Elements of Surgery

by Robert Liston

OF WOUNDS.

These vary in extent and nature. The instrument by which they are inflicted, the violence attending the injury, and the nature and importance of the parts divided, or in the neighbourhood of the wound, must all be attended to, for, from an accurate knowledge of these circumstances, the treatment of the case comes to be conducted accordingly. Wounds are divided into incised, punctured, bruised, and lacerated; that is, into such as are inflicted by a sharp-edged, sharp-pointed, or an obtuse body. In the first kind, there is greater or less effusion of blood, according to the size and number of the vessels divided. Some extend but a little way beyond the subcutaneous cellular tissue, and are consequently attended with but slight bleeding; others penetrate to a greater depth, and occasion hemorrhage from a large vessel, or other alarming symptoms, by having reached some important organ; others, though not of so great a depth as the former, may still, on account of their mere extent, be accompanied with very considerable loss of blood from a number of small branches. It is seldom that fatal effects immediately follow external wounds; but they may and do occur when bloodvessels of the first class only are cut. They are most likely to prove suddenly fatal when the arteries are only partially divided, and when the large veins accompanying them are also involved. When the artery is cut through, its extremities retract, effusion takes place into the sheath and compresses the orifice; the formation of a coagulum within the vessel is thus promoted, and the hemorrhage arrested. But, when a portion only of the circumference is divided, the blood continues to flow through the aperture and onwards, as if into a smaller ramification of itself, no retraction or contraction of the vessel can occur, coagulation is slow, and the bleeding profuse. I have seen a wound of so small a vessel as the internal mammary prove almost instantaneously fatal. Wounds of the large internal vessels for the most part prove immediately fatal; as wounds of the heart, or the large vessels passing to and from its cavities, at the root of the lungs, or at the upper part of the liver. When the heart, or the vessels within the pericardium, have been divided, it can be readily understood how life should be immediately destroyed, since the blood effused into the cavity of the pericardium by its pressure completely arrests the action of the heart. But occasionally punctured wounds, in such situations, have not been followed by instant death. In such cases, alarming symptoms occur at the time, but subside, and the patient may for some time suffer no uneasiness, but afterwards expires suddenly during muscular exertion, or perhaps in a fit of violent passion. Blood must have been effused into the pericardium at the first, causing symptoms of, or actual, syncope; but then the aperture in the vessel had become obstructed by coagulum before blood had been poured out in such quantity as to effectually prevent the actions of the heart; at a future period the coagulum gives way, and the subsequent effusion is limited only by the pericardial cavity being completely filled. In wounds, hemorrhage is the symptom which most alarms the bystanders, and which demands immediate attention; but, to operate successfully, the surgeon must divest himself of all fear, and learn to look boldly on the open and bleeding mouths of arteries. Effusion of blood ceases spontaneously, even from considerable vessels, on faintness supervening, and thus many lives are saved; but as soon as reaction commences it generally recurs, and may prove fatal, unless proper measures be resorted to.

When an artery is divided, its extremity retracts within the sheath, it also contracts, and coagulation occurs; thus the orifice is obstructed, and a temporary barrier formed to further hemorrhage. The tube, however, is permanently closed by effusion of lymph from its orifice, and consolidation of the surrounding parts.

The circumstances which follow division of an artery are these:—The immediate effect is retraction of its ends within the investing sheath, and a simultaneous contraction of the coats, so as to diminish the calibre. From the superior orifice there is necessarily a profuse flow of blood, which is discharged through the sheath that formerly enclosed that part of the vessel which has retracted. After considerable effusion of blood, the flow becomes slower and less profuse; particles of blood adhere to those filaments which previously connected the artery to the sheath, but which were lacerated by the sudden retraction of the divided extremity; these particles coagulate, and lessen the canal through which the blood is discharged, whilst they present an irregular surface, on which the blood continues to be deposited and to coagulate; and thus the aperture in the sheath is ultimately closed. This external coagulum is found to commence at the extremity of the artery, where it is of a cylindrical form, and shuts up the mouth of the vessel; it then extends along the canal in the sheath, frequently assuming a conical form; and, if a free discharge has been allowed for the blood, it will terminate at the cut margin of the sheath, otherwise it will be found continuous with the coagulum blocking up the external wound. Also, when hemorrhage has been resisted by the shutting of the external wound, blood is infiltrated into the cellular tissue around the bleeding point, and there coagulates; but this circumstance can be productive of little or no pressure on the parietes of the vessel, so as to assist those other natural means which obstruct it. The flow of blood through the divided vessel being prevented, the circulating fluid necessarily passes through the nearest collateral branches, leaving the blood in the extremity of the larger trunk in a state of comparative rest; consequently, coagulation occurs in this situation. The internal coagulum, however, is small, and not sufficient to occupy completely the cavity of the vessel; it is of a conical form, its apex being towards the heart, and opposite to the first collateral branch, and its base resting on the external coagulum, and there adhering to the internal surface of the artery. But, whilst this latter process is advancing, the capillary vessels supplying the cut margins of the artery have begun to act; they throw out coagulating lymph, and continue to do so until their secretion has completely filled the vessel immediately opposite to its divided margins; thus a third and more effectual coagulum is formed,—one of plastic matter, situated between the external and internal coagula of blood, and in general closely adherent to them. Lymph is also effused externally to the artery and its sheath, forming a dense stratum, which separates the extremity of the vessel from the external wound; it becomes organised, forms granulations, and thus the parts are consolidated, and the wound cicatrised. When the artery is permanently obstructed by the adhesion of its cut margins, the external coagulum can be dispensed with, and is gradually absorbed. Afterwards all the newly formed parts are condensed, and diminish in size; the artery contracts, its internal surface finally embraces the coagulated blood which lay loose in its canal; its coats appear to be thickened, and it is firm and hard. Ultimately, in consequence of the continuance of absorption, it becomes much more attenuated, so as scarcely to differ from the surrounding cellular tissue. Similar changes occur in the lower extremity of the divided artery; in general it retracts farther, its orifice is more contracted, and, the flow of blood being much less profuse than in the superior, the natural means for its temporary closure are sooner accomplished. When an artery has been divided close to the origin of a collateral branch, no bloody coagulum can form internally, for the blood in that situation is necessarily in a state of constant motion.

If the hemorrhage is suppressed artificially, either by ligature, or by otherwise well-applied pressure, no external coagulum is formed; there appears only the internal bloody coagulum, the lymphatic effusion, and consolidation of the compressed part. The natural contraction and retraction cannot occur in vessels partially divided; hemorrhage, therefore, is more violent and dangerous from a partial than from a complete section. Again, transverse wounds are more dangerous than longitudinal; in the latter, the edges of the wound are spontaneously approximated on account of the structure of the vessels, whilst, from the same cause, the margins of the latter continue separate, and, in fact, the aperture is a complete circle; the lips of an oblique wound will be more or less apart, in proportion as it approaches to the transverse direction. When an artery has been punctured, the wound in the sheath perhaps does not correspond with that in the vessel; blood, therefore, accumulates between the vessel and its sheath, and there coagulates. The wound is thus compressed, its edges kept in contact, and the farther escape of blood prevented; the lips of the incision are then agglutinated by effused lymph, and cicatrisation occurs. This, however, cannot be expected to take place unless methodical pressure has been applied from the first. Even from small punctures blood is effused under the sheath and into the neighbouring cellular tissue, rapidly, and in such quantity as to prevent adhesion. The effusion continues, and a false aneurism is formed. If a considerable part of the circumference has been divided, the lymph may be, and generally is, superabundant, and often to such an extent as to close up the canal of the artery at that point; but, if the aperture is minute and in a longitudinal direction, lymph will seldom be effused in greater quantity than is sufficient for the cicatrisation; and, though it should be superabundant, it is afterwards removed by the absorbents. In all cases, the cellular tissue round the wounded point is much thickened and condensed by the deposition of lymph, but this gradually disappears after cicatrisation has been completed. Sometimes, and generally when the wound has been transverse and large, the process of adhesion is disturbed, and suppuration occurs; in this case the wound in the vessel communicates with the fistulous track in the externally effused lymph, and may be the source of troublesome hemorrhage. In other instances of extensive transverse wounds, the undivided slip ulcerates, and the artery becomes obliterated, by means of the same natural processes that occur in complete division. In cases of laceration of an artery, when its coats have been forcibly torn rather than divided, little or no bleeding takes place. The vessel retracts; the lacerated margins of its inner coat become puckered up, so as to contract greatly the orifice of the vessel; the lacerated sheath is pulled out to a point, and closed at a little distance from the divided inner coats. If a large artery is torn asunder in the dead body, this stretching out and contraction of the sheath will prevent injection passing; in short, the immediate effects of the injury are such as to favour the instant formation of coagula, by which the hemorrhage is arrested until the orifices of the vessel be permanently closed by the adhesive process. Thus, in instances where the whole of an extremity has been torn off, the patients have generally lost but a very small quantity of blood.

From wounds of veins the blood flows, not in a sub-saltatory but in a uniform stream: its colour is dark, and the flow is easily suppressed. The common opinion is, that to place a ligature on a vein is dangerous, and to be scrupulously avoided. The process of reparation, besides, in a wounded vein, is different from that in an artery. Veins are less disposed to the secreting action by which adhesion is perfected; and, when inflamed, the inflammation is extremely apt to extend along the coats of the vessel; which latter circumstance has been ascribed to the great proportion of cellular tissue in their coats. When punctured longitudinally, the lips of the wound remain in contact, and cicatrisation, by means of effused lymph, is soon effected; in fact, the wound heals by the first intention. But if opened obliquely or transversely, not to a great extent, the immediate result is discharge of blood, and, when this has ceased, a coagulum forms in the wound, the margins of which remain separate; and this coagulum generally communicates with blood effused into the sheath of the vessel. After some time, the lips of the wound, encircling the coagulum which occupies the aperture, and which has temporarily averted the hemorrhage, become somewhat turgid, and increased in vascularity; they then appear to assume a secreting action, by which a membranous substance, of extreme delicacy, is produced; and the extent of this membrane is increased until it form an expansion, investing the outer surface of the clot; it then becomes thickened, by addition of matter, similar to itself, from the recent vessels which ramify in it. At the same time it forms adhesions to the surrounding cellular tissue, and resembles the original tunics of the vein. After being consolidated, so as to prevent the flow of blood through that part, the coagulum, formed to arrest the hemorrhage until a more complete barrier should be furnished, is gradually absorbed. But the membrane long remains smooth, thin, and diaphanous, and can be thereby readily distinguished from the original coats. This reparative process is much longer in being finished than the corresponding one in arteries; and, from what has been stated, it is evident that the two actions differ in other respects than the time requisite to complete them. When a vein has been completely divided, the extremities are closed by means similar to those which have been already detailed in regard to arteries.

In many, nay in most, instances of hemorrhage from a wounded artery, the surgeon cannot wait for the natural processes by which the flow of blood is arrested, but must have recourse to immediate and certain means. In division of the smaller arteries, or in minute wounds of the larger, pressure, well applied, will often be sufficient. In both cases it immediately stops the flow: in the former, it prevents the blood from penetrating into that portion of the sheath which has been vacated by the retracted artery; and it being thereby confined, and kept in a state of rest, coagulation soon takes place. At the same time, the compression brings the divided margins of the vessel into close apposition, and thereby permanent closure, by adhesion, is quickly accomplished. In the latter, the mere circumstance of the escape of blood being prevented, naturally hastens the closure of the minute aperture by the natural process; and, if the compression be accurate and very firm, the opposite surfaces of the vessel, being brought in contact, may adhere, and the canal be obliterated at the wounded point. It is obvious that, in this latter class, pressure can only be of advantage immediately after the infliction of the wound, and not when blood is extravasated to a great extent.

Pressure may be used along with styptics, or along with escharotics, actual or potential. They may be often employed when pressure ought not; styptics promote the contraction and retraction of the divided extremities, and thereby expedite the formation of a coagulum. Escharotics form a slough, which, adhering to the extremity of the vessel, stops the flow of blood, and the cut margins of the vessel, being stimulated by the application, soon cohere. Active stimulating applications merely cause effusion quickly of coagulated lymph, and thus often arrest hemorrhage from very vascular surfaces better than the so-called styptics. Not unfrequently, after the separation of the slough, it is found that union has not taken place, and hemorrhage is renewed; from this circumstance, the remedy cannot be trusted to, except when the divided vessels or vessel are of small size. It may be stated, generally, that these means are of little avail without methodical pressure. In oozing from small vessels, pressure may be applied by means of agaric, sponge, or lint. In bleeding from small vessels, where there is general oozing from the surface, and pressure cannot readily be made, applications tending to produce effusion of lymph—stimulants, such as turpentine or creosote, are often remarkably efficacious, and very speedily so; but in wounds of the larger vessels, the most efficient mean is a graduated compress of lint placed immediately on the external wound, and supported by a firmly-applied bandage. The bandage ought to encircle not only the wounded part, but every part of the limb with a uniform tightness, not so great as to arrest the general circulation; the parts are thereby supported, and engorgement prevented. This method, when employed previously to the effusion of much blood into the cellular tissue, has proved effectual in wounds even of the brachial, femoral, and carotid arteries. When blood has been extensively injected into the limb, when the aperture in the vessel has remained pervious, and when a large diffused aneurism exists, bandaging is worse than useless. By its application in such a case the limb becomes discoloured and swells extensively; there is a risk of mortification from impeded circulation. If a small quantity only of blood has escaped, its diffusion and increase may be prevented by the bandage: but a cyst will nevertheless be formed in the cellular tissue; its parietes will communicate with the margins of the aperture in the artery, its cavity with the canal of the vessel; an aneurism of the false kind will be established, and will run the course of one arising spontaneously.

A ligature, well applied, is the only means that can be relied on. The immediate effect of a tightly-drawn ligature is to avert the flow of blood, to divide the internal and middle coats at the deligated point, the cellular coat remaining entire, and to narrow the canal for some extent above the point at which it is applied. Coagulation then occurs within the vessel above the ligature, provided there is no collateral branch in the immediate vicinity. The ruptured margins of the internal coat effuse lymph and cohere; lymph is effused also in the cellular tissue, exterior to the artery and to the ligature; by the compression of the ligature, ulceration occurs in those parts which it envelopes, and the foreign body is discharged; but before this occurs the canal of the vessel has been obliterated by an internal coagulum, and by the effused lymph. Afterwards, the same absorption and consolidation occur as in a divided artery, the orifice of which has closed permanently and spontaneously.

When from a punctured wound profuse hemorrhage ensues, there is reason to suspect that an important vessel has been hurt, and the bleeding point must be sought for. After the artery giving out the blood has been discovered, the external wound must be enlarged, so as to expose the vessel, and admit of the convenient application of a ligature. It will not be sufficient to include the vessel above the wounded point, for the lower part will, after some time, be supplied with blood by the collateral branches almost as freely as by the large trunk, and, consequently, bleeding will be renewed. Two ligatures are to be employed, one above, the other below, the wound. The wounded vessel must be exposed, as already stated, but not detached more than is sufficient for the application of the ligature; and at the same time the ligatures ought to enclose nothing but the vessel. Neither ought the ligatures to be placed at any considerable distance, but as close to the wounded point as possible; otherwise circulation in the included part may be restored. The ligature, round, narrow, and firm, ought to be tightly applied. Cases of hemorrhage have occurred in which the tying of the vessel immediately above the wound has been successful; but these are few, and by no means afford any authority for the general adoption of such a measure. If the vessel is merely punctured, it is necessary to apply the ligature by means of a blunt pointed needle, and the parts are to be disturbed as little as possible. If, however, the artery is completely divided, its cut extremities are to be drawn out of their sheath by a hook or forceps, and the ligatures applied close to the connections of the vessel; the vasa vasorum, in the immediate vicinity of the deligated point, being left to carry on those processes by which obliteration is accomplished. In punctured or partial wounds of arteries, it deserves consideration whether the hemorrhage may not be restrained by the application of slight pressure, so regulated as to prevent the flow of blood laterally through the wound, but not so forcibly applied as to stop the onward current of the blood along the vessel, from the part of the tube above to that below the puncture. Some experiments made by Dr. Davy seem favourable to this view; as bleeding from the carotid arteries, partially divided transversely, in dogs was easily arrested by the means above-mentioned, the wound of the vessel readily healing, so as to preserve its tube entire; whereas, when the pressure was increased, the hemorrhage became violent. The subject is mentioned as one worthy of a further experimental investigation. The instrument which will generally be found most useful for laying hold of the vessel is the common dissecting forceps, but a tenaculum will, in certain circumstances, be more convenient. By far the most convenient machine is that here represented.

When no assistant is at hand, and in cases of emergency, the surgeon provided with this little instrument can tie vessels without the least difficulty; and in operation, when many vessels spring, several of these forceps can be applied; there is besides this great advantage in their employment, that a clumsy assistant can scarcely include the point of the instrument with the vessel. Hemorrhage from the smaller vessels soon ceases; and, before reaction occurs, their orifices have generally become so obstructed as to resist the effusion of blood.

The effects of ligature on a vein are somewhat different from those on an artery. The inner coat of the former is more dense and elastic, and remains entire, whilst the external and middle are divided. It is puckered by the ligature, and its opposite surfaces are placed in immediate contact; but there is no breach of surface, and adhesion does not occur till the tunic has been divided by ulceration; then the opposite margins cohere, the vessel is obliterated, and undergoes changes resembling those in an artery similarly circumstanced. The coagulum between the ligature and extremity is of considerable extent, dense, and completely filling the canal of the vein, and consequently, of a cylindrical form.

The edges of the wound, in the soft parts, ought not to be approximated till the bleeding has entirely ceased, and the surface become glazed, for the interposition of the slightest quantity of blood prevents union by the first intention. When bleeding has ceased, the divided edges are to be brought together as accurately as possible, and adhesion promoted. The minute vessels assume an action greater than in the healthy state, though not equal to inflammatory action; they effuse coagulating lymph, by which the opposed surfaces are agglutinated, though the union is at first feeble and easily broken up. Soon the lymph is firmly attached, by newly-formed vessels, to the surface from which it was secreted; in effect, it becomes organised, and rendered capable of undergoing, through its inherent powers, the changes necessary for its perfection and stability. Similar processes go on in it as in any sound part of the body; new matter is deposited, and the superfluous is absorbed. The process of nutrition, however, is not the same in all parts of its substance, that is, the new matter deposited is not exactly similar at all points; but, according as the new secreting vessels proceed from the different tissues of which the margins of the recent wound are composed, so, in various parts of the new formation, these vessels assume peculiar modes of action, one set forming muscular, another cellular tissue, and a third a substitute for skin, formations corresponding to the primary tissues from which the secreting vessels proceed.

Thus the vasa vasorum, ramifying on the divided ends of the minute vessels, secrete a substance which is transformed into a set of minute capillaries, and these also, assuming a secretive action, produce an arterial or venous tube, similar to that nourished by the original vasa vasorum. By this process the lymph becomes well supplied with bloodvessels, those from the opposite surfaces meeting, and freely inosculating with each other. These bloodvessels, as already stated, have been produced from arteries possessing different powers, and hence the newly-formed assume actions similar to those of the primary, and thereby interstitial matter is deposited of its proper kind and in its proper place, a cuticular membrane superficially, then cellular tissue, afterwards muscular, and so on according to the primary tissues which had been divided; these parts do not at first resemble exactly the corresponding natural tissues, but, by the continued action of the new vessels and capillaries, they are moulded and prepared for the due performance of their respective functions. If the degree of action necessary for the accomplishment of these processes increase to inflammation, adhesion is interrupted till the action be lowered to its previous standard.

From this view it is evident, that, besides a certain excitement of the bloodvessels, it is necessary that the raw margins be in close apposition, and carefully retained so, for, by ever so slight movement of the parts, the recent and delicate bond of union will be ruptured; and, if this motion be allowed to continue, adhesion may be at divers times begun, but can never be perfected. Whereas, if the necessary precautions are adopted, union is often completed in thirty or forty hours, sometimes sooner, seldom later. From a knowledge of the astonishing powers of nature in repairing injuries, many and important improvements have of late years been made in the practice of surgery. In the majority of instances it is also requisite that the parts be brought in contact soon after division, otherwise granulation will have commenced in the different parts of the wound, and the surfaces then approximated will not so readily adhere: pus is formed, and, having lodged between the surfaces, acts as an extraneous substance, keeping them apart, and separating them still farther by its accumulation. All foreign bodies in the wound must be removed before adhesion can occur; and, on the same principle, care ought to be taken that no effused blood be interposed. In many cases the margins of the wound can be accurately adjusted by careful attention to the position of the part, or by the application of a few strips of adhesive plaster; but the latter, from indiscriminate use, often prove the source of much irritation, and totally frustrate the end for which they are designed. When employed, they ought to be narrow and few. If such means be considered insufficient, recourse must be had to a few points of interrupted suture, and these are not productive of bad consequences which have been by some attributed to them. When neatly applied, they can produce but little irritation, more especially if removed as soon as their presence is unnecessary, that is, as soon as adhesion has fairly commenced, and the natural bond of union is of such strength as to need no artificial assistance. By these the edges of the wound are more neatly and suitably placed than by any other means; they meet easily, without the puckering or overlapping of each other; and, from the circumstance of sutures obtaining a more just coaptation, they can be sooner discontinued. In most wounds no other dressing is required; but in some a combination of sutures, adhesive plaster, and compress, is necessary.

Of late, I have greatly dispensed with stitches and the common adhesive plaster, using, instead of the latter, slips of glazed riband smeared with a saturated solution of isinglass in brandy, which is much less irritating and more tenacious than the common adhesive compost. The parts are fixed temporarily with a single stitch, or two at most, and cloths dipped in cold water are placed over the wound; the ribands are not applied till the adhesive substance has partly congealed, and the oozing of blood ceased. The divided margins being approximated by the fingers of an assistant, the ribands are laid gently over, and held for a few seconds. Soon after a sufficient number have been applied the stitches are withdrawn, being no longer necessary. No other dressing is required unless suppuration occur; the ribands will adhere firmly till the completion of the cure, and thus the pain and irritation caused by frequent dressing is avoided. Even the largest wounds, as after amputation, are treated in this manner with the most satisfactory results. Of late years a plaster, made by coating oiled silk with a solution of isinglass, has been used instead; the glazed surface of the slips is moistened, and applied as here directed.

If at any part adhesion fail, suppuration and granulation must follow. The adhesion may be prevented by any of the circumstances already mentioned, or by an unfavourable state of the constitution, the nature of the wound, exposure to bad air, the occurrence of fever, or of a flux natural or not. The wound may contain foreign matter; blood or the contents of canals may be effused into it, and many other obstacles may exist to retard, or prevent adhesion. Notwithstanding, in all cases, though the chance of union be but small, the parts should be approximated. A great point is gained if certain parts only are brought to adhere, for by their natural attachments the opposite surfaces are preserved in more direct contact than they could otherwise be, and thereby but little space remains to be filled up with granulations. If, on the contrary, the surfaces are not approximated, the flap is diminished in size, and when afterwards placed in contact with the surface from which it was detached, it is found not to correspond, leaving considerable deficiency to be repaired by the comparatively slow process of granulation. Whereas, if it had been early replaced, partial attachments would probably have been formed by adhesion, the flap thereby retained in situ, and prevented from shrinking, so that but little new matter would be required.

Sometimes union does occur, and that speedily, after the flap has remained separate for a considerable time; and in such cases it may be doubted, whether union is accomplished by adhesion, strictly so called. Most probably it is by this process that the rapid union occurs in such circumstances: the divided parts have assumed an excited action, and effused lymph; during their state of separation, the lymph will become organised when it is connected with the original parts, just as well as if the surfaces had been in contact; and when they are at length so placed, they will be agglutinated to each other by the outer part of the effused lymph, which still continues soft and unorganised. If motion be then prevented, organisation, which has already commenced in the connecting medium, will proceed undisturbed, converting the agglutination of soft unorganised lymph into firm and permanent union by means of organised tissue. In these circumstances, it is not to be wondered at if adhesion should be completed in a shorter time than when the surfaces are brought together immediately after their division; in each instance the process is the same, only in the one it has to proceed from its very commencement, whilst in the other it is previously all but perfected, and after the parts have been put together, the last stage only requires completion. It is only in a particular stage of a granulating surface, that adhesion will take place speedily, when the discharge is diminished, but healthy, and the granulations florid and firm.

When a wound is to heal by granulation, the exposed surface at first is dry, painful, and slightly swelled, and afterwards a thin discharge of bloody serum is poured out, with relief to the painful sensations; the surface is at this time covered by a thin layer of coagulated lymph, and the parts, if approximated, are in the most favourable state for adhesion. Soon, however, the vessels assume a different mode of action, and secrete a fluid which becomes purulent; the effused lymph has been organised, forms a living part of the surface from which it was deposited, and is covered and protected, in its yet delicate condition, by the purulent fluid. This new matter is disposed in numerous small conical projections of a florid colour; and these, by their own power, form others similar to themselves, at the same time discharging purulent matter; so that, in a healthy constitution, the cavity is soon filled by the granulations, which come to the same level as the surrounding integument. Sometimes they are exuberant, soft, and spongy, and in this state possessed of little sensibility, and but ill supplied with bloodvessels. At others, they are slow in approaching the surface, and then often morbidly sensible. In all cases, the new matter is very apt to be absorbed, either from the state of the patient’s health, or from the nature of the applications; and foreign substances, in a state of solution or minute division, are more readily taken into the system from the raw surface than from the sound skin. When, then, the granulations approach the skin, the sore contracts, the newly formed parts being modelled into a more firm and dense condition by the action of the absorbents. Sometimes, in superficial sores, the skin is seen spreading from several parts near the centre; but at these points portions of the original skin must have remained uninjured, though the others were destroyed, and have formed cutaneous matter as soon as they were on the same level with the surrounding granulations; for these insulated portions of skin are not a product of granulations, as some suppose, but of a substance similar to themselves. Skin is formed from skin. Thus, where a part of the integuments has been completely removed by operation, or destroyed by accident, no islands of skin are observed during the cure, but the sore is uniformly covered by skin proceeding from its margins. The margins of a healing sore are of a white colour, and adherent to the subjacent parts; but in an unhealthy one the margins are often unsupported, the subjacent granulations are absorbed, and their place is occupied by thin purulent matter; the new skin is unable to maintain its independent existence, continues of a dark colour, perhaps for a long period, then wastes away or sloughs. The recent cutaneous matter covering a sore contracts, and the neighbouring old skin is extended; the new surface is thus diminished; it assumes a slightly puckered appearance, and is termed cicatrix. This is at first pretty vascular, the vessels running straight; after a time they contract and become invisible, and scarcely admit fine injections. Frequently the scar is so far absorbed after some time, as to leave only a firm line, whiter and more dense than the surrounding integument.

If union by the first intention does not take place, then all the application to procure it must be abandoned, all sutures, plasters, compresses, &c., must be dismissed, for they now can do no good, and may be productive of harm; the attention, on the contrary, must be directed to effecting union by granulation; with this view, other means are to be chosen, so that to continue those which were formerly used to promote adhesion would be absurd, when adhesion can no longer be expected. The stitches must then be taken out, when inflammation has gone off, and œdema remains, the parts are to be supported; and by attention to position, and gentle bandaging, the size of the wound will be diminished. Inflammation must be subdued by the usual means, and suppuration encouraged by fomentation and poulticing, or warm water dressing. After inflammation has subsided, tension disappeared, purulent discharge occurred, and granulations formed, the edges of the wound are to be gently brought together, so as to render the quantity of new matter requisite for filling up the cavity as small as possible. Nature will then accomplish the union in her own way, and we can only assist and minister to her; for who thinks now of healing wounds by pure force of surgery? The dressings ought to be light, the ointment, if any is used, scanty; in some cases the application may be dry; but in many cases various lotions will be found of much advantage. These latter are used of different qualities, according to the nature of the sore; and these can be of little avail unless evaporation be prevented, by a piece of oil-silk laid on the outer surface of the dressing. In most granulating wounds, they require to be of a mildly stimulating nature, and the one which I have most frequently employed is a weak solution of the sulphate of zinc. The integuments round the wound may be occasionally washed, to prevent excoriation, but no good can accrue from washing the sore; its natural discharge is its best protection, and if superabundant, it can be removed by means of dry lint or tow from the surrounding parts.

From bruised and lacerated wounds there is little or no hemorrhage, but in proportion to the severity of the bruise, is the bleeding slight, and the danger great. The bloodvessels are so torn and twisted as to permit the spontaneous and temporary suppression of hemorrhage to occur almost immediately; and the larger arteries may escape entirely, owing to their elasticity. Sometimes after bruised wounds, such as those inflicted by gunshot, the large vessels bleed instantly and violently; often, however, hemorrhage occurs only after the sloughs separate, many days after the infliction of the injury, and then it is generally very profuse; in some instances, limbs are torn, bruised, or shot away, without hemorrhage occurring to any great degree, or at any period. Frequently the vitality of the parts surrounding the wound is much diminished; and the whole limb is apt to become gangrenous, either immediately, on account of the extreme violence of the injury, or consecutively, from greatly excited action going on in parts whose power of resistance has been much impaired: it often arises also from constitutional peculiarity. The gangrene extends often rapidly, in consequence of the infiltration of putrid serosity into the cellular tissue. In the treatment of bruised wounds, the position of the parts must be carefully attended to; they must be placed in a state of relaxation. In general, it is unnecessary to retain the margins of the wound in contact, for adhesion cannot occur—suppuration must ensue, and is to be desired—and the dead and dying parts must be loosened and discharged before union can take place. Sometimes, as when a large flap has been detached, and the parts not much injured otherwise, approximation ought to be accomplished, for the reasons already mentioned. In almost all cases, and most certainly in those in which the mechanical injury has been severe, and its effects extensive, violent inflammatory action is to be dreaded, and measures must be taken to ward it off: notwithstanding the prophylactic treatment, violent inflammation often comes on, and then recourse must be had to the means proper for the subduing of it. Blood is to be taken from the part, if necessary, and soothing applications used, in the form of fomentation and poultice. The main indications are to prevent extravasation into the substance of the limb, and strongly excited action. When the sloughs begin to separate, emollient poultices promote the suppuration and discharge of dead matter, and afterwards the sore must be dressed, according to the nature of the case, with the applications most fit for granulating sores in their different degrees of action and advancement. During the after treatment, the sides of the sore ought to be well supported, so as to prevent, as much as possible, suppuration from extending along the neighbouring cellular tissue; but, at the same time, the dressing must not be so tightly applied as to cause irritation. When abscesses have formed in the neighbourhood, the cavities should be freely exposed by incision; thus a free discharge will be given to the matter, and the cavity brought to granulate from the bottom. During the suppurating stage, the patient’s strength must be maintained by generous diet.

Punctured wounds are dangerous, from the deep and internal effusion of blood and serum which usually attends them. The effusion, which in open wounds is poured out externally, and moderates and prevents the excited action from exceeding what is salutary, is, in punctured wounds, poured into the substance of the limb to its detriment. It is followed by severe inflammatory action and profuse suppuration. In order to prevent these untoward results, it was formerly the practice immediately to dilate the wound; but this is hurtful, for if the wound be deep, as it generally is, dilatation of its whole extent is a proceeding severe in itself, and in its consequences; whilst, if the external part only of the wound is dilated, the operation will entirely fail to effect what is intended. The knife will be used in great good time where a foreign body is found to be lodged in the wound, when tension has occurred, or matter has formed. Sometimes the wound heals throughout its whole track by adhesion, without any bad symptoms being so much as threatened. Setons, recommended in this class of wounds, are of no service. It is not the narrowness of the external opening, as is sometimes supposed, that is the cause of all the mischief, but the injury and consequent inflammation of deep-seated parts.

Poisoned wounds are rare in this country. Wounds by the stings of certain trifling insects produce considerable swelling in some constitutions, and when the injury has been inflicted on a loose texture. In some parts of this country, the bite of a small adder causes pain, swelling, and unhealthy suppuration of the part, with some constitutional disturbance, but the results are seldom serious, and never fatal. In warmer climates, the bites of some snakes are followed by the most violent symptoms; in some cases proving fatal in a few hours, in others after a day or two. Great swelling occurs almost immediately, attended with excruciating pain, and extends upward along the limb; vision becomes impaired, the patient lies in a state of stupor, and ultimately succumbs under convulsions and delirium; the symptoms vary in particular instances according to idiosyncrasies and the state of the constitution when the injury is inflicted.[22] In this country, the bites of rabid animals are more dangerous than those of animals naturally poisonous. Rabies most frequently occurs in dogs, and others of that species, such as wolves, foxes, &c. They become dull, sluggish, and irritable; have unnatural appetites and cravings, devouring their excrement and urine; the stomach is generally found full of chopped straw, pieces of wood, &c. Derangement of the cerebral functions is not complete,—they know and obey their master. They are often not afraid of water, but lap it and go into it readily. From them the disease is communicated to the human subject, and to the lower animals, such as cats, sheep, cattle, and even fowls; the virus is not communicable, except by the deposition of the saliva on an abraded surface, or into a wound. It is not produced by eating the flesh of a rabid animal. During the first days of the attack, pustules are, it is said, observed under the tongue, but there is no apparent change in the glands. The symptoms of hydrophobia in man seldom appear before the twentieth day after the infliction of the wound, and in some instances they have not presented themselves till after the lapse of months. The most prominent are great restlessness, much irritability and anxiety, and convulsions of the muscles concerned in deglutition, produced either by attempts to swallow, or by fluid being presented to the patient. Ultimately, the spasms become general, are induced by the most trifling exertions or noises, and prove fatal in a few days. Frequently the patient retains his senses throughout, and is fully aware of his lamentable situation; in other instances, he soon becomes delirious, raves, and threatens his attendants. For this horrible disease we are unacquainted with any cure. In general, profuse bleedings are employed, and large quantities of opium given internally; every powerful antispasmodic, as well as every violent medicine, has been made trial of, but in vain: some certainly mitigate the symptoms, but none cure the patient. It has been even proposed to suspend or destroy the function of the nervous system for a time, by the employment of the Wourali poison, keeping up at the same time respiration by artificial means, under the expectation that thus the impression on the system might be got over. The morbid appearances usually observed after death are marks of inflammation of the pharynx and air-passages, and of the mucous surface of the stomach and intestines. It is evident that the disease ought to be prevented if possible, and for its prevention the most efficient measure is timely excision of the affected parts; and they should be cut out a long period before the constitutional affection comes on: when excision is dangerous, or wholly impracticable, and when the patient does not apply soon after the accident, the injured parts may be destroyed by some active caustic, as the potassa fusa. The nitrate of silver has been strongly recommended and extensively employed by Mr. Youatt, whose experience in this disease is very great. This application should scarcely be trusted to alone. The removal of parts wounded by snakes, even after violent symptoms have appeared, has proved successful, ammonia having been at the same time administered internally. In some instances, arsenic has been found efficacious when given in large doses, and frequently repeated.[23]

Wounds received during dissection occasionally have unpleasant consequences from the absorption of animal matter. The absorbents leading from the wounded part become swelled and painful, and in slight cases there are shivering and general indisposition for some days. The more violent symptoms arise from examining bodies which are rather recent, and in which putrefaction is just commencing, and very frequently from inspecting the bodies of females who have died of puerperal diseases. The absorption may take place from punctures made by scissors, the point of a knife, or spiculæ of bone, or from old scratches, or chops by the side of the nail or on the hand. There is little or no danger from an open and bleeding wound, as by the flow of blood the part is completely cleaned; it is generally from slight punctures that untoward symptoms need be apprehended. Effects similar to those resulting from wounds in dissection often occur in nurses and others who have pricked themselves with pins while washing foul clothes, or from handling poultices or dressings removed from bad, putrid, or sloughing surfaces. The symptoms already mentioned are soon followed by others more severe: shivering continues, and the patient is seized with vomiting; the part affected, and often the greater part of the arm, becomes red and much swollen; the cellular tissue is infiltrated with serum often dark and putrescent, abscesses form at various points along the limb to the axilla, and purulent matter is diffused throughout the unhealthy cellular tissue, which in many instances sloughs, and gives rise to extensive sores. Typhoid symptoms soon appear, and in the more aggravated cases speedily prove fatal. When such local and constitutional symptoms arise, it will generally be found that the patient was of a broken-up constitution previously to the infliction of the wound; did they solely depend on the inoculation of virus, they would be of very common occurrence, considering that wounds are so frequently received during dissection; but it is seldom comparatively that any unpleasant symptoms follow such an accident. In all cases, however, it is prudent to adopt measures in order to prevent absorption of the virus. With this view, the wound is made to bleed by means of pressure or suction, and by the latter method the exposed surface is most effectually purified; afterwards nitrate of silver maybe applied to deaden the surface, and protect it by an eschar. If such means be unavailing, the after symptoms must be encountered as they appear, local inflammation subdued, tension relieved, abscesses opened, sloughs removed, &c. General bleeding is seldom admissible, but purgatives and antimonials will prove beneficial at the commencement; afterwards the strength is to be supported, and, if the patient be much reduced, stimulants are to be liberally administered.

We shall next treat briefly of gunshot wounds; under this head are included the contused and the lacerated, caused by splinters, &c. The vitality of the injured surface is generally destroyed at once, whence bleeding seldom occurs, even after whole limbs have been shot away; in some cases, however, hemorrhage is profuse, as when a large artery has been wounded by small shot. The effects on the system are extremely various; some persons are affected with tremors, anxiety, and depression from slight wounds; while the most severe injuries are often unaccompanied by any disturbance of the nerves. The shock is generally of short duration, disappearing soon, on the patient’s being reassured and encouraged, or after his taking a little wine or opium. In gunshot wounds, those inflicted from a distance or close at hand can in general be readily distinguished. In the latter, the wound is large and lacerated, portions of the wadding are impacted, and the skin around is marked with grains of gunpowder. In the former, the wound is small and clean. When a ball passes through a fleshy part, the opening at its entrance is small and depressed; whilst that by which it escaped is open, with everted edges. When it follows a superficial course, its track is marked by a wheal, or elevation of the skin with discoloration. At one time, it was believed that the most serious consequences resulted from a ball passing close past the body without even touching it—that in this way violent concussion of the brain, proving instantly fatal, was produced; but this notion has been disproved by experience; part of the head accoutrements, of the hair, of the nose, and of the ears, have been shot away by cannon-balls, and yet no disturbance of the brain has followed either immediately or consecutively. The opinion originated from the circumstance of soldiers having been found dead without any evidence of injury; but bones are often broken and comminuted by an indirect blow, or by a spent ball, without any breach of surface or external sign remaining; internal injuries indeed—rupture of viscera—more than sufficient to cause instant death, are thus inflicted without any apparent external læsion.

The course of a ball in the body is often very strange, depending on the force with which it is projected, or the resistance which is opposed to it, and on the position of the struck part. Balls often pass under the integument almost completely round the head or chest, having first struck the bone at a very oblique angle. Frequently they remain, lodged along with part of the clothing which they thrust before them. In such cases, they may be immediately removed, their exact situation being previously ascertained by external examination, or by means of a probe. They can generally be extracted through the aperture by which they entered; but if situated superficially, and at a distance from the opening, this will be more readily accomplished through an incision made upon them; if allowed to remain, suppuration will occur in the neighbourhood, the surrounding cellular tissue will be condensed, an abscess will be formed containing the foreign body, and by the process of absorption proceeding in the parts external to the abscess, the ball will at last reach the surface, and be discharged. The track is often so extremely tortuous, as to render it impossible to ascertain the situation, or even the existence of the foreign body, which greatly impedes the operation; and, in other instances, it may be necessary to allow the ball to remain undisturbed, on account of its being placed near important parts, which might be injured by any attempt at removal. Foreign bodies often remain lodged in fleshy or membranous parts for years, having become enveloped in a dense cyst, and having ceased to produce any great irritation. In consequence of the force with which they have been projected, and the resistance which has been opposed to their progress in the body, musket-balls, when extracted, either immediately after the infliction of the injury, or after a considerable time has elapsed, are seldom found to retain their globular form, but are flattened and ragged, and not unfrequently completely divided by the bones on which they have impinged. A bullet may be divided into numerous fragments on a bone, and part may enter into the osseous substance, whilst other portions penetrate in all directions into the soft parts, and, though sharp and irregular, may remain long in the dense cellular cyst which forms over them, without producing pain or inconvenience. There will necessarily be suppuration, and generally discharge of dead matter, from gunshot wounds, in consequence of the bruising of the parts by the ball, which may be expected to injure the superficial layer of parts in its tract so severely, that it must slough more or less.

Besides, the bones are often splintered by the force with which they are struck, and loose portions of them lodge amongst the muscles; then they are the cause of much mischief, for, on account of their long, sharp, and irregular form, they occasion great irritation, suppuration ensues in various parts, sinuses form, and the cure is rendered very tedious. In other cases, the bone is split in a longitudinal direction, and, in the cylindrical bones, these fissures are often of great extent.

Considering the nature of the body which inflicts the injury in a gunshot wound, and the velocity with which it is impelled, it is evident that the cure must be in all cases tedious, in consequence of the sloughing and suppuration which is induced, particularly at the aperture through which the ball passed. The foreign body ought always to be removed as early as possible, provided it can be accomplished without much violence, or injury to the parts. Dilatation of gunshot wounds is now had recourse to only to facilitate the removal of balls, splinters, &c., and even with this view, it ought to be employed but to a very slight extent, if at all; for foreign substances, when deeply seated, can be much more easily taken out when the sloughs are separating, and the parts relaxed by suppuration; then, too, they can be more readily reached through a counter-opening, when their situation renders this expedient. In short, the surgeon is not justified in cutting for balls, unless they are easily felt, and not deeply lodged. In order to discover the foreign body, probes will sometimes be required; the finger often answers the purpose best, unless when the wound is of considerable depth. If, on examination, the ball cannot be discovered, and if there is reason to think that it has followed an indirect course, the surgeon will, sometimes, be assisted in his search by placing the patient in that position in which he received the wound, and then judging of the circumstances most likely to affect the foreign body in its passage. In many cases, extraction can be accomplished by means of the finger alone; in others, forceps and scoops, various in length and size, are indispensable. Afterwards, light dressings are to be employed; and in the first instance, cold applications may prove advantageous in keeping down the inflammatory action; but when inflammation has commenced, and to encourage suppuration, warm fomentations and poultices are to be preferred; they will in many cases be both more grateful to the patient and more beneficial in their results, when used even from the commencement. Afterwards, it will be necessary to afford sufficient support to the parts by bandaging, and to change the applications according to the particular circumstances:—soothing, if the wound be irritable, stimulating, if inert, and gently escharotic, if the granulations be exuberant.

In severe injuries of the limbs, the surgeon must be guided by the state of the part, and of the constitution, by the circumstances in which he is placed, as to accommodation, and mode of transportation, &c., in deciding on the removal of the part by amputation,—or on making an attempt to save it, by trusting to, and assisting, the processes of nature. The question whether to amputate immediately, and on the spot, merely allowing the shock, if any exist, to pass away, or to delay till suppuration occur, is now scarcely a matter of dispute. When it is evident, from the extent, violence, and nature of the injury, that there is danger of speedy mortification, or of extensive and severe inflammation and suppuration, amputation is to be instantly performed,—delay is inadmissible. In comminution of the hard, with contusion and laceration of the soft parts—where limbs have been shattered and completely detached, or nearly so—in lacerations of parts, including the principal bloodvessels and nerves—fractures of the heads of bones, with openings into the joints—and in bad compound fractures, more especially of the thigh (for all compound fractures of the upper part of the thigh are dangerous), amputate at once. When the limb has been retained, and gangrene arises in consequence of the external injury, and when there is no reason to suppose that any internal cause is also in existence; or when the violence of inflammatory action has subsided, and the patient is become hectic, with profuse purulent discharge, and with disunited bones, then amputate. But, in this latter case, the chance of recovery is not so great, and the proportion of recoveries small; whereas, in the immediate or primary operations, the very reverse holds true. Such is the experience of the greater number of military surgeons. In civil practice, the results are somewhat different; a greater proportion of primary amputations are unsuccessful, and the secondary turn out more favourably than the statements of military surgeons would lead one to believe. In all cases, the judgment of the surgeon must guide him in his determination. The circumstances of the case, and the probable contingencies, must be all duly considered, and he must not proceed with his knife where there exists even a slight chance of preserving the limb.

Paralysis occasionally follows wounds of the arm, forearm, face, &c., inflicted by accident or operation, and this arises from an important nerve, or set of nerves, being divided. In cases of simple division, without much separation of the parts, reunion of the nerves may take place, and their functions be restored. If the limb remains paralysed, after cicatrisation of the wound, tepid effusions, friction, dry or with liniment, stimulating applications, &c., may sometimes be advantageously employed.