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 1854-55, 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.

by G. J. Guthrie

LECTURE XXVI.

WOUNDS OF THE INTERNAL MAMMARY ARTERY, ETC.

362. Wounds of the internal mammary and intercostal arteries have so much occupied the attention of theoretical surgeons, and so many inventions have been broached for the suppression of hemorrhage, particularly from the latter, that it becomes consolatory to know that bleeding from these vessels rarely takes place; that the inventions are more numerous than the case requiring them, and that no notice need be taken of them, they being as unnecessary as they are useless. I have never had occasion to see a distinct case of hemorrhage from an internal mammary artery, but if bleeding should take place from a wound in its neighborhood, of a nature to lead to the belief that it came from this vessel, the wound should be enlarged until the part whence the blood flows can be ascertained, when, if it be from that artery, the vessel should be twisted or secured by ligatures, and if these methods should be impracticable, the wound should be closed and the result awaited.

The following method of operating for the application of a ligature on this vessel has been proposed by M. Goyraud. It may be done with ease in the three first intercostal spaces, it offers some difficulties in the fourth, is very difficult in the fifth, and is scarcely to be done lower down. An incision two inches in length is to be made near the side of the sternum from without inward, at an angle of forty-five degrees with the axis of the body. The middle of this incision should be three or four lines distant (a quarter of an inch) from the bone, and in the center of the intercostal space, within which the vessel is to be found. The skin, cellular substance, and the great pectoral muscle having been divided, the aponeurosis of the external intercostal muscle with the muscular fibers of the inner intercostal muscle are to be separated and torn through with a director, until the artery and its two venæ comites are laid bare at the distance of three lines from the edge of the sternum, lying before the fibers of the triangularis sterni muscle, which separates these vessels from the pleura. A bent probe, or other proper instrument, can then be readily passed under the artery. The vessel can only be secured in this way when injured at the upper part of the chest; below this it must bleed into the cavity, unless there be an open wound.

363. The intercostal artery, although often injured, rarely gives rise to hemorrhage so as to require a special operation for its suppression; but whenever it does so happen, the wound should be enlarged so as to show the bleeding orifice, which should be secured by one ligature if distinctly open, and by two if the vessel should only be partially divided. The vessel is sometimes so small as to be easily twisted, or its end sufficiently bruised as well as twisted, to arrest the hemorrhage. It lies between the two layers of intercostal muscles, and in the middle of the ribs it runs in a groove in the under part of each.

I have had occasion to twist and bruise the end of an artery bleeding in an intercostal space, and I have tied the vessel under the edge of the rib; but I have not met with any of the great difficulties usually said to be experienced in suppressing a hemorrhage from this artery, when the wound was recent, and the parts were sound; no reliance should be placed on the hypotheses often entertained on this subject.

When the parts are unsound, and the hemorrhage is secondary, greater difficulty is sometimes experienced in arresting it, because the ligature easily cuts its way through the softened parts, and styptics are liable to fall into the cavity of the chest.

The late General Sir G. Walker, G.C.B., after scaling the wall of Badajos, with the fifth division, was wounded by a musket-ball, which struck the cartilages of the lower ribs of the right side, broke the bones, penetrated the chest, and then passed outward. He remained in Badajos under my care during the first three weeks, with many of the other principal officers who were wounded; and overcame the first inflammatory symptoms in a satisfactory manner. After I left him the wound sloughed, some part of the cartilages separated, and one of the intercostal arteries bled, although the bleeding was arrested once by ligature, and afterward, on its return, by different contrivances; each time it reappeared his life was placed in considerable jeopardy from it and the discharge from the cavity of the chest, which was profuse. The bleeding was ultimately arrested by the oil of turpentine, applied on a dossil of lint, and pressed on the bleeding spot by the fingers of assistants until the hemorrhage ceased. He recovered after a very tedious treatment, with a considerable flattening of the chest, and a deep hollow at the lower part of the side, whence portions of the rib, and of the cartilages had been removed.

A young man, aged fifteen, was wounded by small shot in the chest, between the first and second ribs, and near the sternum, at the distance of about forty-eight paces. He ran about six hundred paces, fell, and died thirty-eight hours afterward. On opening the injured cavity of the thorax, it was found to contain twenty-eight ounces of blood, the lung having collapsed to one-fourth its natural size. An opening on its upper part corresponded to the external one in the paries; but the track of the shot could not be traced into its substance for more than two inches and three-quarters; a lacerated spot was, however, perceived at the lower edge of the sixth rib, about two inches from its head, at which part the intercostal artery was found to be torn through; the shot could not be found, and there was no opening in the skin behind.

The discussions which took place on this case led to the statement of an anatomical fact—that when a man is standing erect, a line drawn horizontally from the upper border of the second rib in front would touch the upper edge of the fifth rib behind, and that very little inclination, viz., an inch and a half, was necessary to make the shot wound the intercostal artery of the sixth. Auscultation would have made known the extravasation, and relief might have been given by an incision over the spot where uneasiness was felt; for the loss of blood was not sufficient of itself to destroy life, unless some other injury had been sustained, which was not perceived.

364. Wounds of the neck which are made with swords, or by knives or razors, by persons attempting to destroy themselves, are to be treated on two great principles. The first is, not to place the parts in contact until all hemorrhage has ceased, lest the patient be suffocated. In the mean time, while any oozing continues, a soft sponge should be placed between the edges of the cut. When the larynx or trachea is obstructed by a quantity of blood, it may be sucked out, or drawn up by an exhausting pump, and it may be advisable in some cases to introduce a tube. If the trachea be cut across, a stitch will be necessary to keep the ends in contact. The second is, to keep the divided parts in contact afterward, by position and bandage, but not by suture. If the œsophagus be wounded, nourishment should be administered by a gum-elastic tube introduced through the nares into the stomach. It is almost unnecessary to add that the artery, if wounded, should be secured by ligature. A hole in the internal jugular vein may be closed by a thread passed around it when raised by a tenaculum.

Captain Hall, of the 43d Regiment, was wounded by a ball which passed between the upper part of the back of the larynx and the termination of the pharynx, without causing much further inconvenience than the loss of voice. In this instance it must have been the superior laryngeal nerve that was injured, and not the recurrent, yet the voice could only be heard in a whisper, and was not completely recovered for years. If a ball should lodge in the trachea, it must be removed by the operation of laryngotomy or tracheotomy, if the original wound cannot be enlarged; although Birch, says Christopher Wren, hung up a man wounded in this way by the heels, when the ball dropped out through the glottis and mouth. General Sir E. Packenham, who was killed at New Orleans by a ball which went through the common iliac artery, had been twice shot through the neck in earlier life. The first shot, which went through high up from right to left, turned his head a little to the right. The second shot, from left to right, brought it straight. My kind and excellent friend had ever afterward a great respect and regard for the doctors and a strong feeling for the wounded. The recollection of that regard, and the advantages derived from it, have made me sometimes think it might be advantageous for the unfortunate as well as for the doctors if every general could be at least shot once through the neck or the body, before he was raised to the command of an army in the field; for there is nothing like actual experience of suffering to make men feel for their fellow-creatures in distress. A Minister at War would not perhaps be the worse for a little personal experience in this matter.

365. Wounds of the face made by swords or sharp-cutting instruments should be always retained in contact by sutures. When the cut is of small extent, and not deep, the skin only should be included by the thread, and that in the slightest possible manner, and the part supported by adhesive plaster and bandage. When the cheek is divided into the mouth, one, two, or more sutures may require to be inserted more deeply, but the deformity of a broad cicatrix will in general be avoided, by carefully sewing up the whole line, taking the very edge of skin only; and a cut in the bone or bones of the cheek should not prevent the attempt being made to unite the external wound over it.

Incised or even lacerated wounds of the eyelids and brows should be united by suture, as far as can possibly be done in the first instance, by which a subsequent painful operation may be avoided; great care should be taken in doing this; the suture must be inserted through the eyelid, and a leaden thread is often the best, the first being introduced at the very edge of the lid, and two, or as many more afterward as may be necessary. They may remain for three or more days, as circumstances seem to require. If the eye be wounded, any part protruding beyond the sclerotic coat should be cut off with scissors; but the eye, however injured, should not be removed unless the ball be detached in every direction, or destroyed. The treatment should be strictly antiphlogistic, in order to prevent suppuration of the eyeball, which may in general be effected, if too much injury have not been done to it, and if the treatment be sufficiently decided and well continued. These observations apply to the nose and ears, and all parts not actually separated—or, if separated, for a short time only—should be replaced in the manner directed, and every attempt made to procure reunion. If this should fail, surgery may yet be able to yield assistance by replacing the loss by a piece of integument dislodged from the neighboring parts—a proceeding requiring a separate consideration. Injuries from musket-balls are often attended by considerable laceration, particularly when near the eyelids. Whenever this occurs, the parts likely to adhere should be brought together by suture, after any splinters of bone which may present themselves, or can be seen or felt, have been removed from the holes made by the ball. If the bones should be broken, and not splintered, they will frequently reunite under proper management.

366. Wounds of the eye from small shot are remediable when these small bodies lodge in the cornea or sclerotica, whence they may be removed by any sharp-pointed instrument. When a shot or piece of a copper cap is driven through the cornea, into the iris, or lies in the anterior chamber, it should be removed by an incision to the extent of about one-fourth or one-fifth of the cornea, near its junction with the sclerotica, but in these cases a cataract, if not amaurosis, frequently results. When the shot passes through all the coats of the eye, it can neither be seen nor removed with safety; vision will be lost, much pain may be endured, and the eye will frequently be destroyed by suppuration, or by a gradual softening, and ultimate diminution in size. A contused wound from a large shot which only injures the coats of the eye, but does not perforate them, will oftentimes be cured by a proper antiphlogistic treatment, which in all cases should be most strictly enforced, although loss of sight is a frequent consequence after such injuries.

When a ball lodges behind the eye, it usually causes protrusion, inflammation, and suppuration of that organ. If it be not discovered by the usual means, its lodgment may be suspected from the gradual protrusion and inflammation of the eye itself. If it be discovered, it should be removed together with the eye, if such proceeding be necessary for its exposure. If suppuration have commenced in the eye, a deep incision into the organ will arrest, if not prevent, the horrible sufferings about to take place, and allow of the removal of the offending cause. If the eye remain in a state of chronic disease and suffering, a similar incision will give the desired relief. If the chronic state of irritation affect the other eye, the incision and sinking of the ball of the one first affected or injured is urgently demanded, and should not be delayed. If the back part of the eye be left with the muscles attached to it, a stump remains, against which an artificial eye may be fitted, so as sometimes to render the loss of the natural one almost unobservable.

367. I have several times seen both eyes destroyed and sunk by one ball, with little other inconvenience to the patient; one eye sunk, the other amaurotic, and both even amaurotic, almost without a sign of injury, by balls which had passed from side to side through both orbits, but behind the eyes. When the eye becomes amaurotic from a lesion of the first branch of the fifth pair of nerves, the pupil does not become dilated; the iris retains its usual action, although the retina may be insensible and vision destroyed. This was well shown in the case of the late Major-General Sir A. Leith, who was wounded by a sword in the forehead, this nerve being divided. It has so often occurred as to leave no doubt of the fact, and of the error formerly existing on this point.

368. Penetrating wounds implicating the bones of the face are always distressing. When the bones of the nose are carried away, there must always be some deformity remaining, although there is oftentimes but little suffering. When these bones are merely splintered and depressed, great pains should be taken to keep them properly elevated. If the duct of the parotid gland be implicated by an incised wound, care should be taken to divide the cheek into the mouth, if it should not have been already done, and to keep the incised wound open until the external one is closed. If a salivary fistula have formed externally, from inattention or otherwise, it must be treated according to the ordinary methods adopted in such cases. When a wound of the gland itself becomes fistulous, and weeps, which is a rare occurrence, it will be best treated by actual or potential cauterization, if moderate pressure should fail. When these wounds are of some extent, they are often followed by partial paralysis, in consequence of the seventh pair of nerves being injured, when the mouth is drawn somewhat to the other side. When the lachrymal bones or sac are injured by balls or swords, the tears usually continue through life to run over, and give inconvenience, although much good may be done by early attention to the injuries of this part. Wounds injuring the upper jaw are oftentimes followed by much suffering, and by permanent inconvenience.

General Sir Colin Halkett, G.C.B., was wounded on the 18th of June, at Waterloo, when in front of his brigade, which was formed in squares for the reception of the French cavalry, by a pistol-ball, fired by the officer commanding them, which struck him in the neck, and gave him great pain, but without doing much mischief. A second shot shortly afterward wounded him in the thigh, and he was obliged to leave the field toward the close of the day, by a third musket-ball, which struck him on the face, when standing sideways toward the enemy. It entered a little below the outer part of the cheek-bone on the left side, and, taking an oblique direction downward and forward, shattered and destroyed in its course several of the double teeth in the upper jaw, fracturing the palate from its posterior part, forward to the front teeth. The ball then took a direction obliquely upward, destroying the teeth of the opposite side of the upper jaw, which bone it also broke, and lodged under the fleshy part of the cheek. These wounds gave great pain, and until the ball was removed, the left ear was totally insensible to sound and all external impressions, although the general suffered much from distressing noises in his ear. These subsided on the removal of the ball some days afterward.

The treatment of this wound, however, was most painful; the extraction of several pieces of bone was necessary at different times, during the three following years, before the wounds were finally closed. Considerable derangement of health followed, the deafness remains; and the general has ever since been subjected to attacks in the head of an increasing and most distressing nature.

369. Wounds of the lower jaw are perhaps more common, and are certainly more troublesome than those of the upper; they are more difficult of management, and, for the most part, end in greater deformity, unless particular care be taken to prevent it, and then only in very severe cases, by operations which were formerly not in use, but which the intrepidity of the surgeons of the present day have deprived of all their terrors. I mean the methodical division of the soft parts, the sawing off and removal of the broken pieces of bone, and the rounding off of those parts of the jaw which may remain irregular and pointed. M. Baudens has given two good examples of the success of this proceeding during his campaigns in Algeria. In the first case, the ball entered at the middle of the left cheek, and came out by the side of the spinous process of the seventh cervical vertebra. The ascending ramus of the lower jaw was broken into numerous splinters. M. Baudens divided the soft parts down to the bone, entering the straight bistoury four lines, or the third of an inch, below the articulation of the jaw with the temporal bone. He then carried it downward, and a little obliquely forward, so as to terminate it in the fibers of the masseter muscle, about half an inch below the base of the bone. This incision was begun below the seventh pair of nerves, and exposed the parotid gland divided vertically at its middle part. The splinters were removed, a part of the pterygoideus internus muscle was divided, and a projecting point of bone attached to it sawn off. He then separated the attachments of the buccinator, temporal, and pterygoideus externus muscles, divided the ligaments, and removed the coronoid and articulating processes, taking care to avoid the fifth and seventh pairs of nerves. The bleeding from two arteries was suppressed by twisting their ends; and the parts were afterward brought together by sutures, which remained for eight days. A month after the operation the patient ate solid food, and in six weeks was cured. In the second case, the ball entered near the left commissure of the lip, and came out behind on the side of the middle of the neck; three inches of the jaw were splintered, the ends of the bone being sharp and angular. In order to remove the splinters, and to prevent the evils anticipated, M. Baudens divided the lip from the angle downward and outward, below the base of the bone, as far back as the edge of the masseter muscle. He then separated the flaps, and sawed the jaw across, first near the symphysis, and then behind, outside the attachment of the masseter. The facial artery was twisted, four sutures were inserted, and the jaw duly supported. The patient was bled twice, and in six weeks was cured; at the end of that time he could eat solid food. After the healing of such wounds, mechanical means are often necessary to enable the sufferer to eat and to live without causing disgust to his neighbors and his friends.

It is said there are fifteen men in the Hôtel des Invalides, in Paris, wearing silver masks on the lower part of their faces, in consequence of injuries of this kind.

Colonel Carleton was an instance of a ball fracturing the jaw directly through its body, near where the masseter muscle is attached on both sides; the jaw was broken into three pieces, besides splinters; several teeth were knocked out, and the tongue very much hurt. By sawing off the splinters both from within and without, and by cleansing and supporting the parts with great care, he recovered after a length of time, the deformity after such a wound being much less than might be expected.

370. Incised wounds of the tongue do sometimes give rise to hemorrhage somewhat difficult to restrain, particularly if it occur a few days after the receipt of the injury, when the tongue is swollen and painful. It does not so frequently occur after gunshot wounds. As the vessels of one side do not communicate with those of the other, any bleeding which continues after the artery of one side has been properly secured, can only take place from a wound of the artery of the other, which must then also be tied. This should be done by drawing the tongue as far as possible out of the mouth by a flat pair of forceps, which may be easily effected at an early period, when it is not tender and painful. At a later date, and under difficult circumstances, various styptics, such as the mineral acids, nitrate of silver, etc., will be useful. The actual cautery has been recommended, but I have never seen it used in such cases.

371. One of the most curious instances of the lodgment of a foreign body in the face occurred in the person of Captain Fritz, at Ceylon; his gun burst in his hand, and drove the iron breech into the forehead, whence it descended into the nares, and, at the end of a year, part of it made its appearance in the mouth, through the palate. He died eight years afterward, having suffered much inconvenience from the offensive discharge it occasioned. When the iron was removed, it had obviously injured no part of any material importance to life. I have seen balls descend in this way into the throat and soft palate, and have removed them from both places with success, and from the hard palate with equal surprise and advantage to the patient. I have known a ball lodge in the superior maxillary sinus for months, and even for years, before it was removed, or the death of the patient proved the fact.