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 UNIVERSITY OF CALIFORNIA, SAN DIEGO 
 
 3 1822 01835 2492 
 
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 University of California, San Diego 
 
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 CI 39a (4/91) 
 
 UCSD Lib.
 
 PRINCIPLES 
 
 OF 
 
 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 
 
 OF 
 
 MILITARY SURGERY, 
 
 COMPRISING 
 
 OBSERVATIONS ON THE ARRANGEMENT, POLICE, 
 AND PRACTICE OF HOSPITALS, 
 
 AND ON THE 
 
 HISTORY, TREATMENT, AND ANOMALIES 
 
 OF 
 
 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.
 
 TO 
 
 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 
 
 OF 
 
 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 
 
 TO 
 
 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.
 
 ADVERTISEMENT 
 
 TO 
 
 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 
 
 TO 
 
 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 
 
 I
 
 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 
 
 c
 
 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 
 
 OF 
 
 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 
 
 B
 
 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 
 
 c2
 
 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.
 
 22 
 
 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.
 
 80 
 
 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. 
 
 M
 
 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. 
 
 E 
 
 I
 
 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. 
 
 e2
 
 no 
 
 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.
 
 65 
 
 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 
 
 F
 
 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.
 
 76 
 
 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 
 
 G
 
 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 
 
 H
 
 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 
 
 I 
 
 I 
 
 ^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 
 
 I: 
 
 \K 
 
 5TiCh pio- 
 oscolar 
 
 -- ri:rter 
 
 edof 
 
 C 
 
 nr^ 
 
 T: 
 
 - 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 
 
 i2
 
 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 
 
 K
 
 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- 
 
 l2
 
 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 
 
 M
 
 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 
 
 V
 
 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 
 
 n2
 
 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 
 
 I" 
 
 * 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, 
 
 o
 
 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.
 
 1^ 
 
 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. 
 
 p2
 
 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 
 
 Q
 
 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- 
 
 q2
 
 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- 
 
 R
 
 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- 
 
 s
 
 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 ; 
 
 s2
 
 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 
 
 T
 
 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 
 
 t2
 
 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. 
 
 U
 
 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 
 
 u2
 
 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- 
 
 X
 
 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. 
 
 x2
 
 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
 
 I 
 
 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 
 
 V
 
 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 
 
 L
 
 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- 
 
 z2
 
 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. 
 
 I
 
 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 
 
 2o
 
 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 
 
 26
 
 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 
 
 16 
 
 m 
 
 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. 
 
 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§ 
 
 43 
 
 761 
 
 Number of 
 
 Days 
 
 without 
 
 Mercury. 
 
 9 
 
 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- 
 
 2n
 
 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 
 
 r 
 
 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 
 
 53 
 
 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. 
 
 36 
 
 From 5 to 10 
 
 63 
 
 From 3 to 10 
 
 19 
 
 11 20 
 
 40 
 
 11 20 
 
 42 
 
 21 30 
 
 43 
 
 21 30 
 
 13 
 
 31 40 
 
 10 
 
 31 40 
 
 13 
 
 41 50 
 
 5 
 
 41 50 
 
 5 
 
 51 60 
 
 1 
 
 51 60 
 
 1 
 
 71 80 
 
 1 
 
 61 70 
 
 2 
 
 91 98 
 
 2 
 
 71 80 
 
 4 under cure at 
 
 
 4 
 
 81 90 
 
 the date of 
 
 
 1 
 
 93 
 
 last return. 
 
 
 1 
 
 109 
 
 
 
 1 
 
 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. 
 
 d 
 
 8 
 15 
 
 4 
 
 8 
 
 2 under 
 cure at the date 
 of last return. 
 
 From 5 to 10 
 11 20 
 21 30 
 31 40 
 41 60 
 
 10 
 
 18 
 
 13 
 
 4 
 
 4 
 
 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. 
 
 2 
 
 1 
 
 1 
 
 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 
 
 I 
 
 4 under 
 cure at the date 
 of last return. 
 
 In the following 
 number of days. 
 
 From 7 to 10 
 
 11 
 
 20 
 
 21 
 
 30 
 
 31 
 
 40 
 
 41 
 
 60 
 
 61 
 
 60 
 
 71 
 
 80 
 
 91 
 
 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. 
 
 r 
 
 a. Eruptions 
 only 
 
 !/3- 
 
 Tubercular 
 
 Esantheinatous 
 
 Pustular 
 
 Tubercular and Scaly ... 
 Tubercular and Vesicular 
 
 15 
 
 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- 
 
 1 
 
 li 
 
 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 
 
 24 
 
 j:. Sore throat only 3 
 
 Total number of Secondary Affections treated 
 
 22 
 
 46
 
 550 
 
 SYPHILIS. 
 
 II. Period of Occurrence, and Time required for the Cttre^ 
 
 II. 
 
 ^ w a 
 
 a a S 
 •2-2 1 
 
 o 
 
 
 3 
 
 be 
 
 u 
 u 
 
 a 
 
 c 
 
 cd 
 
 9 
 
 
 Description of Secondary Affection. 
 
 bo 
 
 
 B 
 
 
 
 
 •o 
 
 
 41 
 
 
 « 
 
 
 
 ii 
 
 
 9 
 
 
 C0 
 
 1 
 
 n 
 
 
 
 i 
 
 
 3 
 
 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 
 
 c 
 
 IS . 
 Il 
 
 REGIMENTS. | = 
 
 = i 
 
 :§ 
 
 No. Bo 
 
 unliea 
 
 thy, wi 
 
 ;^ tlieresn 
 
 J 
 
 ■ i 
 th' 
 
 It. 
 
 « 
 
 e 
 c 
 
 
 S'o. who have 
 become un- 
 healthy since 
 Birth. 
 
 
 ■5 
 
 E 
 
 c 
 S3 
 
 13 ' 
 
 5' 
 
 V ; 
 £ 
 
 JZ 1 
 
 01 
 
 .1 
 
 1 
 a 
 
 
 
 5 
 
 > 
 
 s: 
 
 B 
 
 
 
 
 
 a . 
 , 
 
 5 
 
 REMARKS. 
 
 •ith Drao'. Guards ... 
 
 
 1 
 
 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. . . . 
 
 
 
 
 i 
 
 i 
 
 
 
 40th To. 3 . 
 
 J 
 
 80th Do. 1 . 
 S8th Do. 8 
 
 Detachment of Do. 1 . 
 1st Batt. Rifle Briff. . . . 
 
 . 3 .. 
 . 1 .. 
 
 2 6.. 
 
 . 1 .. 
 
 • • 
 
 i 
 
 ■ • 
 
 " 
 
 1 
 
 • • 
 
 1 
 
 4 
 m. 
 
 
 
 7th Veteran Batt. . . . 
 
 . 1 
 
 
 
 
 Pflinliiircrh F)pnot 
 
 1 
 
 
 
 
 
 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
 
 i 
 
 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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