseased thems<ilves have, from
education arid from habit, gone hand in hand with their medical

SYPHILIS. 503

advisers, who have doubtless been often forced to employ mer-
cury in compliance with the wishes of their patients, rather than
from any conviction in their own minds, either of its necessity
or propriety. An oUi French author has made a very shrewd
remark upon this subject. " When pocky people," says
Nicholas de Blegny, " have been told that they can't be re-
covered but by salivation, and that they are only quacks and
empirics who promise to cure it by other means, they become
deaf to all further instructions and advice, and firmly believe
that all other methods are dangerous and erroneous ; nay, they
will hardly believe that mercury can produce any other than
salutary evacuations. But which is yet more strange, they be-
lieve they have no reason to complain, whatever be the bad
effects and consequences of this remedy ; and those patients
who do are said to be splenetic."

*' But 'tis far otherwise, when the patient happens to be
managed by other remedies, for the slightest indisposition is
ascribed to a certain quantity of impure matter retained in the
body, and they are persuaded, that this only circumstance, to-
gether with not being treated or cured by that which they call
the best method, is an infallible sign of an imperfect cure; and
for some small pimples, flea-biting, and the like, they will have
the patient to undergo another course of salivation; and, not
being able even by this to bring forth the imaginary impurity,
they so drain the body of its natural humours, or so much alter
the nature of the solid parts, that the patient dies in a little
time, or becomes hectic and consumptive."*

Previous to inquiry into the effects of some of the numerous
remedies employed in the cure of syphilis, it is proper to direct
our attention to the opinions of those who hold that it has
undergone great changes in its nature since the end of the
fifteenth century. It may be that such an alteration has been

* The Art of Curing Venereal Diseases explained by natural and mechanical
Principles.*' English Translation of 1707, part iii. chap, ii.

504 SYPHILIS.

produced in it either from the effects of remedies, or by natural
causes, as seriously to influence the results of our treatment at
the present day. The analogy of leprosy and of scurvy^
which at one time raged throughout Europe, but are now
almost unknown, is strongly in favour of the supposition of a
change of character in syphilis; we have also direct testimony
which shows that its symptoms have become milder and more
tractable.

No author is better entitled to speak on the disease than the
well known German Ulrich de liutten, if personal sufliering
can confer such a melancholy distinction. After having suffered
for nine years under it, and we may naturally suppose studied
its history minutely, he tells us in his work published in 1519,*
that for the first seven years after i!s appearance in Germany
it raged with the utmost violence, but that when he wrote, its
virulence had considerably abated. In 15G3, upwards of forty
years afterwards, Benardinus Tomitanus of Padua,f after noting
some changes of symptoms which had taken place in the disease
since its first appearance in Europe, bears strong testimony
to its increasing mildness at the time he wrote. All the plea-
sures of social life, he says, had been poisoned on the breaking
out of the Morbus Gallicus; in his time, however, men were
less terrified, and no lunger abstained from convivial intercourse
with those affected ; they began also to contract marriages
without their former fears, and their inquiries were now in*
fluenced more by the amount of the dower they expected, than
by the fear of pox. He then goes on to predict, that, in a
short time, the disease would no longer be communicable by
coition, as it had become old, and was hastening to decay.

The learned and indefatigable Astruc has collected the au-
thorities of various physicians and historians to the same effect,
including a period from 151() down to 1711, to which he adds

• Apud Luisinum, torn. i. |i. 27H. I.eydoii edition of 1728.
t Ibid, torn. ii. p. 1015, &c. lib. ii. cap. I and 2.

SYPHILIS. 505

his own testimony, dated 1735. In it he says, " 1 have, by
careful and repeated observation, found the venereal disease
daily to grovs^ milder ; it may perhaps be more frequently con-
tracted than formerly, yet its rage is less violent, its symptoms
are not so many, so painful, nor so difficult to be cured; it
yields more readily to remedies properly applied, and, in a word,
seems by little and little to approach towards its close.*

Previous to the employment of mercury, and while the phy-
sicians of the day were struck with horror at the suddenness
and violence of the disease, a mode of cure, denominated the
" Rational" or " Methodical," was adopted. First, they bled, if
the strength of the patient admitted of it; they then purged,
and afterwards, to carry off the foul humours, they administered
decoctions of various emollient and medicinal herbs, after which
they purged again. The eruptions were anointed with unguents,
emollient, desiccative, or anodyne, according to circumstances,
and the diet was strictly abstemious. In short, they endea-
voured to alleviate urgent symptoms, without any view to a
specific remedy. Their success was at first indifferent, but still
it is clear that many must have recovered, otherwise Europe
would have been depopulated.f Whether we suppose that the

• Astruc, lib. i. cap. 13.

t From some extracts from the rare volume of Ruy Diazde Isla, " Contra las
Bubas," Salamanca, 155 — , with which Dr. Thomson, Professor of Military Sur-
gery, has favoured me, I find that, in no town in Europe of 100 inhabitants
were there fewer deaths than 10 on the first appearance of syphilis among thera.
Now, if we recollect that the numerous monks and nuns spread the disease through
all classes of society, it is not an extravagant calculation that fifty out of the
hundred were poxed. This will give us one death in five : the remaining four
survivi>rsmust have owed their lives to the " Methodical or Rational" cure. I
doubt whether the mortality was greatly less than this while the gross abuses of
mercury prevailed under the form of daubings, with 41b. of quicksilver to 21b. of
lard, applied over the whole body. " Cum quo," says Torella, " infinites inter-
fecerunt. — interficiuntur homines, non moriuntur." (Luisin, torn, i.p, 528.). But
putting the mortality out of the question, Hutten expressly states, that hardly one
in one hundred was perfectly cured, the disease returning upon them again, as it
did en himself after eleven salivations. (See Ulrichus de Hutten de Morbo Gallico

506 SYPHILIS.

disease was transplanted by Columbus, or that it existed long
before, either supposition is equally favourable to its having
been cured without mercury ; that remedy was unknown in the
new world, and it was unemployed in the old, except locally,
against vermin, itch, &c.

At length Mercury was introduced as a constitutional remedy
in the cure of syphilis also, whether by Berengarius Carpensis,
or John de Vigo is undetermined, but it is certain that both
these persons made their fortunes by the practice. It had pre-
viously been used locally in various forms. Thus in the work
of Natalis Montesaurus of Verona, " De Dispositionibus quas
vulgares mal franzozo apellant," published in 1498, the author,
after describing the internal medicines and diet to be employed
in conformity to his first and second indications, or the eva-
cuation of humours, and the attention to the non-naturals, then
proceeds to the third, or the selection of local remedies. If the
itching was severe, he recommends ointments with the lees of
wine, myrrh, litharge, ceruss, tutty, pipe-clay, sulphur, &c. If
that symptom was not very urgent, he advises common oil and
hog's-lard. He then goes on to say, " Et in corporibus duris
possumus addere viride aeris, maxime ubi intendimus remo-
tionem malae carnis, et in quibusdam argentum vivum sublima-
tum, nonnulli autem ponunt cum praedictis rebus argentum
vivum, quoniam extinguit pruritum, quod nobis non placet' '♦

After mercury had been introduced as a constitutional re-
medy, it was so grossly abused, that numbers died under its
effects. It must not be supposed, however, that these detest-
able abu.ses were universal. Some physicians, although they
reprobated it in excess, still employed it in small quantities.
Among these was Gaspar Torrella, a Spaniard, Bishop of St.
Justa in Sardinia, and Physician to Pope Alexander VI. the

apud Luisinum, cap. iv. torn. i. p. 281 and 283;) but after guaiacum was intro-
duced, only one individual died in Germany >fhile under its use, and his death was
attrihuted to excess in veniry.
* Apud LuiBinum, torn. i. p. ISM.

SYPHILIS. 507

infamous father of the equally infamous Caesar Borgia. The
earliest edition of his work is dated in 1497. One of his oint-
ments contained a twentieth, and one only a fortieth of quick-
silver, extinguished in saliva; yet even in this limited quantity
he did not always prescribe it, but preferred the methodical
cure, by which means, without the smallest assistance from
mercury, he asserts that he cured several patients of severe
poxes. With one of his vegetable remedies his success was
remarkable, and his cures were not followed by secondary
symptoms, as he expressly states to us ; it consisted of the
juices of bugloss, endive, hops, borage, fennel, and parsley,
each four ounces, in which were infused, for a day, half an
ounce of senna, two drachms of polypody and aniseed, a drachm
of turpith, and half a drachm of cinnamon; it was then boiled
down to one half. He calls it, " Syrupus mirabilis et exper-
tus, cum quo innumerabiles non solum curavi, verum etiam
praeservavi ab omnibus defoedationibus cutaneis et doloribus
panniculorum, lacertorum et nervorum."*

But Torella did not confine himself to any one particular set
of remedies; he sometimes used one and sometimes another,
and even conceived, that, under judicious treatment, the patient
might recover, whatever medicine was employed. This opinion
is very fully expressed in his " Dialogus de dolore in Puden-
dagra."f The dialogue is supposed to be held between a phy-
sician and one of the vulgar; the passage is as follows:
VuLGUS. — " Multa et varia remedia scripsisti, die mihi ex-
pertiora." Medicus. — " Omnia sunt experta, si sciveris ea
applicare loco, et tempore." Vulgus. — *' Potest h. nobis hie
morbus extirpari." Medicus. — " Potest cum auxilio tamen
omnipotentis Dei, ae gloriosissimae Virginis Mariae, matris
ejus." His plan for effecting the extirpation, is to take up all
the infected prostitutes, place them under strict control, and
cure them, before sending them back on the town. Consider-

* LuJsinus, torn. i. p. 499. + lb. torn. i. p. 618,

508 SYPHILIS.

in<r the a^e in which he lived, and how much it was his interest
to shield the monks from suspicion, by inculcating the doctrine
of the disease being communicable by the air, this avowal does
him great credit. Astruc, who takes many opportunities of
undervaluing Torrella, laughs at his scheme as Utopian. The
truth is, Torrella's speculations on the origin of the disease dif-
fered from those so ably supported by Astruc; he therefore
attempts to impeach his veracity, although he quotes and makes
deductions from many of his practicalfucis ; but these doubts
of Torrella's truth appear to me to be founded on two very in-
suflBcient reasons, viz. his exorbitant praises of such a villain
as Caesar Borgia, and the nature of his ecclesiastical employ-
ments, which he confesses occupied his time for ten years.
Now, as Torrella published, according to Astruc himself, in
1497, it is clear that the first six of these ten years had passed
away before syphilis was known ; and, besides, Torrella men-
tions his ecclesiastical duties, in his observations to his patron,
just as a modern author excuses any imperfection in his work.
With regard to the first charge, the same excuse may be offered
— he was a bishop addressing an all powerful patron ; but the
corroboration his assertions meet with from facts under our
own eyes, sufliciently justify our placing confidence in his asser-
tions, even did no contemporary support them. This, however,
is not the case. Antony Benivenius, of Florence, who died in
1502, in his work " De Abdilis morborum causis," after enu-
merating blood-letting, sudorifics, purgatives, and medicated
drinks, together with various external applications, mercurials
among them, states, that instances are not wanting of patients
who are cured by drinks containing the decoctions of lac, aloes,
and myrtle.* Wendclino lJock,|- who wrote about the same
lime as Benivenius, speaks of his cures by nearly the same re-
medies, l)ui when the symptoms were so severe as to resist
them, then he had recourse to mercury, but with great caution,

• Lu'iHin, toni. i. p. 402. + lb. torn. i. p. 338.

SYPHILIS. 509

*' propter discordiam et controversiam inter doctores." This
practitioner says, Ihat though he had cured many by mercury,
yet he had known the pains of the limbs return afterwards more
severely than ever — a fact in which he is most completely borne
out by every day experience.

From these extracts, which I might easily multiply, from the
rich mine of information preserved for us in the '• Aphrodi-
siacus," we see that the " Rational and Methodical" cure con-
tinued to have its advocates long- after the powers of mercury
were known, and while they were by several physicians limited
within judicious bounds. But the frequent occurrence of fatal
accidents among quacks, and imprudent regular practitioners,
from overdosing that remedy, opened the road for a very
favourable reception of Guaiacum in Spain, in 1508, and in
Italy in 1517, whence it was generally introduced into all parts
of Europe.

It would be a waste of time to enter into an account of the
cures performed by Guaiacum ; if we may place any confidence
in human testimony, we must admit of the fact; for there is not
one point in physic on which the assertions of authors from
Delgado to Boerhaave, — a space of two hundred years, have
been stronger and less contradictory. On its first introduction,
indeed, it was despised, and its powers denied. Thus, Bras-
savolus says, that he was the first who administered it to Eneas
Pius, in 1526. It was looked upon by all the other physicians
as a new and unheard-of remedy, and a great many laughed at
it till they saw that illustrious gentleman restored to health by
it.* Its price, which was at first enormous,f must have limited
its employment to the rich, while other classes of society still
continued to employ either the methodical or the mercurial mode.
To obviate the expence, the same wood was often subjected to
decoction, but at length it was imported in such quantities, that

* Lusin. torn. i. p. 706.

f Eleven golden crowns an ounce, according to Nicholas Massa

510 SYPHILIS.

if got into common use. Three thousand Spaniards are re-
ported by Nicholas Poll to have been cured by it at one time ;
and, in short, all over the continent of Europe, multiplied ex-
amples of its efficacy were to be found. It is quite impossible,
at this distance of time, to discover the precise nature of the
diseases of which these patients were relieved. We may
admit that many of them laboured under symptoms which
might have been removed by diet, regimen, and cleanliness,
without any medicine ; we may also admit, that, as in the cases
of ulcerations of the genitals, and in the cutaneous eruptions
which succeed them, with which we are familiar at the present
day, some were not truly syphilitic ; but, to suppose that
among the entire number cured, none were so, is an assumption
perfectly gratuitous, and, (considering some of the authorities,)
I might be justiBed in saying ridiculous. ** I remember," says
the most scrupulously correct of all reporters, the illustrious
Morgagni, " I remember when I was quite a young man, and
went to Bologna, that both methods (external and internal) of
using mercury were so far deserted, that I never saw any phy-
sician make use it, or even heard of his using it, for the whole
space of eight years, during which 1 studied |)hysic there, in
either one way or the other way.* What remedies, then, have

• Epist. 68, art. 16. In England an attempt was made many years before, to
prove the possibility of curing the disease without the employment of mercury
in must cases, and without producing its effects as a silagogue, in any. Of the
work I know nothing, except from the Bibiiotheca of Haller, and from the rery
imperfect account given of it in the year it was published, in the Philosophical
Transactions, anno 1684, No. 150, vol. xiv. It is entitled " Tula ac Eflicax Luis
Venereal saepe ahs^jut: Mercurio, ac semper absque salivatione mcrcuriali
Curanda; M<;thodns ; — autiiorc, Davidc Abercroniby, .M. I). i2ino, I^oiidini, ]68i.
It was translated into French by St. Ilomnin, in 1(590. The practice seems never
to have gained ground, and the book remained long neglected. From the days
of Clowes, the mercurial practice was in full vigour in this country ; he is the
earliest English writer on Syphilis, and pubiishc<l, anno 1575, " A New and
Approved Trratise concerning the Cure of the French Pockcs, liy the U'lctions,"
8to. London. Astruc refers to a manuscrii)t in the Sloanian Library, of the
still earlier date of 1572. 1 have seen a small l2[no. volume by R. Bunworth,

SYPHILIS. 511

you seen those very excellent physicians make use of, you will
say, against the Lues Venerea ? Why, the decoction of the
woods," &c. In this interesting- article, Morgagni, after men-
tioning that different methods of cure have been used by
different persons, and that what had formerly been in vogue
was often deserted, and tbat which had been exploded substi-
tuted in its stead, concludes by saying, that from the time he
resided at Bologna, to the period at which he wrote, a period of
6fty-four years, mercury was again brought into use, as an anti-
venereal remedy, in that city.

A few very plain questions arise, on this assertion of Mor-
gagni : — Could the whole of the medical profession of Bologna
have been for eight years blind to the injuries inflicted on their
patients by the want of mercury ? or, coald they have been
blind to those entailed on their offspring, had such untoward
events occurred ? Is it possible tbat there was a suspension of
the symptoms of true syphilis, for eight entire years, exclusively
in the city of Bologna ? Admitting, however, that some of the
cases cured without mercury were not really syphilitic, and that
the physicians were deceived, is it to be supposed that they
wer« deceived in them all ? It would assuredly be somewhat
unfair to the Italian physicians, and rather flattering to our-
selves, to suppose that they were deceived by what occurred
before their own eyes in 1720, and that we, in 1820, know much
better the real state of their patients than they did themselves.
What, then, it may be asked, made the physicians of Bologna
revert to the use of mercury, after an interval of fifty years i
The reply which I should make to this, would be comprised in
the following question and its answer: — What has occasioned
all the revolutions in physic, from the foundation of the science

dated London, 1662, in which he speaks familiarly of nine different modes of
curing syphilis, five of which are without mercury. One of these last, he says,
" is the only way for those that have sharp and eating humours, insomuch that
they are fearful of losing the palate of their mouth, or the bridge of their nose,
aad have holes in their head, or any other part," pp. 38, 39.

512 SYPHILIS.

to the present hour ?— A fashion, founded in some degree on
truth, but in a great degree, also, on the combined causes of
imitation, habit, and adaptation to local circumstances, the
adoption of which was not productive of such fatal events as
would justify a violent and universal rejection of it, but which
left to the physician the consciousness of having treated his
patient according to the plans of his contemporaries, and
thereby exonerated him from all blame under the occurrence of
any sinister event. Nothing, I may here observe, can be easier
than for persons at a distance of either time or place to point
out omissions, or discrepancies, or unsatisfactory details, in any
one written case of physic, and thus, if they are so inclined,
propose almost insurmountable obstacles to the settlement of
points for theeludication of which details of cases are required:
but if a case possesses a majority of those characters admitted
by general consent to constitute a particular disease, it is alto-
gether frivolous, to make objections at a period when a re-
examination cannot be instituted. For instance, is it not
presumptuous to insinuate, that Drs. Rutherford, or Currie, or
Rollo, or any other eminent physician, could not decide on the
genuine character of a chancre before their eyes, but that Drs.
A, or B, or C, at a distance of some hundred miles from them,
could do so at once J If, indeed, the character of the narrators
is doubtful, their assertions contradictory, and their conclusions
absurd, then we may hesitate, and give to iheir opinions and
cases that value only which they appear to deserve.

It w(juld be a matter of vast importance did we possess any
work on the comparative mcrils of the treatment by guaiacum
and other woods, and lliiit by mercury ; none with which I am
acquaintxid exists ujion the subject, liiit wo may collect some
detached observations on consulting the works of those who
speak on both melhods. Thus, Gabriel Fallopius, in his 9Gth
chapter, Dc Ossium Corruptione,* speaking of the loss of the

* Luisin. torn. ii. ji. 8y7.

SYPHILIS. 513

bones of the nose and palate, says, " Et sciatis quod non in
omni inveterato gallico hoc fit, sed tantum in illis in quibus
inunctio facta est cum hydraro^yro." Fernelius, who appears to
have had great opportunities of witnessing the treatment of
syphilis by mercury, though certainly at a time when it was
pushed beyond all reasonable bounds, in his 6th chapter, de-
scribing the great injuries sustained by the mercurial cure and
the frequency of relapses, observes, " Recidiva raro similis est
radici, neque iisdem symptomatis exercet, sed fere distillatione,
arthritide tophis vel ossium carie."* But his scholar, Julian
Palmarius, is still more pointed, and institutes a comparison
between the two practices, in his work De Morbis Contagiosis,
published at Paris in 1578.t He there, speaking of the affec-
tion of the bones, uses the following remarkable words; Sed
hoc iis duntaxat contingit, qui olim a lue venerea hydrargyrosi
vindicati putarentur, non qui decocto guaiacino et alexiphar-
maco curati fuissent." This opinion, with regard to the diseased
state of the bones being the consequence of mercury, was
generally adopted all over Germany. When we reflect that
mercury is soluble in the albumen of the blood, and has often
been detected in it in persons who have undergone long courses
of the mineral, we must be convinced of its very powerful and
protracted influence. I shall not enter into the inquiry, whe-
ther it has ever been found existing in the cancelli of the bones
in its metallic form in examinations of the dead body, but we
know for a fact, that the bones of those who have undergone
long mercurial courses, never make such white or elegant
skeletons as others. :|: It becomes a point well worthy of in-
quiry, whether mercury produces diseases of the bones where

* Joannis Fernelii, De Luis Venereae Quratione, Apud Gruner. — Aphrodisiacus,
vo). iii. p. 146.

+ Cap. 7, Lib. 2, p. 12*.

+ Leber's anatomy article, " Color Naturalis Ossium." Monro, in his
Anatomy, mentions molities ossium as having succeeded to a course of mercury.
See also a case of Mr. Carpue's, alluded to at p. 369 of this work.

2 L

514 SYPHILIS.

a predispositiou to these diseases does not exist. I am well
coaviuced tbat the carious affections of the bones, which are ao
common in persons treated by long mercurial courses, have
proceeded, not from the disease, but from the remedy rapidly
and irregularly thrown in while periostitis existed; as a proof
of which, I have not seen a single case of carious bone in the
military hospitals since the non-mercurial treatment was adopted,
except where mercury had formerly been used, — so that those
gentlemen who so kindly and compassionately harangued on
falling noses and rotten bones, have displayed their sensibility
in vain.

It would be a most laborious task to inquire into the com-
parative merits of all the medicines or plans which succeeded
to guaiacum in the cure of the venereal disease; they have
amounted to many hundreds. Some of them have been power-
fal, as the acids, opium, sudorifics, bloodletting, purging, &c.;
others have been quite inert, as boxwood, balsam of sulphur,
calamus aromaticus, &c.; some of them ridiculous, as burying
the patient in horse or human dung; and others immoral, as
coition with a sound person; but it is very remarkable, that
there is no one remedy which has ever been proposed or used,
which has not frequently succeeded in the cure ; this can only
be accounted for upon the supposition that the disease, in many
instances, cures itself. Upon this principle, all empirical
remedies which have contained the mild juices or extracts from
plants, and which were said by their inventors to be powerful
specitjcs, have probably appeared to be successful. There are
too many instances of cures having taken place while patients
have been using such remedies, to deny the fact, although we
may not adn)it the conclusion, that the cures were produced by
the use of the remedy.

The observation of Leo Africanus is particularly worthy of
attention; it is to be found in his work, entitled " Joannis
Lfonis African!, African Descriptio." Lugd. Batav. 1632,
p. HG; it ik also quoted by Mr. Pearson in his introduction to

SYPHILIS. 515

his Observations on the Effects of various Articles in the cure
of Lues Venerea, 8cc. (he refers to an older edition than mine,
viz. that of Antwerp, 155G, fol. 33.) In this passage, Leo very
positively asserts that the disease undergoes a cure by change
of climate in Africa, spontaneous, and without the employment
of mercury. This assertion, which has been laughed at, is
most remarkably confirmed by a modern traveller Horneman,
speaking of the people of Fezzan, a kingdom in the verv centre
of Africa, says, " There are various sorts of venereal disorders
prevalent in Fezzan, — that imported from Soudan is the worst.
The common lues venerea, brought from Tripoli and Cairo, is
called franzi, or the frank evil. For the cure of either species
they use salts, and the fruit caudal (colocynth) as powerful
cathartics ; and the sores, if any, are at the same time washed
with natron water, or dissolved soda. These remedies seldom
fail, unless the disease has taken a very deep root." Horne-
man's Travels from Cairo to Mourzouck, 4to. London, 1802,
p. 63. In a subsequent letter he ccmiirras the authenticity of
his former report. I apprehend little specific power will be
attributed to the purgatives and the alkali, but we have some
interesting European and American confirmation of this African
practice, as it regards the external application of the alkalies,
(not to mention Peyrilhe's testimonies of their effects when
used internally.; Dr. Mitchell of New York, in the Medical
Repository for 1799, assures us, that a great number of venereal
ulcers were cured in the hospitals of that city by the local
application of potash or salt of tartar, from which fact he
draws the very natural conclusion that neither nitrous acid nor
mercury produced any specific effect upon these ulcers.* In
Scotland, soda has been used for the same purpose with no

♦ Some of our troops, during the last war, served at Ceuta, on the coast of
Africa. Dr. French, Assistant-Surgeon to the Forces, who was quartered at that
place, informs me, that tlie Moors seldom think of using mercury for syphilis,
but trust its cure entirely to cleanliness and native herbs. la some of the mari-
time towns mercury is used by those who have visited the European ports.

2l2

516 SYPHILIS.

small success by Dr. Andrew Ferguson of Aberdeen, in the
form of a solution, of one ounce of the sulphat dissolved in
four pounds of boiling water, and applied by the medium of a
cold poultice, a lull account of which practice is to be seen in
the Medical and Physical Journal, vol. x. p. 499. And
although the author was not aware of the full extent to which
his practice might have been pushed, or of all the conclusions
which might be deduced from, it, he is entitled to much credit
as a faithful observer and judicious practitioner, and his report
very remarkably confirms the observations of preceding and
later authors.

The domestic medicine of the American Indians and other
nations may be inquired into advantageously for proofs of
spontaneous cure ; the fact that they often apply for advice and
for mercury to European surgeons, militates very little against
the authenticity of cures by their own indigenous plants, for
the multiplication of remedies against disease is a propensity
natural to man, in both his savage and his civilized states. I
shall not enter farther into the iiujniry of the spontaneous cure
of this disease, but shall refer to the works of Tomitanus,
Fracastorius, De Blegny, De Ilery, Fernelius, Ramazzini,
Van Swieten, and Vercellonus, among the writers of older
date; and to Lagneau, but especially to Vacca Berlinghieri,
among the moderns.

In collecting materials for a history of the symptoms of the
venereal disease under the mercurial regime, we have to se-
parate the effects of the complaint from the effects of the
remedy ; — wo should not take these from the exaggerated
accounts of interested men, but select them from the ordinary
results of mercurial courses. The situation in which Gilders
a\)d other artists are placed, and also that of the unfortunate
beings who dig <|uicksilver from the mines, are extreme and
comjjlicated cases; but from the facts presented to us, under
more ordinary circumstances, it is established that scrofulous
habits are peculiarly liable to suffer during the employment of

SYPHILIS. 517

mercury^ — that the phthisical tendency is greatly aggravated
and often evolved by it,* — that profuse hemorrhages from the
lungs are frequently produced by it,f — that it gives rise to the
most aggravated and distressing forms of dyspepsia, — that
dropsy and aflPections of the urinary organs are often produced
by its abuse, — that although a powerful remedy in hepatic dis-
ease, it often gives rise to jaundice, (indeed, in diseases of the
liver this remedy is often grossly abused,) — that it produces
very irregular states of the bowels, — that its effects on the
nervous system are often extremely severe and complicated,
appearing under the forms of pain in the head, insomnolency,
and that state of disease termed by Mr. Pearson Erethisraus,
affecting the brain, heart, lungs, and diaphragm, and indicated.
by pains, slirinking, and a peculiar appearance of distress in
the countenance, anxiety, partial or universal trembling, palpita-
tion of the heart, sighing, and difficult respiration, and not
unfrequently by sudden death on an attempt to move, — that the
maniacal tendency is particularly aggravated by it. In some
instances, different members of the same family have become
furious during mercurial courses ; nor has it been in the instance
of mania alone that the family disposition to be injured has

• In Dr. Prout's paper in Thomson's " Annals of Philosophy," 1814, it is
stated that the formation of carbonic acid in the lungs is diminished by the
use of mercury.

+ Scarpa states, that persons who have had lues venerea are particularly
predisposed to ulceration and disorganization of their arteries. Is this the effect
of mercury? See a case in this work, p. 187. With regard to the effects of
mercury on the pulmonary system, I have been always struck with the following
experiment performed by Clayton, so far back as the year 1694, and detailed in
the Philosophical Transactions for that year, p. 121. It is also quoted by
Dr. Saunders, in his admirable work on Diseases of the Liver, 3d edition, p. 307.
Two drachms of crude mercury were injected into the crural vein of a Dog. On
the second day there were obvious symptoms of fever ; in two or three days
more, dyspnoea supervened, followed by cough, and a daily increasing aftectioa
of the lungs, until the animal died. On examination, his lungs m ere found in
^ tubercular state, many of the tubercles had suppurated, and formed vomicae,
and on making sections into them, each contained a globule of mercury forming
a kind of nucleus to the circumscribed inflammation.

518 SYPHILIS.

manifested itself; in many instances there seems to be an
hereditary constitution with which it uniformly disagrees, pro-
ducino all its most violent effects, and under no mode of
mauao-emeut, nor in any prudent quantity exciting ptyalism, or
any beneficial effect on external sores. In gouty habits a very
small portion of mercury often excites the disease ; but the
most troublesome and most common of all its effects is the
pbagedanic ulceration, which it often induces both in chancres
and open buboes, and the disposition to fresh ulcerations of a
spreading and intractable character, which it gives rise to in
parts where the skin had not been previously broken. In the
throat most severe ulcerations are excited by it, erosions of the
gums and palate are produced, and the popular and other
eruptions on the skin, which so often appear as a secondary
form of the disease, are frequently exasperated into open
ulcerations. I have not seen a single case of ulceration suc-
ceeding to a cutaneous eruption in the military hospitals since
the non-mercurial practice has been adopted, except where
mercury had been long and irregularly used.*

• A curious instance of the efl'ccts of mercury is uUuiled to in the 6th volume

of the Edinburgh Med. and Surg. Journal, p. 613, and is the most unmixed case

that can possibly be imagined. Several boxes containing leather bags filled

Willi quicksilver were brought up from the wreck of a Spanish vessel at Cadiz,

and stowed on hoard some of our ships of war ; the bags rotted, and the fluid

mercury penelratid through all the parts of the ship, and was even mixed in

minute particles with the bread and other provisions ; a general salivation took

place, the domestic animals, even, I believe, the fowls and birds were affected,

and every rat, mouse, and cockroacli on board died. I saw se\ oral of the oflicers

and crew of the Triumph at Gibraltar in IblO, many of wlioni, I undtrslood, bad

a mo*t narrow escape with their lives, and some that 1 examined had severe

febrile exacerbations, swellings, and ulcerations of the tongue, ulcers of the

throat, enlargement of tho submaxillary and cervical glands, erylhimatous

afTeclions of the skin, various nervous allerlions, and severe pains in the bones

and joints, and in the muscular parls of their limbs. The surgeon of the

Triumph was so kind as to show me the ca.ses at the time, but my notes of tbem

arc loM. A report on the subject by that gentleman would be most valuable ;

few such opportunities will ever occur for observation so extensive on individuals

SYPHILIS. 519

From the various ill effects of the medicine, prudent phy-
sicians have at all times been cautious, and intermitted its use,
sending their patients to the sea shore, or to the country, in
order to recover their constitutions, and to be thus enabled to
try it again ; by these means enormous quantities have been
introduced. Sometimes the constitution has resisted, but much
oftener it has sunk. Hence, we will invariably find, that
where most mercury has been used, there has the mortality
been greatest; not, I apprehend, that the poxes were most
severe, but that the specific was administered in the largest
quantities. Many practitioners, in order to avoid these incon-
veniences, have combined the tonic and the mercurial plans,
and have given the mercurial oxyds in combination with de-
coction of cinchona. This has been thought a very superior
mode of treatment, and I believe it to be a very useful one ;
not that the patient is by it enabled to take more mercury, but
that he actually takes less ; for the chemical discoveries of
Berthollet show us, that the astringent principle of vegetables,
particularly of the cinchona, decomposes the mercurial, as well
as the antimouial, oxyds, and of course renders them inert.

Some physicians have been very anxious to call into action
the dormant venereal virus, so as to render it more tangible to
future courses of mercury. M. Swediaur has taken much pains
on this subject. In the minutes of the proceedings of the
•' Medical Society of Brussels," he gives an account of some
experiments, made with a view to this purpose. Tbe symptoms
he observes, often entirely disappear, under the employment of
mercury, yet the patient still remains uncured. As a remedy
capable of renewing the activity of the virus, he recommends
the preparations of iron.* Are not the effects of this medicine

in perfect health, and under their usual mode of living. A detail has been
published since the date of this note by Dr. Burnet. See Johnson's Medico»
Chirurgical Review, for March 1S24, p. 1010.

* Proceedings of September 27, 1797. The Black Oxyd is the preparation
recommended, " Actes de la Soci6t6 de Med., &c. a Bruxelles," tome i.

520 SYPHILIS.

rather to be considered as those of a tonic, during the employ-
ment of which the mercurial cachexy gets time to subside? and
is not the reiteration of a mercurial course much more likely to
destroy than to restore the constitution of the patient?

While T have thus enumerated many of the ill effects pro-
duced by mercury when it acts as a poison, I must give my
strongest testimony to the admirable results which proceed
from its judicious use in persons not constitutionally disposed
to be injured by it, and who do not lead profligate lives, or are
not exposed to the foul air of hospitals fully saturated with its
fumes. In common with other physicians, I have, however,
frequently observed that mercury, like many other substances
with which we are familiarly acquainted, frequently mitigates
in small doses, but without effectually removing, many of the
symptoms which it has occasioned when very largely used, a
property which has often led to serious mistakes,* and which
must detract considerably from the value of any examples
drawn from the cases of those whose constitutions have been
constantly charged with the mineral, when such cases are
brought forward as unquestionable proofs of its efficacy, where
syphilis has resisted every other means of cure. I would by
no means, however, be understood to assert, that many cases
have not yielded to mercury, which had previously resisted
every other medicine. Of its unquestionable eflicacy there can
be no doubt ; but its indiscriminate employment in every case,
whether old or recent, suspicious or confirmed, and m ithout any
view to the patient's diet, or his general health, has produced
the most dreadful consequences. To reduce its employment
within the limits where it can be salutary only, without creating
or evolving other diseases, is the best means of suppf>rting the
reputation of the medicine. ^^ here Hunter and Abernethy,
Pearson and Carmichael, have hesitated, we surely may be per-
mitted to pause. These eminent men greatly contributed to the

* Sec Matthias,

SYPHILIS. 521

elucidation of the circumstances under which mercury was im-
proper ; their precepts and their example have reduced the
quantity formerly given to comparatively moderate bounds; but
it remained for the inquiry, which is at present prosecuting in
the military hospitals, to show, that even these bounds are too
extensive, and that the practitioner has, in a vast number of
instances, the option whether to defer its use, to limit it, or to
omit it altogether. Settled as it now is, beyond a doubt, that
syphilis does not run on uninterruptedly to a fatal event if not
checked by mercury, that practitioner cannot be admitted to do
full justice to -his patient, who does not avail himself of the
fact; — to his own judgment must be left the extent to which he
may be pleased to do so.

It is impossible for me to mention the revered name of
Hunter, without pausing for a moment to speak of the man.
That he was a powerful and original genius, an enthusiastic
investigator of truth, and the possessor of an acute and almost
peculiar tact, as an anatomist and an experimenter, is uni-
versally allowed. But, like every other being of finite endow-
ments, he had his deficiencies and his errors ; the errors of a
daring, a strong, and an original mind, and always more ob-
servable in bis speculations than in his investigations— in his
theory than in his facts. His language has been, in many
instances, but very remarkably in his Treatise on the Venereal
Disease, confused, and not seldom unintelligible; — a confusion
and obscurity which may often be traced to the erroneous point
of view in which he saw a subject, and on which he has dwelt
the longer, the more he was in the wrong, endeavouring to re-
concile himself and his readers by a multiplicity of words, to
speculative points which no language, however pure, could ex-
plain, and no reasoning, however ingenious, could elucidate.
Truth was, in the mouth of Mr. Hunter, always simple, beau-
tiful, and impressive ; our veneration for the man has alone
permitted the attempts to veil or disfigure it to exist for a
season uncontroverted. To his successors in error, however.

522 SYPHILIS.

■who possess a double portion of his perplexity, without one ray
of his genius, we owe no such deference ; and in truth, be has
sustained through such persons, bloated as they are with
borrowed importance, more than his just proportion of blame.
Upon the whole, perhaps the most serious practical fault of this
great man was the conBdence which he placed in the mercurial
diagnosis, or that which leads us to suppose, that because a
sore or a symptom has yielded to mercury, the disease must have
been necessarily syphilitic. By this exclusive rule we can
never positively determine what a sore or a secondary symptom
actually is, but must decide upon its nature by what it has been,
— a retrospective mode of reasoning, far from satisfactory,
and founded upon an assumption, the truth of which is more
tlian problematic.

Though the important facts recently established require no
authorities or analogies fur their support, it is pleasing and
instructive to find them mutually corroborated and corrobo-
rating ; it is delightful to show, that the assertions of phy-
sicians, travellers, and historians, which formerly were deemed
fabulous, or at best doubtful, may now be considered as fully
entitled to belief, and that those who advanced them were
neither deceived themsel-ves, nor wilfully deceived others. But
while we pay this just tribute to the veracity of these persons,
it should not be forgotten that it is to their successors we owe
the power of doing so. The investigations carried on under
the sanction of the Director-General of the Medical Depart-
ment of the Army, have done more in three years towards the
elucidation of the natural history of syphilis, than had been
effected for three centuries before. Previous to Ihese investi-
gations, tlu; admirable work of Mr. Pearson afforded the best
account in the Knglish language of the diflerent modes of
treating syphilis, and of the comparative powers of the re-
medies employed. Jn France, the iible " Parallele" of M. Louis
was of c(|ual authority. Did my confidence in Mr. Pearson's
conclusions depend solely upon respect for the talents and

SYPHILIS. 523

learning of that author, or on a perfect conviction of his desire
to decide impartially on the evidence then before him, it would
have remained unshaken still ; but circumstances of recent
date, which could not have been known to him when he com-
posed his work, appear to me to call for a reconsideration of
the whole subject.

I shall not degrade myself by entering into disputes with
those who have sheltered themselves behind the lecturer's
chair, from whence .they have poured forth abuse against the
army surgeons, as unmanly as it was unmerited. I little envy
that man his feelings, who dares to utter such a calumny against
the army surgeons, as that they could for one moment entertain
the idea of abusing the power placed in their hands : and his
head must be very weak, who does not see, that the most suit-
able return to the government for all the public money laid out
on the hospitals, and to the individuals of the army for that
proportion which they pay to the support of these establish-
ments, is to investigate carefully and honestly the best means
of treating diseases, and thus to curtail the expences both of
the individual and the community. Did the officers of the
medical department of the army, under their most enlightened
and active Director, prefer their own ease and convenience to
the benefit of science, mercury was at hand to cover their
apathy ; and even the few facts which the present inquiry has
brought to light might have gone down to oblivion, with the
hundreds of thousands of other facts, which, in the course of
three centuries, have been confounded or totally lost, by a
blind, non-discriminating, and often fatal confidence, in the
powers of one remedy alone, to the exclusion of every other
resource of art.

In the practical remarks which I am now about to make, I
propose to embody the whole of the information that I have
been able to collect in the various military hospitals under my
superintendence for the last four years, as well as from the

624 SYPHILIS.

latest official documents which have been promulgated to the
army by the Medical Board, and of which, by the liberality of
Sir James ISrGrigor, I am permitted to avail myself. But
before I enter upon this subject, in order to avoid all possibility
of misconception or misrepresentation, I feel it incumbent upon
me again clearly and distinctly to avow, that I entertain no
doubt of the utility of mercury, when properly employed as an
auxiliary in the treatment of venereal complaints, especially
when they become chronic; but while I admit this, I am
equally confident that the disease, like many other diseases, is
susceptible of a spontaneous cure in many cases ; that in many
others it is curable without the employment of mercury, either
externally or internally; and that where mercury is emploved,
the doses may be greatly diminished from what was lately sup-
posed necessary, and that its effects may be always limited to a
moderate irritation of the gums, so as that the poisonons effects
of the remedy may be as much as possible avoided. Having
premised thus much, it is also necessary that I should say, that,
convinced though I am of the possibility and facility of the
non-mercurial cure, 1 am by no means authorized from my ex-
perience to assume, that its cUyib'ditij, in every case, or under
a// circumstances, is yet established. How far the observations
I have to offer may tend towards this end, it will be for the
reader to judge, and for further experience to determine. All
theoiies, or pre-conceived opinions on the subject formed in the
closet, and promulgated by /«////j(7 physicians and philosophers,
if unsupported by actual experiment, I look upon as perfectly
worthless. No man could have been more firmly convinced
than I was, five years ago, of the extravagance of supposing
that this disease could, umler any circumstances, be cured
without mercury, (to which alone I had trusted in at least a
thousand cases,) until conviction was forced upon me by re-
peated observation, confirmed by an attentive consideration of
tiie testimonies of the best informed practical writers of past

SYPHILIS. 525

limes, and the opinions, both oral and written, of those of the
present, whose opportunities have been such as to entitle their
opinions to any weight on a practical subject.

It is painful to confess that we are not in possession of the
knowledge of any invariable characteristic symptoms, by which
to discriminate the real nature of the primary sore, and we are
equally at a loss in many of the secondary symptoms. I am
well aware that some practitioners have assumed to themselves
the possession of a " tactus eruditus," by which they can at
once distinguish a chancre, or a venereal ulcer or eruption, in
which mercury is indispensable, from one of a different nature,
but I have seen too many instances of self-deception to give
them all the credit that they lay claim to. It would be by no
means difficult to show that the high round edge, — the scooped
or excavated sore, — the preceding pimple, — the loss of sub-
stance, — the hardened base and edge whether circumscribed or
diff'used, and the tenaciously adhesive discharge of a very fetid
odonr, are all observable in certain states and varieties of sores
unconnected with a venereal origin. The hardened edge and
base, particularly, can be produced artificially by the application
of escharotics to the glans or penis of a sound person, and if
any ulceration, or warty excrescence, previously exists on
these parts, this effect is still more easily produced.

What, then, it may be asked, would I recommend as the
proper treatment of the diseases produced by sexual inter-
course? I shall endeavour candidly and conscientiously to
answer the question.

Is?, In every primary ulcer I would give up the idea of using
mercury at first, treating it as if it were a simple ulceration by
cleanlinesss, rest, and abstinence, and applying to it the most
simple and mildest dressings.* If the sore did not put on a
healing appearance in a reasonable time, the extent of which

* A very early application of the lunar caustic will often supersede all other
reniedi es.

526 SYPHILIS.

raust depend on the circumstances of the patient, I should make
use of more active dressings. But if, beyond all calculation,
it remained open, I should certainly not sacrifice every con-
sideration to a dislike of mercury, knowing how many persons
have been seriously benefited by a judicious and mild adminis-
tration of that remedy. 2(1, The same principles which guide
me in the primary ulcers, would have the same, if not greater
force, in the case of buboes. In their irritable state, I con-
sider mercury as altogether inadmissible. Moderate pressure,*
and cold a|)plications, will often disperse them in their com-
mencement, aided by Girtanner's plan of frictions of volatile
liniment on the thigh of the affected side.f If they suppurate,
opening witb the kali purum is by far the best plan ; they
then heal from the bottom. Sd, The cutaneous eruptions I
would treat at first on the same general principle, but I should
not very long postpone the employment of the mildest mercurial
alteratives, aided by warm bathing and sudorifics. 4th, In the
affections of the throat I would be more guarded than in any
others in the employment of mercury, until all indammatory
disposition was removed ^ after that, I have seen them yield as
if by magic, so soon as the local effects of the mercury on the
parts within the mouth became obvious ; but before the in-
flammatory symptoms were subdued, I have seen avast number
of instances where irremediable mischief has been done, bth,
In the bone cases during the stage of periostitis, or any approach
towards it, local bleeding, blistering, warm-bathing, and absti-
nence, are the proper remedies to the entire exclasion of
mercury. When indammation is subdued, that remedy may be
tried in moderation, but if caries exists, I hold it to be highly
improper under any form.

So far has delay been from injurious in the cases which have
come under my inspection, that f have invariably found the

* The Kpring truss Lsa very conveiiiciU inhtrumctit for aiiplying the pressure.
+ Blistcrii uro ofteu of great service where thoy remain in a torpid state.

SYPHILIS. 527

sanative powers of mercury most remarkably assisted by tlie
previous preparation which the patients have undergone by
minute attention to cJeanliuess, rest and rigid abstinence, and
by the action of purgatives and sudorifics, or of venesection
where it was found necessary. If, in any case, this was more
conspicuous than in another, it has been where the ulcerations
on the penis have been irritable and extensive, and almost
threatening its destruction,* or where the throat has been
severely affected. The extent of the period for which mercury
is deferred must entirely depend on the circumstances of the
patient ; in delicate phthisical habits, we now know that there
is no necessity for hurrying ; at the same time, no person in
private practice, whose constitution could tolerate mercury,
would willingly continue to bear about his person those sus-
picious looking stains and eruptions on the skin which a judicious
employment of that remedy so often relieves.

That the cure of some of the cases treated in the military,
hospitals under my superintendence would have been accele-
rated by the use of mercury, is extremely probable; but a
mixed mode would obviously have left the trial without mercury
incomplete, and its success still dubious. Desirable, however,
as it has been, to ascertain how far that powerful mineral may
be dispensed with, in the cure of the disease for which it has
been so long looked on as the sole specific, the point would
have been left undecided, had its decision involved the consti-
tutions of the patients, or compromised the characters of their
medical attendants. In no case, I most firmly believe, has the
health of an individual been wantonly trifled with, nor has the
utmost professional exertion been spared, to elucidate the
history of this most interesting and most common of all military
diseases, even in the persons of some of the professional
men themselves.

* In hospitals where the aimosphere is slrojigly mercuraljzed, this event rery
frequently occurs.

528 SYPHILIS.

With regard to the mercurial preparations which have been
locally applied, they were nsed to try how far they would
accelerate the healing of the sores, or the removal of scaly
eruptions, but never to such an extent as to affect the consti-
tution; cold water has been long substituted in their place by
many surgeons. Considering the extremely minute proportion
of mercury they contained,* the observation that the cure was
due to them, comes with peculiar ill grace from persons who
declare that nothing but ///// courses of mercury can cure the
disease; the same observation is applicable to any mercurial
purgatives that may have been given with a view to their effects
on the biliary organs ; but that practice also is now generally
given up. It has been supposed, or at least very loudly
asserted, that the cures eflected ajyparently without mercury
have been actually performed by means of the different prepa-'
rations of the mineral, and by caustic surreptitiously employed.
But the slightest acquaintance with the discipline of military
hospitals, as at present conducted, would point out the im-
possibility of such a practice.

The first trials which 1 witnessed were made at Hilsea Hos-
pital in the year 1810, and they were conducted under the eye
of my able friend Dr. Knox, a gentleman peculiarly qualified
for the task by professional zeal, sound judgment, and an
intimate acquaintance with all that had been done or written
upon the subject by his predecessors or his contemporaries.
At that period, I supposed that the Hunterian chancre and
its consequences were absolutely incurable without mercury;
wherever, therefore, the characters of this species of sore were
detected, no time was lost, and that medicine was at once

• Tbc Black Wash commonly employed in our hospitals contains one drachm
of calomel to sixteen ounces of lime-water ; certainly not more than the fourth
part of an ounce is em|)loyc(l in the day, and it is not very extra\agant arithmetic
to calculate, that not a fortieth part of it is uhsorbed, even admitting that
absorption takes place unaided by friction. The quantity of mercury, there-
fore, will probably not amouut to the fortieth part of a grain daily.

SYPHILIS. 529

adininislered in moderate quantity.* Of fifty-eight primary
sores which occurred between the 1st of May and 24th of
September, twenty-eight were cured without mercury, the
remainder were considered as true chancres, and were treated
accordingly. During this period we received into hospital ten
secondary cases, chiefly foreigners from the Mediterranean,
seven of these were cured by mercury ; in the remaining three
the secondary symptoms were distinctly traced to gonorrhoea,
and were cured without the administration of that remedy. In
one of the secondary cases we had a remarkable illustration of
the fact, that they occur after a well regulated course of mer-
cury, illustrating Mr. Hunter's doctrine, " that if the disposition
to the diseaL^e is formed, mercury cannot cure it until it come
into action;" which, in plain language, as Mr. Guthrie has well
expressed, " means nothing more than that the disease cannot
be prevented in certain constitutions from running its own
course, when it may at last be cured." In the case alluded to,
no quantity of mercury, in whatever form administered, could
be made to aflect the salivary glands; a quantity, however, was
used, which was deemed sufficient to eff'ect a radical cure ; all
the primary symptoms gave way, but some time after having
left off the use of mercury, secondary symptoms appeared in
the form of ulcerations in the throat ; no more mercurial
medicines were administered, and this symptom gradually
disappeared of itself. Some of the uon-Hunterian sores oc-

* To prevent all cavilling about words, I understand by Hunterian chancre,
true chancre, or true syphilitic ulcer, a sore answering the definition given by
Mr. Hunter in the first chapter of the fourth part of his treatise, edited by
Dr. Adams, London, 1810, pp. 314, 326, and repeated by Mr. Carmichael, Essay
on the Venereal Diseases, &c. p. 25. Although the callous nature of the ulcer
has been handed down from the earliest writers on the disease as characteristic, I
use the term Hunterian, because the deseriplion by that eminent man is more
generally known and read than that of the older writers, and is by some supposed
to include every possible shade of sore capable of producing syphilis. See the
authors in the collections of Luisiuus and Gruner, and ihe work of Clowes ; but
particularly sec Wiseman.

2 iM

530 SYPHILIS.

carred in officers, the rapidity with which they healed under
the wash of lime-water and calomel was astonishing, but the
patients were so much impressed with the fear of subsequent
pox, that the assistant who attended them was obliged to supply
them with pills supposed by them to be mercurial, but really
composed of bread ; no ill consequences followed this innocent
deceit ; bat it is remarkable that in one of the patients the
mouth became sore, partly from imagination, and partly perhaps
from his frequent attempts to ascertain the eftects of the remedy
by pressure on his gums with his fingers and lips. Since this
occurrence, I have had frequent opportunities of witnessing the
same fact, particularly at the military hospital at Dover, under
the care of my friend StafF-Surgeon Macleod.

It was not till I took charge of the North British district in
October, 1817, that I had an opportunity of verifying the re-
ports which I had received of the practice in the Huuterian
sores and its consequences, as followed by Messrs. Guthrie,
Rose, Dease, and others in London, and by the medical officers
of the army in France. On my arrival I found the practice
adopted to a great extent in the hospital of the 88lh regiment
quartered in Edinl)urgh Castle, under the able care of Mr. John-
ston, Surgeon, and Dr. Bartlet, Assistant-Surgeon, gentlemen
to whom I am greatly indebted for many interesting facts, and
from whom I experienced every assistance which could be
derived from men who, well informed themselves on this par-
ticular branch of their profession, were zealous without preju-
dice, and decisive without petulance. From Dr. Jones of the
40th rej;iment, who was, during the same period, quartered at
Glasgow, I received equal information and equal support in my
numerous visits to that city ; other corps have come less under
my notice, or have remained in Kdit)biirgh or other stations for
too short a period to admit of my having derived e(jual informa-
tion and equal assistance from them, hut of their abilities and
inclination I can have no doubt. To speak of Stall-Surgeon
Thomson would be superfluous ; the result of his practice in

SYPHlLi,S. 531

private, as well as in the military hospitals of Edinburgh, before
I took charge of them, is already in the hands of the profession.
I have had many opportunities of witnessing the justice of his
remarks, and have seen him persevere in the non-mercurial
treatment in the most unpromising cases, with results equally
fortunate and unlocked for.

The appearances of the primary sores contracted by sexual
intercourse, which have presented themselves in the military
hospitals, have varied extremely, but in many instances they
have been very much influenced by their particular position.
The following circumstances have been principally remarked in
them : 1st, Ulcers on the external integuments have generally
had round callous edges, level surfaces, but little induration of
base ; they were less irritable than others, became sooner clean,
and healed uiiiformly, but slowly. 2d, Ulcers on the internal
membrane of the prepuce have been generally either superficial
or elevated ; their surfaces covered with a light coloured slough,
or of a bright red, with villous appearance ; their edges either
regularly defined, or spread out like excoriations; their bases
have been, in general, but little indurated, but when the ulcers
have spread out, they have sometimes acquired a cartilaginous
hardness, and have been extremely difficult to heal. 3d, Ulcers
immediately behind the corona glandis have been, in general,
highly irritable, deep, scooped, indurated in their edges and
base, foul, with membranous bridles, running- across them,
throwing off" a perceptible slough, but, if mildly treated, soon
healing after that event. 4tk, Ulcers on the froenum have ge-
nerally followed lacerations of that part, have had considerable
induration of base, and have been generally slow of healing.
5/A, Ulcers of the glans have been generally excavated, but
with little hardness of base, quickly throwing oft" a slough, and
then healing rapidly.

It has sometimes happened, that where a sore has spread and
occupied different textures, each of its parts has exhibited
the character which has generally prevailed in sores confined to

2 M 2

532 SYPHILIS.

that particalar texture. Thus, in a sore which has implicated
part of the internal prepuce, corona, and glans ; on the first
spot it has been elevated, on the corona it has been indurated
and irritable, and on the glans excavated, but with little hard-
ness. Besides these differences, which have been apparently
occasioned by position, ulcers on the organs of generation take
on diiferent actions, like those on different parts of the body,
and are attended with simple purulent, or vitiated discharge, —
with increased or decreased action, — with phagedaena, slough-
ing, &c. Excoriations also appear, which, in some instances,
proceed from mechanical injury, and in some from the applica-
tion of an acrid matter, or from the acquired acrimony of the
natural sebaceous secretion which lubricates the parts. In all
these cases, early attention is a great means of preventing the
sores from acquiring an irritable character. Cataplasms,
astringents, and stimulants, have all their peculiar merits at
particular times, and even the solution of arsenic has been
found to give immediate relief from excruciating pain and
phagediena, which had followed great irritation previous to the
patient being taken into hospital. In some cases blood-letting,
both local and general, has been had recourse to with advan-
tage. In many cases cleanliness alone has efl'ected the cure;
but ill no instance has the application been of such a nature as
to destroy the structure of the parts, and by that means prevent
the absorption of the virus ; this is shown by the occurrence of
secondary symptoms in our hospitals, which seldom take place
when the primary sores are early destroyed.* In all cases, rest
in the horiz<intal posture is an important part o( the treatment.
Some of the primary sores have gone on rapidly to a cure,
sonic have been more slow, and a few have retained their
hardened edges and bases for a long time; the great majority
have healed as in ordinary cases, some leaving a pit or scar be-

• Some trials are now making on the comparative merits of destroying the sores
by tho nitrate of silver on their very first appearance.

SYPHILIS. 533

hind, and some, particularly the elevated sores, have had a
scab formed, which, on dropping off, has left the parts sound
beneath. In many instances, after having healed up, the
sores having broken out again without any obvious cause; in
others, the friction of the clothes, or rough handling, has occa-
sioned their re-appearaoce, and some on the prepuce have
appeared as if mechanically torn open in the effort of uncover-
ing the glans. In all these cases, the healing of the renewed
sore was as certainly effected without mercury, as that of the
original one.

We have bad frequent opportunities of remarking two or
more sores of different kinds existing at the same time ; an
irregular shaped diffused sore ; an elevated sore, covered with
a light coloured slough, as if a bit of shamoy leather had been
stuck on by some tenacious substance ; a groove or streak along
the glans, as if made by a scraping instrument, filled with pu-
rulent matter ; and the true and perfect chancre according to
Mr. Hunter's definition, or the true syphilitic ulcer according
to Mr. Carmichael. This last has in some cases occupied the
glans, in some the prepuce, while the sores of another descrip-
tion have been on the same part close beside it, or on another
part at a distance. Three of these cases I particularly selected
for examination and public demonstration in the Castle hos-
pital ; in one, the Hunterian chancre was on the glans, and a
sore witliout any hardness on the prepuce; in another, it was
on the prepuce and a simple ulcer on the glans; in the third,
a most perfect specimen of Hunterian chancre occupied the
internal prepuce close to the corona glandis ; and at about half
an inch from it, nearer the froenum, but farther from the glans,
was an elevated ulcer ; in all these cases the Hunterian chancre
healed several days before the others.

Soldiers are gregarious in their amours, and we have fre-
quently several men at the same lime in hospital, infected by
the same woman with whom they have had connection in very
rapid succession ; some of them have had one kind of sore.

534 SYPHILIS.

some another, and some both.* In all the instances in thefoF-
lowing tables wliere there have been two or more ulcers, if one
has possessed the Hunterian characteristics, both the secondary
symptoms and the primary sore have been classed under that
head. We have been very careful in our endeavours to distin-
guish the sore that has the hardened edg-e and base naturally,
from that which may acquire it by art. This can only be
done by watching the sore from its very commencement, for
there is not the smallest doubt, that a sore can be artificially
produced by the application of the kali purum to a sound man,
which is not to be distinguished from chancre by a person not
aware of the circumstance; the hardened edge and base can be
perfectly imitated, and the specific distance (as it has been
called) of the hardness can be increased or diminished by proper
management of the caustic.

In primary sores of a complicated nature, the non-mercurial
plan has been as strikingly useful as in the more simple. In
phymosis, with clustering sores on the point of the prepuce, and
concealed ulceration of the glans with hardened edges, where
no irritating substance has been employed to occasion them,
the success has been uniform ; the livid chancre of Mr. Car-
michael (page 20") has been treated with equal success. In fine,
every thing I have seen of the practice confirms me in the
possibility of healing primary sores on the genitals, of whatever
description they may be, without the employment of mercury;
and I have met with nothing to make me question the propriety
of making the trial. Of some hundred cases, none have hitherto

* A curious case is given by Vigarous, which occurred in six young French-
men, who had connection succi'ssivrly with the same woman. The 1st and 4th
in the order of connection had cliancresand buboes, tlie 2d and 3d gonorrhoea, the
5th chancre, and the Glh bubo. Vigarous, (Kuvres de Chirurgie-praclique, Civile
et -Militaire, Montpellier, IK12. Complication du vice Venerien, page 8. I have
had an instance of three individuals similarly circumstanced ; the first escaped,
the '.M lijid true cliancros and elivati-d sores, the 3d had gonorrhoea. The connec-
tions took place within an hmir.

SYPHILIS. 535

resisted; in some of these, it is true, I should never have
thoug-ht of using- mercury ; but far the greater number were of
that description, that not only I myself, but practitioners of
much greater experience, vs^ould not formerly have thought of
deferring it for a single day. I may, to a certain extent, apply
the same observation to the secondary symptoms that have suc-
ceeded the non-mercurial treatment. I have now seen a great
variety of them, but I have not yet studied and compared a
sufficient number of cases, to enable me to offer such positive
testimony to the expediency of abstaining from mercury altoge-
ther in this class, as in the former. The facts at present
ascertained are these: Secondary symptoms occur more fre-
quently, and appear at an earlier and more determinate period
than when mercury had been used; but they in many cases have
gone oflFas soon, never, as has been supposed, proceeding from
bad to worse, or from one succession of parts to another in un-
abated violence; on the contrary, they by no means exhibit the
same violent and unrelenting symptoms which we have observed
in many instances where mercury has been used ; the eruptions
have not run into ulceration ; they have not formed into large
scales, or extensive blotches ; nor have the bones of the nose,
or of other parts, been in any instance affected with caries. 1
cannot take upon me to assert, that these events will not
occasionally take place, but in the numerous cases which I
have watched with the utmost anxiety, I can aver that they
have not.

With regard to the eruptions, there has been in many in-
stances a general reddish mottled efflorescence of the skin,
resembling roseola, or what the soldiers have themselves called
♦* Trout Back." The more determinate eruptions have been
papular, pustular, scaly, or tubercular ; they have been chronic
in their nature, and, as well as the sore throats and inflamma-
tions of the eye, they have all gradually, though sometimes
slowly, disappeared without the use of mercury, and without

536 SYPHILIS.

seeming to Lave left any injurious effects behind them. Erup^
tions, so far as my observations go, are much more common in
those treated without that remedy, than in those I have for-
merly seen treated with it, but in no instance have they ended
in ulcerations, as the latter have frequently done. I have fre-
quently had occasion to observe, that eruptions of the same
nature and character have succeeded to the foul, indurated,
excavated ulcer, and to the simple excoriation ; some of these
eruptions have been more obstinate than others, and have re-
quired a treatment of several weeks, with decoct, sarsaparillae-,
antimonials, the warm bath, &c, before they have disappeared ;
but I have not seen the general health more seriously affected
in the cases under cure without mercury, than it has been when
that remedy has been used. On the contrary, I am inclined to
think that it has suffered less. In the annexed table will be
seen the proportion which the different species of eruptions,
and other secondary symptoms, have borne to each other, as
well as the proportions in which the primary symptoms have
appeared. 1 beg to say, however, that I do not assume this as
the conntant ratio in which these appearances take place.

In fifteen cases of eruptions unaccompanied by any other
symptoms, which succeeded the Hunteriau sore, six were tu-
bercular, five exanthematous, two pustular, one tubercular and
scaly, and one tubercular and vesicular.

In four cases following the same sore, but in which the
eruptions were complicated with sore throat, two were tuber-
cular, one was tubercular and scaly, and one was tubercular
and exanthematous.

In twelve cases following the iVbw-IIunterian sore, and in
which eruptions wore the only symptoms, six were pustular,
three were exanthematous, two were tubercular, and one was
tubercular and scaly.

In seven cases wh'ere the eruption was accompanied with
sore throat, three were exanthematous, two were tubercular,

SYPHILIS. 537

one was papular, scaly and tubercnlar, and one was pustular
and tubercular. An examination of the table will show the
existence of other morbid combinations.

The eruptions, after having disappeared, have, in some
cases, again occurred a second and a third time, and in a dif-
ferent form from the original attack ; cold and excess were
the causes to which this re-occurrence has been principally
traced. In these relapses, the mottled, the papular, and the
pustular, have been the most common forms, and have in
general preceded the scaly and the tubercular eruptions. The
scaly, although in some instances it has been from the first
under the form of Psoriasis, or branny scurf, has been in general
a degeneration of the papular, and occasionally it has appeared
on the apices of the tubercular, or was intermixed with them.
In truth, the eruptions have presented such appearances at
different times, and have undergone such changes, as to bid
defiance to correct classification. In one most obstinate case
treated by Df. Thomson at Queeusberry House, the eruptions
appeared at different times under tlie form of Impetigo, Acne,
Herpes, and Psoriasis in succession, and even some specimens
of each were co-existent at different periods during the course
of the cure, but they all disappeared after a treatment of
twenty weeks, during which the spontaneous efforts of nature
were very little interfered with by medicine. The patient was
of a scrofulous constitution, but he was dismissed from hospital
with his health unimpaired, and far different from the state in
which subjects of that description are usually left after mercu-
rial courses.

In another very instructive case, an Hunterian chancre was
at the distance of ten weeks, succeeded by a papular eruption,
which, in the course of a month, was removed by low diet,
purgatives, and the decoction of sarsaparilla. In two months
after, an eruption of a similar nature appeared, without any
fresh infection. This was treated by mercury continued during

538 SYPHILIS.

five weeks, and pushed to such an extent as to excite moderate
salivation. Under this treatment the eruption faded, having
during its progress assumed the appearance of vesicles and
pustules, and at length falling off in amber-coloured scales \eith
livid bases. Notwithstanding this mercurial course, the pa-
tient was a third time admitted at the distance of ten weeks,
(without any intervening primary affection,) with a pustular
eruption very similar to small pox, but with bases more in-
flamed. This was finally cured without mercury in the course
of six weeks, the pustules falling off in squamulae. In one
month after this attack, and without any fresh infection, he
was a fourth time taken into hospital, with a very thickly dis-
persed pustular eruption, somewhat different in appearance
from the former, being more numerous, smaller, and acumi-
nated. It yielded in twenty-two days to the non-mercurial
treatment. During all these attacks the patient suffered,
though not severely, from aphthous sore throat, and occasional
flying pains in his joints, but his general health was in no de-
gree injured, and he is now in possession of a perfectly sound
constitution, at the distance of nearly six months from the last
attack. I conceive that this case very clearly proves, that even
a full and judiciously conducted mercurial course does not pre-
vent the re-appearance of venereal eruptions, and that they
assume at different times different characters, notwithstanding
the interruption they receive in their natural progress by the
nse of that remedy.

In some of these cases, I have observed considerable advan-
tages result from the employment of the acids internally, and
also from their application externally to the eruptions. The
local aj)plication8 to some few of them have been the ungt- hy-
drargyr. nitrat. the ungt. picis. or a mixture of equal parts of
both, but in no instance has the most remote approach been
made towards affecting the constitution with the mercury con-
tained in these compositions. The local applications to the

svPHiLis. 539

primary sores, which have preceded these eruptions, have been
the black wash of calomel and lime-water, saturnine lotions,
cupreous solutions, and the unguentum resinosura.

I have not had occasion to see a single instance in which the
bones of the nose have been affected ; some cases of periostitis,
and of pains and swellings of the bones of the cranium and the
extremities, have been met with, but except in two, I have not
myself seen any nodes which could be regarded as unequivocally
syphilitic. One of these yielded to blisters and sarsaparilla, as
many of the anomalous tumours had done before ; the other, in
which the guaiacum and sudorifics bad been employed without
effect, but in which the sarsaparilla and blisters had not been
tried, was treated with mercury, and also disappeared ; whether
it would not have been combated without mercury, with equal
success as the first case, I cannot take upon me to assert, and
in an inquiry like the present, I shall offer nothing from
conjecture.

It must be obvious, that, to bring the question of eligibility
to the test of as rigid inquiry as the question of possibility has
already undergone, will be a work of some time, and surely by
every rational man it will be considered as time well spent.
On this point I chiefly have to rely at present upon the trials
made during the half years ending 20th of December, 1818,
and 20th of June, 1819, in Edinburgh Castle, conducted with
the utmost accuracy, and entered upon with the strongest dis-
position to strict impartiality. In extent, they fall far short of
what I could have desired, for the laws of rigid scrutiny re-
quired that not only should all cases of primary sores proceeding
from sexual intercourse be included, whether possessed of the
supposed genuine characteristics or not, as they had in pre-
ceding trials, but that, in order to guard against all sources of
fallacy, no patient who had, on former occasions, been subjected
to the non-mercurial cure, should be treated on the new com-
parative plan, (for primary affections at least,) for great
ambiguity would arise in any secondary symptoms that might

540 SYPHILIS.

occur in individuals where the two modes had been adopted.-
With this exception, the patients were taken indiscriminately as
they came into hospital. But there was another circumstance
which curtailed the number of our comparative trials, viz. the
diminution of our applicants for relief, and this not confined to
Edinburgh alone, but extending over all the quarters occupied
by our troops. Our numbers treated in hospitals during the
half year ending 20th of June, 1818, were 148 primary vene-
real cases, and that ending 20th of December, only 105; of
these only 14 fresh cases appeared in Edinburgh among the
infantry, and 2 among the cavalry ; and only 11 were met with
at Glasgow, a diminution so extraordinary as to give every
reason to suppose that it did not depend on chance. Whether
it may have proceeded from increased cleanliness on the part of
the soldiers and their paramours, or from the actual disappear-
ance or modification of the poisons contracted by sexual inter-
course, I shall not pretend to say ; but no person knowing the
character of British soldiers will suppose that morality had any
thing to do in the business, for they exposed themselves then,
as they always have done, to every disease which can be pro-
duced by unbounded venereal excesses with the most depraved
objects in nature.

Eighteen primary affections were treated in Edinburgh Castle
by the most approved mercurial plan. Of these, three possessed
the reputed syphilitic characters more or less, and filteen were
without them. The three of the first class consisted of one
case of chancre alone, and two of chancre and bubo, both of
which buboes had commenced before admission into hospital.
The cure of these cases was effected as follows ; two of the chan-
cres healed in ten days, and one in twelve; the bubo which did
not suppurate was discussed iu sixteen days, that which suppu-
rated remained open for forty-two days.

We now turn to the fifteen non-syphilitic cases ; ten of them
were ulcers only, and five were ulcers and buboes, four of
which buboes bad appeared before admission into hospital, and

SYPHILIS.

641

one afterwards. The ulcers healed as follows ; two in 4 days,
one in S days, four in 11 days, three in 14 days, one in 28 days,
one in 32 days, one in 36 days, one remained under cure at the
end of the half year, and another, from having been treated
before coming into hospital, is not taken into account, as we
could not be accurate as to the number of the days. Of the
five buboes, three were discussed, one in 4 days, one in 7 days,
and the third in 26 days; and two suppurated, one of these
healed in 32 days, the other remained under care at the end of
the half year. No secondary symptoms have, to the date of
the latest report, appeared in any of these cases.

I shall now give an average table, observing first that the
averages in it are taken from 47 cases on one side of the ques-
tion, and 18 only on the other, or an excess of more than one
and a half of the cases treated without mercury over those
treated with it.

Table showing the average Number of Days required for
the Cure of different kinds of Primary Venereal Affections,
with Mercury, and without it.

Description of Cases treated.

Average
Number of
Days requir-
ed for the
Cure with-
out Mer-
cury.

Average
Number of
Days re-
quired for
the Cure
with Mer-
cury.

Ulcers with the reputed Syphilitic characters ....

Ditto without the reputed Syphilitic characters . .

Buboes ending in resolution, and following Hun-

terian Chancres

24f
15H

28i

28|

lOH

62i

lof

42
33

Buboes ending in resolution, and following Non-
Hunterian Chancres

Buboes ending in suppuration, and following Hun-
terian Chancres

Buboes ending in suppuration, and following Non-
HuDterian Chancres

Thus, then, the balance from these limited and dispropor-
tionate trials appears to be considerably in favour of the mer-

642

SYPHILIS.

carial plan in the primary sores. The ulcers with the reputed
syphilitic characters yielded in less than half the tiaie, while
those without it were very nearly, if not quite on par. The
buboes of a syphilitic nature were resolved in a little more than
half the time, and those of the non-syphilitic in a little less.
The buboes which suppurated, and which bore the syphilitic
characters, healed in much less than half the time; those which
did not possess these characters required considerably more.

The comparative trials did not stop here; four secondary
cases were treated with mercury, and five without it. The
following tables, No. I. and II. exhibit the results ; they were
drawn up by Mr. Johnston, to whom exclusively all the credit
of these trials is due.

No. I.

Table showing the Period of Occurrence and Time required
for the Cure of Secondary Aft'ections with Mercury.

Description

of Primary

Allectiou.

Hnnterian
Chancre.

Non- Hnn-
terian.

Do.

Description of Secondary AtTectiou.

Period of
occurrence
after (he Pri-
mary Sores.

Time re-
quired for
the Cure.

Sore throat, swelling of the Fas- I

cia and Ligaments 1 1 months

Tubcroular,* Scaly, and Papular

Eruption 56 days

Tubercular Eruption, with Sore

Throat 88 days

Papiihir, Scaly, and Tuhf'rr\ilar

Eruption, wUli Soru 'J'luoal, 15 months-
and Afleclions of the Bones . . '

5 months

86 days

' .38 days
remained
uiidrr cure at
the end of
the hut f year.

• The Tuhercula, though denied to exist as a consequence of true syphilitic
ulcers, have been by no means an unfrcquont occurrence with us after sores
posiiesMing much of that character, and what is not a litllc extraordinary, the
■moolh tul)ir(le has existed along with the rough, and the (iorid with the livid,
•t the same lime, in the same subject.

SYPHILIS.

543

No. II.

Table showing the Period of Occurrence and Time required
for the Cure of Secondary Affections without Mercury.

Description
of Primary
Affection.

Hunterian
Chancre.

Do.

Non-Hun-

terian.

Do.
Do.

Description of Secondary Affection.

Eruptions, Scaly, Pustular, Tuber-
cular, and Papular

Affections of the Bones only

Tubercular Eruption, with Sore
Throat

Scaly and Tubercular Eruption, with
Sore Throat

Scaly and Tubercular Eniption, with
Sore Throat

Period of
occurrence
after Pri-
mary Sores.

3 months'
12 months

1 10 days

8 months

10 months

Time re-
quired for
the Cure.

26 days.
24 days.

34 days.
74 days.

35 days.

I may observe, that in one of these cases treated by mer-
cury, that mode of cure was followed, because, before the man
came into the head quarters hospital, he had been treated with
mercury. In a second it was used, because the disease was of
great obstinacy, and did not yield to the non-mercurial treat-
ment. In the two others it was tried to accelerate the removal
of symptoms which had of themselves begun to yield.

I count little or nothing on these trials, and shall draw no
parallel from them ; but I deemed it but fair to mention them,
since they were treated with mercury, though not altogether as
could have been wished. The great difficulty in these particu-
lar cases is, to find secondary symptoms for comparative trials
alike in all, or nearly all respects. From causes beyond
Mr. Johnston's coutroul, salivation occurred in three, and mer-
curial eczema in two instances. In one instance I had occasion
to remark, for the first time since my arrival in Scotland, the
livid retorted edge of bubo, — a very well known acquaintance
under the violent mercurial practice ; and in another, the mer-
curial ulceration of the throat, with general erethysm, doubtless
from some peculiarity of constitution.

544

SYPHILIS.

The next comparative trials were made during' the half year
between December, 1818, and June, 1819. Thirty-four patients
were subjected to them, 16 of whom were cured with mercury,
and 18 without it.

The following table will show these results at one view.

Average Table of Comparative Results with and without

Mercury.

Description of Cases treated.

Hunterian Ulcers

Non-IIunterian Ulcers

Buboes discussed following Hunterian Ulcers. .. .

Buboes discussed following Non-Hunterian Ul-
cers

Buboes suppurated following Hunterian Ulcers. ,

Buboes suppurated following Non-Hunterian Ul-
cers

Number of
Days with
Mercury.

18§

761

Number of

Days

without

Mercury.

22|
27

Among the patients treated with mercury, constitutional
symptoms appeared in one, in the form of tubercular eruption
and periostitis, with great debility. In those treated without
mercury, secondary symptoms appeared in two instances ; one
of these presented scaly, brown blotches, scarcely elevated ;
the other, general erythema, and a pustular eruption; but as it
appeared three days only after the appearance of chancre, and
that the patient had had syphilis in 1818, which was cured by
mercury, the connection of these symptoms with his present
disease is very doubtful.

TIm' results of this half-year's coni()aralive trials, when con-
trasted with those of the preceding one, are peculiarly striking,
for they are altogetla^r as decidedly in favour of the non-
mercurial plan, as the others were the reverse. A prudent and
unprejudiced practitioner, knowing that mercury will agree
with one set of patients, and disagree with another, though
their symptoms may be alike, and even contracted from the
same source, will not draw hasty conclusions from either, but

SYPHILIS. 545

wili wait patiently, until, in the progress of events, the respec-
tive merits of those pUins become more fully developed. In-
deed, the numbers subjected to comparison are too limited to
deduce from them any positive or fixed corollaries.

Since the date of the last trials by Mr. Johnston, mentioned
above, I find by a report from him, transmitted to me from the
station to which he moved from Edinburgh Castle, that, in one
of his cases treated with mercury, for a constitutional affection,
consisting of periostitis and eruption, which was tubercular on
the shoulders, and on the face resembled " rupia prominens,"
he apprehended that mercury would not prove effectual, and
that it might be necessary to leave it off to complete a cure ;
indeed, it was persisted in but a short time, as, during its
continuance, all the symptoms of the constitutional disease had
gone on from bad to worse ; the primary symptoms had not
been removed, and the general health of the patient had been
materially injured by the mercurial treatment, although con-
ducted in a cautious and moderate manner: soon after the
mercury was left off, a sensible improvement took place in the
general health of the patient, and all the symptoms of his
disease gradually disappeared. His convalescence, however,
was slow, and he was not discharged till three months after-
wards.

Another of these patients, treated with mercury, had under-
gone that treatment when on detachment at Aberdeen, and had
left that station to join the head quarters of the regiment, at
Hull, before the disease was completely cured. On his arrival
at the latter place, he was taken into hospital with a sore on the
penis, much irritated and extended by the march, and his
general health much injured by the mercury which he had used
for its cure ; the treatment with mercury was therefore not re-
sumed, but the cure of the sore was effected by such means as
would have been used for the cure of a simple inflamed ulcer.
This individual has since suffered attacks of pulmonic inflamma-
tion and rheumatism ; and there can be little doubt that in hira
the predisposition to inflammatory disease has been the conse-

546 ' SYPHILIS.

qaence of his use of mercury. A third patient treated with
mercury, had, during his treatment for the primary symptoms,
a pustular eruption over the shoulders, which was first accom-
panied by a slight febrile movement, but as yet, no other con-
stitutional symptoms have appeared.

Mr. Johnston concludes his half yearly report with the fol-
lowing observations : " From the foregoing account of the
syphilitic diseases which I have treated for the last half-year,
it appears, that of three cases in which mercury had been
used, secondary svmptoms have occurred in two while the
primarv were under treatment, in one of which it became ne-
cessary to abandon the use of mercury before a cure could be
effected, and that in this patient, as also in the third, the intro-
duction of that substance had occasioned consequences highly
pernicious to the general health ; on the other hand, it appears,
that of the twenty primary cases treated without mercury, con-
stitutional symptoms have appeared in three during their cure,
in two of which this affection consisted solely of an eruption
so unimportant, that it probably would have escaped the notice
of the patients themselves, unless it had been pointed out to
them; tliat in the third case, it seemed extremely doubtful
whether the constitutional symptoms had had a venereal origin,
or were only to be considered as a distinct cutaneous disease,
accidentally occurring while the patient laboured under pri-
mary syphilis. It also appears that only one case with se-
condary symptoms has occurred, as the consequence of some
former primary affection treated without mercury ; and which
secondary symptoms appear at present to be going on towards
a cure without the u^e of that substance."

I shall now give the Analytical Tables drawn from the prac-
tice of the Regimental Surgeons, in thos^^ corps of the army
which were quartered in Scotland, tluring a considerable por-
tion of the time that I held the superintendence of that part of
the united kingdom. I'or two half-yearly periods, I was not
abU' to construct the return as accurately as I could have wished,
I therefore forwarded the reports of individual corps direct to
the Board, and the results appear in the circular letter annexed.

SYPHILIS.

547

Analytical Return of Venereal Diseases treated withcmt
Mercury, in the Military Hospitals of Scotland, under the
Superintendence of John Hf.nnen, M.D. Deputy-Inspec-
tor, from June 20tli, 1817, to December 20th, 1819.

PRIMARY AFFECTIONS.

1. Description of Cases that have been Treated.

' a. Ulcers only

109

A. AfFeetions
possessing the J
true Hunte-
rian character.

b. Buboes
succeeding <(
to ulcers.

48
10

a. Before admission into
hospital

S. After admission into
hospital

y. Of which were dis-
cussed

5. Of which suppurated 1.3

e. Under cure at the date r .
of last return S -^

I-

y 68

167

B. Affections
of various
kinds not pos-
sessing the
true Hunte-
rian character.

a. Ulcers only

154

b. Buboes
succeeding
to ulcers.

a. Before admission into

hospital
$. After admission iuto
<^ hospital

y. Of which were dis-
cussed
^ S. Of which suppurated

L c. Buboes without previous ulcer.

73^1
12

^84

31 j

Total number of primary affections treated

240

407

2. Time required for the Cure.

A. OF ULCERS.

Hunterian.

Non-Huuterian.

The following
number of cases
were cured.

In the following

number of days.

The following
number of cases
were cured.

In the following
number of days.

From 5 to 10

From 3 to 10

11 20

21 30

31 40

41 50

51 60

71 80

61 70

91 98

71 80

4 under cure at

81 90

the date of

last return.

109

113

18 under cure at

date of last return.

2n2

548

SYPHILIS.

B. OF BUBOES ENDING IN RESOLUTION.

Buboes following Hunterian Ulcers.

Following Non-Hunterian Ulcers.

The following
number of cases
were cured.

In the following
number of days.

The following
number of cases
were cured.

In the following
number of days.

8
15

2 under
cure at the date
of last return.

From 5 to 10
11 20
21 30
31 40
41 60

4'under
cure at the date
of last return.

From 2 to 10
11 20
21 30
31 40
41 60

C. OF BUBOES ENDING IN SUPPURATION.

Buboes following Hunterian Ulcers.

Following Non-Hunterian Ulcers.

The following
number of cases
were cured.

4 under
cure at the date
of last return.

In the following
number of days.

From 30 to 40

41
51
61

77
92

60
60
70

The following
number of cases
were cured.

1
2
6
3
4
3
1
3
2
2

4 under
cure at the date
of last return.

In the following
number of days.

From 7 to 10

100

101

110

111

113

179

Note. — In the Table A. of Ulcers, the period of cure of some of these
affections is not specified, as it was not fully ascertained from some corps ; but
in no case did it extend beyond the average period of the cases which are
Bpecilied in the table.

SYPHILIS.

549

SECONDARY AFFECTIONS.

I. Description of Cases treated.

a. Eruptions
only

!/3-

Tubercular

Esantheinatous

Pustular

Tubercular and Scaly ...
Tubercular and Vesicular

A. Succeed-
ing the Hun-
terian ulcer.

b. Er

comh
with s
throat

■ pti > t a. Tubercul

ned 1 (i. Tiibercr

ore \ y. Tubt-rcu

( tous ..

Tubercular

lar and Sca'v

lar and Exanthi-ma-

Tubercular Eruption combined with Iritis

Tubercular and Papular Eruption, couibined )

with Iritis, Periostitis, and Sore Throat f

Tubercular and Exanthematous Eruption com- \

bined with Periostitis S

Sore Throat only

Exostosis only

a. Eruptions
only

B. Succeed-
ing Ulcers <J 6. Er'ptions
not Hunte-
rian.

combined
with sore
tliroat

Pustular fi \

Exanlheniatous 3 /

TubercMilar •' {

TuherciilTr ^ l S '■

F.xin'he.iatr u^ \

Tnherciilar 'i /

Papi:'ar, Sealv, and Tulercular 1 /

Pustular aa' Tubercular 1 j

j:. Sore throat only 3

Total number of Secondary Affections treated

550

SYPHILIS.

II. Period of Occurrence, and Time required for the Cttre^

II.

^ w a

a a S
•2-2 1

u
u

Description of Secondary Affection.

•o

Tubercular Eruption

Exantlienuitoiis Eruption

Pustular Eruption

Tubercular and Scaly Eruption

Tubercular and Vesicular Erup-
tion

Tubercular Eruption with Sore
Throat

Tubercular and Scaly Eruption
with Sore Throat

Tubercular and Exanthematous
Eruption with Sore Throat. .

Tubercular Eruption combined
with Iritis

Tubercular and Papular Erup-
tion combined with Iritis, Pe-
riostitis, and Soi;e Throat . .

Tubercular and Exanthematous
Eruption combined with Pe-
riostitis

Sore Throat only

Exostosis only

C 5 Pustular Eruption

Jl Pustular Eruption

(2 Exanthematous Eruption
J 1 Exanthematous Eruption

Tubercular Eruption

Tubercular and Scaly Eruption

/" 1 Exanthematous Eruption

1 with Sore Throat

< 1 Exanthematous Erujjtion

with Sore Throat

Exunthemutous Eruption

with Sore Ttiroiit

Tubercular Eruption with Sore

Throat

Papular, Scaly, and Tubercular

Eruption with Sore Throat *

Pustiiliir, ami Tubercular ICrup-

tion with Sore 'I'iiruat

Sore Throat only

Period of occurrence af-
ter Primarj' Affection.

From 7 ds to 6 ms

i 28 ds to 6 ms

21 ds to 38 ds

40 ds

22 weeks
46 to 75 ds
5 weeks

2 ms

14 weeks

45 ds

5 ms
5 weeks
74 ds

From 49 to 820 ds

5 ms
90 to 240 ds

29Sds
23 to 122 ds

19 ms

Simultaneous with
the Ulceration

4 weeks

59 ds

76 to 91 ds

20 ms

08 ds
60 to 77 d»

Time required for the
Cure.

From 10 to 60 ds

3 to 42 ds

18 to 43 ds

25 ds

27 ds
31 to 240 ds
66 ds
60 ds
45 ds

84 ds

29 ds
33 ds
14 ms

From 19 to 58 ds

Under cure
date of last return
From 28 to 120 ds

Under cure
date of last return
From 26 to 35 ds

Under cure
date of last return

29 ds

42 ds
Under cure
date of last return

From 14 to 81 ds

^ Under cure at
^ the date of last
J return

From 43 to 63 ds

Primary Affections cured by Mercury at a former period.

SYPHILIS. 551

One half at least of tlie primary symptoms in the foregoing
return were daily under my notice; and I saw in my different
tours of inspection at least one half of the remainder. Every
secondary case I particularly examined, and of these three-
fourths were constantly under my inspection ; I trust, therefore,
that I may be acquitted by every candid reader of having taken
up my opinions on insuflBcient grounds ; few men could have
been more fortunate in their opportunities, and I assuredly am
not conscious of having either abused or perverted them.*

The results above stated have been drawn from a very limited
number of patients compared to those on whose cases the in-
teresting remarks contained in the following circular letter,
addressed to the surgeons of the army, are founded.

(Copy) Army 31edical Department,

2d April, 1819.

Circular.

ON SYPHILIS.

In transmitting the following summary of the conclusions on
the question of syphilis and its treatment, we have to assure all
that it may be considered as an unprejudiced statement drawn
up from the answers alone of the regimental surgeons, to the
queries transmitted by us to them in December last.

Without Mercury.

1st, That since December 1816 to December 1818, there
appears to have been treated for primary venereal ulcerations
on the penis (including not only the more simple sores, but also
a regular proportion of those with the most marked characters
of syphilitic chancre, as described by Hunter and other writers)
1940 cases.

• AU my cases are, of course, included in the General Return of the Army at
large.

552 SYPHILIS.

2d, That of these 1940 cases so treated, 96 have had secon-
dary symptoms of different sorts.

Sd, That in these 96 cases of secondary symptoms following-
sores treated without mercury, it was deemed necessary to have
recourse to mercury for a cure for twelve of them, for which
change the following different reasons are assigned in different
cases by the surgeons who treated them.

a. On account of sloughing ulcers in the throat.

b. The protraction of cure beyond the third week.

c. Because the general health seemed to suffer.

d. With a view of expediting the cure.

e. The re-appearance of eruptions, or aggravation of symp-
toms.

Note. — In several of these 12 cases, alterative doses of mer-
cury were sufficient to eflFect the cure.

^Ih, That in 1940 eases of primary symptoms treated with-
out mercury, (as described in par. 1st,) its use was resorted to
in 65 of them ; the reason assigned being as follows :

a. An indisposition to yield to the local application in three
weeks.

b. The sore spreading.

c. The appearance of fresh sores.

d. Buboes suppurating, and not disposed to heal.

e. The general health appearing to suffer.

/. A belief that the constitution became affected from the
continuance of the sores.

5th, That these 1940 cases, treated as here above stated, are
now " recovered of tlieir venereal complaints," and either doing
their duty as soldiers, or have been discharged for military rea-
sons totally unconnected with venereal disease.

6th, That the principal remedies employed have been (speak-
ing in general terms, and with reference to primary sores) con-
finement to bed in many cases, in all to hospital, spoon diet,
occasionally general bleeding when inllammation ran high, (in
six or eight cases,) purgatives, aniimonial.s, |)retty generally

SYPHILIS.

553

emollient soothing applications in the first instance, generally
cold or warm water, :^the latter frequently injected between the
prepuce and glans,) and the first externally applied, the water
frequently mixed with the liquor plumbi ; in the latter stages,
the lotio hyd. submuriat., or muriat. in aqua calcis, lotio sulphat.
cupri, argent., nitrat., &c. were employed. With reference to
secondary symptoms, when mercury was not had recourse to,
purgatives, antimonials, nitric acid, sarsaparilla, guaiacum in
substance, or in combination with sarsaparilla, warm bath, nitro-
muriatic acid bath, gargles when the throat is affected. In
nodes, fomentations, scarifications, leeches, and blisters.

1th, That the average period required for the cure of primary
symptoms without mercury, when bubo did not exist, has been
21 days; with bubo 45 days.

8M, That the average period for the cure of secondary symp-
toms without mercury has been from 28 to 45 days.

9th., That every man treated without mercury has been fit for
immediate military duty on dismissal from hospital.

With Mercury.

\st. That during the period specified before, there appears
to have been treated of venereal ulcerations of the penis (the
characters given of which do not appear to have been, in any
essential degree, different from those treated without mercury)
2827.

Note. — " It may be perhaps well to view these as more ge-
nerally bearing the character of Hunter's chancre."

2d, That of the 2827 thus treated and healed, 51 have had
secondary symptoms.

'Sd, That there are good grounds for believing, that, in the
majority of instances, when secondary symptoms have occurred,
where the primary symptoms have been treated with mercury,
that the secondary symptoms are more severe, and more in-
tractable than when mercury had not been used for the primary
sores.

554 SYPHILIS.

4th, That one man treated by mercury for primary sores has
been discharged the service on accoant of the injury his con-
stitution sustained therefrom.

bth, That another man, after treatment for secondary symp-
toms by mercury, has been discharged the service in consequence
of that complaint.

6th, That the average period occupied for the cure of pri-
mary symptoms without bubo, with mercury, has been 33 days,
with bubo 50 days, and that the great majority were fit for im-
mediate military duty on dismissal from hospital.

7th, That the average period occupied in the cure of secon-
dary symptoms has been 45 days.

Note. — " The treatment by mercury is so generally known
that it is deemed useless to describe it in either case." Much
the same local applications were used in the treatment with
mercury to the sores, as was described in that witliout it;
perhaps more stimulating and escharotic applications were
used, and less attention paid to regimen and diet, when mer-
cury was given, at least less stress seems to have been laid on
these.

General Ohservalions.

1st, From the statement above made, it would appear that
all kinds of sores, or primary symptoms of syphilis, may be cured
(as far as a period of nearly two- years will warrant the conclu-
sion) without mercury.

It is considered that the exceptions noted in paragraph 4th
do not present valid objections to the above conclusion on view-
ing the general testimonies on this point; but to the reasons
there assigned for the necessity of having recourse to mercury
the most particular attention is ro(|uired, as on these must the
propriety or impropriety of that measure depend.

"^d, To guard against any fallacy in the comparative estimate
of time employed in the cure of primary symptoms with and

SYPHILIS. 555

without bubo, it must be noticed that this is only an average
statement; in some individual regiments the period required
without mercury has been longer than that with mercury.

3d, That it appears that the frequency or rarity of secondary
symptoms would seem to depend on circumstances not yet
sufficiently understood or explained, although the. following
fact would tend to the belief that either the constitutions of the
men, or the mode of conducting the treatment without mer-
cury, are the causes that possess the greatest influence in their
production.

In one regiment 4 secondary cases out of 24 treated without
mercury supervened. In another regiment 68 cases have been
treated within the specified time without mercury, all bearing
marks of true venereal disease, (and 28 of these especially se-
lected for their decided characters of chancre ;) no secondary
symptoms of any kind have hitherto made their appearance, and
in all fifteen months have elapsed since they were treated.

To this circumstance most particular attention is required,
both with the view of ascertaining if peculiarity of constitution
influences the appearance of secondary symptoms, and of point-
ing out the necessity of attending to the proper selection of
local remedies adapted to the different stages and states of the
sore, and to the general treatment of the constitution during
the time the patients are in hospital, and that whether mercury
be used or not.

4:th, That it appears that no peculiar secondary symptoms are
seen to follow from peculiar primary sores.

6th, It has been remarked, that in cases Lealed without mer-
cury, iritis has been frequently observed as a secondary symp-
tom, in some instances by itself, in others attended with eruptions
of different kinds. In these instances, mercury has been gene-
rally resorted to with success.

6fh, The reappearance of the primary ulcer, and repeated
attacks of eruption, are the diseases which have been most fre-
quently observed to succeed the non-mercurial practice.

556 SYPHILIS.

1th, The conclusions arrived at by the additional testimony
of many more regiments, not included in the number from
whence this report has been drawn up, confirm in every ma-
terial circumstance the results staled under both methods of
treatment.

From all that has been reported to us, we see no reason to
stop the prosecution of the present inquiry, nor have we any
objection to its being continued, but strictly in that spirit of
patience, liberality, candour, and fidelity, that ought to charac-
terize the inquiries after truth, — a spirit altogether remote from
the precipitancy of innovation, the acrimony of disputants, or
the stickler for any particular doctrine.

\st, It is therefore desired, that the queries heretofore sub-
mitted, with these additional points left undecided in this letter,
may be considered as the leading objects for consideration in
the future prosecution of the subject.

2c?, That every syphilitic case, whether secondary or primary,
be duly entered in the register, with full description of the cha-
racters of the sores, symptoms, and treatment, so that the results
of each half year may be distinctly and clearly stated in the
reports required on these occasions ; — that every man belonging
to any regiment, treated in a different regimental hospital to his
own, shall invariably be reported through this office to his own
regimental surgeon, who will duly register the report, and at
the half yearly periods state the results.

That it is essentially necessary that each regimental surgeon
keep a watchful eye over all men treated without mercury, and
frequently examine them, and that whenever answers are re-
quired to these (jueries at a future period, which they will, (say
1st January, 1820,) the state of the men now reported shall at
that lime bo distinctly referred to, in the same tabular form as
was rejjuired by the late queries, commencing as before from
2()lh December 181G.

We wish it to be distinctly understood, that we do not en-
force the non-mercurial plan of treatment in any case, still

SYPHILIS. 557

farther is it our wish to incur any unnecessary risk or danger
to the soldiers, by unnecessary detention from duty, from a pro-
tracted treatment without mercury, in those cases where it has
been begun. At all times, this is left to the discretion of the
surgeon, who, we are persuaded, will act in the most conscien-
tious manner for the good of his patient, and the interests of the
service.

(Signed) " J. M'Grigor,

" W. Franklin."

A fresh objection has recently been started to the non-mer-
tjurial practice in Syphilis, by Dr. Hamilton, junior. Professor
of Midwifery in the University of Edinburgh, in his work on
the " Uses and Abuses of Mercurial Medicines." He conceives
that very alarming consequences are likely to arise to children
yet unborn from the practice of the army surgeons. But while
I most willingly acknowledge the high character, acuteness, and
zeal of my former teacher, I cannot admit the validity of the
arguments he adduces to prove the truth of his opinion, which
appears to me to be chiefly founded on the assumption that a
point of pathology is perfectly settled, which still remains not
only dubious in all its relations, but which is actually denied by
very high authorities.

It must be recollected that there are various opinions on the
subject of the venereal disease of the foetus in utero ; they are
as follows: 1st, It is contended that the mother, not the father,
communicates the disease to the foetus. 2d, That it is the
father, not the mother. 3d, That the child can be diseased by
both parties. And 4th, Mr. John Hunter denies the possibility
of the foetus in utero being affected by either.*

* Mr. Hunter's commentator, Dr. Adams, asserts that Mr. H. was of a differ-
ent opinion. I own my inability to understand many parts of his writings ; but
I follow what appears to me to be Mr. H's. meaning deducible from his opinion ;

558 SYPHILIS.

I am well aware of the diflSculty of forming a judgment in
these points, and of the great delicacy necessary to be observed
in investigating them, but it becomes an important duty for every
professional man to throw out what light he can upon the sub-
ject; and under this impression I shall first state my speculative
opinions, and then I shall detail such facts as I have been able
to collect. Unless a man has primary symptoms himself, I ap-
prehend it is physically impossible for him to communicate
primary symptoms to a female. Unless a female has primary
symptoms, I hold it equally impossible for her to have secon-
dary symptoms; and except she has secondary symptoms, she,
I apprehend, cannot communicate them to the children in her
womb ; she may, indeed, as we all know, communicate primary
sores to the foetus in its passage through her vagina. With
regard to the facts to be met with in authors, many instances
are on record, and within our daily view, where women having
secondary symptoms bring forth healthy children; and many,
where fathers, who have long had secondary symptoms, beget a
perfectly sound offspring. That children are born with a dis-
ease, supposed to be syphilis, and that this disease is not only
fatal to them, but can be communicated by them to their nurses,
and be propagated by the nurse to the destruction of more
lives, is a fact that no man can pretend to deny. The nurse,
however, n^ust have a primary sore on her nipple or elsewhere,
before she can disease the child. I know it to be a positive
fjict, that a nurse with secondary symptoms may suckle children
with perfect impunity to them. Many instances have occurred
where children have been diseased without the most remote
proof that the father has ever been poxed. Many others where
there is ecjually strong reason to suppose that the mother has
never been poxed; and nniny where there is every reason to

that the matter of secondary sores is incapal)lo of producing tlie disease ; and
this view is, I believe, generally adopted. Sec Adams's Hunter, 8vo. edit. IBIU,
p. 4a7.

SYPHILIS. 559

suppose that neither party have had the disease. To these po-
sitions, which are applicable to the individuals of both sexes,
has been added another, which is common to each, viz. that the
wounds and fractures of persons infected with syphilis, unless
when inflicted on diseased parts or their neighbourhood, heal as
readily as those of uninfected persons, — a fact first insisted
upon by Petit, which shows how little the powers which
regenerate or model the human frame are affected by the syphi-
litic virus. Instances have occurred where a sound mother has
brought forth a diseased child, and without taking any medicines
of a mercurial kind, has afterwards brought forth a sound child.
A case has been stated to me, where five children were thus
chequered, while the mother, sound to all appearance, had never
taken one grain of mercury ; and to my own knowledge, a lady
has brought forth three children at successive births, the 1st
and 3d diseased, the 2d sound, without having taken any medi-
cine but the decoction of the woods : the husbands in both cases
men of irreproachable lives, and the women of acknowledged
virtue. Whether there are any cases on record, where of two
children born at the same time, one has been diseased and the
other sound, 1 have not yet been able to ascertain.

It is doubtless very difficult to say why the foetus should not
be liable to syphilitic infection from its parents, seeing that other
diseases are equally transmitted by both parties ; Rut I think
the facts above stated render it extremely doubtiul from which
of the parties the disease is transmitted, or, indeed, whether it
is transmitted by either; at all events, we have proofs that sound
children have been produced from diseased parents, and that
diseased children have been produced from sound parents. The
ablest men have distrusted their judgment on these points, and
surely, at an era like the present, when we have been obliged to
give up many articles of our syphilitic creed which had been
admitted by general consent, we cannot be accused of obstinate
scepticism when we hesitate at allowing as certain, a point which
has been debated for more than three centuries.

560 SYPHILIS.

I have already said, that children are born infected with a
disease capable of infecting- others, — but is this disease really
and truly syphilitic? To suppose that its syphilitic nature is
proved by its yielding to mercury, is throwing us back into the
abyss of error from which we have but recently escaped, and
establishing that retrospective diagnosis which has already
given rise to so much confusion. It is quite unnecessary among
modern pathologists to assert, that because a disease has yielded
to mercury, it is not necessarily syphilis. Neither are habitual
abortions to be charged upon syphilis, because the habit may
at a subsequent period be broken by a course of mercury.

Wherever the impregnation of the female, whether human or
brute, has been the subject of speculative inquiry, the inquirers
have indulged themselves in whims the most extravagantly ca-
pricious, and many of their experiments, if not the follies, may
be looked upon as at least the toys of the learned. I have there-
fore thought it more satisfactory not to enter into theoretical
speculations, but to elicit all the facts that I could. The pre-
sumption certainly was not in favour of the deadly effects on the
rising generation which Dr. Hamilton has assumed, for in that
case, the population of Italy formerly, and that of Portugal at
the present day, must have been most seriously diminished;
indeed, the inhabitants of the latter country, especially about
Lisbon anS other great towns, should by this time, have been
almost extinct. From a wish to collect every fact, I circulated
a set of queries in Scotland and in the northern district of
England, the results of which are given in the following table.
This table is less complete than it will hereafter be made, when
more evidence is collected, and when a longer period has elapsed
from the dismissal of the patients from hospital treatment.
Measures, however, have been taken wliich, in their opera-
tion, will subject to the most rigid incjuiry this and every point,
either directly or remotely connected with the syphilitic (jues-
tion, and which it is to be expected will leave us one disease
at least, where facts and not opinions will be the basis upon
which our practice is to be founded.

SYPHILIS.

r^Gl

Return showing- the Number of Children born of Parents
who have undergone the Non-Mercurial Cure for S\philis,
with the results, as far as can be ascertained.

Edinhurgh, December, 1819.

IS .
Il

REGIMENTS. | =

= i

:§

No. Bo

unliea

thy, wi

;^ tlieresn

■ i
th'

It.

e
c

S'o. who have
become un-
healthy since
Birth.

■5

c
S3

13 '

V ;
£

JZ 1

1
a

a .
,

REMARKS.

•ith Drao'. Guards ...

None maiTied.
No Births.
None married.
None married.
None married.
r Four Men only have
) married, none of
\ whom have Chil-
V. dren.

/Two Men only mar-
J ried, — as yet with-
( out offspriDg.
r These Children are re-
\ spectively 3, S, and
"S H months old and
/ all healthy.

This Child " is now 5
\ months 'old, and in
1 every respect heal-
C thy."

^ These cases will be
^ explained hereafter
This Child's disease
\ was obstinate Por-
■^ rigo, a disease alto-
1 get her unconnected
^ with Syphilis.
No Births.

i No distinct accounts
\ received.
S No distinct accounts
} can be collected.
No Birth.

6th Do ...

, .',

Till Hussars ...

, ,

lOth Do

(

loth Do.

13th Foot

31st Do. . . .

40th To. 3 .

80th Do. 1 .
S8th Do. 8

Detachment of Do. 1 .
1st Batt. Rifle Briff. . . .

. 3 ..
. 1 ..

2 6..

. 1 ..

• •

■ •

• •

4
m.

7th Veteran Batt. . . .

. 1

Pflinliiircrh F)pnot

j 1

Totals, 13

2 11 Ml

1
1

—

'^ o

562 SYPHILIS.

From this table it appears, that of 13 children born of pa-
rents treated without mercury, 11 have been born alive, and
healthy, and two have been still-born ; none of the 11 children
have since died, nor manifested any suspicious symptoms of ill
health, although some of them are now in their third year.
Indeed, I question whether the balance of survivorship (as-
sumed on the principles of Halley, De Moivre, or Price) is not
in favour of the children born of parents treated without mer-
cury; but this is a point which must be ascertained from a much
greater number of individuals than my table at present com-
prehends. I shall therefore leave speculation for which I have
not sufficient data, and proceed to explain the cases of the two
still-born children, and of the child who was taken ill four
months afterbirth.

Although I was well aware that infected women often pro-
duce sound children, I was extremely anxious to ascertain the
point in the person of a woman of the 88th regiment, noticed
in the above return, who excited great attention in the hospital
of Edinburgh Castle. I watcbed her with great anxiety, but
before her full period of utero-gestation, she moved to Hull
with her liusband and the regiment. I therefore wrote to Mr.
Johnston, Surgeon of the corps, respecting her, and I re-
ceived from that gentleman the letter which follows, in which
an account is not only given of the woman I inquired after,
but also of another, of whose case I was not aware when I
wrote:—*' Of Mrs. F. who was treated without mercury for
secondary venereal symptoms, while in a state of pregnancy
in the latter end of 1818, and the beginning of 1819, I beg
leave to state the following particulars: — At the time of the
appearance of these secondary symptoms, she was three months
pregnant ; and, according to her account, for about a fortnight
previous to their appe-arance, slu; had been afl'etted with exco-
riations of the labia, discbarge Irom the vagina, and a bubo in
the right groin ; these local symptoms had disappeared at the
time she was taken under treatment. Her husband was never

SYPHILIS. 563

known to me to have a venereal complaint, no appearance
of disease having ever been detected upon him at my health in-
spections ; hut she says she had reason to believe he had the
disease some time before her own illness, from his having had
commerce with a woman of the town, and from her having ob-
served an eruption of blotches on his legs. Her treatment
was continued three months and a half, when the eruption dis-
appeared, leaving sliglit depressions in the cuticle, somewhat
discoloured ; the fauces continued slightly inflamed for a con-
.^iderable time after her discharge from hospital ; she is at
present in perfect health. She had a still-born child about six
weeks after her discharge, and at the Sth month of her preg-
nancy ; she had not felt the movement of the foetus for about
two months before the birth, and thinks she must have carried
it a long time dead. I was not informed of her delivery, and
did not see the child; but she informs me that the cuticle was
stript from the thighs, hands, and fore-arms, that there was no
appearance of eruption, or any other mark of disease, discover-
able on any part of the child.

" Another woman of the regiment was treated during the
same time without mercury for ulcers on the labia and sore
throat; this last she ascribed to cold, and it was not accompa-
nied by any other secondary symptom, which leaves some
doubt of its nature; but its obstinate continuance gives reason
to suspect that it was venereal. She was also pregnant about
five months at the commencement of her treatment. She was
under treatment six weeks, and at the end of the seventh month
of the pregnancy was delivered of a dead child. As in the
former instance, 1 was not informed of her delivery, and did
not see the child, but she describes the appearances as being
similar to those of the preceding woman's child, only that the
abrasion of the cuticle took place to a greater extent, and was
upon the arms and sides, and a livid coloured bulla was ob-
served on the back of one hand. No other marks of disease
was observed. Her husband was treated in hospital for an

2o2

564 SYPHILIS.

ulcer on the penis without mercury, in February 1818. In no
other instance among the children born at head-quarters of the
resriment since their fathers have been treated for venereal
complaints without mercury, have any symptoms been observed
bearing the least analogy to syphilis.

" As in most of the instances of venereal complaints among
the soldiers the subjects are either unmarried, or have only
married recently, but a small number of them have had chil-
dren born to them since their treatment. Among the com-
panies that are at present at head-quarters, there have been
only eight children born to fathers of this description. One of
these, the child of the latter woman, was still-born, as already
stated, and another child died a few weeks after birth of small
pox. The other six children are all healthy and thriving, and
free from any appearance that can excite the slightest sus-
picion of venereal taint. I ought to have stated, in its proper
place, that the first mentioned woman had, on two former occa-
sions, brought forth still-born children ; she has also had four
born alive. The latter woman conceives she also must have
carried the foetus a long time dead, from not having been sen-
sible of its movements for a month before delivery."

Of the eruption in the child belonging to the detachment of
the 8Sth regiment, there is not the most remote reason for sup-
posing that it proceeded from a syphilitic taint. With regard
to the two still-l)orn children, it must be admitted that there
was room for suspicioti , but it would be in vain to enter into an
investigation, as they were never subjected to the examination
of a medical man, and the appearances on their bodies, are
merely described from the reports of tluir m(»thers, who, in the
class of persons tu which these women behniged, are always
prone to exaggeration, and delighted with the marvellous. It
is to be observed, that the reputed sym[)toms of lues in chil-
dren do not appear, in general, until sometime after birth; and
many eminent men, Mr. Pearson, I believe, among them, have
never met with an instance where the child has been born with

SYPHILIS. 565

the disease. It is farther to be recollected, that, long previous
to the non-mercurial trial in one of these women, she had
produced still-born children.

The same spirit of candid investigation which has directed
the Army Surgeons in the preceding steps of their inquiry,
will, I have no doubt, influence them in future; and the objec-
tions of the ingenious Professor of Midwifery iu Rdinburgh
will meet with that patient examination which their importance
deserves, and which his rank and character justifies. In the
mean time, I may be allowed to review, iu a cursory manner,
some of the leading circumstances said to characterize the
syphilis of infants, ist, Ophthalmia. This is said to be the
leading symptom ; but it may occur, and assuredly does so in
the majority of cases, from causes altogether unconnected with
syphilis. The acrid discharges of the mother, more especially
when she labours under gonorrhoea or tluor albus, most fre-
quently occasion this disease by their local effect on the eyes of
the infant during its passage through the vagina. 2d, Pustules
running into vlceraiion. Not to mention that the various
eruptions which affect the tender cutaneous texture of infants
arise from numerous causes, altogether unconnected with con-
stitutional disease, we should not forget that there is the
strongest reason for supposing, that, in pure unmixed syphilis,
eruptions rarely, if ever, run into ulceration, except where
mercury has been pushed very far. Ulcerated pustules, there-
fore, are to be looked upon more as a proof of the employment
of mercury, than of the existence of syphilis. 3f/, Discoloration
of the skin ; stridulous voice ; and the appearance of old age.
To enlarge upon all the cutaneous doefadations and congenital
spots of infants, is a task on which I do not conceive myself
qualified to enter, but it would not be difficult to prove that
they all occur without any just cause for attributing them to
syphilitic infection. Indeed, we know that the very symptoms
above enumerated are ihe most prumment marks of maiconfor-
mation of the heart and great vessels, by which so many deaths

5G6 SYPHILIS.

are occasioned in infants. The dissection, therefore, of the
" petit vieillard," will become an object of importance in sach
cases as may hereafter occur, and we may perhaps be enabled
to refer to an anomaly in nature, which has hitherto been con-
sidered as attributable solely to an error of the parent. Ath,
ApJithce. From how many sources aphthous affections may
arise is known to every practitioner, and it is equally well
known that they are produced from causes where there does not
exist the most remote reason for suspecting syphilis. A child
with an aphthous affection of its mouth will often communicate
a most severe disease to the nipple of its mother, capable df
being- propagated to another infant, and of exciting severe
constitutional irritation. Even in adult age aphthous affections
are communicable by the touch in many instances, and give
rise to great uneasiness from their obstinate character. I am
intimately acquainted with a physician who contracted an
aphthous affection of his lip, by taking a last farewell of a most
respectable lady who was far advanced in phthisis, and whos6
lips were affected with those aphthous eruptions which so often
arise in the latter stages of that disease. In a short time the
point of his tongue was covered with small and very painful
ulcers, extremely like minute chancres, and in some weeks after
he became affected with a scaly eruption of the hairy scalp.
I had occasion particularly to examine him in about three
months after the first appearance of the ulcerations of his
tongue ; the eruption was gone, but from one part of the scalp
the hair was dropping very fast.

With regard to still-born children, it is almost unnecessary
to say, that one miscarriage will lay the foundation for many
subsequent ones, and that, until the habit is broken, the same
propensity may continue during the remainder of life. It is
also well known, that in whatever state of health the mother
may be, the long retention of a dead foetus occasions various
morbid states of the skin, such as partial excoriations, extensive
peelings when touched, loose, puckered, or wrinkled appear-

SYPHILIS. 567

ance, &c. Upon the whole, without pretending to enter more
minutely into all the symptoms said to proceed from syphilis in
infants, I have the authority of a teacher of unquestionable
reputation to assert, " that there is perhaps no individual
symptom which can decidedly characterize syphilis in infants;"
and, " that many children are rashly put upon a course of
mercury who do not require it; perhaps because the practitioner
thinks it a point of honour to determine the nature of the
disease at the first glance."*

Another question arises on this subject. Admitting that the
disease of infants is really syphilis, does it indispensably require
the mercurial treatment in every instance i If it were proved,
that all the children thus affected were infallibly restored to
health by the use of mercury, and that all those who did not use
it infallibly died, no man of common sense, or of any pretensions
to humanity, could be justified in withholding it. Indeed, in
these tender subjects, this remedy is borne so much better than
in adults, that we are encouraged in the employment of it in
their cases, especially when we recollect how much their con-
stitutions appear to be influenced by the peculiarities of their
hepatic system, and how sensibly the preparations of mercury
operate upon that system ; but notwithstanding Dr. Hamilton's
opinion to the contrary, so strongly expressed at p. 61 of bis
work, we have just reason to suppose that children have
recovered from the disease, not only without mercury, but
spontaneously, and without any other remedy whatever, and
this from the testimony of Messrs. Bertin and Mahon, the most
distinguished writers upon the subject, both of them staunch
mercurialists, and generally quoted for an opposite opinion.
The former, in his introduction, (second part, p. 45,) while
speaking of the diflSculty of the diagnosis, alludes to the spon-
taneous disappearance of many of the symptoms ; and Mahon,
in his " Oeuvres Posthumes," details a case at p. 416, which

• Principles of Midwifery, by John Burns, 2d edition, p. 621.

5C8 SYPHILIS.

he precedes by the following words : " On ne pent nier cepeu-
dant qu'il ne puisse arriver que les symptomes venerlens
disparaissant chez des enfans nouveau nes a qui on n'a fait
aucun remede. J' en ai eu plusieurs exemples," &c.

While the great mass of medical men believed that the
syphilis of adults was absolutely incurable without mercury, it
was natural for them to apply the same opinion to the disease,
or the suspected appearances in infants; but it is to be hoped,
that, in the present state of our knowledge of the natural his-
tory of syphilis, imperfect though it be, we will not withhold
from the rising generation the chance of those benefits which
have already accrued to those of more advanced years, by
limiting and diminishing the employment of mercurial medicines.

Thus have I given a faithful account of all that I have
learned with regard to the non-mercurial treatment of Syphilis,
as it has been practised in the Military hospitals. It gives me
great pleasure to be able to state, from good authority, that the
practice has been adopted by some of the Naval surgeons with
a success even greater than ours; and I have at present before
me a letter, which I trust, will soon be published in a more
enlarged form, giving an account of the successful treatment
of no less than fifty patients in one ship, in one only of whom
did secondary symptoms appear, (under the form of blotches,)
and they were entirely removed in the course of eight days,
without the employment of one particle of mercury, either
externally or internally. While these sheets are going through
the press, I have also had before me testimonies from the
officers of our own service, which still farther tend to confirm
the principles which I have advocated. These documents
will, at some future period, be suhmitted to the judgment
of the profession.

APPENDIX.

As I have made such frequent reference to diet, I shall, for
the non-military reader, give the present improved scale of
British Hospital Dietary, which I conceive to be the most
perfect hitherto adopted in armies.

DIET TABLE.

For Full Diet. Breakfast, one pint of oatmeal or rice groel.
Dinner, three-fourths of a pound of meat, one pound of bread,
one half pound of potatoes, one quart of table beer. Supper,
one pint of oatmeal or rice gruel. For Half Diet. Breakfast,
one pint of oatmeal or rice gruel. Dinner, one-half pound of
meat, three-fourths of a pound of bread, one pound of potatoes.
Supper, one pint of oatmeal or rice gruel. For Low Diet.
Breakfast, tea. Dinner, one-fourth of a pound of meat, one-
half pound of bread, one-half pound of potatoes. Supper, one
pint of oatmeal or rice gruel. For Spoon or Fever Diet.
Breakfast, tea. Dinner, one-half pound of bread made into
panado or pudding, or sago. Supper, tea.

Extras. All extra diet must be stated and charged in the
proper table of the periodical return, against the patient's
name ; wine used in panado or sago, or in any other kind of
food, must be similarly specified in the wine return. The fever
or spoon diet is adapted to such cases as will not allow of any
excitement from animal food, in the shape of broth, or other-
wise ; and any extras to this rate of diet are supposed to be
given with the same view.

570 APPENDIX.

Articles composing the different diets for a day, avoirdupois
weight. Full, meat twelve ounces, bread sixteen ounces,
potatoes eight ounces, oatmeal three ounces, or rice two ounces,
barley three-fourths of an ounce, sugar one ounce, salt one-
fourth of an ounce, beer one quart. Half, meat eight ounces,
bread twelve ounces, potatoes sixteen ounces, oatmeal three
ounces, or rice two ounces, barley three-fourths of an ounce,
sugar one ounce, salt one-fourth of an ounce. Loto, meat four
ounces, bread eight ounces, potatoes eight ounces, oatmeal one-
half ounce, barley one-half ounce, tea two drams, sugar one
ounce, salt two drams, milk two ounces. Spoon or Fever,
bread eight ounces, or sago four ounces, tea two drams»
sugar one-fourth of an ounce, milk four ounces. — Note. — The
meat is to be boiled, so as to make a pint of good broth for the
dinner of each patient, for which the barley is allowed.

When it shall be found necessary to put any patient upon
a milk diet, it is to be done by giving a pint of milk morning
and evening for breakfast and supper, in place of tea, the
spoon or fever diet, and one pint for dinner; and it will be
expected, that medical officers be careful not to order any milk
under the other heads of diet, or promiscuously, in cases of
disease, as in many it is not only unnecessary, but rather
prejudicial; while, in several of the sequels of pneumonia, and
of syphilis, and in phthisis pulmonalis, as well as in hectic
fever accompanying other cbronic diseases, milk may be ex-
hibited in the way above mentioned. If, on any other occasion,
a medical officer shall think it expedient to order extra milk, a
detail of the necessity will be expected, as it will also be when
other extra articles are given ; the present table of diet allowing
amply for alniost all cases of disease and convalescence. During
tlie period of convalescence, it is recommended to medical
officers to put the patients gradually upon such diets as ap-
proach nearest to their ordinary food in health, for much injury
often arises, as has but too frequently been observed, from their
passing at once from low, or even spoon diet, with either one,
or perhaps ntimeruns extras, to the usual food of a hoalthy man.

INDEX

Abdomen, wounds of, 405.

Abrantes, hospital gangrene at, 237.

Abstinence, its utility. See Fever, Joints, Head, Thorax, Abdomen.

Affections of the system from'wounds, 199.

Air, free circulation indispensable in hospitals, 205. Analysis of,
60, 243.

Amaurosis and other affections of the eye from wounds, 350.

Ambulance Volante, 25.

Amputation on the field, 38. In general, 255. At the Shoulder-
joint, 262. Hip-joint, 40, 265. Thigh, 265. Fore-arm, 269.
Foot and hand, 269. Second performance of, 270. Causes of
death from, 271.

Anatomical collection founded by Sir James M'G rigor, 401.

Anchylosis, 163. See Joints.

Analysis of the air in hospitals, 60, 243.

Aneurism, varicose, a case of, 185. Of the supra-scapulaT artery,

397.

Antiraouials, their utility, 283.

Anus, artificial, cases of, 411, 413.

Arm, amputation of, 269.

Arsenic, used with success in hospital gangrene, 231.

Arteries, someti.nes do not bleed, 39, 169. Intercostal burst, 97.
Wounds of, 169. Pressure on the carotid, 168. Cutting for, 172.
Small orifice in one in a case of hemorrhage, 174. No orifice
discoverable on injecting a limb, 174. Tying, 175. External
'iliac tied, 187. Femoral tied in Hospital Gangrene, 224. Axil-
lary tied in Hospital Gangrene, 224. Their state in Hospital

572 INDEX.

Gangrene, 224. Subclavian commanded with great ease, 261.

Carotid tied, 358. Of the Scapula injured, 392. Aneurism of

the Supra-scapular, 397.
Arthur, Dr. Staff-surgeon, his treatment of exfoliations, 134.
Assalini, his splints, 116.
Authors on Military Surgery, 8.

Balls, their courses, 34. Extraction of, 76. Often split, 90.
Wind of, 95. Lodged in Bone, 106, 450. In Brain, 296. In
the Thorax, 373. In the Abdomen, 410. Passed by Stool, 408^
In the Bladder, 432.

Bandages, their importance, 74. Fixed in wounds of the Thorax,
374.

Baths fixed in Hospitals, much wanted, 166.

Bareges and other mineral waters, 164.

Bark, remarks on its use, 202.

Barllett, Dr. 88th Regiment, his experiments on Varicella, 481.

Bayonet stabs, 48. Of the Head, 284. Thorax, 375. Abdomen^
406.

Bed sores, 143,

Bell, Mr. John, his opinion oa the compression of the subclavian,
artery, 261.

— — Mr. Charles, his reports, 240, 261.

Bertrandi on sympathetic affections of the Liver, 314.

Bilboa, Hospital Gangrene there, 213.

Blackadder, Assistant Stafl'-surgeon, cases by him, 278, 292, 401.

Bladder, wounds of, 425. Balls in, 432. Incision of, 432.

Blood-vessels, injuries of, 167. See Arteries, Veins.

Boggie, Dr. Stafl'-surgeon, seton used by him, 134.

Bones, injuries of, 104. See Exfoliations, Fracture, Necrosis, Peri-
osteum, Dissection.

Bowels, state of very necessary to be watched, 69.

Boyer, his apparatus for Fractures, 11(5

Brain, concussion of, 320. Compression of, 320. Fungi of, 315.
Wounds of, 289. Balls lodged in, 292. Diseased appearances
of, 340.

INDEX. 573

Brugmans, Professor, of Leyden, his experiments on the air of Hos-
pitals, 60, 243. His observations on Hospital Gangrene, 235.
Brussels, Hospital Gangrene at, 238.
Bryce, Mr. the excellence of his Vaccine test, 494.
Burton, Dr. Surgeon 66th Regiment, case by him, 346.

Calculi in wounds of the bladder, 432.

Calculations on the proportion of wounds, 30.

Caries. See Bones.

Carotid artery secured sometimes by pressure, 168. Tied, 3-58.

Its wounds generally fatal, 362.
Cases. Original, list of. Illustration of the effects of scarification,
71. Cannon ball lodged in the thigh, 79. Grape-shot lodged in
the sole of the Foot, 80, Grape-shot lodged in the Thigh, 81.
Splinter of Shell lodged in the abdominal Muscles, 82. Pieces
of Coin lodged in the Thigh, 83, 85. Piece of a Cranium lodged
in the Thigh, 86. Piece of the ulna and olecranon lodged in the
bend of the Elbow, 87. Tooth lodged in the Temple, 87. Frag-
ment of ball lodged on the Jugular Vein, 90. Fatal contusion from
a cannon ball, 93. Death from an unknown cause, 96. Rupture
of the Vena axygos and intercostal artery from contusion, 97.
Contusion of the Abdomen and Ruptured Intestine, 98, 101. Con-
tusion of the Abdomen, 102. Ball lodged in the condyle of the
Femur, 106. Secondary Injury of the Femoral vessels, and of the
Os Femoris, 128. Longitudinal fracture of the Tibia, 131. Com-
pound fracture of the Thigh, 131. Complicated fracture of the
Thigh, 138. Wound of the knee-joint terminating fatally, 147, 148,
Wound of ditto terminating successfully, 149, 153. Spontaneous
Luxation of the Hip-joint, 159. Arteries divided without hemor-
rhage, 169. Arterial hemorrhage, source unknown, 173. Varicose
Aneurism of the femoral artery, 185. External Iliac artery tied, 187.
Varicose Veins after gunshot wound, 190. Ligature on the Axillary
plexus, 193. Death after amputation from disease of the Lungs,
275. Death after amputation from disease of the Liver, 276. Death
after amputation from disease of the Lungs, and a collection of mat-
ter in the Hip-joint, 277. Death after amputation from inflamed
veins where no ligatures were applied, 278. Instant death from

574 INDEX.

injury of Hie Brain, 289. Fracture with depression not trepanned,
290. Ball extracted frora the Brain, 292. Ball lodged in the Brain,
295, 296, Extensive fracture, ball lodged, 29B. Paralysis mis-
taken for dislocation, 305. Affection of the Genital Organs from
wound of the Occiput, 306. Severe injury of the Head with loss
of speech, and other nervous affections, 309. Severe injury of the
Brain with Fungus, 316. Fatal relapse with abscess in the Brain,
323. Successful application of the trephine for the removal of
coagulated blood, 327. Counter fracture of the base of the Cra-
nium, 334. Severe concussion, compression, and fracture, 336.
Musket-ball lodged under the Eye without impairing vision, 346.
Injury of the Eye succeeded by mental derangement, 347. Diplo-
pia, 349. Severe Sabre wound of the Face, 354. Injury of the
Tongue and singular course of a ball, 356. Severe gunshot
wound of the Throat, 362. Wounded Larynx and (Esophagus,
368. Extraneous body passed through the Thorax, 372. Se-
condary Emphysema, 384. Penetrating Sabre Thrust, 391.
Severe wound of the Lungs, 394. Phthisical tendency excited
by injury of the Thorax, 398. Wound from a Grape-shot
passing through the Abdomen, 407. Musket-ball passed by stool,
408. Artificial Anus, 411, 413. Severe wound of the Thijrh
and Intestinal Canal, 414. Complicated wound of the Kidney,
422. Passage of Cloth by the Urethra, 426, Passage of Bone by
the Urethra, 426, Passage of Air by the Urethra, 430. Wound
of the Liver, 435. Complicated Wound of the Liver, 437. Injury
of the Diaphragm in two places by a ball, 441. Rupture of the
Spleen from a blow on the Stomach, 445. Somnolency combined
with mental hallucination, 469, Increased action of the Heart
produced at will, 477. Small-pox after Vaccine disease directly
taken from the Cow, 492.

Chastanet, M. Iub Cahes of woundx «»f the heart, 402.

Chylopoietic organs, their deiacig^Mneiit, 68.

Cicatrix, line of, after amputation, 270.

Classification of wounds, 63.

Clavicle, injuries of, 394.

Cleanliness, a jireveutative of fever, 204. See Hospitals.

Coatt^i, .Staff-surgeon, his siicce^if in Contracted cases, 161.

INDEX. 575

Collapse, not an universal occurrence, 33. Symptoms of, 46.

Collier, Staff-surgeon, tied the Carotid, 358.

Comminuted fracture, 136.

Compound fractures, 47, 109.

Compression of the Subclavian artery simple, safe, and effectual, 260.

Of the Brain, 320.
Concussion of the Brain, 320. Of the other Viscera, 446.
Contagious gangrene, 213.
Contractions, 161.
Contusions, 49, 92, 97, 101, 102.
Cooper, Sir Astley, on short cut ligatures, 182. Staff-surgeon,

case from him, 326.
Counter fractures, 334.
Course of balls, 34.
Cumin, Dr. of Glasgow, on short cut ligatures, 180. Case by him,

477.
Curtis, Mr. on mortification, 245.

Dease, Staff-surgeon, his almost bloodless shoulder-joint amputa-
tion, 261. Case of wound of the Head, 323. Case of severe
wound of the Face, 354. Of Abdominal injury, 409. Of Cys-
totomy, 432.

Delpech, Professor, of Montpelier, on short cut ligatures, 179.

Denmark, Dr. cases by him, 137, 196. Tracheotomy performed by
him and Dr. Johnson, 368.

Depression of the skull, 290.

Dewar on bandaging, 75. Case of ball passed by stool, 408.

Diaphragm, wounds of, 441.

Dickson, Dr. case by him, 169. His paper on Tetanus, 252.
Observation on the slow healing of wounds on the decks of ships,
61.

Diet, 63. See Head, Thorax, Abdomen, Joints, Appendix.

Diplopia, case of, 349.

Dissections, appearances on, in Blood-vessels, 124, 170, 224, 271.
Bones, 124, 223. Compound Fractures, 123. Diaphragm, 442.
Emphysema, 389. Head, 302, 333, 339, &c. Heart, 401^
403. Hospital Gangrene, 222. Joints, 124, 156. Liver, 44J.

576 INDEX.

Lungs, 390. Muscles in Compound Fractures, 124. Mortifica-
tion, 244. Nerves, 195. Tetanus, 251. Thorax, 371, 387, 390.
Trachea, 367.

Dressings, 33, 05, 66, 72.

Dura Mater, puncture of, 324.

Ear, injuries of, 352.

Edwards, Assistant-surgeon, dissection by him, 1'29.

Electrical appearances from wind of ball, 90.

Elizabeth Hospital at Brussels, 241 .

Emphysema, 380.

Empyema, 388.

Erysipelas, in wounds of the head, uncommon at present, 282.

Escharotics, caution in their employment, 74.

Examination of Recruits, 454.

Excess, hemorrhages from, 188.

Excision of the heads of bones, 39, 204.

Excoriations, 143.

Exfoliation, 133.

Extra Diet, often a fatal indulgence, 200.

Extraction of foreign bodies, 76.

Extraneous substances, 76.

Eye, injuries of, 344.

Face, injuries of, 344.

Feet, wounds of in general, 269.

Feigned diseases, 463.

Femur, fractures of, 114. Spontaneous luxation of, 169.

Fergusson, Dr. Inspector of Hospitals, his notice on short ligatures

180.
Fever in general, 190. Intlainmatory, 199. Hectic, 202.
Field duties, 22. Stores, 24. Panniers, 25.
Forbes, Dr. Charles, Depuly Inspector of Hospitals, principal medical

officer at Bilboa, 216.
Fore-arm, amputation of, 269.
Foreign bodies, extraction of, 70. See Cases.
Fournier, M. \m case of wounds of the heart, 401,

INDEX. 577

Fractures, compound, 47, 109. Comminuted, 136.

French wounded at Brussels, 239.

Frontal bone, extensive fracture of, 305, 324. Its injuries not so

dangerous as that of other bones, 351.
Fuge, Mr. his case of wound of the heart, 404.
Fumigations, their inefficacy, 206. See Appendix.
Fungus cerebri, 315. Of bandages, 217.

Gall-bladder, wounds of, 440.

Gall and Spurzheim, their theory of the seat of the organ of sexual
love, 807.

Gangrene, contagious, 213. Common, 244.

Gastroraphy, a superfluous operation generally, 416.

Generative faculty, loss of in wounds of the head, 306.

Gens d'armerie hospital at Brussels, 239.

Gordon, Dr. Theodore, Deputy-Inspector, case by him, 430,

Graefe, Dr. his experiments on Fumigation, 207.

Gestation, its good effects, 257.

Gunning, Mr. Inspector of Hospitals, recommended amputation on
the field, 43.

Gunshot wounds, first eflfects of, 33. Field treatment of, 33. Hos-
pital treatment of, 65.

Guthrie, Mr. Deputy-Inspector of Hospitals, his hip-joint operation,
40, 265. His account of the practice of primary amputation, as
practised on the Peninsula, 43, 109. His objection to the short
cut ligatures, 179.

Haire, Mr. used short cut ligatures in the year 1786, 183.
Halliday, Dr. Staflf-surgeon, case of extensive wound of the thorax,

394. His work on Emphysema, 404.
Halkett, Staff-surgeon, case reported by him, 295.
Hammick, Mr. of Plymouth Royal Naval Hospital, his preparations,

298, 400.
Hand, injuries of, 269.
Head, wounds of, 281.

Heart, injuries of, 402. Preparation of a singular appearance, 402.
Hectic Fever, 202.

2 JP

578 INDEX.

Hemorrhage. See Arteries, Veins, Ligature.

Hernia of the Brain, 315. Through the Diaphragm, 442. Of the
Lungs, 394. Of the Heart, 400. Disposition to, left after blows
on the Abdomen, 415.

Hicks, Mr. Surgeon 92d Regiment, tied the external iliac, 187.

Hill, StafF-surgeon, case treated by him, 300.

, Assistant StafF-surgeon, cases of Paralysis detected by him,

-305.

Hilsea, apparatus at the hospital for contracted extremities, 161.

Hip-joint, amputation at, 40, 2G5. Balls lodging near it, 157. Spon-
taneous luxation at, 159.

Historical notices of military surgery, 1.

Hospital stores, how to carry and arrange, 23. Ventilation of, 55.
Arrangement of, 52. Cleanliness of, 58. For officers, 62.

Hospital Gangrene, 213.

Hughes, Staff-surgeon, cases by, 87, 106, 159, 277, 289, 306, 437.

Humboldt, remarkable case from his Personal Narrative, 208.

Hume, Assistant Staff surgeon, suggested short cut ligatures, 177.

Humerus, excision of its head, 39, 262. See Amputation.

Hutchison, Mr. his report on the wounded at Algiers, 17.

Hunter, Mr, John, his cases of injury of the knee-joint, 147. His
opinion on primary amputation, 45.

Jaw, injuries of, 354.

Jesuits' Hospital at Brussels, 239.

Iliac, external tied unsuccessfully, 186; successfully, 187.

Incisions for extracting bones, 132.

Inflamriiation of the lungs from compound fractures, 126. Of the
blood-vessels after amj)utation, 271. Of the brain, 282. See
Joints, Thorax, Abdomen.

Inflammatory stage of compound fractures, 115.

Instruments, how to preserve, 27.

Intestines, injuries of. Sutures employed in. Authors on their in-
juries. See Abdomen.

Introductory remarks, 1.

Joints, injuries of, 143.

INDEX. , 579

Johnson, Dr. of Portsmouth, case by him, 367. Tracheotomy per-
formed by him and Dr. Denmark, 367.

— , Mr. Surgeon 88th Regiment, cases by him, 333, 336; his

comparative trials in Syphilis. See Syphilis.

Kennedy, Dr. case by him, 79.

Kidney, wounds of, 420.

Knee-joints, injuries of, 147.

Knox, Dr. cases by him, 131, 297. His success at Hilsea in con-
tracted cases, 161. His experiments in feigned diseases, 463. In
Syphilis, 528.

Larrey, his illustrations of the utility of primary amputation, 43.

Cases of his referred to 289, 313. His treatment of thoracic iu-

juries, 372, 374.
Larynx, wounds of, 368.
Ligatures, common, 176. Short cut, 177.
Lindsay, Staff-surgeon, case trepanned by him, 91.
Liver, affections of, after amputation, 276, iu injuries of the head,

313. Wounds of, 436.
Loading field stores, 24.
Lower part of wards in hospitals unfriendly to the healing of wounds,

61.
Lungs, wounds of, 375. Affections of, from fractures, 126.

Machinery for contracted extremities, 161.

Maclagan, Dr. Physician to the Forces, his Essay on Tetanus, 252.

M'Leod, Staff-surgeon, case by him, 359.

Mercury, used to dissolve leaden balls, 433. See Syphilis.

Metastasis after amputation, 272.

Mortality, estimate of, in compound fractures, 109.

Mortification, 244.

Mouth, wounds of, 353.

Neck, wounds of, 360. Paralysis frequent in them, 361. Bleeding
of in general fatal, 361 . -1

2 P 2

580 INDEX.

Necrosis, from gunshot wounds, 127. See Bones.
Nerves, injuries of, 193. Ligatures on, 194.

O'Beirne, Dr. Assistant-surgeon, royal artillery, cases attended by

him, 94, 120.
(Edema after gun-shot wounds, 198,
CEsophagus, wounds of, 368.

Operations on the field, 38. In the hospitals, 256.
Opium, remarks on, 69, 201.
Ossification, process of, 122. Retarded, 120. Of cicatrices, 163.

In some contracted cases, 164.
Osteo-sarcoma, cases of, 223.

Panniers for field stores, 24.

Paralysis in wounds of the head, 305. Neck, 361. Spine, 448.

Parfe, Ambrose, his services as an army surgeon, 7. Case from him^

108. Posture recommended by him in Fractures, 1 10.
Pelvis, wounds of, 449.
Perforating fracture, 134.
Periosteum, its importance, 128.
Phlebotomy. See Venesection.
Pitcairn, Dr, Deputy-Inspector of Hospitals, his account of primary

amputation in Egypt, 43.
Pockels, Dr. Surgeon in chief of the troops of Brunswick, cases by

him, 153, 347, 407.
Poultices, their utility, 65.

Pott, Mr. posture recommended by him in fractures, 110.
Phthisis, from fractures, 126.

Pulmonary affections from compound fractures, 126.
Pulse, its state not conclusive in tetanus, 250, nor in fever, 200.

Remarkably slow in an injury of the head, 317.
Purgatives, their utility, 68.
Pus, removal of from compound fractures, 118.
Preparations at Plymouth, 298, 400. At Chatham, 401.
Preparatory measures on taking the tield, 22..
Prisoners, treatment of, 50.
ProjfTtiles, their force, 31. *

INDEX. 681

Quesnay, on injuries of the head, 292.
Question of amputation, 42.

Ranby, distribution of medical officers recommended by him, 28.

Rear, conveying wounded to, 28.

Receiving hospital, 54.

Recruits, examination of, 454.

Reid, Assistant-surgeon, cases by him, 82, 372, 398, 415.

Relapse, tendency to in wounds of the head, 323.

Refreshments after a battle, 50.

Roach, Staff-surgeon, his case of wound of the face, 357.

Rogers, Assistant-surgeon 10th Hussars, case by him, 391.

Sabre wounds, 47. See Head, Thorax, Abdomen.

Saws, various kinds of, 26.

Scapula, and its vessels, wounds of, 49, 393, 396.

Scarifications, their utility and abuse, 50, 70.

Scott, Dr. Assistant-surgeon 11th Regiment, case operated on by

him, 129.
Secondary haemorrhages, 171, 173.
Setoris, their use, 121.
Shell, splinters of lodged, 82,
Shoulder- joint amputation, 261.

Silk, not impenetrable to balls, 35. Ligatures of, absorbed, 178.
Simpson, Assistant-surgeon 36th Regiment, cases by him, 147, 148.
Skin, state of in wounds, 69.
Sloughing, see Hospital Gangrene.
Small-Pox, 483.

Speech, loss of, remarkable case of, 313.
Spinal pyramid, injuries of, 448.
Spleen, wounds of, 445.
Splinters, extraction of, 130.
Splints, employment of, 115.
Spontaneous luxation of the femur, 159.

Spurzheim and Gall, their opinion of the generative faculty, 307.
Staff, distribution and station of, 28.
Steel, Surgeon 23d Draj^oons, cases by him, 98, 102.

582 INDEX.

Stuart, Dr. 71st Regiment, case by him, 327.

Stimulants highly improper in injuries of the head, 321.

Stomach, wounds of, 443.

Stone found in the bladder, formed on balls, 432.

Subclavian artery compressed with ease and safety, 261.

Suppuration, 70.

Sympathy in wounds of the head, 313.

Symptomatic Fever, 69, 199.

Syphilis, 496.

Testicle, wounds of, 4ol.

Tetanus, 248.

Thorax, wounds of, 371 .

Throat, wounds of, 362. Tooth lodged in, 359.

Thomson, Professor, his division of hemorrhage, 174. Case of

emphysema, 384. Case of double wound of the diaphragm, 441.

Case of a ball in the ilium, 450.
Tooth lodged in the temple, 87. In the throat, 359.
Tongue, wounds of, 356.
Topography, medical, queries on, 458.
Tourniquets, 27, 260.
Trachea, wounds of, 366.
Travers on wounds of the intestines, 416»
Trephine, when to be applied, 326.

Ulcer, sloughing, see Hospital Gangrene.

Ureter, injuries of, 430.

Urine, effusion of prevented, 425.

Vaccination, 483.

Viilsalve's treatnienl »»f aneurisms, 153.

Varicose aneurism, case of, 185. Varicose veins, 190.

Variola, 483.

Veins, jugular, burst, 91. Vena axygos burst, 97. \'aricose, 190.

To be tied if they bleed in weakly subjects, 268. Death from

their inflamed slate, 272.

INDEX. 583

Veitch, Mr. of the navy, his improvement on ligatures, 176. His

Hip-joint operation, 266.
Venesection on the field, 37, 68. In Gangrene, 227. In wounds of

the Head, Thorax, Abdomen. See these articles.
Ventilation, the only security against contagion, 55. Modes of

effecting, 56.
Vomiting, its employment in hospital gangrene, 226.

Webster, Mr. Surgeon 51st Regiment, his case of hydrophobia, 252.

White, a navy surgeon, his opinions on primary amputatioa, 44.

Wiedmann, Professor, his wurk on Necrosis, 130.

Wine, its use in the field, 27. In hospital gangrene, 22G. Its
abuse, 126.

Wiseman, his opinion on early amputation, 44. His cure of emphy-
sema, 381 .

Women, a nuisance in hospitals, 61, 203, 325.

Wounded French at Brussels, 239. Prisoners in general, 50.

Wounds of the Abdomen, 405. Bladder, 425. Blood-vesssels, 167.
Bones, 104, Brain, 289. Breast, 371. Diaphragm, 441. Ear,
344. Eye, 344. Extremities, 38, 64. Face, 353. Gall-blad-
der, 440. Hands, 269. Head, 281. Heart, 400. Intestines,
405. Jaw, 360. Joints, 145. Kidney, 422. Larynx, 368.
Liver, 437. Lungs, 375. Neck, 360. Nerves, 192. Nose,
359. (Esophagus, 368. Parotid duct, 358. Pelvis, 450. Pe-
rinaeum, 450. Spinal pyramid, 450 Spleen, 441 . Stomach,
443. Testes, 451. Thoracic duct, 404. Thorax, 371. Throat,
362. Tongue, 356. Trachea, 366. Ureter, 430.

Zetzell, Dr. his calculations on the comparative frequency of wounds,
30.

Printed by J. Davy,
16, Queen Strett, Seven Dials.

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