thought he would die, I left him to dress other wounded. After twenty minutes he revived, and said he was much better, and I then dressed him. We were in the snow, and as he was very cold the whole of his head was well wrapped up in charpie and bandages. He set off to Warsaw with another wounded soldier; went partly on foot, partly on horseback, or in a cart, from barn to barn, and often from wood to wood, and reached Warsaw in six days. Three months after I saw him in hospital, perfectly recovered. He had lost his sight on the right side; the eye and lid had, however, preserved their form and mobility, but the iris remained much dilated and immovable." He mentions another case in which "a ball passed through a soldier's head, from the top of the base of the right parietal bone, and which he extracted from the zygomatic pit on the other side. He was cured in four months, and walked about at the end of a month." He refers also to a case of DE LIMBOURG'S, of which the following is an extract :A young man was ramming down the powder in his fowling-piece with an iron ram-rod, the gun went off, and the ramrod struck the head of a person a few paces distant, and, entering a finger's breadth by the side, and as much above the outer corner of the eye, at the root of the zygomatic arch, passed through the teguments at the back of the head, at the posterior superior angle of the parietal bone, a finger's breadth from the sagittal suture, and as much above the superior angle of the occipital bone. The wounded man immediately endeavoured to pull the ramrod out, but ineffectually; but one of his companions at last pulled it out, as straight as when it left the maker's hands. He lost little blood and only at the apertures of the wound, which healed quickly and completely by simple but proper treatment. In speaking of gun-shot wounds in the neighbourhood of, or penetrating the orbit, the following are some of the most important mentioned by HENNEN:-"Sometimes the ball passes behind the eyes, destroying their power, either by cutting the optic nerves at once, or causing their subsequent inflammation and thickening. An additional proof of the decussation of these nerves is afforded by the effects of gun-shot wounds of the eye; for, in many instances, an injury by a ball inflicted in the neighbourhood of one produces paralysis of the other." (p. 340.) "In some cases the ball passes into the orbit without bursting the eye-ball, although the power of vision is totally lost." (p. 341.) "Diplopia sometimes, though rarely, takes place from gun-shot wounds in the neighbourhood of the eyes, of which the following case is an example:-A. B. received a wound from a musket-ball, which brushed along the root of the nose and onwards towards the right eye-brow, but without producing any injury to the bone, and so little derangement that the wound healed in a very few days. Immediately on being struck by the ball, double vision took place. * ** In about two months the disease was removed, but, on running into some excess in drinking, it returned again, and the wound burst out afresh. A recurrence to a more rigid regimen perfected the cure in a fortnight, and he was discharged entirely from hospital." (p. 345.) Sometimes a ball will enter the orbit, and afterwards descend into "the posterior part of the fauces, forming a tumour behind, and nearly in contact with the velum palati," which happened to a soldier, who, in consequence, suffered severe pain, had his respiration impeded, his deglutition obstructed, his speech rendered indistinct, and much irritation in the fauces, attended with constant flow of saliva and frequent inclination to vomit." (pp. 341, 42.)] PLATNER, Progr. de Vulneribus Superciliis ilatis, curcæcitatem inferant ad locum Hippocrates. Lipsia, 1741. BEER, Lehre von den Augenkrankheiten, Wien, 1813, vol. i. p. 168. VON WALTHER, in his Journal für Chirurgie und Augenheilkunde, vol. iii. p. 1. 459. Slight longitudinal and transverse Wounds of the Eyelids may be always united by court plaster, if it be only so placed that its ends are not loosened by the moisture of the tears. In vertical wounds, dividing the eyelid, the suture is always to be recommended, the threads, however, are to be drawn only through the external fold of the skin, and between the threads strips of court plaster are to be applied. The eye is to be kept closed with a vertical strip of plaster, and covered with a compress. Horizontal wounds of the eyelids, if large and connected with loss of substance, require the suture for their perfect closure, although, in many cases, they can be united by strips of sticking plaster stretched from the cheek to the forehead, and the cheek is to be kept up by the bandage called monoculus. Small strips of plaster are to be laid between the threads, and the motions of the eyelid are to be prevented by vertical strips of plaster. 460. Wounds of the Ear are difficult to unite on account of the many elevations and depressions of the auricle; and it is for the most part necessary to put in, at several points, sutures, which should penetrate only the external skin. If the ear-passage be also injured, it must be stopped with charpie, by which the edges of the wound are brought together, and its secretion prevented collecting there (1). Charpie having been laid about the whole ear and in its cavities, it is to be covered with a compress, and the whole fastened with a cloth folded together, which being placed under the chin is carried up over the ears and bound together on the head. If the external ear be completely cut off, or attached only at a small part, its union must always be attempted. [(1) If the gristly part of the ear-passage be cut or torn, on no account must CHELIUS's recommendation of stuffing it with charpie or lint be followed. It is not necessary, for the parts can easily be kept together by supporting the back of the auricle; and it is sure to be mischievous and painful, because it plugs up the hollow in which the inflammatory swelling has opportunity otherwise to take place. If there be much bruising, it is preferable to cover the whole ear with a bread poultice, and bring the edges of the wound together afterwards when they have begun to granulate.—J. F. S.] 461. Wounds of the Nose may split it either in the middle or on its wings, or a part of the nose may be almost or completely divided like a flap. Cuts which split the nose in the middle may be united with sticking plaster, and the union assisted with compresses and a double T-bandage, or by a piece of sticking plaster, cut out in shape of the letter U. If the wings of the nose be divided, they must be united with the suture, which should hold only the skin. Wounds which divide the length of the nose horizontally, or more or less obliquely, so that a piece is either entirely divided, or remains only slightly attached, must be united by the stitch and by sticking plaster. But when a small portion of the tip of the nose, in this direction, is lost, a piece of plaster put on obliquely may be useful. Elastic tubes are to be placed carefully in the nostrils, and properly fastened to the bandage. The bandages for the nose, to wit, 1st, the simple bandage; 2nd, the single accipiter ; 3rd, the double accipiter; 4th, the nose-sling; 5th, the upsilon-bandage; 6th, the T-bandage; 7th, the double T-bandage of SCHREGER, the operation of which consists either in lateral compression of the nostrils, in pressure upwards or downwards, are, as regards their application and operation, extremely uncertain, and may be rendered superfluous by the proper employment of sticking plaster (as the four-headed sticking plaster and plaster bandage of BÖTTCHER.) 462. Wounds of the Cheek may mostly be united by sticking plaster; but when they gape much, are angular, the lips completely divided, or the salivary duct injured, they require the suture. In all penetrating wounds of the cheeks and lips, when any vessels are to be tied, the ligatures are to be applied in the mouth, and to be led out from one or other of its corners. If, in injuries of the salivary ducts, the wound do not heal perfectly by quick union, and the spittle flow from the still open aperture, the healing of the duct must be always attempted, and the origin of salivary fistula prevented by repeatedly touching with lunar caustic, and by compression of the parotid duct with the halter bandage. Chewing and speaking are also to be forbidden. 463. Wounds of the Tongue, when superficial, heal if it be kept at rest; but deeper and especially transverse wounds require sutures. The patient must neither speak nor chew; he must be fed with strong broth, which is to be conveyed into the stomach by an elastic pipe passed through the nose, or by nutritious clysters. [LAWRENCE observes (a), when the tongue is severely bitten during fits," that bleeding takes place which is very difficult to stop. I remember," says he, “having had a child under my care who had bitten very deeply into the substance of the tongue, just at the broadest portion of its loose under part; he had divided it horizontally, nearly in the middle line, and bleeding took place, which I found it impossible to restrain by any styptic application. I employed in vain the oil of turpentine, and a saturated solution of alum freely, and the child had lost so much blood, that I deemed it in danger, if hæmorrhage continued or recurred. But at last I stopped the bleeding by the following measure, which, however, seems rather a rough one: I introduced at the basis of the loose part of the tongue, bringing it downwards, a strong needle armed with a ligature, and cutting the ligature off after I had brought the needle through, made two ligatures; I tied them tightly one on each side, so as to embrace between the two the whole surface of the wound, including nearly half of the loose under part of the tongue. This stopped the haemorrhage. I was rather apprehensive that, by causing the loss of so much of the substance of the tongue, some bad effect might have been afterwards produced, but it was not, and the subsequent articulation of the child was perfect." (p. 763.)] OF WOUNDS OF THE NECK. 464. Wounds of the Neck either injure merely the coverings, the superficial muscles, or the deeper-lying vessels and nerves, the wind-pipe and gullet, or even the spinal marrow. Cuts are the most frequent and have either a vertical or transverse direction. If they penetrate merely through the skin and superficial muscles, they may be united with sticking plaster, and the union of transverse wounds on the front of the neck may be assisted by binding the neck forwards, but in longitudinal wounds it must be stretched backwards. Bleeding from the external jugular vein may be stanched, either of itself or by slight pressure. In wounds with loss of substance, or such as suppurate largely, the head, towards the end of the cure, must always be kept straight, and the sinking of the pus behind the breast-bone prevented. [ASTLEY COOPER says that the wound above the larynx, which passes through the muscles of the jaw and tongue, into the pharynx, being generally inflicted between the chin and os hyoides, is the most frequent injury. (p. 242.) The wound may be either above or below the tongue-bone, and in the latter case the epiglottis is commonly more or less completely sliced off, which renders the case more dangerous on account of the irritation to which the larynx is subjected. In one such case ASTLEY COOPER Stitched the epiglottis to the thyroid cartilage, and the patient recovered, but he was uncertain whether the recovery was attributable to that proceeding.] 465. Deeper penetrating wounds, in which the large vessels are wounded, are usually soon mortal from the sudden bleeding. In injury of the carotid artery assistance is still possible if it be at once compressed by an assistant at the wounded part, the wounded end laid bare and tied (b). In slight injury of the internal jugular vein, the bleeding should be stanched by compression, or, if it be completely cut through, it must be compressed above the injury, and the upper end tied after proper enlargement of the wound. In making these ligatures sufficient care should be taken that the nerves lying Lectures in Lancet, 1829-30. vol. ii. ABERNETHY's Surgical Works, vol. ii. p. 115. HENNEN, JOHN, Observations, &c., p. 356. COLLIER; in the Medico-Chirurgical Trans actions, vol. vii. p. 107. COLE; in London Med. Repository, May, 1820 tions made in the British Military Hospitals in Belgium, &c., 1816. London. 8vo. BRESCHET; in French edition of HODGSON'S Treatise on the Diseases of Arteries and Veins, &c., 1815. London. vol. ii. sect. v. p. 37, note. TEXTOR; in Neuen Chiron., vol. ii. p. 2. close to the vessel, especially the pneumo-gastric, be not included in the ligature. The injured branches of the carotid artery may be tied either in the open wound, or after carefully enlarging it, or, if this be not possible, the principal trunk of the carotid is to be tied (1). [(1) The celebrated Marquis of LONDONDERRY destroyed himself by stabbing the carotid artery with a penknife; and at the time it was believed that had his medical attendant acted promptly and properly, his life might have been saved. I recollect an instance many years since under my friend TRAVERS's care in St. Thomas's Hospital, in which either the lingual or facial artery was also wounded with a penknife in an attempt at self-destruction. The wound was enlarged with the intention of tying the bleeding vessel, but the wound in it was too close to its origin to admit such proceeding. The common carotid artery was therefore tied; but the case was unsuccessful, as adhesion never took place, and when the ligature ulcerated through, bleeding occurred several times; at last a large clot formed in the wound, from which constant oozing went on; and on the removal of this to secure the artery, a violent gush of blood followed, and the patient died immediately.-J. F. S.] 466. Injuries of the Pneumo-gastric Nerve cause loss of voice, spasmodic symptoms, and death. Injury of the Recurrent Nerve also causes loss of voice; this, however, may occur subsequently. Injury of the Laryngeal Nerve is mortal from arrest of breathing (a); and this is also the especial branch which so quickly produces death after the division of the whole nerve. According to DUPUY's (b) experiments, animals may live for some time after division of both pneumo-gastric nerves, if the airtube be opened below the larynx; but, if the opening be not made, the animal dies on account of the palsy of the nerves spreading over the muscles opening the chink of the glottis. If the Sympathetic or Phrenic Nerve, or the spinal marrow be injured, death in convulsions follows. 467. Wounds of the Windpipe are either longitudinal or transverse; the windpipe may be either only cut into, or cut through, or a piece of it taken away as in shot-wounds. Vertical wounds of the windpipe require union with sticking plaster, and that the head should be inclined much backwards. Transverse wounds divide it either partially or entirely; they are mostly consequent on attempted self-destruction, and are usually found at the upper part of the neck, between the larynx and the tongue-bone; penetrate to a great extent into the back of the mouth; allow the air, spittle, and drink to escape through them, or even penetrate into the larynx. They are rare at the lower part of the windpipe. In these wounds, if the voice be at once lost, the air passes through the wound (1), frequently an air-swelling is produced (2), and blood flowing into the windpipe may give rise to dangerous symptoms. This may occur without the carotid artery, jugular vein, or pneumo-gastric nerve being wounded; the bleeding may come only from the superior thyroid, or from the lingual artery. [(1) The loss of the voice in large wounds of the windpipe simply depends on the air passing out through the aperture, instead of proceeding through the larynx; this is readily proved, if by bringing the head forward, the edges of the wound can be brought sufficiently close to prevent the escape of the air through it, as then the air takes its natural course through the larynx, and a whisper more or less loud, or even a feeble voice can be heard. (2) HENNEN says:-" Emphysema is also a frequent though not dangerous symptom of wounds of the windpipe; indeed I have met with it oftener in wounds of the larynx and trachea than in those of the lungs, probably because the action of the muscles subservient to respiration is exerted in such a manner as to send a current of air through (a) PYE, Aufsätze und Beobactungen aus der gerichtlichen Arzneiwissenschaft. Saml. vii. p. 185. (b) Journal de Médecine, par Le Roux, etc. vol. xxxvii. p. 351.-MECKEL, Handbuch der gerichtlichen Medecin. Halle, 1821, p. 172. the larynx, whence it is drawn forcibly into the cellular substance. Simple puncture is, in these cases, the best remedy." (p. 362.)] 468. When in transverse wounds of the windpipe the bleeding is stanched, the edges of the wound should be brought together by bending the head much forwards towards the chest, in which position it is to be retained. This is done less certainly by bandages than by KOHLER'S cap; the patient is at the same time to be slightly inclined to one side, so that the secretion may not readily flow into the windpipe. If the windpipe be not completely divided, the edges of the wound should not be separated far apart, and the position already mentioned is favourable to union, as the stitches excite only irritation and cough which mostly hinder the union. Only when the windpipe is cut through, and the edges of the wound gape widely, should they be drawn together with a broad ligature fastening the external skin merely. According to FRICKE (a), severe wounds of the neck should not at once be healed with the stitch; he prefers waiting for a perfect suppuration, and the production therewith of new granulations, and then first puts in the suture to bring the suppurating edges into contact. [Position in the treatment of wounds of the windpipe, at whatever part, is always preferable to stitches, which are really of little service, as from the constant drag upon them in the frequent attempts made to get rid of the mucus, and of the adhesive matter which begins to be secreted a few hours after the injury, they speedily ulcerate and are of no use, but rather hurtful from their additional irritation. The only real benefit obtained from them is that of preventing the edges of the skin turning into the wound, which interferes with the union; but even in this attempt they often fail. Keeping the edges of the wound as near together as possible with strips of adhesive plaster, applied longitudinally and obliquely across the neck, and over these a roller twice or thrice around the neck is all that is either necessary or proper. It must, however, be recollected that even at the very first it is not always proper to close the edges of the wound, and the Surgeon must therefore carefully notice, in dressing the wound, how the patient can breathe when the edges are brought together and covered up. Not unfrequently the breathing cannot be carried on by the mouth, but only by the wound; under which circumstances, if the wound be shut up, difficulty of breathing and even suffocation may ensue, unless all the dressings be removed and the air allowed to escape by the wound. Its complete closure, therefore, must be dependent upon the freedom or difficulty of breathing by the mouth; if there be no difficulty the wound may be carefully closed; but, if there be difficulty, a sufficient space must be left opposite the wound into the windpipe, to permit the free passage of the air. Another circumstance may be also noticed as to the unneedfulness of stitches, that is, that these wounds rarely, if ever, unite by adhesion, but almost invariably by granulations, even under the most favourable circumstances. But the use of stitches after the establishment of the granulating process, as proposed by FRICKE, is quite superfluous. It is certainly proper at first to attempt union by adhesion, and sometimes the angles of the external wound will effect it; but generally the parts have been so much handled in search of bleeding vessels as well as irritated by their continual separation by the air and mucus forced through the wound, that the greater part of the surface becomes sloughy. When this happens, it is better to remove all the dressings, except two or three strips of plaster for support, and to surround the whole neck with a light bread poultice in a muslin bag, so as to prevent any of the crumbs dropping into the air-tube. -J. F. S.] 469. In these wounds there always occur severe inflammation of the windpipe, spasmodic symptoms, especially severe cough, which is more violent in injuries of the larynx than of the windpipe (1). If the wounded person have not lost much blood, he must be bled freely from a vein, and nitre in emulsion must be given internally. If pain and cough arise, bleeding from a vein (even the application of leeches) must be repeated, (a) Fünfter Eericht über die Verwaltung des allgemeinen Krankenhauses, 1832, p. 232. VOL. I. 2 F |