COMMENTARIES
ON THE
Surgery of the War

IN PORTUGAL, SPAIN, FRANCE, AND
THE NETHERLANDS,
FROM THE BATTLE OF ROLIÇA, IN 1808, TO THAT OF WATERLOO, IN 1815;
WITH ADDITIONS RELATING TO THOSE IN THE CRIMEA IN 1854-1855.
SHOWING
THE IMPROVEMENTS MADE DURING AND SINCE THAT PERIOD IN THE GREAT ART AND SCIENCE OF SURGERY ON ALL THE SUBJECTS TO WHICH THEY RELATE.
REVISED TO OCTOBER, 1855.
BY G. J. GUTHRIE, F.R.S.

SIXTH EDITION.

PHILADELPHIA:
J. B. LIPPINCOTT & CO.
1862.

TO
The Right Honorable
The Lord Panmure,
SECRETARY OF STATE FOR THE WAR DEPARTMENT,
ETC. ETC. ETC.,

THESE COMMENTARIES
ARE, BY PERMISSION,
INSCRIBED,
BY HIS LORDSHIP’S VERY OBEDIENT
AND FAITHFUL SERVANT,

G. J. GUTHRIE.

PREFACE TO THE FIFTH EDITION.

Twenty months have elapsed since the Introductory Lecture was published in The Lancet; fifteen others succeeded at intervals, and fifteen have been printed separately to complete the number of which the present work is composed. Divested of the historical and argumentative, as well as of much of the illustrative part, contained in the records whence it is derived, it nevertheless occupies 585 pages—the essential points therein being numbered from 1 to 423.

Sir De Lacy Evans, in some observations lately made in the House of Commons on the subject of a Professorship of Military Surgery in London, alluded to these Lectures in the most gratifying manner; he could not, however, state their origin, scope, or object, being unacquainted with them.

On the termination of the war in 1814, I expressed in print my regret that we had not had another battle in the south of France, to enable me to decide two or three points in surgery which were doubtful. I was called an enthusiast, and laughed at accordingly. The battle of Waterloo afforded the desired opportunity. Sir James M’Grigor, then first appointed Director-General, offered to place me on full pay for six months. This would have been destructive to my prospects in London; I therefore offered to serve for three, which he was afraid would be called a job, although the difference between half-pay and full was under sixty pounds; and our amicable discussion ended by my going to Brussels and Antwerp for five weeks as an amateur. The officers in both places received me in a manner to which I cannot do justice. They placed themselves and their patients at my entire disposal, and carried into effect every suggestion. The doubts on the points alluded to were dissipated, and the principles wanting were established. Three of the most important cases, which had never before been seen in London nor in Paris, were sent to the York Military Hospital, then at Chelsea. The rank I held as a Deputy Inspector-General precluded my being employed. It was again a matter of money. I offered to do the duty of a staff-surgeon without pay, provided two wards were assigned to me in which the worst cases from Brussels and Antwerp might be collected. The offer was accepted; and for two years I did this duty, until the hospital was broken up, and the men transferred to Chatham. In the first year a Course of Lectures on Military Surgery was given. The inefficiency of such a Course alone was soon seen, for Surgery admits of no such distinctions. Injuries of the head, for instance, in warfare, usually take place on the sides and vertex; in civil life, more frequently at the base. They implicate each other so inseparably, although all the symptoms are not alike or always present, that they cannot be disconnected with propriety. This equally obtains in other parts; and my second and extended Course was recognized by the Council of the Royal College of Surgeons as one of General Surgery.

When the Court of Examiners of the Royal College of Surgeons of England—of which body I have been for more than twenty years a humble member—confer their diploma after examination on a student, they do not consider him to have done more than laid the foundation for that knowledge which is to be afterward acquired by long and patient observation. When a student in law is called to the bar, he is not supposed to be therefore qualified to be a Queen’s counsel, much less a judge or a chancellor. The young theologian, admitted into deacon’s orders, is not supposed to be fitted for a bishopric. When the young surgeon is sent, in the execution of his duties, to distant climes, where he has few and sometimes no opportunities of adding to the knowledge he had previously acquired, it is apt to be impaired; and he may return to England, after an absence of several years, less qualified, perhaps, than when he left it. To such persons a course of instruction is invaluable. It should be open to them as public servants gratuitously, and should be conveyed by a person appointed and paid by the Crown. He should be styled, in my opinion, the Military Professor of Surgery, and be capable, from his previous experience and his civil opportunities, of teaching all things in the principles and practice of surgery connected with his office, although he may and should annually select his subjects. Leave of absence for three months might be advantageously granted to officers in turn for the purpose of attending these lectures, and the Professor should certify as to their time having been well employed. For thirty years I endeavored to render this service to the Army, the Navy, and the East India Company, from the knowledge I had acquired of its importance. To the Officers of these services my two hospitals, together with Lectures and Demonstrations, were always open gratuitously, as a mark of the estimation in which I held them. By the end of that period the enthusiasm of the enthusiast who wished for another battle in 1814 had oozed out, like the courage of Bob Acres in “The Rivals,” at the ends of his fingers. The course of instruction was discontinued, but not until such parts were printed, under the title of “Records of the Surgery of the War,” as were not before the public, in order that teachers of civil or systematic surgery should be acquainted with them.

4 Berkeley Street, Berkeley Square,
June 21, 1853.

PREFACE TO THE SIXTH EDITION.

The rapid sale of the fifth, and the demand for a sixth edition of this work, enable me to say that the precepts inculcated in it have been fully borne out and confirmed by the practice of the Surgeons of the Army now in the Crimea in almost every particular. To several of these gentlemen I desire to offer my warmest thanks for the assistance they have afforded. Their names are given with the cases and observations they have been so good as to send me, and a fuller “Addenda” shall be made from time to time, as I receive further information from them, and others who will, I hope, follow the example they have thus set. More, however, has been done; they have performed operations of the gravest importance at my suggestion, that had not been done before, with a judgment and ability beyond all praise; and they have modified others to the great advantage of those who may hereafter suffer from similar injuries. They have thus proved that if the Administrative duties of the Medical Department of the Army have not been free from public animadversion, that its practical and scientific duties have merited public approbation; which I am satisfied, from what they have already done, they will continue to deserve.

The precepts laid down are the result of the experience acquired in the war in the Peninsula, from the first battle of Roliça in 1808, to the last in Belgium, of Waterloo in 1815, which altered, nay overturned, nearly all those which existed previously to that period, on all points to which they relate. Points as essential in the Surgery of domestic as in military life. They have been the means of saving the lives, and of relieving, if not even of preventing, the miseries of thousands of our fellow-creatures throughout the civilized world.

I would willingly imitate the example lately indulged in, by many of the best Parisian surgeons, of detailing circumstantially the improvements they have made in practical and scientific surgery; the manner in which they were at first contested, and the universal adoption of them which has succeeded, were it not that I might run the risk of being accused of gratifying some personal vanity, while only desirous of drawing the attention of the public to the merits of the men who so ably served them in the last war, nearly all of whom are no more; and who have passed away, as I trust their successors will not, with scarcely a single acknowledgment of their services, except the humble tribute now offered by their companion and friend.

4 Berkeley Street, Berkeley Square,
October 7, 1855.

CONTENTS.

COMMENTARIES
ON
SURGERY.

LECTURE I.

ON GUNSHOT WOUNDS, ETC.

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

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

3. When a limb is carried away by a cannon-shot, any destructive bleeding usually ceases with the faintness and failure of strength subsequent on the shock, and a hemorrhage thus spontaneously suppressed does not generally return; it is the effort of nature to save life. The application of a tourniquet is rarely necessary, unless as a precautionary measure, when it should be applied loosely, and the patient, or some one else, shown how to tighten it if necessary. A musket-ball will often pass so close to a large artery, without injuring it, as to lead to the belief that the vessel must have receded from the ball by its elasticity. A ball passed between the femoral artery and vein of a soldier at Toulouse without doing more injury than a contusion, but it gave rise to inflammation and closure of the vessels, followed by gangrene of the extremity. General Sir Lowry Cole was shot through the body at Salamanca, immediately below the left clavicle; a part of the first rib came away, and the artery at the wrist became, and remained, much diminished in size. General Sir Edward Packenham was shot through the neck on two different occasions, the track of each wound being apparently through the great vessels. The first wound gave him a curve in his neck, the second made it straight. His last unfortunate wound, at New Orleans, was directly through the common iliac artery, and killed him on the spot. Colonel Duckworth, of the 48th Regiment, received a ball through the edge of his leather stock, at Albuhera, which divided the carotid artery, and killed him almost instantaneously.

4. Secondary hemorrhage of any importance from small vessels does not often occur. On the separation of the contused parts, or sloughs, a little blood may be occasionally lost; but it is then generally caused by the impatience of the surgeon, or the irregularity of the patient, and seldom requires attention.

5. A large artery does sometimes give way by ulceration between the eighth and the twentieth days; but the proportion is not more than four cases in a thousand, requiring the application of a ligature; exclusive of those formidable injuries caused by broken bones, or the inordinate sloughing caused by hospital gangrene, when not properly treated.

6. A certain constitutional alarm or shock follows every serious wound, the continuance of which excites a suspicion of its dangerous nature, which nothing but its subsidence, and the absence of symptoms peculiar to the internal part presumed to be injured, should remove. The opinion given under such circumstances should be very guarded; for if this symptom of alarm should continue, great fears may be entertained of hidden mischief. Colonel Sir W. Myers was shot, at Albuhera, at the head of the Fusilier Brigade, at the moment of victory, by a musket-ball, which broke his thigh, and lodged. The continuance of the alarm and anxiety satisfied me it had done other mischief. He died next morning, of mortification of the intestines. General Sir Robert Crawford was wounded at the foot of the smaller breach at the storming of Ciudad Rodrigo, by a musket-ball, which entered the outer and back part of the shoulder, and came out at the axilla. There was a third wound, a small slit in the side, apparently too small to admit a ball. The continuance of the anxiety and alarm pointed out some hidden mischief, which I declared had taken place; and when he died his surgeon found the ball loose in his chest. It had been rolling about on his diaphragm. Surgery was not sufficiently advanced in those days to point out the situation, or to authorize an attempt for the removal of the ball. It must in future be done.

This constitutional alarm and derangement are not always present to so marked an extent. A soldier at Talavera was struck on the head by a twelve-pound shot, which drove some bone into, and some brain out of his head: he was walking about, complaining but little, immediately after the accident, although he died subsequently.

7. It is not always possible, from their appearance, to decide which opening is the entrance, which the exit of an ordinary sized round ball; or when two holes are distant from each other, to ascertain whether they have been caused by one, or by two distinct balls. When a ball is not impinging with much impetus, it may become a penetrating, without being much of a contused wound, which will close in and heal with little suppuration. If the ball do not press upon, or interfere with some important part, the slight degree of irritation which follows may give rise to the formation of a sac, which adheres to it and possibly keeps it quiet for years, if not for life.

8. The wound made by the entrance of an ordinary musket-ball is usually circular, depressed, of a livid color, and capable of admitting the little finger, the exit being more ragged, and not depressed. It is sometimes little more than a small slit or rent, although at others, as in the face or in the back of the hand, it may be much torn, giving to an otherwise simple wound a more frightful appearance, such as is not usually seen in the thigh, or other equally firm fleshy part.

9. Wounds from flattened or irregular-shaped musket-balls, pieces of shells, or other sharp-edged destructive instruments, are often very much lacerated, and their entrance is less marked. The part thus torn can generally be preserved, and the wound healed with comparatively little loss of substance.

10. When it is desirable to ascertain the exact course of a ball, and, if possible, the internal part injured by it, the sufferer should be placed in the position he was in when he received the injury, with especial reference to the probable situation of the enemy, when that will often become very intelligible which was before indistinct. My attention was directed, after the battle of Toulouse, to a soldier, whose foot was gangrenous without an apparent cause, he having received merely a flesh wound in the thigh, not in the exact course of the main artery, which, nevertheless, I said was injured. On placing the man in the same position with regard to us, that he supposed himself to have been in toward the enemy when wounded, the possibility of such an injury was seen; and dissection after death proved the correctness of the opinion.

11. When one opening only can be seen, it is presumed the ball has lodged; but this does not follow, although the finger of the surgeon may pass into the wound for some distance. At the battle of Vimiera, I pulled a piece of shirt, with a ball at the bottom of it, out of the thigh of an officer of the 40th Regiment, into which it had gone for at least three inches. After the battle of Toulouse, a ball, which penetrated the surface of the chest, and passed under the pectoral muscle for two inches, was ejected by the elasticity of the rib against which it struck. Scarcely any inconvenience followed, and the officer rapidly recovered. After the battle of Waterloo, I was requested to decide whether a young officer should be allowed to die in a few days, or to have a chance for his life by losing his leg above the knee. The joint was open, the suppuration profuse. A large or grape-shot was supposed to be lodged in the head of the tibia. The limb was amputated, and he is now alive, forty years afterward, but no shot was found in his limb. It had dropped out after doing the injury.

12. The treatment of simple gunshot or flesh wounds should be, under ordinary circumstances, as simple as themselves. Nothing should be applied but a piece of linen or lint, wetted with cold water; this may be retained by a strip of sticking-plaster, or any other thing applicable for the purpose of keeping the injured part covered. A compress of linen, or other similar substance, moistened with cold or iced water when procurable, will be useful; and a few inches of a linen bandage may be sewed on, to prevent the compress from changing its position during sleep. When the wound becomes tender, a little oil, lard, or simple ointment may be placed over it. A roller, as a surgical application, is useless, if not injurious. At the first and second battles in Portugal, every wound had a roller applied over it; it soon became stiff, bloody, and dirty. They did no good, were for the most part cut off with scissors, and thus rendered useless. When really wanted, at a later period, they were not forthcoming. An advancing army cannot, and ought not to carry casks full of rollers into the field; and the apothecary-general had better have instead, two casks or boxes full of good wax candles; for, although every regimental surgeon ought to have four in his panniers, kept as carefully for emergencies as his capital instruments, they will require from time to time to be replaced. No roller should be more than two inches and a quarter wide, and made of good, strong, coarse linen, very much, in fact, the reverse of the rollers which have until lately been supplied to the army.

13. Cold or iced water may be used as long as cold is grateful to the sufferer. When it ceases to be so, it should be exchanged for warm, applied in any convenient way which modern improvements have suggested, whether by piline, gutta-percha, oiled silk, etc. An evaporating poultice may be used in private life, but no poultices should be permitted in a military hospital, until the principal surgeon is satisfied they are necessary. They are generally cloaks for negligence, and sure precursors of amputation in all serious injuries of bones and joints. They are properly used to alleviate pain, stiffness, swelling, the uneasiness arising from cold, and to encourage the commencing or impeded action of the vessels toward the formation of matter. As soon as the effect intended has been obtained, the poultice should be abandoned, and recourse again had to water, hot or cold, with compress and bandage. I was in the habit of calling a poultice when misapplied a cover-slut.

14. Many simple flesh wounds are cured in four weeks; the greater part in six. Fresh air and cold water are essential. Purgatives may be occasionally given, and abstinence is an excellent remedy. Emetics, bleeding, and something approaching to starvation as to solids, are of great importance if the sufferers should be irregular in their habits, or the inflammatory symptoms run high. In weakly persons, a generous diet with tonic remedies will be necessary.

15. In wounds of muscular parts inflammation usually occurs from twelve to twenty-four hours after the injury, and the vicinity of the wound becomes more sensible to the touch, with a little swelling and increase of discoloration. A reddish serous fluid is discharged, and the limb becomes stiff and nearly incapable of motion, from its causing an increase of pain. These symptoms are gradually augmented on or about the third day; the inflammation surrounding the wound is more marked; the discharge is altered, being thicker; the action of the absorbents on the edges of the wound may be observed; and, on the fourth or fifth, the line of separation between the dead and living parts will be very evident. The wound will now discharge purulent matter mixed with other fluids, which gradually diminish as the naturally healthy actions take place. The inside of the wound, as the process of separation proceeds, changes from a blackish-red color to a brownish yellow, moistened by a little good pus. On the fifth and sixth days, the outer edge of the separating slough is distinctly marked, and begins to be displaced; the surrounding inflammation extends to some distance, the parts are more painful and sensible to the touch; the discharge is more purulent, but not great in quantity. On the eighth or ninth day, the slough is, in most cases, separated from the edges of the track of the ball, and hanging in the mouth of the wound, although it cannot yet be disengaged; the discharge increases, and the wound becomes less painful to the patient, although frequently more sensible when touched.

If there be two openings, the exit of the ball, or the counter-opening, is in general much the cleaner, being often in a fair granulating state before the entrance of the ball is free from slough. If the inflammation have been smart, the limb is at this time a little swollen and discolored for some distance around; fibrin and serum are thrown out into the cellular membrane, or areolar tissue, as it is now termed; the redness diminishes; the sloughs are discharged, together with any little extraneous substances which may be in the wound; and there is frequently a slight bleeding, if the irritable granulations are roughly treated. The limb on the twelfth, and even fifteenth day, retains the appearance of yellowness and discoloration which ensues from a bruise, and which continues a few days longer. The sloughs do not, sometimes, separate until this period, and, in persons slow to action, not even until a later one. The wound now contracts; the middle portion of the track first closes, and is no longer pervious; the lower opening soon heals, while the upper, or that usually made by the entrance of the ball, continues to discharge for some time, and toward the end of six weeks, or sometimes two months, finally heals with a depression and cicatrix, marking distinctly the nature of the injury that has been received.

16. The state of constitution, the difficulties and distresses of military warfare, exposure to the inclemency of the weather, the season of the year, or the imprudence of individuals, will sometimes bring on a train of serious symptoms, in wounds apparently of the same nature as others in which no such evils occur. After the first two or three days, the symptoms gradually increase, the swelling is much augmented, the redness extends, and the pain is more severe and constant. The wound becomes dry, stiff, with glistening edges, the general sensibility is increased, the system sympathizes, the skin becomes hot and dry, the tongue loaded, the head aches, the patient is restless and uneasy, the pulse full and quick; there is fever of the inflammatory kind. The swelling of the part increases from deposition in the areolar tissue to a considerable extent above and below the wound, and the inflammation, instead of being entirely superficial or confined to the immediate track of the ball, spreads widely. The wound itself the sufferer can hardly bear to be touched; it discharges but little, and the sloughs separate slowly. Pus soon begins to be secreted more copiously, not only in the track of the wound, but in the surrounding parts; sinuses may form in the course of the muscles, or under the fascia, and considerable surgical treatment be necessary, while the cure is protracted from three to four, and even to six months; and is often attended for a longer period with lameness, from contraction of the muscles or adhesions of the areolar tissue. The parts, from having been so long in a state of inflammation, are much weaker, and if the injury have been in the lower extremity, the leg and foot swell on any exertion, which cannot be performed without pain and inconvenience for a considerable time. The treatment should be active; the patient, if robust, ought to be bled if no endemic disease prevail, vomited, purged, kept in the recumbent position, and cold applied so long as it shall be found agreeable to his feelings; when that ceases to be the case, warm fomentations ought to be resorted to, but they are to be abandoned the instant the inflammation is subdued and suppuration well established. The feelings of the patient will determine the period, and it is better to begin a day too soon than one too late. If the inflammation be superficial, leeches will not be of the same utility as when it is deep seated; but then they must be applied in much greater numbers than are usually recommended. The roller and graduated compresses, or pressure made by slips of adhesive plaster under them, are the best means of cure in the subsequent stages, with change of air, and friction to the whole extremity, which alone, when early and well applied, will often save months of tedious treatment. If the limb become contracted and the cellular membrane thickened, it is principally by friction (shampooing) that it can be restored to its natural motion.

17. If the ball should have penetrated without making an exit, or have carried in with it any extraneous substances, the surgeon must, if possible, ascertain its exact situation, and remove it and any foreign bodies which may be lodged; indeed, if there be time, every wound should be examined so strictly as to enable the surgeon to satisfy himself that nothing has lodged. This is less necessary where there are two corresponding openings evidently belonging to one shot; but it is imperiously demanded of the surgeon, where there is one opening only, even if that be so much lacerated as to lead to the suspicion of its being a rent from a piece of shell; for it is by no means uncommon for such missiles, or a grape-shot, to lodge wholly unknown to the patient, and to be discovered by the surgeon at a subsequent period, when much time has been lost and misery endured. A soldier during the siege of Badajoz had the misfortune to be near a shell at the moment of its bursting, and was so much mangled as to render it necessary to remove one leg, an arm, and a testicle, (a part of the penis and scrotum being lost.) In one of the flesh wounds in the back part of the thigh and buttock a large piece of shell was lodged, and kept op considerable irritation until it was removed. The man recovered.

18. In examining a wound, a finger should be gently introduced, if possible, in the course of the ball, to its utmost extent; in parts connected with life, or liable to be seriously injured, it is the only sound usually admissible. While this examination is taking place, the hand of the surgeon should be carefully pressed upon the part opposite where the ball may be expected to lie, by which means it may perhaps be brought within reach of the finger, and for want of which precaution, it may be missed by a very trifling distance. While the finger is in the wound the limb may be thrown as nearly as possible into that action which was about to be performed on the receipt of the injury, when the contraction of the muscles and the relative change of the parts will more readily allow the course of the ball to be followed. If this should fail, attention should be paid to the various actions of the limb, the attendant symptoms arising from parts affected, and what may be called the general anatomy of the whole circle of injury. A muscle, in the act of contraction, may oppose an obstacle to the passage of an instrument in the direction the ball has taken, especially if it should have passed between tendons or surfaces loosely connected by cellular membrane; as by the side of, or between the great blood-vessels, which by their elasticity may make way for the ball, and yet impede the progress of a sound. When the ball is ascertained to have passed beyond the reach of the finger, a blunt silver sound or elastic bougie may be used, and the opposite side of the limb should be carefully examined, and pressure made on the wounded side, when it will probably be found more or less deeply seated. If the ball should not be discoverable by these means, the surgeon should consider every symptom, and every part of anatomy connected with the wound, before he decides on leaving the ball to the operations of nature.

19. It is unnecessary to dilate a wound without a precise object in view, which might render an additional opening requisite. This dilatation or opening, when made, should always be carried through the fascia of the limb. A wound ought not to be dilated because such operation may at a more distant period become necessary. The necessity should first be seen, when the operation follows of course.

Suppose a man be brought for assistance with a wound through the thigh, in the immediate vicinity of the femoral artery, which he says bled considerably at the moment of injury, but the hemorrhage had ceased. Is the surgeon warranted in cutting down upon the artery, and putting ligatures upon it on suspicion? Every man in his senses ought to answer, No. The surgeon should take the precaution of applying a tourniquet loosely on the limb, and of placing the man in a situation where he can receive constant attention in case of need; but he is not authorized to proceed to any operation, unless another bleeding should demonstrate the injury and the necessity for suppressing it. By the same reasoning, incisions are not to be made into the thigh on the speculation that they may be hereafter required. If the confusion which has enveloped this subject be removed, and bleeding arteries, broken bones, and the lodgment of extraneous substances be admitted to be the only legitimate causes for dilating wounds in the first instance, the arguments in favor of primary dilatation in other cases must fall to the ground.

When the inflammation, pain, and fever run high, the tension of the part being great, an incision should be made by introducing the knife into the wound, and cutting for the space of two or three inches, according to circumstances, in the course of the muscles, carefully avoiding any other parts of importance. The same should be done at the inferior or opposite opening, if mischief be seriously impending, not so much on the principle of loosening the fascia as on that of taking away blood from the part immediately affected, and of making a free opening for the evacuation of the fluids about to be effused.

It is no less an advantageous practice in the subsequent stages of gunshot wounds, where sinuses form and are tardy in healing. A free incision is also very often serviceable when parts are unhealthy, although there may not be any considerable sinus. Upon the necessity of it where bones are splintered, there is no occasion in this place to insist.

20. In making incisions for the removal of balls in the vicinity of large vessels, particularly in the neck, the hand should always be unsupported, in order to prevent an accident from any sudden movement of the patient. This caution is the more necessary on the field of battle, where many things may give rise to sudden alarm. At the affair of Saca Parte, near Alfaiates, in Portugal, I stationed myself behind a small watch-tower, and the wounded were first brought to this spot for assistance. A howitzer had also been placed upon it, being rising ground, and at the moment I was extracting a ball situated immediately over the carotid artery, the gun was fired, to the inexpressible alarm of surgeon, patient, and orderly, who bolted in all directions. From my hand being unsupported, no mischief ensued, and the operation was completed as soon as all had recovered their usual serenity. When a ball is discovered on the opposite side of a limb, through which it has nearly penetrated, but has not had sufficient power to overcome the resistance and elasticity of the skin, it should be removed by incision. An opening is thus obtained for the evacuation of any matter which may be formed in the long track of such a wound, and any other extraneous bodies are more readily extracted. When a ball has penetrated half through the thick part of the thigh, in such a direction that it cannot readily be removed by the opening at which it entered; or, from the vicinity of the great vessels, it may be considered unadvisable to cut for it in that direction; or if the ball cannot be distinctly felt by the finger through the soft parts, it ought not to be sought for at the moment, for an incision of considerable extent will be required to enable the surgeon to extract it. Much pain will be caused, and higher inflammation may follow than would ensue if the wound were left to the efforts of nature alone, by which, in time, the ball would in all probability be brought much nearer to the surface, and might be more safely extracted. It frequently happens, that after a few days or weeks, a ball will be distinctly felt in a spot where the surgeon had before searched for it in vain. A wound will frequently close without further trouble, the ball remaining without inconvenience in its new situation; and the patient not being annoyed by it, does not feel disposed to submit to pain or inconvenience for its removal. A very strong reason for the extraction of balls during the first period of treatment, if it can be safely accomplished, is, that they do not always remain harmless, but frequently give rise to distressing or harassing pains in or about the part, which often oblige the sufferer to submit to their extraction at a later period, when their removal is infinitely more difficult; and may be more distressing than at the moment of injury.

Nothing appears more simple than to cut out a ball which can be felt at the distance of an inch, or even half an inch below the skin, but the young surgeon often finds it more difficult than he expected, because he makes his incision too small; and cannot at all times oppose sufficient resistance to prevent the ball from retreating before the effort he makes for its expulsion with the forceps or other instrument. The ball also requires to be cleared from the surrounding cellular substance, to a greater extent than might at first be imagined; for all that seems to be required is, that a simple incision be made down to the surface of it, when it will slip out, which is not usually the case. When a ball has been lodged for years, a membranous kind of sac is formed around it, which shuts it in as it were from all communication with the surrounding parts. If it should become necessary to extract a ball which has been lodged in this manner, the membranous sac will often be found to adhere so strongly to the ball that it cannot be got out without great difficulty, and sometimes not without cutting out a portion of the adhering sac.

It often occurs that a ball lodges and cannot be found, especially where it has struck against a bone, and slanted off in a different direction. If the ball should lodge in the cellular tissue between two muscles, it often descends by its gravity to a considerable distance, and excites a low degree of irritation, which slowly brings it to the surface, or terminates in abscess. Colonel Ross, of the Rifle Brigade, was wounded at the battle of Waterloo by a musket-ball, which entered at the upper part of the arm and injured the bone. More than one surgeon had pointed out the way by which it had passed under the scapula and lodged itself in some of the muscles of the back. About a year afterward I extracted it close to the elbow, the ball lying at the bottom of an abscess, which was only brought near the surface by time, by the use of flannel, and by desisting from all emollient applications.[1]

[1] Various instruments have been invented for the removal of balls which have been deeply lodged in soft parts; but little assistance has been derived from them hitherto, although many of them are very ingenious.

21. A ball will frequently strike a bone, and lodge, without causing a fracture, although it will a fissure. It will even go through the lower part of the thigh-bone, between or a little above the condyles, merely splitting without separating it, and some balls have lodged in bones for years, with little inconvenience. It should nevertheless be a general rule not to allow a ball to remain in a bone, if it can be removed by any reasonable operation. The rule is not entirely devoid of exception. Lieutenant-Colonel Dumaresq, aid-de-camp to the present Lord Strafford, was wounded at Waterloo by a ball which penetrated the right scapula, and lodged in a rib in the axilla. The thoracic inflammation nearly cost him his life, but he ultimately quite recovered, and died many years afterward of apoplexy, the ball remaining enveloped in bone.

22. When a bayonet is thrust into the body it is a punctured wound made by direct pressure; when of little depth, much inconvenience rarely ensues, and the part heals slowly, but surely, under the precaution of daily pressure. A punctured wound, extending to considerable depth, labors under disadvantages in proportion to the smallness of the instrument, and the differences of texture through which it passes. When the instrument is large, the opening made is in proportion, and does not afford so great an obstacle to the discharge of the fluids poured out or secreted as when the opening is small. Lance wounds are therefore less dangerous than those inflicted by the bayonet. When a small instrument passes deep through a fascia, it makes an opening in it which is not increased by the natural retraction of parts, inasmuch as it is not sufficiently large to admit of it; and which opening, small as it is, may be filled or closed up by the soft cellular tissue below, which rises into it, and forms a barrier to the discharge of any matter which may be secreted beneath. If the instrument should have passed into a muscle, it is evident that if that muscle were in a state of contraction at the moment of injury, the punctured part must be removed to a certain distance from the direct line of the wound when in a state of relaxation, and vice versa. The matter, secreted, and more or less in almost every instance will be secreted, cannot in either case make its escape, and all the symptoms occur of a spontaneous abscess deeply seated below a fascia. That inflammation should spread in a continuous texture is not uncommon; that matter, when confined, should give rise to great constitutional disturbance is, if possible, less so; but that this disturbance takes place without the occurrence of inflammation, or the formation of matter, may be doubted; and it may be concluded that there is no peculiarity in punctured wounds that may not be accounted for in a satisfactory manner. Serious effects have been attributed to injuries of nerves, but without sufficient reason; nevertheless, those who have seen locked-jaw follow a very simple scratch of the leg from a musket-ball, more frequently than from a greater injury, are not surprised at any symptoms of nervous agitation that may occur after punctured wounds. As many bayonet wounds through muscular parts heal with little trouble, it is time enough to dilate them when assistance seems to be required. Cold water should be used at first; care should be taken not to apply a roller or compress of any kind over the wound; matter, when formed, should be frequently pressed out, and, if necessary, a free exit should be made for it.

23. A great delusion is cherished in Great Britain on the subject of the bayonet—a sort of monomania very gratifying to the national vanity, but not quite in accordance with matter of fact. Opposing regiments, when formed in line, and charging with fixed bayonets, never meet and struggle hand to hand and foot to foot, and this for the very best possible reason, that one side turns round and runs away as soon as the other comes close enough to do mischief; doubtless considering that discretion is the better part of valor. Small parties of men may have personal conflicts after an affair has been decided, or in the subsequent scuffle if they cannot get out of the way fast enough. The battle of Maida is usually referred to as a remarkable instance of a bayonet fight; nevertheless, the sufferers, whether killed or wounded, French or English, suffered from bullets, not bayonets. The late Sir James Kempt commanded the brigade supposed to have done this feat, but he has assured me that no charge with the bayonet took place, the French being killed in line by the fire of musketry; a fact which has of late received a remarkable confirmation in the published correspondence of King Joseph Bonaparte, in which General Regnier, writing to him on the subject, says: “The 1st and 42d Regiments charged with the bayonet until they came within fifteen paces of the enemy, when they turned, et prirent la fuite. The second line, composed of Polish troops, had already done the same.” Wounds from bayonets were not less rare in the Peninsular war. It may be that all those who were bayoneted were killed, yet their bodies were seldom found. A certain fighting regiment had the misfortune one very misty morning to have a large number of men carried off by a charge of Polish lancers, many being also killed. The commanding officer concluded they must be all killed, for his men possessed exactly the same spirit as a part of the French Imperial guard at Waterloo. “They might be killed, but they could not by any possibility be taken prisoners.” He returned them all dead accordingly. A few days afterward they reappeared, to the astonishment of everybody, having been swept off by the cavalry, and had made their escape in the retreat of the French army through the woods. The regiment from that day obtained the ludicrous name of the “Resurrection men.”

The siege of Sebastopol has furnished many opportunities for partial hand to hand bayonet contests, in which many have been killed and wounded on all sides, but I do not learn that in any engagements which have taken place regiments advanced against each other in line and really crossed bayonets as a body; although the individual bravery of smaller parties was frequently manifested there, as well as in the war in the Peninsula.

LECTURE II.

ON INFLAMMATION, MORTIFICATION, ETC.

24. In some very rare cases, an intense, deep-seated inflammation supervenes after some days, almost suddenly and without any obvious cause. The skin is scarcely affected, although the limb—and this complaint has hitherto been observed only in the thigh—is swollen, and exceedingly painful. If relief be not given, these persons die soon, and the parts beneath the fascia lata appear after death softened, stuffed, and gorged with blood, indicating the occurrence of an intense degree of inflammation, only to be overcome by general blood-letting; and especially by incisions made through the fascia from the wound, deep into the parts, so as to relieve them by a considerable loss of blood, and by the removal of any pressure which the fascia might cause on the swollen parts beneath.

25. Erysipelatous inflammation is marked by a rose or yellowish redness, tending in bad constitutions to brown or even to purple, but in all cases terminating by a defined edge on the white surrounding skin. It frequently spreads with great rapidity, so that the limb, and even the whole skin of the body, may be in time affected by it, the redness subsiding and even disappearing in one part, while it extends in another direction. When this inflammation attacks young and otherwise healthful persons of apparently good constitution, it should be treated by emetics, purgatives, and diaphoretics, in the first instance, with, perhaps, in some cases, bleeding. When the habit of body is not supposed to be healthy, bleeding is inadmissible, and stimulating diaphoretics, combined with camphor and ammonia, will be found more beneficial after emetics and purgatives; these remedies may in turn be followed by quinine and the mineral acids, with the infusion and tincture of bark. Little reliance can be placed on large doses of cinchona in powder; they nauseate and therefore distress.

When the inflammation extends deeper than the skin, into the areolar or cellular tissue, it partakes more of the nature of the healthy suppurative inflammation, commonly called phlegmonous, is accompanied by the formation of matter, and tends to the sloughing or death of this tissue at an early period. The redness in this case is of a brighter color, although equally diffuse, and with a determined edge; the limb is more swollen and tense, and soon becomes quagmiry to the touch. The skin is then undermined, and soon loses its life, becomes ash colored and gangrenous in spots, and separates, giving exit to the slough and matter which now pervade the whole extremity affected. If the patient survive, it will probably be with the loss of the whole of the skin and the cellular substance of the limb.

As soon as the inflamed part communicates the springy, fluctuating sensation approaching, but not yet arrived at the quagmiry feel alluded to, an incision should be made into it, when the areolæ or cells of the cellular tissue will be seen of a bright leaden color, and of a gelatinous appearance, arising from the fluid secreted into them, being now nearly in the act of being converted into pus. The septa, dividing the tissue into cells, have not at this period lost their life, and the fluid hardly exudes, as it will be found to do a few hours later, when the matter deposited has become purulent. When this change has taken place, the patient is in danger, and if relief be not given, he will often sink under the most marked symptoms of irritative fever of a typhoid type. Nature herself sometimes gives the required relief by the destruction of the superincumbent skin; but this part is tough, offers considerable resistance, and does not readily yield until the deep-seated fascia is implicated, and the muscular parts are about to be laid bare.

An incision made into the inflamed part through the cellular tissue, down to the deep-seated fascia, which should not be divided in the first instance, gives relief. One of four inches in length usually admits of a separation of its edges to the amount of two inches, by which the tension of the skin, which principally causes the mischief which follows the inflammation, is removed. As many incisions are required as will relieve this tension, according to the extent of the inflammation, which is also relieved by the flow of blood, but that requires attention, as it is often considerable, particularly if the deep fascia be divided on which the larger vessels are found to lie. If the necessary incisions be delayed until the quagmiry feeling is fully established, the skin above it is generally undermined and dies. The following case is given as the first known in London, in which long incisions were made for the cure of this disease, and their effect in relieving the constitutional irritation is so strongly marked as to need no further explanation:—

Thomas Key, aged forty, a hard drinker, was admitted into the Westminster Hospital, under my care, on the 21st of October, 1823, having fallen and injured his left arm against a stool, four days previously. On the 30th, the skin being very tense, the part springy, and yielding the boggy feel described, pulse 120, mind wandering, I proposed, in consultation with my colleagues, to make incisions into the part, but which were considered to be unusual and improper. On the 31st, the pulse being 140, and everything indicating a fatal termination, I refrained from any further consultation, although directed by the rules of the hospital; and, after my old Peninsular fashion, made an incision eight inches long into the back of the arm, and another of five on the under edge, in the line of the ulna, down to the fascia, which was in part divided; one vessel bled freely. The next day, November 1, the pulse was 90; the man had slept, and said he had had a good night. The incision on the back of the arm was augmented to eleven inches; and from that time he gradually recovered, being snatched as it were from the jaws of death.

This case, published at the time, has been the exemplar on which this most successful practice has been followed throughout the civilized world—a practice entirely due to the war in the Peninsula.

When this kind of inflammation attacks the scrotum, which it sometimes, although rarely, does, as a sporadic disease, independent of any urinary affection, incisions into it should be made with great caution, not extending beyond the discolored spots, in consequence of the loss of blood which would ensue from the great vascularity of the part. They should be confined to, and not extend beyond, the parts obviously falling into a state of slough or of mortification.

26. Mortification is the last and most fatal result of inflammation, although it may occur as a precursor of it in the neighboring parts, and not as a consequence. The essential distinction is, between that which is idiopathic or constitutional and that which is local; and has not existed long enough to implicate the system at large, or to become constitutional. Idiopathic or constitutional mortification, sphacelus or gangrene, may be humid or dry. Humid, when the death of the part has been preceded by inflammation and a great deposition of fluid in it, followed by putrefaction and decomposition, as after an attack of erysipelas following an injury. It may then be said to be acute. Dry, when preceded by little or no deposition of fluid in it, and followed by a drying, shriveling, and hardening of the part, nearly in its natural form and shape, unless exposed to external causes usually leading to putrefaction. The most remarkable instances have occurred in persons suffering from typhus fever, and exposed to cold, without sufficient covering or care. When it occurs in old persons, or in those who have lived on diseased rye or other food, it may be called chronic. The gangrene which follows wounds has been termed traumatic, which explains nothing but the fact of its following an injury.

Local mortification may be the effect of great injury applied direct to the part, or of an injury to the great vessels of the limb. It may occur from intense cold freezing the part, or from intense heat burning or destroying it.

27. It sometimes happens that a cannon-ball strikes a limb, and without apparently doing much injury to the skin, so completely destroys the internal textures that gangrene takes place almost without an effort on the part of nature to prevent it. This kind of injury was formerly attributed to the wind of a ball; but no one who has seen noses, ears, etc. injured or carried away, and all parts of the body grazed, without such mischief following, can believe that either the wind, or the electricity collected by it, can produce such effect.

The patient is aware of having received a severe blow on the part affected, which does not show much external sign of injury, the skin being often apparently unhurt or only grazed; the power of moving the part is lost, and it is insensible. The bone or bones may or may not be broken, but in either case the sufferer, if the injury be in the leg, is incapable of putting it to the ground. After a short time the limb changes color in the same manner as when severely bruised, and the necessary changes rapidly go on to gangrene. The limb swells, but not to any extent, and more from extravasation between the muscles and the bones than from inflammation, which, although it is attempted to be set up, never attains to any height. The mortification which ensues tends to a state between the humid and the dry, and rather more to the latter than the former. These cases are not of frequent occurrence, and are not commonly observed until after the blackness of the skin, and the want of sensibility and motion attract attention; for the patient is generally stupefied at first by the blow, and the part or parts about the injury feel benumbed. I made these cases an object of particular research after the battle of Waterloo, but could find only one among the British wounded. The man stated that he had received a blow on the back part of the leg, he believed from a cannon-shot, which brought him to the ground, and stunned him considerably. On endeavoring to move, he found himself incapable of stirring, and the sensibility and power of motion in the limb were lost. The leg gradually changed to a black color, in which state he was carried to Brussels. When I saw it, the limb was black, apparently mortified, and cold to the touch; the skin was not abraded; the leg was not so much swollen as in cases of humid gangrene; the mortification had extended nearly as high as the knee; there was no appearance of a line of separation; and the signs of inflammation were so slight that amputation was performed immediately above the knee. On dissecting the limb, I found that a considerable extravasation of bloody fluid had taken place below the calf of the leg, and in the cavity thus formed some ineffectual attempts at suppuration had commenced. The periosteum was separated from the tibia and fibula; the popliteal artery was, on examination, found closed in the lower part of the ham by coagulated lymph, proceeding from a rupture of the internal coat of the vessel. Two inches below this the posterior tibial and fibular arteries were completely torn across, and gave rise, in all probability, to the extravasation. The operation was successful. The proper surgical practice in such cases is to amputate as soon as the extent of the injury can be ascertained, in order that a joint may not be lost, as the knee was in this instance. It is hardly necessary to give a caution not to mistake a simple bruise or ecchymosis for mortification. To prevent such an error leading to amputation, Baron Larrey has directed an incision to be previously made into the part, and to this there can be no objection.

When a large shot or other solid substance has injured a limb to such an extent only as admits of the hope of its being possible to save it, this hope is sometimes found to be futile, at the end of three or four days, from a failure of power, in the part below the injury, to maintain its life for a longer time: mortification is obviously impending. In military warfare, uncontrollable events often render amputation unavoidable in such a case. Under more favorable circumstances, the surgeon should be guided by the principle laid down of constitutional and local mortification; and, although the line cannot perhaps be distinctly drawn between them at the end of three, four, or more days, it will be better to err on the side of amputation than of delay. If the limb should be swollen or inflamed to any distance, with some constitutional symptoms, in a doubtful habit of body, the termination will in general be unfavorable, whichever course be adopted, more particularly if the amputation must be done above the knee. The consideration of the circumstances in which the patient is placed, his age, and habit of body, should have great weight in forming a decision in the first instance, as to the propriety of attempting to save the limb, which ought only to be done in persons of good constitution and apparent strength.

28. Whenever the main artery of a limb is injured by a musket-ball, mortification of the extremity will frequently be the result, particularly if it be the femoral artery; it will be of certain occurrence if both artery and vein are injured, although they may not be either torn or divided. There may not then be such a sudden loss of blood, in considerable quantity, as to lead to the suspicion of the vessel being injured. The fact is known from the patient’s soon complaining of coldness in the toes and foot, accompanied by pain, felt especially in the back part or calf of the leg, or in the heel, or across the instep, together with an alteration of the appearance of the skin of the toes and instep, which, when once seen, can never be mistaken. It assumes the color of a tallow candle, and soon the appearance of mottled soap. Although there may be little loss of temperature under ordinary circumstances of comfort, there is a feeling of numbness, but it is only at a later period that the foot becomes insensible. This change marks the extent of present mischief. The temperature of the limb above is somewhat higher than natural, and some slight indications of inflammatory action may be observed as high as the ham, and the upper part of the tibia in front; it is at these parts that the mortification usually stops when it is arrested. The general state of the patient, during the first three or four days, is but little affected, and there is not that appearance of countenance which usually accompanies mortification from constitutional causes. In a day or two more, the gangrene will frequently extend, when the limb swells, becomes painful, and more streaked or mottled in color; the swelling passes the knee, the thigh becomes œdematous, the patient more feverish and anxious, then delirious, and dies.

An extreme case will best exemplify the practice to be pursued. A soldier is wounded by a musket-ball at the upper part of the middle third of the thigh, and on the third day the great toe has become of a tallowy color and has lost its life. What is to be done? Wait with the hope that the mortification will not extend. Suppose that the approaching mortification has not been observed until it has invaded the instep. What is to be done? Wait, provided there are no constitutional symptoms; but if they should present themselves, or the discoloration of the skin should appear to spread, amputation should be performed forthwith, for such cases rarely escape with life if it be not done. Where in such a case should the amputation be performed? I formerly recommended that it should be done at the part injured in the thigh. I do not now advise it to be done there at an early period, when the foot only is implicated; but immediately below the knee, at that part where, if mortification ever stops and the patient survives, it is usually arrested; for the knee is by this means saved, and the great danger attendant on an amputation at the upper third of the thigh is avoided. The upper part of the femoral artery, if divided, rarely offers a secondary hemorrhage. The lower part, thus deprived by the amputation of its reflex blood, can scarcely do so; and if it should, the bleeding may be suppressed by a compress. The blood will be dark colored. If the upper end should bleed, the blood will be arterial, and by jets, and the vessel must be secured by ligature.

29. When from some cause or other amputation has not been performed, and the mortification has stopped below the knee, it is recommended to amputate above the knee after a line of separation has formed between the dead and the living parts. This should not be done. The amputation should be performed in the dead parts, just below the line of separation, in the most cautious and gentle manner possible, the mortified parts which remain being allowed to separate by the efforts of nature. A joint will be saved, and the patient have a much better chance for life.

30. A wound of the axillary artery rarely leads to mortification of the fingers or hand. If it should do so, the principle of treatment should be similar, although the saving of the elbow is not so important as that of the knee: neither is the amputation in the axilla, below the tuberosities of the humerus, as dangerous as that above the knee.

31. Mortification after the sudden application of intense cold or heat is to be treated on similar principles.

32. When a nerve or plexus of nerves conveying sensation and motion, and going to a part, or an extremity of the body, is divided, the part or limb is deprived of three great qualities: motion, sensation, and the power of resisting with effect the application of a degree of heat or of cold, which is innocuous when applied in a similar manner to the opposite or sound extremity. In other words, it will be scalded by hot water and frost-bitten by iced or even cold water, which are harmless when applied to another and a healthy part.

An officer received, at the battle of Salamanca, two balls, one under the left clavicle, which was supposed to have divided the brachial plexus of nerves, as the arm dropped motionless and without sensation to the side. The other ball passed through the knee-joint, which suppurated. The left side of the chest became affected; he suffered from severe cough, followed by hectic fever, and was evidently about to sink. As a last chance, I amputated his leg above the knee, after which he slowly recovered. Fourteen years afterward he showed me his arm in the same state, and told me he had been indicted for a rape, but that the magistrates, seeing the wooden leg and the useless arm, while admitting the attempt, would not assent to the committal of the offence.

33. When one nerve only of several going to an extremity such as the arm and hand, is divided, the loss sustained is confined to the extreme part more immediately supplied by the injured nerve. Thus, if the ulnar nerve only be divided, the little finger and the adjacent side of the ring finger suffer, perhaps in some degree the inner side of the thumb and the adjoining fingers; if the median nerve, the thumb and other fingers; if the radial, the back of the hand next the thumb. In some instances there seems to be a kind of collateral communication by which a degree of sensibility is after a time recovered.

34. If any foreign substance should lodge in and continue to irritate the nerve, the wounded part often becomes so extremely painful as not to be borne; the nerve at that part forms a tumor of a most painful character, requiring removal, or in extreme cases even the amputation of the extremity.

35. After an ordinary amputation, the extremity of a nerve enlarges so as to resemble a leek, and if this should adhere to the cicatrix of the wound, painful symptoms, referred to the toes and other parts of the removed leg, are experienced often to an almost unbearable degree; the end of the nerve should be removed. The pain apparently felt in and referred to the toes is merely the effect of irritation of the extremity of the nerve.

36. Wounds or injuries of nerves, which do not entirely divide the trunk, or a principal branch given off from a plexus of nerves, may give rise to general as well as to local symptoms; that is, by sympathy, connection, or continuity of disease, other nerves and organs of the body are affected. This applies also to the spinal marrow, when the injury does not destroy at once. General Sir James Kempt was wounded at the storming of the castle of Badajoz, on the inside of the left great toe, by a musket-ball which, from the appearance of a slit-like opening, was supposed to have rebounded from the bone, but was discovered a fortnight afterward flattened and lying between it and the next toe. Inflammation had ensued, followed by great irritability and numerous spasmodic attacks, appearing to render locked-jaw probable. The spasms soon became general, extending from the foot to the head, but tetanus did not take place. On his return to England, they gradually subsided, but he did not sleep at night for a year. After the battle of Waterloo the spasms became more frequent and troublesome, attacking the muscles at the back of the neck and throat, causing considerable anxiety. The attack was often traced to exposing the foot to cold or to undue pressure, and frequently to derangement of stomach, although he was most regular in diet. After the lapse of six or seven years these severe symptoms subsided; but during the last forty years of his life he suffered occasionally from them.

Admiral Sir Philip Broke received a cut with a sword on boarding the Chesapeake, on the left side of the back of the head, which went through his skull, rendering the brain visible; the wound healed in six months, although splinters of bone came away for a year. A second cut on the right side did not penetrate the bone. After a temporary paralysis of the right side, he recovered, with a loss of power and a disordered sensation in the second, third, and little fingers of the right hand, aggravated by cold weather and by mental anxiety.

Seven years afterward, he fell from his horse, and suffered from concussion of the brain, which added to his former sensations by rendering the left half of his whole person incapable of resisting cold, or of evolving heat. In a still atmosphere abroad, at 68° Fahr., he said, “the left side requires four coatings of stout flannel, which are augmented as the thermometer descends every two degrees and a half, to prevent a painful sense of cold; so that when it stands at the freezing point the quantity of clothing of the affected side becomes extremely burdensome. When exposed to a breeze, or even in moving against the air, one or even two oilskin coverings are necessary in addition, to prevent a sensation of piercing cold driving through the whole frame. Moderate horse exercise and generous diet improved the general health; the warm bath caused a distressing effect; the shower bath, cold or tepid, increased the paralytic affection. Frictions, with remedies of all kinds, increased it also, and so did sponging with vinegar and water, as well as any violent, stimulating, quick excitement, or earnest attention to any particular subject. The Admiral died unrelieved, twenty-six years after the receipt of the injury, of disease of the bladder.”

37. Brigade-Major Bissett was wounded on horseback, in the Kaffir war, by a musket-ball, which entered on the outside of the lower part of the left thigh, passed upward across the perineum, wounding the rectum within the anus—from which part he lost a quantity of blood—and came out through the pelvis on the opposite side. The course of this ball was accounted for by the fact that he saw the Kaffir who shot him standing some yards below him when he fired. The ball, in its passage upward and across the thigh, injured the great sciatic nerve, and the consequence is continued pain in the toes, instep, and foot, with contraction of the muscles, and lameness, together with the usual incapability of bearing heat or cold, particularly the latter, against which he is peculiarly obliged to guard. The skin shows no sign of discoloration or derangement. Position gives the explanation why the ball took such a peculiar course; the symptoms show the nature of the injury. From other effects he has perfectly recovered, but his leg is comparatively useless, while it is a constant source of suffering.

38. The cases related in the Lectures on wounds of arteries, of mortification taking place in the foot and leg, after the division of the principal artery in the thigh, show that the maintenance of the life of a part depends on the blood. The cases now related show that neither an injury nor the division of the principal nerve, nor, perhaps, of all the nerves going to a part, will destroy that life. The complete failure of the circulation, in a part such as the foot, impairs, but does not totally destroy, the sensibility imparted by the nerves, until after the loss of life has taken place, or until decomposition is about to occur. An injury then to the nerve causes great pain, not usually at the part injured, but in the extreme parts supplied by it; some loss of the power of motion; some deprivation of its ordinary sensibility, as shown by a feeling of numbness, and an incapability, to a certain extent, of resisting heat or cold. When all the nerves have been divided, the power of moving the limb is lost, as well as its sensibility in a general sense. The temperature remains at a natural standard under ordinary circumstances, but no extra evolution of heat can take place by which cold is resisted, nor any absorption of it, which perhaps renders the application of a high temperature, particularly when combined with moisture, dangerous. The circulation is capable of maintaining the ordinary heat of a part, although it is deprived of the influence of the special nerves of sensation and of motion; but a greater evolution of heat appears to depend on something communicated by the nerves in a state of integrity. In the case of Sir P. Broke, this something appeared to be derived from the brain, on which part the wound was inflicted, and the transmission of which was interrupted by the injury. The evolution of animal heat has of late been supposed to be dependent on electricity, from the resemblance which exists between it and the nervous power, although the attempts to identify them have not been successful. That the evolution of heat is the result of nervous power, appears to be indisputable; in what that power consists, physiologists have yet to ascertain.

39. The best means of mitigating the pain, independently of the application of warmth—and cold rarely does good, as the sufferer soon finds out—is by the application of stimulants to the whole of the extremity affected, followed by narcotics. The tinctures of iodine and lytta, the oleum terebinthinæ, the oleum tiglii or cajeputi, the liquor ammoniæ or veratria, may be used in the form of an embrocation, of such strength as to cause some irritation on the skin, short, however, of producing any serious eruption. After the parts have been well rubbed, opium, belladonna, or henbane may be applied in the form of ointment; or the tincture of opium, henbane, or aconite may in turn be applied on linen. Great advantage has been derived in many neuralgic pains from the application of an ointment of aconitine, carefully prepared, in the proportion of one grain to a drachm of lard, at which strength it will sometimes irritate almost to vesication, as well as allay pain.

When the pains return from exposure to cold, particularly in the lower extremity, great advantage has been derived from cupping on the loins, from purgatives, opiates, and the warm bath. Benefit has been obtained occasionally from quinine, and from belladonna, aconite, and stramonium, administered internally in small doses frequently repeated, but not suffered to accumulate without purgation; as the accumulated effects are sometimes dangerous.

LECTURE III.

AMPUTATIONS, ETC.

40. When the wound of an extremity is of so serious a nature as to preclude all hope of saving the limb by scientific treatment, it should be amputated as soon as possible.

41. An amputation of the upper extremity may almost always be done from the shoulder-joint downward, without much risk to life. When necessary, the sooner it is done the better.

42. An amputation of any part of the lower extremity below the knee may be done forthwith, with nearly an equal chance of freedom from any immediate danger, as of the upper extremity at or near the shoulder-joint.

43. It is otherwise with amputations above the middle of the thigh, and up to the hip-joint. They are always attended with considerable danger.

44. There can be no doubt that if the knife of the surgeon could in all cases follow the ball of the enemy or the wheel of a railway carriage, and make a clean good stump, instead of leaving a contused and ragged wound, it would be greatly to the advantage of the sufferer; but as this cannot be, and an approach to it even can rarely take place, the question naturally recurs,—At what distance of time, after the receipt of the injury or accident, can the operation be performed most advantageously for the patient?

45. In order to answer this question distinctly, it should be considered with reference to distinct places of injury:—

1st. When injuries require amputation of the arm below the shoulder-joint, or of the leg below the knee, these operations may be done at any time from the moment of infliction until after the expiration of twelve or twenty-four hours, without any detriment being sustained by the sufferer with regard to his recovery; although every one, under such circumstances, must be desirous to have the operation over. The surgeon having several equally serious cases of injury of the head or trunk brought to him at the same time as two requiring amputation of the upper extremity, may defer the latter more safely perhaps than the assistance he is also called upon to give to the other cases, the postponement of which may be attended with greater danger.

2d. This state embraces those great injuries in which the shoulder is carried away with some injury to the trunk; or the thigh is torn off at or above its middle, rendering an amputation of the upper third, or at the hip-joint, necessary. It is this or nearly this state which alone implies a doubt as to the propriety of immediate amputation, and demands further investigation. It is the state to which attention is earnestly drawn for future observation.

46. It has been implied, if not actually maintained, that a man could have his thigh carried away by a cannon-shot without being fully aware of it, or, if aware of it, that it did not cause much alarm—in fact, that it did not materially signify as to his apprehension, whether the ball took off his limb or the tail of his coat, or only grazed his breeches. An instance of this kind has not fallen under my observation.

47. A surgeon on the field of battle can rarely have a patient brought to him, requiring amputation, under less time than from a quarter to half an hour; a surgeon in a ship may see his patient in less than five minutes after the receipt of the injury; and to the surgeons of the navy we must hereafter defer for their testimony as to the absence or presence of the constitutional alarm and shock to which I have alluded, and to what degree they follow, immediately after the receipt of such injury. The question must not be encumbered and mystified by a reference to all sorts of amputations after all sorts of injuries, but to the one especial injury, viz., that of the upper third of the thigh.

48. My experience, which may be erroneous, like everything human, has taught me, that when a thigh is torn, or nearly torn off, by a cannon-shot, there is always more or less loss of blood, suddenly discharged, which soon ceases in death, or in a state approaching to syncope. When the great artery has been torn, this fainting saves life, for an artery of the magnitude of the common femoral does not close its canal by retracting and contracting in the same manner as a smaller vessel; it can only diminish it; and the formation of an external coagulum is necessary to preserve life, which the shock, alarm, and fainting, by taking off the force of the circulation, aid in forming; and without which the patient would bleed to death. An amputation, in this state of extreme depression, might destroy life, although aided by the exhibition of chloroform.

49. If the cannon-shot, or other instrument capable of crushing the upper part of a thigh, should not divide the principal artery, and the sufferer should not bleed, it is possible he may be somewhat in the state alluded to in which the patient, for he may not be called sufferer, is said to be just as composed as if he had only lost a portion of his breeches. Nevertheless few have seen a man lose even a piece of his skin and of his breeches by a cannon-shot, without perceiving that he was indisputably frightened. Dr. Beith, surgeon of the Belleisle, hospital ship, in the Baltic, informs me that Mr. Wrottesley, of the Engineers, was struck by a cannon-shot, at Bomarsund, on the upper part of his right thigh, which shattered it and his hand, which was resting upon it. His leg was also broken by a splinter from the gun which the ball had previously struck. The femoral artery was not injured, and it was said he lost but little blood. He, however, never rallied from the blow, but sank in twenty minutes after he was brought to Dr. Beith. The constitutional shock and alarm were great; countenance sunk and pallid, pulse scarcely perceptible.

“An East Indian, twenty-two years of age, of healthy aspect, in the month of October, 1854, when proceeding on a shooting excursion, at Moulmein, in Burmah, was most severely wounded by the accidental explosion of his gun, the entire charge of large shot lodging in the center of the left thigh, and causing a bad compound fracture, with fearful laceration of the soft parts. I was asked to see the patient by Dr. Reynolds, the staff-surgeon of the station, at half-past seven A.M., an hour after the injury had been inflicted, and found him laboring under most urgent collapse and great nervous depression. It was of course impossible to save the limb, but I suggested delay for some hours, and the moderate use of stimulants, till the system had in some degree recovered its equilibrium. Such was the case at five P.M., and the flap operation was done while the man was under the full influence of chloroform, (three drachms being required for that purpose.) When placed in bed, he became conscious, but never rallied, and died in half an hour.

“Very little blood was lost during the operation, and the impression on my mind was, that it would have been wiser to have steadily but carefully continued the use of stimulants during the operation, and thus have counteracted the shock of the latter following on that of the injury, from which the system had only partially recovered.”—Case by Dr. Dane, Surgeon to the Forces.

Deputy Inspector-General Taylor informs me that “a young muscular man, of the siege-train, had his left thigh nearly carried off at its middle by a cannon-shot at Sebastopol. The soft parts on the inside, including the artery, escaped laceration; the remaining soft parts and large pieces of bone were entirely carried away, the injury extending above the middle of the bone. The muscles on the fore part of the other thigh were extensively laid bare and injured. The prostration was great; pulse feeble; the man’s spirits were good, and he desired amputation under chloroform. The left thigh was amputated at the upper third. The chloroform, administered on a pocket-handkerchief, lightly folded, and held over the nose and mouth, speedily took effect. I am under the impression that the chloroform not only caused insensibility to pain, but supported the system during the operation, although the man died an hour after its completion. Nevertheless, I think the chloroform enabled the man to bear the operation better than he would have done without it.”

This case does not quite meet my proposition as to the effect of chloroform when the thigh has been carried off nearer the hip-joint, with rupture of the principal artery; cases which have hitherto been usually lost, whether amputation is performed or not.

50. While some persons, under the loss of a thigh high up, are reduced to a state of syncope, or nearly approaching to it, which renders them almost or even entirely speechless, others are said to suffer extreme pain, and earnestly entreat assistance, under which circumstances amputation should be performed forthwith. In the former, the administration of stimulants may render the operation less immediately dangerous. In the latter, they will be beneficial, and may save life.

51. Chloroform, or other similar medicaments, may produce an effect in such cases as yet unknown. Its careful administration may not destroy the ebbing powers of life, and may render an amputation practicable, which could not otherwise be performed without the greatest danger. It may be otherwise; the point, however, is to be ascertained, although in all cases of great suffering its use should be unhesitatingly adopted.

Much difference of opinion having taken place on the subject of chloroform, I requested Dr. Snow, who has superintended its use in many of our hospitals, and in almost all the cases of serious operation in private life, to draw up his observations and opinions in the most compendious form possible, which he has been so good as to do, in the following terms:—

“Chloroform may be given with safety and advantage to every patient who requires, and is in a condition to undergo, a surgical operation. A state of great depression, from injury or disease, does not contra-indicate the use of chloroform. This agent acts as a stimulant in the first instance, increasing the strength of the pulse, and enabling the patient, in a state of exhaustion, to go through an operation much better than if he were conscious.

“Persons who have died from the effects of chloroform had disease of the heart, or of some other vital organ, but the majority had a sound state of constitution; and it seems probable that the average health of persons who have been the subject of accident has been at least as good as that of those who have taken chloroform without ill effects. From these and other considerations I am of opinion that accidents from chloroform are to be prevented by care in its administration, and not by the selection or rejection of cases for its employment.

“When animals are made to breathe air containing not more than four or five per cent. of the vapor of chloroform till death ensues, the breathing ceases very gradually, being first rendered laborious and then feeble, and the heart continues to beat for a minute or two after respiration has ceased. During this interval, while the heart is still beating, the animal can be easily restored by artificial respiration. This mode of death from chloroform might undoubtedly take place in the human subject, if a person were to go on giving it regardless of the symptoms; but a careful examination of all the recorded cases of death from this agent shows that it has not occurred in this manner. On the contrary, the symptoms of danger have in every instance come on suddenly, and the action of the heart has been arrested at the same moment as the breathing, or even before it. This is precisely the way in which the lower animals die when they are compelled to breathe air containing eight or ten per cent. of the vapor of chloroform. It is therefore evident that the cause of death is the inhalation of the vapor of chloroform not sufficiently diluted with common air.

“It requires more chloroform to suspend the functions of the ganglionic nerves, which preside over the contractions of the heart, than to suspend the functions of the medulla oblongata and the nerves of respiration; but the action of the heart may be arrested by the direct effect of this agent. Chloroform, when inhaled, is absorbed by the blood in the lungs, passes at once to the left cavities of the heart, and is immediately sent through the coronary arteries to every part of that organ, in less time, probably, than it can reach the brain; or, supposing the respiration to be suddenly arrested by the action of the chloroform on the brain, the vapor, not being sufficiently diluted, is present in large quantities in the lungs at the moment when the breathing ceases; and becoming absorbed, in addition to that which was already in the blood, has the effect of paralyzing the heart.

“Twenty-five minims of chloroform produce only twenty-six cubic inches of vapor, and as one hundred cubic inches of air, at 60° Fahr., will take up fourteen cubic inches of vapor, and at 70° will take up twenty-four cubic inches, if fully saturated, it is quite possible that the air during inhalation may contain ten per cent. of the vapor, if means be not taken to prevent it. Under these circumstances, each hundred cubic inches of air would contain nearly ten minims of chloroform, and this might be taken into the lungs at once by a rather deep inspiration. The average quantity of chloroform present in the blood of an adult, when sufficiently insensible for a surgical operation, is eighteen minims, while twenty-four minims are as much as can be present in the system at one time with safety. The absorption of a little more than thirty minims would have the effect of causing death, even if it were equally diffused throughout the circulation. It must be evident, therefore, that to take ten minims of chloroform into the lungs at one inspiration, when insensibility is almost complete, must be attended with danger.

“Robust persons, accustomed to hard work or violent exercise, are very apt to become affected with rigidity of the muscles and struggling, when nearly insensible from chloroform; and they often hold the breath for a time, and then draw a deep inspiration. It is under these circumstances that several of the accidents from chloroform have taken place, and extreme care is required to give the chloroform more than usually diluted with air, when this state of unconscious struggling and rigidity occurs.

“The most important point to attend to, in the exhibition of chloroform, is to insure that the vapor shall be sufficiently diluted with air during the whole process of inhalation. This may be effected with a suitable apparatus and proper attention, or if an inhaler be not at hand, the chloroform should be diluted with one or two parts by measure of rectified alcohol. One or two drachms of this may be placed on a hollow sponge, and repeated when required. The spirit has the effect of limiting the quantity of chloroform which rises in vapor, while very little of the diluent is inhaled, since, from its lower volatility, the greater part of it remains on the sponge or handkerchief employed to exhibit the chloroform.

“When the chloroform vapor is so diluted that it does not constitute more than four or five per cent. of the respired air, its effects become developed very gradually and regularly. The suspension of the sensibility of the conjunctiva at the border of the eyelids is the best sign that the patient will bear the operation without flinching, and the inhalation should immediately be left off if the breathing become stertorous. The pulse is not a very important guide in the exhibition of chloroform, for the two following reasons: 1st, if the vapor be sufficiently diluted with air, the pulse cannot be seriously affected by it; and 2d, if it be not so diluted, the pulse may cease suddenly, without previous warning of danger.

“If the vapor of chloroform be sufficiently diluted with air, it is practically impossible that any accident, really due to this agent, should occur. In case of accident, however, artificial respiration, very promptly and efficiently performed, is the only means which affords a prospect of restoring the patient—at all events, this is the only means found to restore animals when it was obvious they would not recover spontaneously. The prospect of success from artificial respiration will depend on the greater or less extent to which the heart is affected by the direct action of the chloroform.”

Mr. Syme, in his “Clinical Observations,” delivered in the Royal Infirmary in Edinburgh, recommends, in cases of approaching death from the use of chloroform, that the tongue should be drawn forward by means of a pair of artery forceps, by which it is presumed the epiglottis is raised, and a greater facility afforded for the admission of atmospheric air, the inconvenience resulting from two small holes in the tip of the tongue being amply compensated by the preservation of life.

Nevertheless, I am of opinion that attention should be paid to the pulse, and whenever it begins to fail or flutter, the inhalation of chloroform should be arrested; for respiration and the pulse often cease almost simultaneously, and in some instances have done so irrecoverably.

I formerly said that chloroform might be used with advantage in all cases of injury requiring amputation, save one, and in that one experience was wanting to decide the point. It is when a thigh has been carried off by a cannon-ball, or destroyed at its upper part by any other means, such as the wheels of a railway carriage or other weighty machine. When the thigh is carried off by a cannon-shot, the artery being torn across, there is so great a shock and so great a loss of blood at the moment, followed by fainting, or such faintness as leads to the belief that the sufferer is dying, and some do actually die without an effort at recovery. In such a case, or in one somewhat similar, Dr. Snow and others think chloroform would act as a stimulus, and that it would enable the patient to bear the operation of amputation with success, which he otherwise might not have done. It may be so; but, as I believe nothing in surgery until fairly tried and found to answer, I refrain, for the present, from expressing a positive opinion, save that the trials should be made with great caution, inasmuch as the observations which have been made in the Crimea have not been sufficiently numerous or so decisive as to settle the point in favor of the chloroform, although they confirm all the others to which allusion has been made. In these cases a tourniquet cannot be applied, and the sudden loss of blood saves the life of the sufferer for the time, by suppressing the bleeding; which suppression, I have long since pointed out, is effected in the artery at the groin, by the formation of a coagulum, and not by the contraction and retraction of the vessel into the shape of the neck of a claret bottle, which would take place at the lower third of the same artery in the thigh under a similar injury; in which case, also, the bleeding would cease by the unassisted efforts of nature. If the artery, there or elsewhere, should, on the contrary, be only partially divided, the person would bleed to death, unless surgery of some kind should come to his aid.

52. When the sufferer is brought to the surgeon at the end of half an hour, having lost a limb below the thigh or shoulder by a cannon-shot, he will often be found in a state of such great depression as to be likely to be destroyed by the infliction of a serious and painful operation like amputation, unless chloroform should relieve it. This has occurred to me so often as to induce me formerly to recommend delay for four, six, or even eight hours, if the unfortunate person did not suffer much, and appeared likely to be revived by the proper use of stimulants. If he should be in great pain, the limb should be removed under chloroform.

53. This recommendation originated from the fact that, as one seriously wounded man has as much claim as another to the attention of the surgeon, all could not be attended to at the same time; and the success following the deferred cases of amputation was as great, if not greater, than in those on which the operation was more immediately performed.

54. The advantageous results of primary amputations, or those done within the first twenty-four, or at most forty-eight hours, over secondary amputations, or those done at the end of several days, or of three or four weeks, have been so firmly and fully established as no longer to admit of dispute.

55. When an amputation is deferred to the secondary period, a joint is often lost. A leg which might have been cut off below the knee in the first instance is frequently obliged to be removed above the knee when done in the second.

56. In the secondary period after great injuries, the areolar and muscular textures near the part injured are often unhealthy, the bones are in many instances inflamed internally, and their periosteal membranes deposit on the surrounding parts so much new ossific matter as frequently to envelop in a few days the ligatures on the vessels, and render them immovable, necrosis of the extremity of the bone following as a necessary consequence, thus protracting the cure for months.

57. Sloughing of the stump, accompanied by inflammation of the vein or veins leading to the cava, frequently takes place. This state of stump is often followed by purulent deposits in and upon the different viscera, and principally in the cavities of the chest. Where febrile diseases are endemic, they often prevail; the constitutional irritation is great; the stumps do not unite, or, if apparently united, open out and slough, and frequently after a few days implicate the veins.

58. In the first edition of my work on Gunshot Wounds, and on the great operations of Amputation, published in 1815, I said, alluding to secondary operations: “In the most favorable state of the stump, the diseased parts do not extend very deep; yet inflammation is frequently communicated along the vein, which is found to contain pus, even as far as the vena cava.” “When I have met with this appearance, I have always considered the vessels as participating in (not originating) the disease, which had existed some days, and thereby more quickly destroying the patient.” I further said that after secondary amputations, the febrile irritation, allayed by the operation, sometimes returns, and more or less rapidly cuts off the patient by an affection of some particular internal part or viscus, especially of the lungs. “If it be the lungs, and they are most usually affected, the breathing becomes uneasy; there is little pain when the disease is compared with pneumonia or pleuritis; the cough is dry and not very troublesome; the pulse having been frequent, there is but little alteration; the attention of the surgeon is not sufficiently drawn by the symptoms to the state of the organ, and in a very short time all the symptoms are deteriorated: blisters are employed, perhaps blood-letting, but generally in vain; and the patient dies in a few hours, as in the last stage of inflammation of the lungs, in which effusion or suppuration has taken place.” “My attention was drawn to it after losing several cases in this way, as a circumstance of more than common accident, from its having happened to a young officer to whom I was paying considerable attention, (at Salamanca.) Since that I had one well-marked case at Santander, of a sudden and fatal affection of the lungs after amputation of the thigh, which was under the immediate care of Dr. Irwin,” and of myself as the principal medical officer. The late Mr. Rose, of the Guards, communicated a case, after amputation of the arm, to Sir James M’Grigor, who forwarded it to me; and my old friend, the late Mr. Boutflower, who served frequently under me during the latter part of that war, and aided me in all my labors and views, forwarded to me, at the same time, two cases from Fuenterabia, which terminated fatally after amputation of the arm, from the deposition of a considerable quantity of pus in the cavity of the thorax. “So insidious,” he said, “was the approach of the disease, that, except a difficulty of breathing which supervened a few hours before death, there were no symptoms indicating the existence of such a morbid affection.” No further notice was taken of this disease by any one in any of the hospitals on entering France in 1813, neither at St. Jean de Luz, nor Bayonne, nor Pau, St. Sever, Tarbès, or Orthez, until after the battle of Toulouse, where the following cases occurred, which I published previously to any one else in 1815.

A soldier suffered amputation of the thigh five weeks after the injury, in consequence of a gunshot fracture at Toulouse, he being in a very reduced state, the discharge profuse, the pain great, hectic fever severe. The third day after the operation, from which he scarcely rallied, he complained of difficulty in swallowing, and pain in the situation of the thyroid gland, which was found next morning to be inflamed. In spite of the means employed, he died on the fourth day of this attack, or the seventh after the amputation, in a state of great emaciation. On dissection, the whole substance of the thyroid gland was destroyed, a deposit of good pus occupying its place, which descended by the sides of the trachea and œsophagus to the sternum, and had all but found its way into the larynx, between the cricoid and thyroid cartilages on the right side.

Daniel Lynch, wounded through the knee-joint at the battle of Toulouse, on the 12th of April, 1814, had his thigh amputated by the late Mr. Boutflower, on the 8th of May. The night succeeding the operation he passed comfortably. Next day, the 9th, the febrile symptoms were augmented. On the 10th he was worse; pulse 150. On the 11th he was better. On the 16th he was considered to be in a state of convalescence, and went on improving until the 22d, when fever recurred. On the 28th his stomach became very irritable; the stump appeared to be nearly healed, the discharge being small, and of good quality; one ligature remained. 30th: Pulse 110; tongue of a brownish hue. During the 31st and 1st of June he got worse, and died. The stump appeared to have united externally, except where the ligatures came out; but, on cutting through the line of adhesion, the muscular parts within were evidently unhealthy; the bone was surrounded for some distance by a case of osseous matter, including the remaining ligature, which could not be removed by any force short of breaking it. The femur was bare, and showed marked signs of absorption having commenced; three inches of it must have come away if the man had lived. The extremity of the vein was in a sloughing state.

Having dissected the other extremity for a clinical lecture I was occasionally in the habit of giving on particular cases, a semi-transparent membranous bag, containing good pus, was found accidentally on the tibialis posticus muscle. The blood in the perineal vein outside of it was coagulated; there were little or no marks of inflammation, and the matter appeared to have been deposited without any. The inner side of the soleus muscle seemed simply to be discolored.

The first edition, containing these facts, which were before unknown, and which furnish another laurel to the surgery of the Peninsular war, having been published before the battle of Waterloo, the opinions and facts stated therein became matters for public discussion, and the reports made by my friends from Brussels, Antwerp, Yarmouth, and Colchester, confirmed all the facts, and, I may add, all the opinions of the slightest importance. They were published in the second edition in 1820, and again more pointedly in the third, published June 18, 1827.

59. Forty years have passed away since I stated my opinion, that inflammation of the veins is of two kinds—the adhesive or healthy, from which the sufferers usually recover, as in the cases of women laboring under the disease called phlegmasia dolens, and the irritating or unhealthy, occurring after operations; the disease being communicated by continuity to the vein, rather perhaps than originating in it. I then said I did not believe that pus is carried from the inside of the vein to the general circulation, the office of the vein as a carrier of blood ceasing on the inflammation taking place in its internal tissue, although I admit that the blood in a vitiated state, from the commencing disease in the stump, or in the system, may have for some time passed along it into the general circulation. The inflammation thus commencing may extend upward and downward, and across to the opposite side of the body, as I first demonstrated in 1825, in the case of Jane Strangemore, p. 47. I never saw it actually in the heart, the sufferers dying by the time it had reached as high as the diaphragm, and in general before it had got so far.

60. When a person, after undergoing amputation, is about to suffer from unhealthy inflammation of the veins, the pulse quickens, and continues above 90, usually rising from 100 to 130. The stomach becomes irritable; there are frequent attacks of vomiting, generally of a bilious character, accompanied by the usual symptoms of fever. A few days after the commencement of the complaint, there is usually a well-marked rigor, followed perhaps by others, but exacerbations and remissions of fever are common. The skin gradually assumes a yellowish tinge, the perspiration is excessive, the bowels irregular, the pulse becomes weaker and more irritable, the emaciation is considerable, and the patient gradually sinks; or the febrile symptoms may subside, with the exception of the frequency of the pulse, the patient rallies a little, but while he says he is better, and the appetite even returns, the deterioration in appearance becomes more marked, more deathlike, even while eating, and an accession of fever rapidly closes the scene. The stump is often not more painful than under ordinary circumstances, neither is there any remarkable pain or tenderness in the course of the vessels.

61. The practical points are, to draw blood with caution, on the accession of fever, provided a remittent or typhoid form does not prevail; to open out the stump as soon as possible, even by a division of the external adhesions, the inner parts being usually unsound; to envelop it in a large warm poultice; to apply cold above, even ice if procurable, in the course of the great vessels, and to soothe the system by calomel, opium, and saline diaphoretic remedies, followed by stimulants, cordials, quinine, and acids.

Private A. Clarke, 79th Regiment, had his thigh broken by a musket-ball a little above the knee-joint, at Waterloo, and was admitted into the clinical ward of the York Hospital, in London, in November, 1816. The bone being in a state of necrosis, Mr. Guthrie amputated the thigh high up, on the 20th of January, 1817. Pulse before and after the operation 104. On the 25th, pulse 120; skin cool; tongue moist; appeared weak and irritable. During the 26th and 27th, symptoms of low fever came on. 28th, suffered severely from vomiting, general fever, greater prostration of strength; stump had not united, but discharged good pus. 30th, skin assumed a yellow tinge.

On the 1st of February, had a rigor resembling a fit of ague, and Mr. Guthrie declared his suspicion of the formation of matter, probably in the liver, and of inflammation of the veins of the stump. The symptoms gradually assumed the character of typhus gravior, and on the 8th he died. On dissection the liver was found enlarged, and weighing six pounds; the other viscera were sound. On examining the stump an abscess containing four ounces of good pus was found in the under part, near the bone. The femoral vein and those going to that part of the stump were inflamed, and contained coagulated blood, lymph, and purulent matter, the disease extending from the femoral to the vena cava. The rigors on the 1st February marked the formation of matter, the typhoid symptoms its continuance, and the inflammation of the veins. Union was discouraged from the first dressing.

The following case is so highly instructive on all points, that it is transcribed from the London Medical and Physical Journal for 1826:—

Jane Strangemore, aged twenty-eight, was admitted into the Westminster Hospital, September 24, 1823, with an elastic swelling of the whole of the knee-joint, measuring twenty-seven inches and a half in circumference. The thigh was amputated by Mr. Guthrie on Saturday, the 27th, the bone being sawn through just below the trochanter. She suffered a good deal from pain after the operation. An opiate was administered and repeated, and she passed a good night.

28th.—The pulse, which previous to the operation was 80, has increased to 100; there is, however, little heat of skin, and she appears easy. Some aperient medicine, and saline draughts to be given every four hours. Toward the evening, she vomited a quantity of bilious matter; pulse 120. Three grains of calomel and one of opium, followed by the common aperient mixture, were ordered, and an enema. Equal parts of ether and laudanum to be applied to the region of the stomach, to which part pain was referred.

October 1st.—Better in all respects, but looking irritable and ill; no pain anywhere; no sickness; appetite good; pulse still quick.

8th.—Two ligatures have come away; the wound looks well; the edges have nearly healed; eats meat, and with a good appetite.

9th.—Not so well; pulse 120; skin hot; feels ill; complains of pain in the other leg and thigh, which disturbed her rest. Was well purged, and the leg fomented; the pain was principally felt in the calf and in the heel.

10th.—Pulse 130; tongue furred; vomiting again of bile; the pain in the thigh, extending upward to the groin and downward to the heel, is intolerable, particularly in the latter part; the thigh and leg much swelled, and tender to the touch, although without redness; the swelling elastic, yet yielding to the pressure of the finger, but not in any manner like an œdematous limb. Mr. Guthrie pronounced the disease this morning to be inflammation of the veins, extending from the opposite side; but after a careful examination, and on pressure, no pain was felt in the course of the iliac vessels of that side, and the stump looked well, save at one small point corresponding to the termination of the femoral vein.

17th.—The symptoms continued nearly the same during the week, the sickness of stomach and purging of bilious matter abating at intervals.

20th.—Less pain in the limb, which is swollen and tender to the touch, the superficial veins being all very much enlarged. The groin more swollen and tender; sickness gone, and her appetite returning; she is allowed good nourishing simple diet. The stump has been poulticed since the 9th, to promote suppuration.

25th.—During these five days it was interesting to see the patient eat, and desire solid food, and, in her extremely emaciated state, seem to enjoy it. The bowels occasionally deranged. Pulse always from 125 to 136. Is slightly jaundiced in color, but declares that she is better, and will get well.

27th.—Gradually sank in the evening, and died; the limb having everywhere diminished in size, except at the groin, where the swelling was more circumscribed, resembling the appearance of a chronic abscess approaching the surface. On examination after death, the termination of the vein on the face of the stump was open, and in a sloughy state; above that, for the distance of four inches, and as high as Poupart’s ligament, the inside of the vein bore marks of having been inflamed, but the inflammation seemed to have been of an adhesive character; above that point, the inflammation appeared to have been of an irritative or erysipelatous kind, had gone on to suppuration, and the vein was filled with purulent matter, lymph, and blood, partly coagulated and partly broken down. These appearances extended up the cava as high as the diaphragm, and traces of inflammation could be distinctly observed almost in the auricle. The disease had passed along the right external iliac and its branches; it had descended along the left iliac vein and its branches in the pelvis to the uterus, and along the limb to the sole of the foot. At the left groin the iliac vein, becoming femoral, was greatly distended with pus, apparently of good quality, and, if the patient had lived a day or two longer, it would have been discharged by a natural effort, as in chronic abscess; the viscera were healthy.

During the last days of this woman’s life, no blood was returned from the lower half of the body, unless by the superficial veins; yet she was comparatively easy, although of a yellow hue, emaciated to the utmost, so as to represent a living skeleton; in this state, with a pulse at 130, craving for and eating a whole mutton-chop and more at a time, with the most deathlike countenance it is possible to conceive.

These two cases mark the course, the symptoms, and the termination of inflammation of the veins after amputation, in as clear (if not a more clear) and distinct manner as any which have since been published, and which they preceded; nevertheless, most authors of more modern date overlook the first, and some appear to avoid as much as possible noticing the second.

62. After the battle of Waterloo, the wounded of the same regiment were sent indiscriminately, some to Brussels, others to Antwerp. Those who remained at Brussels suffered principally from inflammatory fever after amputation; those at Antwerp, from the epidemic fever prevailing at the time, beginning us an intermittent and ending often in typhus; facts of great importance to recollect, as showing the influence of malaria. The following are instances of endemic fever after secondary amputation, ending in subacute inflammation of the lungs and effusion into the chest:—

Charles Brown, 92d Regiment, forty years of age, at that time a healthy man, was wounded on the 18th June by two musket-balls in the right hand and wrist; he was admitted into the hospital at Antwerp on the 25th June. On the 5th July, the arm was swollen above the elbow; discharge profuse and fetid; countenance sallow and dejected; fever. 8th: Arm amputated above the elbow. 9th, 10th, 11th: A little increase of fever. 12th: A paroxysm of intermittent, to which he had been subject occasionally since he had been at Walcheren. On removing the dressing, the edges of the stump were retorted; discharge copious and fetid; respiration hurried; thirst; skin hot and yellowish; pulse 90. 14th: Intermittent returned; head affected in consequence of long continuance in the hot bath. 15th: Complains to-day of fullness and pain in the left side; pulse 100; skin of a deeper tinge of yellow; a sense of suffocation when in the horizontal position. A blister was applied to the whole of the side of the chest. 16th: Was delirious during the night; vomited frequently; became insensible at the hour when the paroxysm of intermittent fever was expected to return; and died in the evening. On opening the chest, the lungs were found adhering to the pleuræ costales in several places, and were hepatized; a quantity of serum and lymph was contained in the left pleura, so as to compress the lung, in which there was a small abscess. The liver was twice the natural size.

J. Lomax, of the Guards, was wounded at Waterloo, suffered amputation of the right arm on the 23d August, and arrived at the General Hospital, Colchester, on the 27th, in a state of high fever, and unable to give any distinct account of himself. He had had the ague, he said, for many days, which left him for a short time, but returned when on board ship; on the 25th he was attacked by pain in the side, which was very severe on the 26th, on which day a blister was applied, which greatly relieved him. The stump had an unhealthy appearance, the edges of the wound evincing a disposition to separate. On the 28th he was free from pain; fever unabated, with a tendency to delirium. He sank rapidly on the 30th, and died on the 31st, notwithstanding the use of the most powerful stimuli. A quantity of serum was found on dissection in the left side of the chest, and the pleura pulmonalis on each side was covered with a thick layer of coagulable lymph. The pericardium was distended with fluid. The liver was enormously enlarged, pushing up the diaphragm, and displacing the lung, having in its substance a large abscess containing at least a quart of pus. The stump did not exhibit any peculiar appearance.

O. Sweeney, 90th Regiment, aged nineteen, was wounded in the hand on the 18th of June, 1815, and taken to Brussels. On the 5th of July he left for England, and arrived at Colchester on the 14th. The wound shortly after assumed an unhealthy appearance; hemorrhage took place, and the arm was amputated on the 30th. The day after, he had severe rigors for fifteen minutes, followed by fever. The next day he was better, and appeared to be doing well until the 6th of August, when fever recurred. Stump quite healthy in appearance. On the 7th, he was attacked by vomiting and purging, which lasted several hours, and reduced him much, returning at intervals until the evening of the 8th. Small quantities of wine and opium agreed best, and a blister was applied to the scrobiculus cordis. On the 9th, he complained of pain and tenderness in the abdomen, which were relieved by fomentations and an enema. The stump looked well, and discharged healthy pus in small quantity; the ligature on the brachial artery came away. On the 10th, his strength failed, and the tongue and teeth were covered with a dark sordes. The adhesions of the stump appeared disposed to separate. At night he was restless, with low delirium; and on the 11th died, with the complete facies Hippocratica. On raising the sternum, the pleura of the left lung was found adhering to that of the ribs, and covered by a thick layer of coagulable lymph. The lung was highly inflamed; and on cutting into its substance, a number of small tubercles was observed. The pericardium and left cavity of the thorax contained more than the usual quantity of fluid. During the progress of this case, eleven days from the amputation no one symptom existed which could induce a suspicion of inflammation going on in the thorax. The stump was in a sloughing state, but the disease did not extend along the brachial veins.

Thomas Haynes, 23d Light Dragoons, aged nineteen, was wounded by a spear on the back of the left forearm, at Waterloo; the wound appeared to do well until he left Brussels for England, when it assumed an unfavorable appearance, and on his arrival at Colchester, on the 14th of July, it was in a sloughing state. The pain was excessive, and the tenderness around the whole circumference of the sore was so great that he could not suffer the slightest pressure with the finger. He was largely bled, and a solution of sulphuric acid, one drachm to twelve ounces of water, was applied twice a day to the whole surface, and the whole kept wet with cold water; this treatment was continued until the 21st, during which period he was bled five times, to about twenty ounces each time. The acid solution was increased in strength from one drachm to an ounce, and care was taken that the sloughing portions only were touched with it. His health was considerably amended, and on the whole a favorable result was expected. At two on the 22d, however, a sudden hemorrhage took place, to the amount of three pints; a second ensuing on the 23d, the arm was amputated. The pulse continued quick; in other respects he was doing well, until the 25th, when some accession of fever took place, and increased. He was bled to ten ounces, and purged. On the 26th, the line of incision in the stump appeared to be healed; and with the exception of the pulse at 140, he had no unpleasant symptom on the 27th, and was free from pain of every kind. On removing the center strap, which had been allowed to remain, a large collection of matter of good quality issued. On the 28th, he was much the same. On the 29th, the countenance had assumed a deathlike paleness; pulse 120, intermitting every fifth pulsation; breathing short and laborious, with some pain in the chest, and every symptom of effusion having taken place. He died at two P.M., six days after the amputation.

The only morbid appearance found on dissection was a large quantity of serous fluid in the pericardium, which was distended by it, and on both sides of the chest. The heart and lungs, with their membranes, were quite sound. On examining the stump, the sanative process was found to have been entirely confined to the integuments. No appearance of granulation could be perceived on the muscular surface.

This last case is worthy of especial observation, on account of the manner in which sulphuric acid was used for the sloughing state, from one drachm to one ounce of the acid to twelve ounces of water, not as something new, but as an ordinary application; and I am doubtful whether there is any case on record of such use, anterior to it. Is the external use of strong acids in sloughing cases also due to the war in the Peninsula? Delpech says Yes,—a testimony I shall confirm in its proper place.

I have departed, in some degree, in the foregoing observations, from the aphorismal form I had prescribed for myself in the commencement of these Commentaries. I have done so as an act of justice to those officers who served at Toulouse, Brussels, Antwerp, and Colchester, in 1814 and 1815, who are all now no more, and who labored hard in the then early investigation of these different states of disease, and have not received the reward they merited of public acknowledgment. I have endeavored, as the late Chancellor of the Exchequer says in his life of Lord George Bentinck, to preserve for them the chastity of their honor.

63. Mr. Hunter, in 1793, described the appearances and the fatal results of inflammation of the veins, as a consequence of injuries inflicted on the surrounding parts, but I apprehend I was the first person to point out the prevalence of this complaint after secondary amputation, and its intimate connection with certain low inflammatory attacks, attended by destructive purulent depositions, particularly in the chest, and their more chronic deposit in other parts. Mr. Rose, of the Guards, published some observations in the fourteenth volume of the Medical and Chirurgical Transactions, in 1828, confirming the remarks made by me in print thirteen years before, but without referring to them. Mr. Arnott has an able paper on that subject in the fifteenth volume. M. Sedillot thinks he has detected globules of pus in different parts of the circulating system in persons who had died of this disease. Mr. Henry Lee, 1850, one of the last English writers on the subject, professedly doubts the accuracy of the observation; this point remains among others for further investigation. He admits, however, that in cases where, from long-continued disease, there have been repeated introductions of vitiated fluids into the circulation, the blood loses much of its coagulating power, which prevents the admission of purulent matter by the veins, by forming coagula with it in them, thus constituting he thinks the essential disease. When the coagulating power of the blood is thus lost, he thinks it possible that pus-globules may then be found circulating in it. Other late writers, and lastly Dr. Hughes Bennett, think these diseases are dependent on the introduction of a peculiar animal poison. Attention should be paid by the medical officers of the public service, whenever there is a war, to the state of the blood, and to the inner lining of the diseased veins under the microscope;[2] and all those gentlemen, when in London, should study its use, under Mr. Quekett, at the College of Surgeons, to whose lectures they have the right of admission, and to whose kindness they will all soon feel greatly indebted. I am not aware that the writers referred to have added anything to the practical facts I had related so long before, which is much to be regretted. It is of little use, although it is a step in the right direction, to describe a disease, or even to show why and wherefore it destroys, unless a means of prevention or of cure can also be indicated.

[2] The India Company have supplied the principal hospital of each presidency with one good microscope at least; one of these, with a person who understands its use, should be attached (but is not) to the principal hospitals during the present war in the East.

64. In the irritable and sloughing state of stump alluded to, hemorrhages frequently take place from the small branches, or from the main trunks of the arteries, in consequence of ulceration; and it is not always easy to discover the bleeding vessel, or, when discovered, to secure it on the face of the stump; for as the ulcerative process has not ceased, and the end of the artery which is to be secured is not sound, no healthy action can take place; the ligature very soon cuts its way through, and the hemorrhage returns as violently as before, or some other branch gives way; and under this succession of ligatures and hemorrhages the patient dies.

Some surgeons have, in such cases, preferred cutting down upon the principal artery of the limb, in preference to performing another amputation, even when it is practicable; and they have sometimes succeeded in restraining the hemorrhage for a sufficient length of time to allow the stump to resume a more healthy action. This operation, although successful in some cases, will generally fail, and particularly if absolute rest cannot be obtained, when amputation will become necessary. The same objection of want of success may be made to amputation; on a due comparison of the whole of the attending circumstances, the operation of tying the artery in most cases is to be preferred in the first instance, and if that prove unsuccessful, then recourse is to be had to amputation; but this practice is by no means to be followed indiscriminately. The artery ought to be secured with reference to the mode of operating, as in aneurism, but the doctrines of this disease are not to be applied to it, because it is still a wounded vessel with an external opening.

To obviate all doubts, the part from which the bleeding comes should be well studied, and the shortest distance from the stump at which compression on the artery commands the bleeding carefully noted; at this spot the ligature should be applied, provided it be not within the sphere of the inflammation of the stump. In case the hemorrhage should only be restrained by pressure above the origin of the profunda, and repeated attempts to secure the vessel on the surface of the stump have failed, amputation is preferable to tying the artery in the groin, when the strength of the patient will bear it.

When hemorrhage takes place after amputation at or below the shoulder-joint, it is a dangerous occurrence. An incision should then be made through the integuments and across the great pectoral muscle, when the artery may be readily exposed, and a ligature placed upon it without difficulty anywhere below the clavicle.

If the state of the stump in any of these cases should appear to depend upon the bad air of the hospital, the patient had better be exposed to the inclemency of the weather than be allowed to remain in it.

In crowded hospitals, hemorrhages from the face of an irritable stump are not unfrequent, and often cause a great deal of trouble and distress. It is not a direct bleeding from a vessel of sufficient size to be discovered and secured by ligature, but an oozing from some part of the exposed granulations, which are soft, pale, and flaccid. On making pressure on them the hemorrhage ceases, but shortly after reappears, and even becomes dangerous. This hemorrhage is usually preceded by pain, heat, and throbbing in the surface from which it proceeds. There is irritation of the habit generally, and a tendency to direct debility. The proper treatment consists in the removal of the patient to the open air, with an antiphlogistic regimen in the first instance, followed by the use of quinine and acids; cold to the stump, in the shape of pounded ice or iced water. Escharotic and stimulating applications should be used with caution. If any of the styptics which are sometimes announced as infallible could be relied upon, their application in these cases would be most advantageous. The solution of the perchloride of iron is the best.

LECTURE IV.

APHORISMS FOR AMPUTATIONS, ETC.

65. Amputation of a limb is the last resource and the opprobrium of surgery, as death is of the practice of physic; it being, notwithstanding, impossible to do impossibilities, and save a limb or a life which can no longer be preserved. Art and science at that point cease to be useful.

66. At the commencement of the war in the Peninsula, all surgeons believed it to be impossible to compress in an effective manner the artery of the thigh against the bone, as it passes over the edge of the pubes, and that the loss of blood on its division must be so formidable as to be murderous. This was merely a surgical delusion, which maintained its ground in London until the end of 1815, when the French soldier, whose thigh I had successfully taken off at the hip-joint, after the battle of Waterloo, without first tying the femoral artery, was shown to all disbelievers. It was the great point in advance in English and European surgery, and one great result of the practice of that war.

67. This great, indeed most important fact, having been established, the surgery of amputation was deprived of nearly all its terrors. Confidence, and with it coolness, were obtained; and many young surgeons diligently sought for an operation on the hip-joint as the ne plus ultra of operative boldness and dexterity, much after the fashion of the young lady pianistes, who do not consider themselves in any way advanced on the road to perfection until they can play at least the overture to Guillaume Tell, if not the Galop Chromatique of Listz, nearly as well as the composer himself.

68. As a tourniquet cannot be applied in this amputation, nor even at that of the shoulder-joint, without doing harm, its inutility in the greatest operations is proved; and recourse should not be had to it in the smaller or less dangerous ones, provided sufficient assistance can be obtained. When the surgeon has only one assistant, he should apply a tourniquet, or even if he should have several bad ones on whom he cannot depend.

69. There is always more blood lost, and particularly in secondary amputations, when a tourniquet is used than when the principal artery is compressed by one assistant, and two others are ready to press on the outside of the flaps, or upon the divided vessels, with the ends of their fingers; the force necessary to prevent the passage of blood through the common femoral, or the axillary artery, being merely that of the finger and thumb, applied in a very gentle manner, or even of the end of the forefinger of a competent person. I have rarely applied a tourniquet since 1812, and few persons have done more formidable operations under more difficult circumstances. The ancient illusion with regard to the necessity for tourniquets in amputation must be given up, except by incompetent persons, or by those who are fearful and superstitious, and do not like to depart from the ways of their forefathers.

70. A tourniquet is useful when loosely applied after an operation, and the attendant should be taught how to turn it, so as to suppress any serious bleeding which may take place until the surgeon can be procured. It may be, although it rarely is, necessary on the field of battle. The surgeon need not, therefore, load himself or his assistant, as formerly, with a sackful, for a thoroughly useful tourniquet can be made in a moment with a pebble and a pocket-handkerchief, or a roller. The great point is to know where and how to apply it. When gentlemen called surgeons by warrant are sent to an army, as many were to that in Spain and France, with only the knowledge of a druggist, having been refused a commission on account of their ignorance, it is necessary this instruction should be especially given to them; and this horrible fact is recorded with the hope it may be useful in preventing any such atrocious proceedings in future. Peace or humane societies, if they cannot prevent a war, may interfere with advantage on this point, to divest it of some of its horrors. At the battle of Inkerman, a young officer, the son of a friend of mine, was wounded in the leg by a musket-ball, which caused much loss of blood. A tourniquet was applied, instead of the required operation being performed, and he was sent on board a transport from Balaklava. The leg mortified, as a matter of course, and was amputated. He died, an eternal disgrace to British surgery, or rather to the nation which will not pay sufficiently able men, and therefore employs ignorant ones—the best they can get for the money.

71. When circular operations were performed in the olden time, particularly on the thigh, the skin, when divided, was dissected, and turned up like the cuff of a coat—a painful proceeding, as unnecessary as it was barbarous. Forty years have elapsed since I demonstrated its absurdity, and showed that the first incision in the thigh should include the fascia lata, any deep attachments it might have should follow, when the parts thus divided ought to be retracted as a whole, to form a proper covering for the stump.

It was at the same time shown that, in whatever way, and however clumsily and tediously, the muscles might be divided, it did not prevent the successful result of the operation, provided the bone was cut short, so as to form a cone, with an elongated or depressed point.

72. The nicking of the periosteum, and pushing it upward and downward, so as to leave a space for the saw, was at the same time forbidden, as leading to necrosis of the part of the bone thus denuded, if unremoved by the saw. The saw was also directed to be held perpendicularly to, and not across, the bone, nor even diagonally to it—an apparently trivial, but yet great improvement. The last part divided is an outer and thin layer of hard bone, which does not so readily splinter on the side as on the under part, by the weight of the leg.

73. The limb to be amputated is not to be held by the assistant in the manner described and usually shown in books: one hand ought not to be above the knee, but below and by the side of it, the other grasping the calf, so that the limb may be duly supported, and drawn inward or outward, in the opposite direction to the saw, as it divides the last layers of the bone.

74. The common integuments of the stump should be drawn together, in primary amputations, by sutures formed of flexible leaden wires; by threads of silk, if leaden wires be not attainable. The vessels which bleed should be carefully secured by single yet fine threads of dentists’ or other strong silk, one end to be cut off in primary amputations. In secondary amputations, when the parts are not always sound, both ends of the ligature should be cut off, and in such cases the edges of the wound should be brought in contact only, with a layer of fine linen between them, without the expectation of, or the desire for, union taking place.

75. The removal of a limb should not occupy two minutes, but the securing the blood-vessels should be done without reference to time; when carefully effected, there is little fear of secondary bleeding, and the stump should be closed at once. It has been lately recommended not to close the stump for four, six, or eight hours after the operation; but this is not advisable, unless the depressed state of the patient, or other causes, should have rendered it impossible to secure, in a proper manner, all the vessels which are likely to bleed. It will be less painful and dangerous to delay, in such cases, than to have to reopen the stump.

76. When the edges of the incision have been brought together by the hands of the assistants, and by the sutures indicated, strips of some kind of agglutinative plaster without resin should be applied between them, and a little wet lint over the incision, retained by two cross-pieces of rollers, the ends of which are maintained in their situation by another roller applied round the body and over the upper part of the thigh, including the extremities of the two cross-pieces; but this roller is not to be applied over the end of the stump. When the war came well in, stump-caps, as they were called, went out, being worse than useless. The stump should be supported on a soft pillow, so as to be as comfortable as possible, and protected by a cradle from accidental injury.

If inflammation, accompanied by pain, should take place, cold or iced water should be applied, particularly in primary amputations. In secondary ones, warm fomentations or light warm poultices will be more advantageous, all constriction by sutures or plasters being removed, the parts being simply approximated to each other. Attention should be paid to the directions in aphorism 61.

AMPUTATION AT THE HIP-JOINT.

77. This amputation essentially owes its existence to the wars of the French Revolution. M. Bourgery says Blandin performed it three times in 1794; once successfully. Baron Larrey did it seven times during his different campaigns, and he says one or two persons who had survived were seen during their cure by an officer in Russian Poland, but they never reached France. Nevertheless, I always assume that one at least did recover, whether he was really seen or not, being a compliment and a reward justly due to the zeal and ability of my old friend the Baron, to whom the surgery of France is so much indebted. This operation was first done in Spain by the late Mr. Brownrigg, at Elvas, in 1811, and by myself after the siege of Ciudad Rodrigo, but none of our patients ultimately recovered. I operated on a French soldier at Brussels soon after the receipt of the injury at Waterloo; he survived; and he was the first and the only man seen for a long time afterward in either London or Paris. The biographer of Baron Larrey says he was present at, and advised the operation to be done; but that is an error, as the Baron did not visit Brussels until after I had left it for Antwerp; neither had I any knowledge of the Baron’s writings in 1811 or 1812, when my first operation was done in Portugal. Eighteen or twenty ways have been suggested for doing this operation, and twenty persons are believed to have survived its performance, several of whom may be living at the present time.

A very extensive destruction of the soft parts, the femur remaining entire, does not authorize the removal of the limb in the first instance, unless the main artery be also injured. Captain Flack, of the 88th Regiment, was struck by a large cannon-shot at Ciudad Rodrigo, on the outside and anterior part of the left thigh, which tore up and carried away nearly all the soft parts from the groin, or bend of the thigh, below Poupart’s ligament, to within a hand’s-breadth of the knee. It was an awful affair. He was supposed to be dying, was returned dead, and his commission was given to another. Left to die in the field hospital after the town was stormed, and finding himself thus deserted by his own friends, he claimed my aid as a stranger. I took him five leagues to my hospital at Aldea del Obispo. The femoral artery lay bare for the space of nearly four inches, in a channel at the bottom of the wound; the whole, however, gradually closed in, and he recovered.

If the injury is on the back part, a flap should be made in amputation from the fore part. If the wound should be on the outside, the flap is to be made from the inside, and vice versa, the object being to make the stump as long as possible. A wound of the artery, accompanied by a fracture of the femur, requires amputation, for although many would survive either injury alone, none would, it may be apprehended, surmount both united.

If after a fracture in course of treatment, the principal artery should be wounded by some accidental motion of the bone, amputation should in general be resorted to. A ligature on the artery higher up would fail, and the operation of seeking for both ends of the injured vessel would cause so much mischief in an unsound part that the consequences would in all probability be fatal.

78. When the femur is suffering from a malignant disease, commencing in the periosteum, or in its cancellated internal structure, I am reluctantly obliged to say, from experience, that the removal of the whole bone at the hip-joint offers the best, perhaps the only chance of success. In such cases, the operator has in general the power of selecting his mode of proceeding.

It may be laid down as a principle in all cases of accident, whether from shot, shell, or railway carriages, that no man should suffer amputation at the hip-joint when the thigh-bone is entire. It should never be done in cases of injury when the bone can be sawn through immediately below the trochanter major, and sufficient flaps can be preserved to close the wound thus made. An injury warranting this operation should extend to the neck, or head of the bone, and it may be possible, as I have proposed, even then to avoid it by removing the broken parts.

79. The principle being established, as a general rule in all cases of recent injury, that the femur must be broken at least as high as the trochanter to constitute an imperative case for this operation, the next point of importance relates to the manner of forming the first incisions. The instructions and recommendations to be found in books for the performance of this operation are frequently inapplicable, and are not to be depended upon; the errors occurring from the operation having been considered and performed on the dead body and not on the living; on the normal and not on the injured state of parts. Thus, for instance, it is recommended that an assistant should rotate the knee outward or inward, to show the head of the femur; to which recommendation there is the insuperable objection, that no person should suffer this operation who has a knee, or half a thigh, or even a third of one, to move by the rotary process. Pure theorists in surgery have decided upon having a large flap made on the fore part of the thigh, and a smaller one behind, regardless of the fact that this cannot be done in many cases requiring a primary operation from the nature of the injury; although it may be done in many secondary cases, in which this severe operation would not have been required if the limb had been amputated in the first instance. It is the mode recommended by Mr. Brownrigg, who in his operations, which were secondary ones, had a choice of integument, and it is, perhaps, under these circumstances, the best.

Baron Larrey tied the femoral artery in the first instance, and then made two lateral flaps; but this operation, dependent on the fear of hemorrhage, was never performed in the British army.

80. My first successful operation, performed in 1815, was done from without inward, the flaps being anterior and posterior, the artery being compressed against the pubis.

The patient is to be laid on a low table, or other convenient thing, in a horizontal position; an assistant, standing behind and leaning over, compresses the external iliac artery becoming femoral, as it passes over the edge of the pubis. The surgeon, standing on the inside, commences his first incision some three or four inches directly below the anterior spinous process of the ilium, carries it across the thigh through the integuments, inward and backward, in an oblique direction, at an equal distance from the tuberosity of the ischium to nearly opposite the spot where the incision commenced; the end of this incision is then to be carried upward with a gentle curve behind the trochanter, until it meets with the commencement of the first; the second incision being rather less than one-third the length of the first. The integuments, including the fascia, being retracted, the three gluteal muscles are to be cut through to the bone. The knife being then placed close to the retracted integuments, should be made to cut through everything on the anterior part and inside of the thigh. The femoral or other large artery should then be drawn out by a tenaculum or spring forceps, and tied. The capsular ligament being well opened, and the ligamentum teres divided, the knife should be passed behind the head of the bone thus dislocated, and made to cut its way out, care being taken not to have too large a quantity of muscle on the under part, or the integuments will not cover the wound, under which circumstance a sufficient portion of muscular fiber must be cut away. The obturatrix, gluteal, and ischiatic arteries are not to be feared, being each readily compressed by a finger until they can be duly secured. The capsular ligament, and as much of the ligamentous edge of the acetabulum as can be readily cut off, should be removed. The nerves, if long, are to be cut short. The wound is then to be carefully cleansed, and brought together by three or more soft leaden sutures in a line from the spine of the ilium toward the tuberosity of the ischium. The ligatures are to be brought out between the sutures, and some adhesive strips of plaster applied to support them. A little wet lint is to be placed over the wound, and some well-adapted compress under the lower flap; the whole to be retained by a soft bandage. In my successful case there was a shot-hole in the under flap, which did good service; and from having seen its use, I have no objection to a small perpendicular slit being made in the lower flap, and a strip of linen introduced to prevent adhesion. The immediate union of the flaps cannot be expected, nor is it often to be desired.

This mode of proceeding is more certain of making good flaps where integuments are scarce. Where the integuments will admit of the anterior flap being made by the sharp-pointed puncturing knife dividing the parts after it has been passed across from without inward, there is no objection to this proceeding, and some prefer it. I have had two such knives added to each of the cases of instruments supplied to the army for the purpose.

Professor Langenbeck, when lately in London, informed me he had performed amputation at the hip-joint several times in the Holstein war, and he believed more than once successfully; making the anterior flap by the pointed knife, cutting from within outward, but the posterior one by cutting through the integuments from without inward, as I have recommended in high amputation below the joint, in order to make the flap of a more equal and proper thickness. One point to be attended to is to leave as little as possible of the internal tendinous structure of the great gluteus muscle, as it does not readily unite with other parts; a second, not to leave too much muscle on the under part; and a third, to remove as much as possible of the ligamentous structure about the joint. The after-treatment will be the same as in other formidable cases. The shock, however, of the injury, and of the amputation, will render blood-letting unnecessary. Cordials, in small quantities, with opiates and a good but light nourishing diet, should be given. The wound should be wetted with cold water, and the patient constantly watched, so that hemorrhage may be arrested if it should take place. In an otherwise successful operation performed by Mr. C. G. Guthrie, at the Westminster Hospital, the patient was lost on the third day from this cause.

Mr. Brownrigg’s operation is to be done in the following manner: The patient is to be placed on a low table and properly secured, with the nates projecting over its edge, the artery being compressed. The surgeon enters the pointed knife between the spine of the ilium and the trochanter major, and carries it across the thigh, as near as may be to the head and neck of the femur, until the point appears on the inside, near the scrotum, which should have been previously drawn away. The knife is to cut slowly downward, to make a flap, under which, and behind the knife, an assistant inserts his four fingers, in order to be able to grasp the flap and aid in compressing the principal artery, as the operator completes the flap, which it is intended should be a large one, as shown in the diagram, fig. 1.

Fig. 1.

Amputation of the Hip-joint as performed by Mr. Brownrigg.

(Upper figure.)

a a a, anterior flap in dotted lines;
c, thumb compressing the artery on the pubis;
d, fingers introduced under the flap;
e, the straight knife, entrance and exit of.

(Lower figure.)

Flap Amputation as performed by Mr. Luke, on the lower half of the thigh.

A, middle of the outside of the thigh and point of entrance of knife;
B, under part;
C, upper part;
A to E, the under flap;
G to F, dotted line of upper flap, beginning short of commencement of under flap.

The assistant holding up the flap, the surgeon cuts the attachment of the gluteus medius muscle, from the upper edge of the trochanter, if it has not been already done, opens the capsular ligament of the joint, and divides the ligamentum teres. The head of the bone can then be readily withdrawn from the acetabulum. The knife being placed behind the head of the bone and the trochanter, should be carried obliquely downward and backward, so as to form a shorter flap behind than was made before. The amputations of the hip-joint, performed in the Crimea, have not, I understand, been as successful as the ability with which they were performed might have led the operators to expect.

Fig. 2.

Mr. Guthrie’s operation.

Left side—
a, anterior superior spine of ilium;
b, commencement of anterior incision, continued by the black line;
c, the posterior incision joining the anterior one.

(Second figure.)

b c, line of incision marked by three sutures.

81. Amputation by the circular incision is to be done in the following manner: When a tourniquet is used, which it should not be, if the surgeon can depend on his assistants, the pad should be firm and narrow, and carefully held directly over the artery, while the ends of the bandage in which it is contained are pinned together. The strap of the tourniquet is then to be put round the limb, the instrument itself being directly over the pad, with the screw entirely free; the strap is then to be drawn tight and buckled on the outside, so as to prevent its slipping, and yet not to interfere with the screw. Should the screw require to be turned more than half its number of turns, the strap is not sufficiently tight, or the pad has not been well applied. The patient being placed on a table at a convenient height, the assistants are carefully to retract the integuments upward, and put them on the stretch downward, by which means their division is more easily and regularly accomplished. The surgeon, standing on the outside, passes his hand under the thigh and round above quite to the outside, and there he begins his incision with the heel of the knife, and with a quick, steady movement, carries it round the thigh until the circular division of the skin, cellular membrane, and fascia has been completed. The skin cannot be sufficiently retracted unless the fascia be divided, and as the division of the skin is certainly the most painful part of the operation, it ought never to be done by two incisions, when the largest thigh can most readily and speedily be encircled by one. If the fascia should not be completely divided by the first circular incision, it is to be cut with the point of the knife, together with any attachment to the bone or muscles beneath. The amputating knife is then to be applied close to the retracted fascia and integuments, and the outermost muscles are to be divided by a circular incision, with any portion of the fascia that may not have equally retracted. This incision completed, the knife is immediately to be placed close to the edge of the muscular fibers which have retracted, and the remainder of the soft parts divided to the bone in the same manner. In making these two incisions, care should be taken to cut at least half an inch on each side of the great artery by one incision, which should be either the first or second, as may be most convenient. The muscles attached to the bone are then to be separated with a scalpel for about three inches in large thighs, by which means the bone will be fairly imbedded when sawed off. The common linen retractor is next to be placed on the limb, and the muscles steadily kept back while the bone is sawed through. The periosteum may or may not be divided by one circular cut of the scalpel after the retractor has been put on. The heel of the saw is then to be applied and drawn toward the surgeon, so as to mark the bone, in which furrow he will continue to cut with long and steady strokes, the point of the saw slanting downward in a perpendicular direction until the bone be nearly divided, when the saw is to be more lightly pressed upon, to avoid splintering it, which this manner of sawing will also tend to prevent. During this operation the thigh should be held steadily above, and in such a manner below that the part to be cut off does not weigh or drag on the bone above; at the same time it must not be pressed inward or upward, or it will prevent the motion of the saw or splinter the bone. The retractor is then to be removed, the great artery to be pulled out by a tenaculum passed through its sides, separated a little from its attachments, and firmly tied with a two-threaded, strong ligature, provided dentists’ silk be not used, and the tenaculum is not to be withdrawn until this has been accomplished; any other vessels that show themselves may be secured, and compression should for an instant be taken off the main artery, when others will start. If used, the tourniquet should now be removed, and the small remaining vessels will be discovered. If the great vein continue to bleed after some pressure has been made upon it, a single-threaded ligature should be put over it; but this should not be done if it can be avoided, and only when the loss of a little blood might be dangerous. If the cancellated part of the bone bleed freely, the thumb of the left hand pressed steadily upon it, while the vessels are tying, will in a short time suppress the hemorrhage. Any inequality of bone should be removed by forceps. The ligatures should now be shortened, one end of each thread being cut off; the stump is to be sponged with cold water and dried, the bandage rolled steadily down the thigh; the muscles and integuments brought forward and placed in apposition, horizontally across the face of the stump, and retained by leaden sutures and adhesive plasters carefully applied, from below upward, and from above downward; the ligatures being brought out nearly as straight as possible, in two or three places between the slips of plaster, unless both ends have been cut short. A compress of lint is to be placed over and under the wound, supported by two slips of bandage, in the form of a Maltese cross, vertically and horizontally, and the whole secured by a few more turns of the bandage. No stump-cap is to be applied; the stump is to be raised a little on a proper pillow from the bed, in which the patient lies on his back; and if the bone appear to press too much against the upper flap, the body may be a little raised, which will relieve it.

In secondary amputation of the thigh, the integuments may not be sound, and will not retract, in which case they must be dissected back to an equal distance all round. If the muscles are much diminished in size, or flabby, they should be left even longer than may appear necessary for the formation of a good stump; and this is to be done more especially on the under part, for the bone will frequently protrude under these circumstances, when enough has been supposed to have been preserved. In all these cases the bone should be shorter than usual, and the skin should, if possible, retain its attachments to the parts beneath. No inconvenience can ever arise from too much muscle and skin in a circular stump; but it does sometimes from too much skin alone.

In primary operations there will be from three to seven vessels to be tied; in secondary ones, from ten to sixteen, and even then there may be an oozing from the stump. In this case a little delay in searching for the vessels is necessary; the tourniquet and all tight bandages should be removed, and the stump well sponged with cold water before it is dressed. A certain degree of oozing is to be expected from all stumps, although it does not always occur: but when there is really any hemorrhage, so that blood distills freely through the dressings, the stump should be opened, when the bleeding vessel will generally be discovered readily, though not visible before. A stump under these circumstances should not be closed in the first instance; the parts should be merely approximated until all bleeding has ceased.

When the operation is performed near the knee, the gradual thickening of the thigh prevents the retraction of the integuments, and has an effect upon the vessels of the stump; both of which evils are avoided after the circular incision has been completed, by making a cut, an inch and a half in length, in the integuments through the fascia on each side, in the horizontal direction in which they are recommended to be placed, after the operation is finished; but this will very rarely be necessary.

82. Amputation of the thigh, by the flap operation, is best accomplished by the method adopted by Mr. Luke, of the London Hospital, which is as follows: The patient being placed so that the thigh projects beyond the table, the surgeon stands with his left hand toward the body, or on the outside when amputating the right, and on the inside when amputating the left thigh. The knife to be used ought to be narrow, pointed, and longer by two or three inches than the diameter of the thigh at the place of amputation. The point of the knife should be entered mid-distance between the anterior and posterior surfaces of the thigh, which may be effected with accuracy, if the eye is brought to a level with the thigh, when the middle point is easily determined. The posterior flap is to be formed first, by carrying the knife transversely through the thigh, so that its point shall come out on the opposite side, exactly midway between the anterior and posterior surfaces. In traversing the thigh, the knife should pass behind the bone, and will be more or less remote from it in different individuals, according to the greater or less development of the posterior muscles, when, by cutting obliquely downward, to the extent of from four to six inches, according to the thickness of the thigh, a posterior flap is formed. The anterior flap is effected, not by making a flap, but by commencing an incision through the integuments and muscles on the side of the thigh opposite to the surgeon, at a little distance anterior to the extremity of the posterior flap. This incision is made from without inward, through the integuments, so as to form an even curve, and without angular irregularity, over the thigh, to near the base of the posterior flap on the side on which the surgeon stands. The length of this flap is determined by that of the posterior. It will therefore vary from four to six inches, as before stated; and for its completion will require a second, or perhaps a third, application of the knife. In the two flaps thus made, the division of almost all the soft structures is included, a few only immediately surrounding the bone remaining uncut. These are to be divided by a circular sweep of the knife, at the part where it is intended to saw the bone; in this way it is sufficiently denuded for the application of the saw. The flaps being held back by an assistant, the bone is to be sawn through in the usual way. In amputations of the lower part of the thigh it usually happens that the ischiatic nerve lies upon the surface of the posterior flap, and should be removed. It occasionally occurs, although not frequently, that the popliteal artery is cut obliquely at its commencement; but in amputations above the passage of the arterial trunk through the tendon of the triceps, this does not take place, the division of the artery being usually included in the circular sweep made after the formation of the flaps. The divided arteries having been carefully secured, the flaps are to be brought together and retained by three sutures passed through the integuments at equal distances from each other, and from the extremity or base of the flaps. It appears to be a matter of considerable importance not only that their edges should be kept in apposition, but that their whole surfaces should be kept in accurate contact. For this purpose, the following method of dressing is adopted: The edges, in the intervals between the sutures, are to be held together by strips of adhesive plaster about one inch in breadth. A compress of lint is then to be fitted over each flap, that upon the posterior being the larger. The compresses are to cover the flaps only, and not to extend over the extremity of the bone, where their pressure would probably be ill endured. The posterior compress is made large, that it may serve as a cushion on which the thigh rests when the patient is placed in bed. The compresses are to be retained in position by one or two strips of plaster, and supported by a bandage applied carefully round the stump. If this be properly accomplished, the whole surfaces of the flaps will be kept accurately in contact with each other, and complete union may be reasonably expected. By securing the perfect apposition and support of the entire surfaces in accurate contact, the disposition to the issue of blood from small vessels is also obviated to a great extent, and it is even probable that vessels of a larger diameter than the smallest, which would bleed if not restrained, are, by the pressure of the opposing surface, prevented from doing so, and the probability of secondary hemorrhage is diminished. Experience has demonstrated the fact that primary union of the flaps is most effectually procured in the great majority of amputations thus treated. Indeed, non-union of the flaps is the exception; union, the rule. In the subsequent treatment of the stump, care must be taken to prevent an accumulation of discharge in the tracks of the ligatures; and the dressings must be renewed according to circumstances having reference to the quantity of discharge, and the uneasiness of the patient. The line of division of the integuments of the two flaps is situated, at first, in the center of the face of the stump; but when the flaps have united, a gradual change takes place in the position of the cicatrix: it recedes, by degrees, to the posterior aspect of the thigh, and the bone abuts upon the anterior flap, by which alone it is eventually covered, and the cicatrix is thus removed from its pressure.

83. A protrusion of bone is a disagreeable occurrence after amputation; it will sometimes happen after sloughing of the stump, without any fault of the operator. If, on completing the operation, it is evident the bone cannot be well covered, a sufficient portion should be at once sawn off, and the error remedied.

When the bone protrudes at a subsequent period to the extent of an inch or more, it should be removed by operation, an incision being made on, and down to, the bone, and the saw applied where it is sound. The chain saw, when at hand, answers well, and some should be supplied for the use of the principal hospitals with every army. The protruded end of bone should be held steadily by pincers, or it may be introduced into a hollow tube, which fixes it firmly.

When the bone has been badly sawn through, or split in the act of dividing the last layer, or the periosteum is unduly separated, the end will often exfoliate with the split, which may extend up for several inches, giving rise to the formation of abscesses, causing much suffering, and occupying a great length of time before the ring of bone and the split portion exfoliate, and the stump becomes quite sound. A splinter of this kind may even require to be removed at a late or at a distant period, from the nervous irritation and suffering it may occasion. This irritation has been often attributed to the extremity of the principal nerve, which always enlarges, assumes a bulbous form, and is painful on pressure, when made for the purpose, although not so under ordinary circumstances. This enlargement never requires removal, unless it should adhere to the cicatrix, or be the subject of disease incidentally occasioned in it. The great sciatic nerve became early thus enlarged in the thigh of the late Marquess of Anglesea, and was mistaken for disease, for which he was advised to have it removed, it being painful on pressure, and therefore the supposed cause of the tic douloureux under which he labored. Consulted on the propriety of this operation, his leg-maker, Mr. Pott, being present, who had also lost a leg above the knee, I requested his lordship to squeeze Mr. Pott’s bulbous nerve, in the same manner as the doctor had squeezed his lordship. He did so, and Mr. Pott roared and sprang from the floor in a manner which quite satisfied Lord Anglesea.

LECTURE V.

REMOVAL OF THE HEAD OF THE FEMUR, ETC.

84. The removal of the head of the thigh-bone from its place in the hip-joint, after it has been separated in a measure from its attachments by disease of a scrofulous nature, is an operation which has been several times successfully performed, and life has been thereby preserved without much suffering or risk to the patient. In this case, the head of the bone is found lying outside the cavity, from which it has been drawn by the action of the muscles. A step further must be taken, and this operation must some day be done in cases of fracture of the head or neck of this bone caused by an external wound—cases which have hitherto been invariably fatal, or in which life has been preserved by amputation at the hip-joint.

The great advance which operative surgery has made within the last forty years, and the success which has followed the removal of the head of the humerus, the whole of the elbow, the ankle, and even the knee-joint, render it imperative on surgeons of ability to endeavor to save life without the performance of so formidable an operation as that of the removal of the whole limb, more particularly when the health is good and the parts sound, with the exception of those immediately injured.

The cases which seem more particularly favorable for this operation are those in which the head or neck of the bone is broken by a musket-ball. Picture to yourselves a man lying with a small hole either before or behind in the thigh, no bleeding, no pain, nothing but an inability to move the limb, to stand upon it, and think that he must inevitably die in a few weeks, worn out by the continued pain and suffering attendant on the repeated formation of matter burrowing in every direction, unless his thigh be amputated at the hip-joint, or he be relieved by the operation which, I insist upon it, ought first to be performed.

85. In order to do this operation with precision, the surgeon should make himself well acquainted with the anatomy of the parts; and as the war in the Russian Empire may offer opportunities for its performance, a recapitulation of the essential points to be noticed may be useful. Two limbs should be injected so as to show the great arteries distinctly, and one should be dissected so that every part may be brought into view at once. That being done, attention should be directed to two points, the great trochanter and the round head of the thigh-bone in its socket, which is directly below and a little internal to the anterior superior spinous process of the ilium.

When the thigh is bent in the dissected limb, the head of the bone will be seen rolling in the socket very distinctly, and, in order to lay it bare for removal, the muscles, etc. around it must be divided. The first, on the anterior and outer part, is the tensor vaginæ femoris; this should be divided; outside this the gluteus medius must be cut, going to be inserted into the upper and outer part of the top of the great trochanter; deeper, and between these two last, lies the gluteus minimus, winding forward to be inserted into the anterior portion of the same part. Now, let the great gluteus muscle be cut through backward in a curve, and the insertions of four muscles at one part—viz., the pit or fossa immediately behind the great trochanter—will be brought into view: these are the pyriformis, the gemelli, reckoned as one muscle, and the obturatores externus and internus. They should all be cut through within half an inch from their insertion. The square muscle lying or placed immediately below them, and running from the ischium to the inter-trochanteric line, is the quadratus femoris; it must be cut across. The head of the femur will now be seen to roll in the socket on the least motion being given to the knee. The surgeon should then open into the exposed joint with great care, when by a gentle rotation of the knee inward the head of the thigh-bone will be readily dislocated outward. The ligamentum teres, or the round ligament, as it is termed, although it is triangular at its origin, should now be divided, with as much of the capsular ligament as may be necessary, when everything will be ready for the application of the saw.

Pause a moment, and view the parts before the saw is applied. Two strong muscles are inserted into the small trochanter by a common tendon, the iliacus internus and psoas magnus. This insertion should remain untouched if the fracture should not extend below the little trochanter. It is not always necessary to injure them, and they will be of great use afterward, if the operation should prove successful. If the neck of the bone be broken through, rotating the thigh as directed may not assist much in dislocating its head. But then, the separation of the fractured parts may be readily completed, and the piece detached, when the remaining part of the head of the bone will be more easily removed. The sawing may be accomplished with the greatest ease by a small common saw, or by the improved chain saw, which will do good service. The arteries to be divided are all of small size. Filled with red injection, they are so small as scarcely to be seen; and they could not give any trouble; for the wound is so large as to give easy access to every part, and readily admit of any bleeding vessel being tied without difficulty. The round ligament should be cut off close to its origin in the acetabulum, and any portion of the capsular ligament and cartilaginous edge of the acetabulum which can be quickly removed with it, but no time should be unnecessarily lost in trying to remove the cartilaginous lining of the cavity itself, which will be gradually absorbed. The sawn end of the femur should now be brought up into the cavity, and kept there if possible by a supporting splint and bandage, with the hope that it may become rounded and adhere by a newly-formed ligamentous structure, in the same manner as the end of the humerus does to the glenoid cavity of the scapula, when similarly treated. The edges of the wound are then to be brought in apposition, and retained so by two or three sutures. The gluteus magnus slides over the trochanter major, having a bursa between them, and this part will not readily throw out granulations. The surgeon may therefore be less solicitous about the accuracy of the apposition of the edges at the under part, through which the discharge will more easily pass. The outside must, however, be supported by sticking-plaster and bandage compress, to prevent any bagging, and to keep all parts in contact. The saving the periosteum of as much of the femur to be taken away, as strongly recommended by MM. Flourens and Baudens in the excision of the head of the humerus, should be attempted, although not easy of execution. (Aph. 118.)

86. The surgeon should now do the operation on the undissected limb. The first cut through the skin, integuments, and fascia lata should be a curved one, beginning just over the inner edge of the tensor vaginæ femoris muscle, as shown on the other leg, curving downward and outward, so as to pass across the bone an inch at least below the trochanter major, when it should turn upward to the extent of three inches or more, as the size of the limb may require. This incision or flap should, when complete, divide, in addition to the integuments, the fascia lata, the tensor vaginæ femoris, and part of the gluteus maximus. The flap thus formed must be raised or turned up by an assistant, to enable the operator to get at and divide the parts below, in the order before named. It is not necessary to stop to tie any bleeding vessel until the operation is finished, for little or no blood will be lost.

Pause again. The surgeon has just done nearly the outer half of the operation as to cutting, for removing the whole limb at the joint; and if he should now find that the bone is so much shattered in the shaft that he cannot hope to save the limb, there is no difficulty in removing it. To do this, place your long knife inside the bone, with the middle of its edge resting against the outer edge of the iliacus and psoas muscles, and at one firm cut of a strong hand let it cut its way inward, forming an inner flap, your assistant steadily compressing the femoral artery against the bone above. This artery and the great profunda will both be divided; seize them with the finger and thumb of the left hand, and place a ligature, or assist in placing one, on each branch with the right; or, if the trunk of the profunda should have been cut very short, tie the main trunk of the femoral. Let the ligature be a single thread of strong dentists’ silk, with which I have successfully tied the common iliac, and no fear need be entertained of its not holding fast if you tie it reasonably tight. The idea usually entertained that a great artery cannot be closed by the ordinary process of nature under a ligature, if a branch be given off near it, is erroneous. I never placed reliance on this opinion unless in the accidental circumstance of the outside of the orifice of the branch being in contact with the ligature, the irritation caused by which outside may not be sufficient to close the orifice within, and the common iliac artery of one of the two cases in which I tied it successfully (the patient dying a year afterward) may be seen in the Museum of the College of Surgeons. It is tied about an inch from the aorta, and was pervious on each side of the ligature, which has closed the vessel to no greater extent than its own width, proving all the facts I have mentioned so frequently on this subject. As to the smaller vessels, they will give no trouble, being easily commanded, each by the point of a finger. I have not done this operation of removing the head and neck of the femur on a healthy living man after an accident, but it must be done, and I am satisfied it will in the end succeed. It was done in the 3d Division of the army in the Crimea after the engagement of the 18th of June. The continuity of the head with the shaft was not altogether destroyed, the fracture being principally confined to the great trochanter and the trochanteric ridge. It was at first thought the operation might be dispensed with, but as great irritation ensued, with every prospect of considerable mischief, the head, neck, and both trochanters were excised. On the 6th of July the man was doing well, but unfortunately he was attacked by cholera three days afterward, and died. This operation has since been done by Mr. Blenkin, of the Grenadier Guards; the result will be stated hereafter.

Amputation at the hip-joint should not be performed, unless the head and neck of the thigh-bone be injured; and it ought not to be done if they be, unless the shaft of the thigh-bone be extensively broken also. The operation I have recommended should be its substitute, and I hope yet to see a man walking with ease and comfort on whom it has been performed. The recommendation thus given is the result of the experience of former times, of the whole of the war in the Peninsula and at Waterloo, matured by that of the last forty years in London hospitals, and by a due consideration of the state of surgery throughout all civilized Europe and America. Surgery is never stationary, and surgeons of the present day must continue to show that it is as much a science as an art.

87. Wounds of the knee-joint from musket-balls, with fracture of the bones composing it, require immediate amputation; for although a limb may be sometimes saved, it cannot be called a recovery, or a successful result, where the limb is useless, and is a constant source of irritation and distress after several mouths of acute suffering have been endured, to obtain even this partial relief from impending death. For one limb thus saved, ten lives will be lost; and the sufferer is often glad, after months and years have elapsed, to lose the limb thus saved, more particularly when the ball has lodged in the articulating surface of either of the bones. Amputation at a secondary period, in these cases, does not afford half the chance of success, for many will not survive the inflammation and the fever which will ensue. The amputation should therefore be immediate, unless excision can be substituted for it, and it is a point to be hereafter decided whether excision may not almost always be so substituted when the wound is made by a musket-ball, and the popliteal artery and nerve are not injured.

88. Compound fractures of the patella, without injury to the other bones, admit of delay, provided the bone be not much splintered. If the ball should have pierced the center of the patella, and passed out nearly in an opposite direction behind, the limb will not be saved. If the ball have struck the patella on its edge, and gone through it transversely, opening into the joint, it will very rarely be saved; but if it be merely fractured, there is hope under the most rigorous antiphlogistic treatment, and delay is proper. A ball will occasionally penetrate the capsular ligament, and lodge in the knee-joint, with little injury to the bones. If it cannot be extracted without opening extensively into the cavity of the joint, and the extraction of the ball is absolutely necessary, amputation or excision had better be performed at first, for it will be ultimately necessary. The condyles of the femur and the lower part of the bone being spongy, a ball may pass through them or between them, and fall into the knee-joint, or it may make a prominence on the side of the patella, without passing out, or immediately interrupting the motion of the leg, for the soldier may walk some distance afterward. The popliteal artery may also be divided in addition, and either of these cases will render amputation necessary, for the ball must be taken out on the fore part, and the general inflammation of the joint will either destroy the patient in a short time, or, after much distress and hazard, leave him no alternative but amputation. If a ball lodge in the condyles of the femur within the capsular ligament, and cannot be easily extracted, excision or amputation is advisable; for the limb, if preserved, will not be a useful one. If the ball, on the other hand, lodge without the capsular ligament, and cannot readily be extracted, the wound should be healed as soon as possible; and, although it may cause some little inconvenience to the knee-joint, the limb and life of the patient may be saved, as I have seen in many instances, when a continuance of persevering efforts to extract the ball would have exposed both to great danger. Many cases of wounds in the knee-joint, in which the capsular ligament has been wounded, and the articulation opened into without injury to the bones, do well, such as simple incised wounds made with a clean cutting instrument. The success attending all wounds of the knee-joint depends entirely upon absolute rest, upon the antiphlogistic mode of treatment being rigidly enforced, on the healthy state of the atmosphere, and on the locality being free from endemic disease. The limb is to be placed in the straight position, a splint to be put beneath it, in order to prevent any motion, and cold or iced water to be applied, especially in summer, to diminish the increasing heat. General bleeding may be had recourse to in sufficient quantity to keep all general inflammatory action in due bounds; but it is on local blood-letting that the surgeon must principally rely for the prevention of inflammation. Cupping can sometimes be performed with marked effect; but leeches are more serviceable when they can be procured in sufficient numbers; from twenty to forty, or more, may be applied at a time; whenever the sensation of heat is felt, and is accompanied by pain, they should be repeated until these symptoms subside. The necessity for the local abstraction of blood is so great that it should never be lost sight of for a moment; for if suppuration take place throughout the cavity of the joint, it is followed, in most instances, by ulceration of the cartilages and caries of the bones. By local and general bleeding, the application of cold, rigid abstinence, and the straight position, a recovery may sometimes be effected; but wounds of the knee-joint, however simple, should always be considered as of a very dangerous nature, infinitely more so than those of the shoulder, the elbow, or the ankle. When a poultice is applied to a gunshot wound of this kind, I consider it the precursor of amputation. Col. Donnellan, of the 48th Regiment, was wounded, at the battle of Talavera, in the knee-joint, by a musket-ball, which gave him so little uneasiness that he could scarcely be persuaded to proceed to the rear. At a little distance from the fire of the enemy, we talked over the affairs of the moment, when, tossing his leg about on his saddle, he declared he felt no inconvenience from the wound, and would go back, as he saw his corps was very much exposed. After he had stayed with me a couple of hours, I persuaded him to go into the town. This injury, although at first to all appearance so trifling, proceeded so rapidly as to prevent any relief at last being obtained from amputation, and caused his death in a few days.

89. Excision of the knee-joint is an operation formerly attended with so little success that it has been but rarely performed until lately. The result will, in all probability, be more favorable in cases of injury from musket-balls, in which the femur and tibia have both been much injured, without so much mischief being inflicted on the soft parts as would have rendered amputation necessary. In such cases, provided every accommodation, and particularly absolute rest and good air, can be obtained for the sufferer, excision should be attempted, in preference to the amputation recommended in 84 and 85. Some cases of success have lately been published by Mr. Jones, of the island of Jersey; some by Mr. Syme, Mr. Mackenzie, Dr. Gurdon Buck, Mr. Fergusson, and others. Mr. Jones’s method of operating is here transcribed, as sent to me by himself:—

“In my first case, the incisions were in this form H, two lateral, one along each side of the joint, and a transverse one immediately over the middle of the patella. The flaps were then dissected upward and downward, the patella removed—and I do not see that any advantage can be gained by keeping it, even if not diseased—the crucial and lateral ligaments were then divided, and the joint completely opened. The leg was afterward bent backward on the thigh, and the diseased portion of the femur was cleared, and removed with an ordinary amputating saw. The same method was followed with the tibia: the bones were then placed in juxtaposition, the flaps brought together by means of a few stitches, and the limb placed in a species of fracture-box. Water-dressing was applied. In the second case, I followed very nearly the same plan, with the exception of my first incisions, which were made something in a horseshoe shape. In the third case, I removed a considerable portion of integument, and, I conceive, with marked advantage. In the two former cases, I think the cure was protracted by preserving all the diseased external parts.”

Dr. Gurdon Buck, of the United States of America, in a case of anchylosis, with deformity, after a gunshot wound, removed the knee-joint by a transverse incision from one condyle to the other across the lower margin of the patella. A longitudinal incision intersected this, extending four inches above and below it. The flaps being dissected up, the joint was opened into by an incision across the ligamentum patellæ at the inferior edge of the bone, and also across the lateral ligaments. The adhesions of the articular surfaces were broken up by forced flexion very gradually applied. A slice was then removed with the common amputating saw from the surface of the condyles of the femur, including the pulley-like surface, care being taken to make this section on a plane parallel with the surfaces of support upon which the condyles rest, when the body is erect. The articular surface of the tibia was next removed on a level with the upper extremity of the fibula, after the insertions of the capsular ligament had been dissected up from the posterior half of the circumference of the head of the bone. The broad, fresh-cut bony surfaces, which were very vascular and healthy, admitted of accurate coaptation without stretching the tendons and other parts in the ham. To secure them in close contact, and prevent displacement, a flexible iron wire was passed through both bones on either side, and the two ends twisted and left out between the flaps of skin. The patella, being disorganized and softened, was removed, except the superior margin, which affords insertion to the quadriceps muscle. The flaps of integument having been trimmed, were brought together by sutures and adhesive plaster, and the limb placed in a fracture-box. The constitutional fever was moderate, and disappeared in a fortnight. Suppuration never exceeded half an ounce daily. At the end of five weeks and a half the wires became loose, and were removed. No exfoliation followed. At the end of nine weeks the wound had entirely healed, and the limb could be raised bodily from the bed. There is no mobility between the bones; the difference in the length of the limb, as compared with the other, is one inch and a half, which permits the foot to clear the surface of the ground, which cannot be done when the limb is of the same length as the other.

Mr. Jones, since the publication of his original cases, has in a subsequent one not only preserved the patella, but even the ligamentum patellæ, which he considers to be a great improvement when it can be effected; he operated in the following manner: A longitudinal incision down to the bone, four inches in extent, was made on each side of the knee-joint, midway between the vasti and the flexors of the leg. These two cuts were then connected by a transverse one just over the prominence of the tubercle of the tibia, care being taken not to cut the ligamentum patellæ. The flap was turned upward; the patella and its ligament were freed, drawn over the internal condyle, and kept there by means of a broad, flat, and turned-up spatula. The joint was thus exposed, the synovial capsule was divided as far as could be seen, when the leg was forcibly bent, the crucial ligaments, almost breaking in the act, only required a slight touch of the knife to divide them completely. The articular surfaces of the bones were now completely brought into view, when the diseased portions were removed by suitable saws, the soft parts being kept aside by assistants; the external condyle had been hollowed out by a large abscess, so that it was necessary to saw off (obliquely) another portion of the carious bone, and to gouge out the remainder, until the healthy cancellous structure was reached. The articular surface of the patella had also to be gouged until sound bone was attained. The bones were brought into apposition, and the patella and its ligament replaced, as nearly as possible; at the end of seven weeks the patient, twelve years old, was able to turn the limb from side to side, and ultimately recovered.

This little boy I saw walking firmly on his leg, an admirable instance of conservative surgery. It is, nevertheless, an operation which ought not to be done on the field of battle, unless perfect quiescence and every desired accommodation can be obtained, and no endemic disease prevail.

90. Amputation of the leg is performed in two ways—by the circular incision and by two flaps, the circular incision being only applicable to the calf. In either way the stump should, if possible, be seven inches long, for the more convenient application of an artificial leg, which is now made with a socket to fit the stump, instead of resting against the bent knee, unless the stump be too short for its proper adaptation otherwise.

The operation by the circular incision is performed by necessity in the thick part of the leg, and the bone is usually sawn through about four inches from the patella, so that, when the stump has healed, there may be sufficient length of bone left to support with steadiness the weight of the body on the knee, and that greater facility may be given to the motion of the leg, from the preservation of the insertion of the flexor tendons. The most eligible place for the application of the tourniquet, when used, is about one-third of the length of the thigh from the knee, on the inside, where the artery perforates the tendon of the triceps muscle, and where it can be most conveniently compressed against the bone by a small firm pad, the instrument being on the outside, or opposite the pad; or the compress may be placed between the hamstring tendons, a little distance from the hollow behind the joint, the instrument itself being on the fore part of the thigh. In this method the pad must be thicker, and the compression is more painful, and not more secure. The surgeon should stand on the inside of the leg to be operated upon, that he may more readily saw the fibula at the same time as the tibia, by which the chance of splintering the fibula is diminished; for this bone is held much more steadily under the saw when the tibia is undivided, whatever pains may otherwise be taken by the assistants to secure it. The limb should be a little bent, and the circular incision made with the smaller amputating knife through the skin and integuments to the bone on the fore part, and to the muscles on the outside and back part; and as the attachment of the skin to the bone will not readily allow its retraction, it must be dissected back all round, and separated from the fascia, the division of which in the first incision would avail nothing, from its strong attachments to the parts beneath. The muscles are then to be cut through, nearly on a level with the first incision, down to the bones. The interosseous ligament between the tibia and fibula is to be divided with the catlin; and as several of the muscles cannot retract in consequence of their attachment to the bones, they are to be separated with the knife; in the same manner the inter-muscular septa, or expansions running between them, are to be divided, as they would else prevent their retraction. The retractor with three slips is now to be put on, the center slip running between the bones, by which the soft parts may be pulled back to a sufficient distance, any adhering part being divided by the point of the knife. The bones are to be sawn through with the usual precautions, and the retractor removed, when the three principal arteries should be secured: the anterior tibial, on the fore part of the interosseous ligament, between the tibia and fibula; the peroneal artery behind the fibula; and the posterior tibial near it, more inward and behind the tibia; this artery will frequently, however, contract very much, and will only show itself on the compression being taken off the artery above. It in general causes more trouble to secure it than the others, and I have two or three times seen, even in London hospitals, the needle dipped round it in despair, when merely pulling out the artery with the tenaculum, and dissecting a little round it, would have shown the small retracted bleeding vessels arising from it, and have prevented, in all probability, a secondary hemorrhage. The tourniquet, if used, being removed, the smaller vessels tied, and the stump sponged with cold water and dried, the integuments and muscles should be brought forward as much as possible, and the strips of adhesive plaster applied from side to side—that is, the wound is to be closed vertically or nearly so, that the strips of plaster may not in any way press upon the fore part of the tibia, by which its protrusion will be avoided, an occurrence which almost invariably follows when the line of approximation is horizontal and the strips of plaster press upon the bone. If the spine of the tibia be sharp, it should be removed by the saw, whether the operation be done by the circular incision or by the use of flaps.

91. The flap operation, as performed by Mr. Luke, differs from that of the thigh in some particulars. There is a greater variety in the proportion which the soft parts in the posterior flap bear to those in the anterior, and the distance from the bones at which the limb is transfixed in the first step of the operation is subject to such variety that, when the calf is large, the mid-point for the introduction of the knife lies at some distance from the posterior aspect of the bones; in a small calf, it is close to it. The course of the knife through the limb is oblique instead of transverse, for the purpose of accommodating the line of incision to the plane of the two bones. The anterior flap is formed in the same way as in the thigh amputation, but it has proportionately more integuments and is thinner; yet its base and length are rendered equal to the base and length of the posterior flap, and may be adjusted evenly with it when the stump is dressed. In the circular division of the remaining soft parts, after the formation of the flaps, there is a necessary variation in the proceedings, from the circumstance of there being two bones united by interosseous membrane. It may, however, be accomplished by sweeping the knife around the more distant bone of the two, its point being afterward carried between the bones through the interosseous membrane. While the knife is between the bones, its edge may be so turned that the membrane may be divided longitudinally to any convenient extent for the easy introduction of a retractor, and the soft parts around the bone nearest to the operator may subsequently be divided by a sweep of the knife in a manner similar to that adopted for the division of parts around the more distant bone. The sawing of the bones and dressing of the stump are accomplished as in the thigh amputation; but more care is required to avoid pressure on the acute margin of the tibia, (which, when very sharp, should be removed,) and to prevent the pendulous state of the flaps.

A. The mid-point between B and C, at which the knife is introduced for carrying it across the limb.
A to D. The course of the incision to form the posterior flap, E.
F to g. The course of the incision to form the anterior flap.

When the nature of the injury renders amputation necessary at or immediately below the tuberosity of the tibia, the operation may be done with safety. Baron Larrey recommended the removal of the head of the fibula in such cases; I have done it with impunity, and thereby made a better stump than if it had not been done; but as the articulating surface of the head of the fibula does sometimes enter into the composition of the knee-joint, and as this cannot be known beforehand, the removal of this portion of the fibula is not advisable, neither must the tibia be sawn through above the tuberosity lest the capsular ligament be implicated. As an operation by which the knee-joint is saved, it is important; for although the stump is very short, it forms a solid support for the body, enables the patient to walk without the aid of a stick, and admits of the adaptation of an artificial leg. The skin, in these cases, must be saved in every direction by flaps, to form a covering. When in sufficient quantity, the operation may be done by the circular incision, as much muscle as possible being saved to aid in forming a covering on the under and outer sides. The posterior tibial artery will be found to have retracted behind the head of the bone, whence it, or others which may bleed, must be drawn out. The nerves should be cut as short as possible.

EXCISION OF THE ANKLE-JOINT.

92. This operation should be performed in the following manner: Begin the incision behind the external malleolus, an inch and a half above its lower extremity, and carry it downward and then forward across the front of the ankle-joint, then under the internal malleolus and upward, close behind this process, to the extent of an inch and a half; this incision should merely divide the skin, and should not, on any account, wound the subjacent parts. Raise the flap thus made, and, placing the leg on its inside, detach and turn aside the peronei tendons from the groove behind the external malleolus. Cut through the external lateral ligaments of the ankle-joint, keeping the knife close to the end of the fibula; then, with the large bone-scissors or nippers, cut through the fibula from one-half to three-quarters of an inch above its junction with the tibia, and, after dividing the ligamentous fibers connecting the two bones, remove the malleolus externus. Turn the leg on to its outer side, and cut through the internal lateral ligament close to the tibia, to avoid wounding the posterior tibial artery; this will allow the foot to be dislocated outward, and the lower end of the tibia to be brought well out through the wound. An assistant keeping the foot and tendons out of the way, the lower end of the tibia is to be removed by a fine saw to the same extent as the fibula, or as high as the injury or disease requires. The articulating surface, or injured part of the astragalus, is then to be removed, after which the foot is to be returned to its proper position, and the cut surfaces of the tibia and astragalus brought into close approximation, and so kept by suture, strapping, and bandage. The limb is to be placed on an outside leg-splint, having a foot-piece to it; and in order to prevent any matter oozing, an opening should be maintained on the outside of the joint, with a corresponding hole in the dressing and splint for this purpose, until the recovery is completed. The shot-hole will sometimes answer the purpose, when the injury is inflicted by a musket-ball. There are no vessels to tie, unless wounded accidentally.

REMOVAL OF THE OS CALCIS.

93. If this bone should be much shattered, and the injury nearly confined to it alone, it may be removed in the following manner: Make a semilunar incision down to the bone from the posterior angle of the inner malleolus, across the sole of the foot to the external malleolus, the convexity of the flap being forward. This flap being turned back, the tendo Achillis is brought into view, and is to be separated from its attachment or cut across above it. The point of junction between the calcis and astragalus having been ascertained, the ligamentous fibers are to be cut through and the joint between them opened, when the knife is to be carried from behind forward, in order to divide the interosseous ligament between them. Some ligamentous fibers passing between the calcis and cuboid bones are then to be cut through, when the os calcis may be dissected out without difficulty. The posterior tibial artery and nerve will be divided.

This bone was first removed for disease of its substance by Mr. Hancock, and the operation has been done several times since by Mr. Greenhow and others with success.

94. When the bones of the leg are not injured, although those of the tarsus are so far destroyed as to render amputation necessary, the operation introduced by Mr. Syme for removing the foot at the ankle-joint will be well adapted for this injury, provided the soft parts have not been so much destroyed as to prevent the formation of the covering flap or flaps. His directions are:—

“Pressure should be made on the tibial arteries by the finger of an assistant or a tourniquet applied above the ankle. The only instruments required are a knife, the blade of which should not exceed four inches in length, and a saw. The foot being held at a right angle to the leg, the point of the knife is introduced immediately below the malleolar projection of the fibula, rather nearer its posterior than anterior edge, and then carried straight across the bone to the inner side of the ankle, where it terminates at the point exactly opposite its commencement. The extremities of the incision thus formed are then joined by another passing in front of the joint.

“The operator next proceeds to detach the flap from the foot bone, and for this purpose, having placed the fingers of his left hand over the prominence of the os calcis, and inserted the point of his thumb between the edges of the plantar incision, guides the knife between the bone and nail of the thumb, taking great care to cut parallel with the bone and to avoid scoring or laceration of the integuments. He then opens the joint in front, carries his knife outward and downward on each side of the astragalus so as to divide the lateral ligaments, and thus completes the disarticulation. Lastly, the knife is carried round the extremities of the tibia and fibula so as to afford room for applying the saw, by means of which the articular projections are removed, together with the thin connecting slice of bone covered by cartilage. The vessels being then tied, and the edges of the wound stitched together, a piece of wet lint is applied lightly over the stump, without any bandage, so as to avoid the risk of undue pressure in the event of the cavity becoming distended with blood, which would be apt to occasion sloughing of the flap. When recovery is completed, the stump has a bulbous form, from the thick cushion of dense textures that cover the heel, and readily admits of being fitted with a boot.

“The advantages which I originally anticipated from this operation were—first, the formation of a more useful support for the body than could be obtained from any form of amputation of the leg; and, secondly, the diminution of risk to the patient’s life, from the smaller amount of mutilation, the cutting of arterial branches instead of trunks, the leaving entire the medullary hollow and membrane, and the exposure of cancellated bone, which is not liable to exfoliate like the dense osseous substance of the shaft. From my own experience, amounting to upwards of fifty cases, and that of many other practitioners who have adopted amputation at the ankle, I now feel warranted to state that these favorable expectations have been fully realized, and that, in addition to its other advantages, this operation may be regarded as almost entirely free from danger to life.”

This operation has not answered, in some of the hospitals in London, the expectations entertained of it from its success in Edinburgh, the flap formed from the under part, or heel, having frequently sloughed. This, Mr. Syme declares, is the fault of the operators, and not of the operation, sufficient attention not having been paid to make the flap of a proper length, and no more, and to preserve the posterior tibial artery intact, until it has divided into its plantar branches. He insists, with reason, that the operation should be done exactly as he has described it in the following explanation:—

“A transverse incision should be carried across the sole of the foot, from the tip of the external malleolus, or a little posterior to it, (rather nearer the posterior than the anterior margin of the bone,) to the opposite point on the inner side, which will be rather below the tip of the internal malleolus, but can be readily determined by placing the thumb and finger at opposite sides of the heel. If the incision be carried farther forward, a considerable inconvenience is experienced from the greater length of the flap; and I believe a great deal of the difficulty that has been attributed to the operation has arisen from this source—the operator getting into the hollow of the os calcis, cuts and haggles, in striving to clear the prominence of the bone, with the desperate energy of an unfortunate mariner embayed on a lee shore in a gale of wind. Another incision is then to be carried across the instep, joining the ends of the former. The next point to be attended to is, that in separating the flap of skin from the os calcis you must cut parallel to the bone. This is of the greatest importance, since when the flap is detached from the bone, its only supply of nourishment must be the branches which run through it parallel to the surface; and if, instead of keeping parallel to the surface, you cut on the flap as a butcher does when he skins a sheep—you will, by scoring it in this way, necessarily cut across these branches. I have reason to believe—nay, to know—that the sloughing which has occurred in some cases has been due to these defects in the performance of the operation; the flap having been cut too long, difficulty has been experienced in separating it from the calcaneum, and this has led to the scoring of the flap, which has been inevitably followed by death of a portion or the whole of it.”

Domestic surgery, or that of civil life, has in these operations of excision of the ankle-joint, and of amputation at that part, repaid her Amazonian sister of military warfare for the improvements she has introduced into the great art and science of surgery; and a degree of generous emulation will be excited and maintained between them, which, it may be hoped, will, during the present war in the East, add much to its scientific and preservative character.

95. A musket-ball will seldom pass through the foot without injuring a joint of some kind, or wounding a tendon or nerve; and the injury to the fascia, which is very strong on the sole of the foot, and frequently covered by much thickened integument, is always attended with inconvenience. The extraction of balls, of splinters of bone, of pieces of cloth, and the discharge of matter become more difficult, and often cause so much disease as ultimately to render amputation of the foot necessary. Tetanus is a frequent consequence of these injuries, and is a disease, in its acute form, certainly irremediable by any operation or medicine at present known. Amputation has always failed in my hands, although it was strongly recommended by Baron Larrey. The operative surgery of the foot should be done as soon after the injury as it can be conveniently accomplished; for a large, clean, incised wound is a safe one, compared with a torn surface of much less extent, and a splintered bone with extraneous substances; as a ball lodged in the foot is always very dangerous, great attention should be paid in the examination of even slight wounds. A cannon-shot can seldom strike the foot without destroying it altogether; it may, however, strike the heel and destroy a considerable part of the os calcis, without rendering amputation necessary, if the ankle-joint be untouched; for by due attention in removing the spicula of bone at first, and by making free openings for the discharge of matter in every direction in which it may appear inclined to insinuate itself, the limb may be preserved in a useful state.

The following case, from the surgeon of the 44th Regiment, in the Crimea, is an instance of the removal of the foot after the manner recommended by the late M. Roux, every effort having previously been made to save it: “Chloroform having been administered, an incision was commenced immediately in front of and below the internal malleolus; this was carried downward and forward until it reached the center of the sole of the foot. From the extremity of this a second incision was made nearly at right angles, extending backward along the sole and upward over the attachment of the tendo Achillis to the os calcis. A third incision was carried from this round and below the external malleolus to meet the first at its commencement. Disarticulation of the ankle-joint was made from the outside, the soft parts put well on the stretch by forcibly depressing the foot, when, by successive sweeps of the scalpel, care being taken to keep the edge close to the bone, the os calcis was separated from its connection with the soft parts. The plantar arteries were divided at the very extremity of the flap. The operation was completed by sawing off the two malleoli and the thin scale of the articulating surface of the tibia. The anterior tibial and the two plantar arteries each required a ligature. Sutures were inserted, and the flap supported by strips of wet lint. The operation was performed on the 4th of July. The stump was dressed the second day after the operation. There had been no hemorrhage; the flap was partially adherent; on the outer side the skin was red, tense, and shining; the sutures were very tight; they were removed from this part; no appearance of sloughing.

“July 26th.—The ligatures came away upon the sixth day; no sloughing of the flap occurred; a small abscess formed both on the outside and inside of the leg, just where the malleoli were sawn off. These were opened; the redness of the skin rapidly disappeared after this. The line of incision is now entirely healed at the outer part; the inner is not so far advanced, but is doing well. The flap is becoming a firm, round cushion; and the pressure, when he walks, will fall upon the skin taken from the sole of the foot. The advantages which this operation appears to possess are, that the flap is not so large and baggy as in the early stage after Syme’s amputation; it is performed with greater facility and rapidity, and there is less chance of wounding the posterior tibial artery.”

The accompanying sketch is of the astragalus and calcis of the right foot, with a ball lodged on the inside, where it joins the smaller apophysis of the os calcis. The round spot (No. 3) represents the ball, and the tendons of the anterior tibial and of the common flexor muscles of the toes must have been divided by it; the proper flexor of the great toe is at some little distance below, and unhurt; the posterior tibial nerve and the artery, about to divide into the two plantars, are still farther distant. In this case the ball might and ought to have been removed by the gouge, the small chisel, the screw, or other instrument supplied for this purpose, as soon as possible after the injury. Nothing was done, however; inflammation and ulceration extended into the ankle-joint, and the amputation of the foot by the flap operation at the joint was performed and failed. The leg became affected; and the case ended in amputation of the thigh, from which the man recovered, and was sent to England. I know not his name, nor the regiment he belonged to, nor the surgeon who attended him, nor any more of the case, as the bone only has been sent to me from Scutari as a personal attention.

1. Astragalus.
2. Os calcis.
3. The ball.
4. Ligament descending from the tibia, torn by the ball.
5. Tendons of tibialis anticus and flexor communis cut across by the ball.
6. The other end of the same tendons.
7. The posterior tibial artery dividing into two branches.
8. The posterior tibial nerve.
9. The tendon of the flexor proprius pollicis.

If the ball had entered to a greater depth, the proper operation would have been to remove the bone altogether, which is a difficult and disagreeable operation, even when done in cases in which this bone has been dislocated, and is projecting under the skin. It is much more so when in its proper place; less so when the ends of the tibia and fibula are also removed for disease of these parts, in which case, the bone being softened, it yields readily to the scissors, by which it should be divided, and to which it opposes, when sound, a great resistance from its solidity. The removal of the astragalus alone has been successfully performed for disease in children, in two instances, by Mr. Statham, of University College Hospital, and has been strongly recommended by Dr. Buchanan, of Glasgow, and others. The operation, according to Mr. Statham’s method, is to be done as follows: An incision, four and a half inches long, is to be commenced within the anterior edge of the fibula, and carried down in a straight line beyond the anterior end of the metatarsal bone of the little toe; a second incision, about an inch in length, should then be made from the center of the wound downward toward the sole of the foot, for the purpose of giving room. The integuments are then to be raised from the bone, from the upper edge of the first incision, carrying with them the extensor tendons toward the inside of the foot, to give more room for ulterior proceedings, without injuring them. The under joint of a pair of short, strong scissors, such as are supplied in the capital cases of instruments, ought then to be pushed under the neck of the astragalus, at the hollow, where it is attached by a strong interosseous ligament to the os calcis. The upper blade being then closed upon the bone, it may be divided, but not without considerable force. The articulating end of the astragalus with the os naviculare can then be easily removed by a strong pair of forceps, its ligamentous attachments being first divided by the knife. In order to extract the remaining portion of bone, the under blade of the strong scissors must be again pushed under it from before backward, and made to cut it in two. The outer part being now separated from the internal end of the fibula, care being taken not to injure the perpendicular ligament going from that bone to the os calcis, this piece should be forcibly removed by strong forceps—an operation which could not be easily borne unless chloroform were used. The remaining piece or pieces must follow, when an examination should be made by the finger to ascertain that none remain. The parts should be brought together, a little lint and cold water applied, the limb placed on a splint, and interfered with afterward as little as possible. The wood-cut represents the forceps for extracting a ball imbedded in the astragalus.

Many years have elapsed since I stated that muscles might be cut across without, or with very little, inconvenience resulting from their division. Mr. Stanley has lately shown that tendons even may be cut across with little disability following, in a boy who had suffered an injury to the wrist; inflammation followed, with disease of the bones; and Mr. Stanley, instead of amputating the hand, made a flap on the back of it through the tendons. He removed seven of the small bones—all, indeed, except the trapezium supporting the thumb. The tendons reunited, and the boy has a remarkably good motion of the hand and fingers—proving the propriety of an operation which does so much credit to Mr. Stanley.

The astragalus may be also removed by a similar flap operation dividing the extensor tendons of the toes, commencing on the outside of the fibula, and being carried round in front, but not so far as to injure the tibialis anticus tendon, nor the anterior tibial artery and nerve; or, when the incision reaches the edge of the outer extensor, the whole of them are to be separated from the parts beneath, and drawn inward, when the operation of removing the bone is to be completed, as in the former instance. But many surgeons believe that when tendons are forcibly drawn aside, after being separated from their attachments, they are apt to slough, and that their division would, in most cases, be less injurious. In neither operation need tendon, artery, vein, or nerve of any importance be divided.

It may perhaps be stated that less regard is paid generally to gunshot wounds of the foot in which balls lodge than is desirable; and that other methods of operating may be devised for removing the astragalus less difficult in their performance, and more advantageous for the sufferers. The other bones of the instep and foot should be treated in a similar manner when balls lodge in them. Their removal may be more readily effected.

96. Wounds from cannon-shot injuring the fore part of the foot are better remedied by amputation at the joints of the tarsus with the metatarsus, than by sawing these bones across; but when the injury affects only one or two toes, they may be removed separately, recollecting that it is of greater importance to preserve the great toe than any other, and that this toe is worth preserving alone, when any one of the others would be rather troublesome than useful. Musket-balls seldom commit so much injury as to require amputation as a primary operation, although they may frequently render it necessary as a secondary one. The splinters of bone are to be removed, the ball and extraneous substances are, if possible, to be taken out; and if the bones, tendons, and blood-vessels are so much injured as to render the attempt to preserve them useless, amputation is to be performed. If the preservation of the limb be thought practicable—and it generally will be so in wounds from musket-balls—the attempt must be made under the most rigid antiphlogistic treatment, the local application of leeches and cold water from the first, with free openings for the subsequent discharge. Musket-balls seldom injure the metatarsal bones so as to require their removal with their toes, and under the treatment above mentioned these wounds will in general be healed without further operation. Wounds from grape-shot occasionally render the removal of the metatarsal bone of the great toe at the tarsus necessary, although much should be done to save it. The little and adjacent toes are also sometimes removed at the tarsus, the middle ones but seldom, as it is not an easy operation to perform, in consequence of the naturally close attachment of these bones, and the additional compactness they have acquired from the pressure of the shoe. Hemorrhage from the arteries of the foot authorizes amputation in a very slight degree, even when superadded to other causes; for the incisions necessary to secure the bleeding vessels will not, in general, add much to the original injury, unless they be very extensive; while, on the contrary, they render the wound less complicated and more manageable.

97. Amputation at the tarsus, when it is proposed to save the flap from the under part of the foot, is performed in the following manner: The joints of the metatarsus with the tarsus having been well ascertained, an incision is to be made across the foot, in the direction of the joints, but from half to three-quarters of an inch nearer the toes, and the integuments drawn back over the tarsus. From the extremities of this incision, two others are to be made along the sides of the great and little toes, for about two inches and a half, according to the thickness of the foot; the ends of these two incisions are to be united by a transverse one down to the bone, on the sole of the foot, the corners being rounded off. The flap thus formed on the under part is to be dissected back from the metatarsal bones, including as much of the muscular parts as possible, as far as the under part of the joints of the tarsus. The metatarsal bones are now to be removed by cutting into and dislocating each joint from the side, commencing on the outside, by placing the edge of the knife immediately above, but close to the projection made by the posterior part of the metatarsal bone supporting the little toe, which prominence is always readily perceived. The arteries are to be secured, any long tendons and loose capsular ligament to be removed with the knife or scissors, and the under flap, formed from the sole of the foot, is to be raised up so as to make a neat stump when brought in contact with the upper portion of integuments that was first turned back; the whole to be retained in this position by sutures, adhesive plaster, and bandage. When the skin of the under part of the foot is much torn, which is not uncommon in a wound made by a fragment of a shell, the flap cannot be formed from it; in this case it must in a great measure be saved from the upper part; but the integuments being here so much thinner, the flap is not so good a defense against external violence, and will be more readily affected by cold. The metatarsal bones may be sawn across in a straight line, in preference to removing them at the joint; and although the whole may be sawn across at once with more ease than any one of them individually, except the outer ones, yet the stump is never so much protected from external violence as when the operation is performed at the joints of the tarsus.

98. Amputation of the foot, leaving the astragalus and calcis, may, in certain cases of injury anterior to these bones, be performed with advantage, care being taken to make the under flap so large that the line of cicatrization may be on the upper and anterior edge of the stump, rather than transversely across the face of it, in order to render it firmer, and better able to resist and sustain any pressure which may be applied to it.

The limb being placed on the table, and held by an assistant, the surgeon ascertains the situation of the joint formed by the junction of the astragalus with the scaphoides, which will be indicated by the prominence on the inside of the tarsus, discoverable by passing the finger forward from the malleolus internus toward the side of the great toe. The joint of the os cuboides with the os calcis on the outside is always to be found about half an inch behind the projection formed by the posterior part of the metatarsal bone of the little toe. The under part of the foot being firmly held in the palm of the surgeon’s hand, he places the point of the thumb on the external joint, and that of the forefinger over the internal one; these indicate a transverse oblique line for the first incision, which should commence near the thumb, and be continued with a semilunar sweep, the convexity toward the toes, until it terminates at the side of the foot where the forefinger was placed. The joint between the astragalus and scaphoides is now to be opened, by directing the knife from within obliquely outward toward the projection of the metatarsal bone of the little toe. These bones are then to be dislocated by pressure, and the ligaments retaining them divided. The joint between the os cuboides and the os calcis is next to be opened from without inward, and the bones dislocated. The strong inter-articular ligament being cut, and the joint largely opened, the knife is to be passed between the under surfaces of the scaphoides and cuboides, and the soft parts adhering to them, and a flap cut from behind forward sufficiently large to cover the wound, which is then to be dressed in the usual manner.

99. Mr. Wakley, jun., has lately performed a successful operation for the removal of the astragalus and calcis, deserving of imitation in peculiar cases. It is done as follows:—

“The patient being under chloroform, the diseased foot (the left) having been drawn forward, so as to be free from the table, an incision was made from malleolus to malleolus, directly across the heel. A second incision was next carried along the edge of the sole, from the middle of the first to a point opposite the astragalo-scaphoid articulation, and another on the opposite side of the foot, from the vertical incision to the situation of the calcaneo-cuboid joint. These latter incisions enabled the operator to make a flap about two inches in length from the integument of the sole. In the next place a circular flap of integument was formed between the two malleoli posteriorly, the lower border of the flap reaching to the insertion of the tendo Achillis. This flap being turned upward, the tendon was cut through, and the os calcis, having been disarticulated from the astragalus and cuboid bones, was removed, together with the integument of the heel included between the two incisions. The lateral ligaments connecting the astragalus with the tibia and fibula were next divided, and the knife was carried into the joint on each side, extreme care being observed to avoid wounding the anterior tibial artery, which was in view. The astragalus was then detached from the soft parts in front of the joint and from its articulation with the scaphoid bone, and the malleoli were removed with the bone-nippers. The only artery requiring ligature was the posterior tibial. During the few minutes the operation lasted, the patient did not manifest the slightest symptoms of pain or uneasiness. On bringing the edges of the flaps together, they were found to fit with accuracy, and were secured by twelve interrupted sutures. The wounds were covered by several folds of lint, and supported by a light bandage. The patient, who had lost but very little blood, was then removed to his bed.

The incisions above described are here marked out on a healthy foot.

The skeleton of the foot will at the same time show the amount of bone removed.

These drawings exhibit the present condition of both sides of the foot—the amount of deformity is less than might have been expected.

“On the 21st of February he was discharged the hospital, exactly two months after the operation, to go into the country, the foot being well, with the exception of a small opening. He came again up to town on the 15th of April, and has become stout. The sinus on the left side of the foot had closed, but a slight collection of matter had formed a little above the instep; this was discharged by means of a puncture with the lancet, and he was directed to return to the country, and dash cold water over the foot two or three times daily. On the 10th of June he returned to town to his employment. There was then not the vestige of a wound, the last opening having completely closed. He was ordered to wear a high-heeled boot. He is now a healthy-looking man, and walks very well.”

As the posterior tibial must be divided, the preservation of the anterior artery is essentially necessary; the success of the operation depends upon it. This artery, accompanied by its vein and nerve, lies close upon the astragalus; the artery may be said to be even attached to it, a point requiring the greatest attention in dissecting out the bone without injuring this vessel, which is seen under the scalpel.

100. Amputation of a single metatarsal bone, on the outside or inside of the foot, is to be done by an incision round the root of the toe, terminating in a line on the outside of the foot, which is continued down to the joint of the tarsus. The integuments are turned back above and below from the metatarsal bone, which is to be dissected out, with the toe attached to it, and the flaps brought together so as to leave but one line of incision. In military surgery, there is always a wound; and when the removal of the bone is necessary, it is in general an extensive one, with loss of substance, so that a covering cannot be saved in this way, especially on the upper part of the foot, when struck by a ball or piece of shell. The surgeon, therefore, must be prepared to look for his covering on the under part, where he will occasionally not be able to procure it in sufficient quantity, and it must not be forgotten that the neighboring parts will often be injured. The object must then be to save the integuments from such parts as are uninjured, so as to cover in the wound as nearly as possible when the bone has been removed. In doing this, the first incision should commence at the upper part and inside of the toe, and be carried round so as to separate the toe from its attachment to its fellow. If the injury be entirely on the upper part, the continuation of this incision must be so regulated as to form the whole of the flap from below, and its commencement above must be continued round the injured part so as to meet the lower end near the articulation of the bone with the tarsus, and vice versa. If the ball have gone directly through, destroying the integuments above and below, the incisions must surround the injured part in such a manner, on the upper and under side of the foot, as to allow the flaps to be formed in every other part, except where the injury was inflicted, from which granulations must arise. By saving skin everywhere else, the wound will be much diminished in size, will heal sooner, will be less liable to suffer from external violence and less obnoxious to the subsequent pain which generally at intervals attends wounds of this kind.

Amputation above Knee.

a, wooden bucket for stump;
b, pin to attach foot;
c, the rolling foot;
d, straps of attachment to body.

Amputation below Knee, No. 1.

a, wooden shape to receive knee;
b, pin;
c, rolling foot;
d, e, straps of attachment.