G. J. Guthrie

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

“ Conceive this poor man, late at night, in the midst of others, some more seriously injured than himself, calmly watching his blood—his life flowing away without hope of relief, one man holding a lighted candle in his hand, to look at it, and another a pewter washhand-basin to prevent its running over the floor, until life should be extinct. The unfortunate wretch next him with a broken thigh, the ends lying nearly at right angles for want of a proper splint to keep them straight, is praying for amputation or for death. The miserable being on the other side has lost his thigh ”

“ They knew that the viscera of the abdomen did sometimes pass through such wounds into the cavity of the chest, but they did not know that a wound of the diaphragm never closes, except under rare and particular circumstances; that it remains an opening during the rest of the life of the sufferer, ready at all times to give rise to a hernia which may become strangulated and destroy the patient, unless relieved by an operation as yet unperformed, but to which attention is especially directed—a fact first pointed out by me early in the war in the Peninsula. ”

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

“ Cases of extravasation or of effusion, terminating by the formation of a sac, pouch, reservoir, or foyer surrounding it, while the rest of the cavity remains free from inflammation, are so rare in natives of our northern climates that I am indisposed to infer that they do take place, except as very accidental circumstances. The fact that such things do take place should be borne in mind, and surgery should not be wanting in giving its aid, under all well-considered and reasonable circumstances. It is easier to do nothing than to think and to act. ”

“ Simple œgophony consists in a peculiar resonance of the voice, which accompanies or follows the articulation of words. It appears to be sharper than natural, more acute and somewhat silvery, vibrating, as it were, on the surface of the lung more as an echo of the voice than as the voice itself. ”

“ When the most courageous persons are wounded in parts essential to life, there is more or less alarm or shock created by the injury; although it has been gravely argued that a man does not always know when he is actually shot or run through the body. A continued state of anxiety and depression after an accident of this kind is a disagreeable accompaniment of the injury, during which little should be done beyond the giving a little cordial, and quieting the apprehensions of the patient, leaving him to rest, if possible, after the necessary applications have been made. ”

“ When a ball, or portion of bone, leather, cloth, wadding, or other foreign substance is driven into the cavity of the pleura, it usually gives rise to fatal results, constituting, therefore, cases of the greatest importance, to which attention has not been sufficiently given, but on which too much cannot be bestowed, if life is to be preserved by the art of surgery. ”

“ When the Court of Examiners of the Royal College of Surgeons of England—of which body I have been for more than twenty years a humble member—confer their diploma after examination on a student, they do not consider him to have done more than laid the foundation for that knowledge which is to be afterward acquired by long and patient observation. When a student in law is called to the bar, he is not supposed to be therefore qualified to be a Queen’s counsel, much less a judge or a chancellor. The young theologian, admitted into deacon’s orders, is not supposed to be fitted for a bishopric. ”

“ Modern surgery has in fact added nothing to our information on the subject, perhaps from the peculiar difficulties of the case, which may not admit of removal in the present state of our knowledge; although all writers seem to coincide in opinion that a sudden stoppage of the circulation of the blood is the more immediate cause of death. That the positive shock communicated to the brain from one side to the other, and the repercussion which follows from its resiliency, are capable of giving rise to a direct and visible injury, is indisputable. ”

“ Amputation of a limb is the last resource and the opprobrium of surgery, as death is of the practice of physic; it being, notwithstanding, impossible to do impossibilities, and save a limb or a life which can no longer be preserved. Art and science at that point cease to be useful.
66. At the commencement of the war in the Peninsula, all surgeons believed it to be impossible to compress in an effective manner the artery of the thigh against the bone, as it passes over the edge of the pubes, and that the loss of blood on its division must be so formidable as to be murderous. ”

“ The absence or the cessation of the hemorrhage by the contraction of the wound, or the formation of a coagulum, is the first step toward a cure, and it was to one or other of these circumstances that most of those who survived the injury for several days or weeks owed their existence for the time, although they usually died from the effects of inflammation, more of the inner lining and outer covering than of the substance of the heart itself. ”

“ It is impossible to say at what period of time the brain may become irritable, and no longer admit of its being touched without convulsive movements ensuing; but when this state of irritation has commenced, and its existence is proclaimed by the excitement which takes place on touching the fragment of bone, the surgeon should at once desist from all attempts to remove the foreign body. The brain under ordinary circumstances is much more likely to recover from an injury, all foreign or irritating matters having been removed, than when suffering from their presence. ”

“ Wounds penetrating the wall of the chest, and implicating any part or portion of its cavity or contents, are among the most dangerous of injuries. They require in their treatment a more careful attention and a greater extent of knowledge than most others which befall mankind. The means which the improved methods of auscultation have afforded cause the progress of the symptoms which follow to be less obscure, and lead to a less doubtful practice than formerly; while they render a knowledge of this branch of medical science an essential part of the education of a surgeon. ”

“ A wound of the artery, accompanied by a fracture of the femur, requires amputation, for although many would survive either injury alone, none would, it may be apprehended, surmount both united.
If after a fracture in course of treatment, the principal artery should be wounded by some accidental motion of the bone, amputation should in general be resorted to. A ligature on the artery higher up would fail, and the operation of seeking for both ends of the injured vessel would cause so much mischief in an unsound part that the consequences would in all probability be fatal. ”

“ If any ten healthy persons were trephined in a hospital, one would in all probability die from the effects of the operation, and three or four more might have a narrow escape from the inflammation of the brain and its membranes, or the other consequences which would probably ensue. It is not the admission of air, which has been even lately supposed to do mischief, that is to be dreaded in these cases, but the same kind of irritation which often follows the abstraction of a piece of bone under other and more ordinary circumstances at a later period of time. ”

“ When a large shot or other solid substance has injured a limb to such an extent only as admits of the hope of its being possible to save it, this hope is sometimes found to be futile, at the end of three or four days, from a failure of power, in the part below the injury, to maintain its life for a longer time: mortification is obviously impending. In military warfare, uncontrollable events often render amputation unavoidable in such a case. Under more favorable circumstances, the surgeon should be guided by the principle laid down of constitutional and local mortification ”

“ When a wound from a musket-ball appears likely to have penetrated the cavity of the chest, and is too small to admit the [428] end of the finger, the opening ought to be enlarged so as to allow its introduction as far as the ribs, in order to ascertain whether those bones have sustained any injury, or whether anything is lodged exterior to or within them. It is not necessary that a man should be cut simply because he has been shot; and an enlargement of the wound should be of no greater extent than is absolutely necessary for the purpose intended. ”

“ When it is desirable to ascertain the exact course of a ball, and, if possible, the internal part injured by it, the sufferer should be placed in the position he was in when he received the injury, with especial reference to the probable situation of the enemy, when that will often become very intelligible which was before indistinct. My attention was directed, after the battle of Toulouse, to a soldier, whose foot was gangrenous without an apparent cause, he having received merely a flesh wound in the thigh, not in the exact course of the main artery, which, nevertheless, I said was injured. ”

“ The first error committed in this case was in calling and believing a wounded artery to be a circumscribed, false, or diffused traumatic aneurism. Nothing can be called an [223] aneurism, by which word a dilated vessel or a diseased shut or closed sac is understood, which has one or more holes in it, made by a ball, or by anything else, the wound or track of which remains open. It is simply a case of wound in which an artery has been divided or injured, and while this track of the ball remains open, no ingenuity of argument can make it otherwise. ”

“ When the physiological doctrines of the circulation are duly considered, as well as the experiments on which they are founded, it will be evident that the action of the heart may be influenced by other causes than those occurring from the part of the brain apparently injured. Pressure made purposely on the brain or dura mater in man during life is always followed, when carried to too great an extent, by a diminution in the frequency of the pulse, and even by syncope. ”

“ When the nerves only are injured, the paralysis is not complete; it usually affects one side more than the other, is a numbness rather than a paralysis, and is accompanied by severe pain, sometimes at the seat of injury, but more usually extending to the thigh and to the extremities of the nerves in the foot. I was consulted in a case of wound from a pistol-shot, in the last dorsal or upper lumbar vertebra, of several years’ standing, in which the paralysis of both limbs was complete. ”

“ The practice to be pursued is to divide the vessel, if it be a small one, such as the temporal artery, when it will be enabled to retract and contract; and the bleeding will in general permanently cease under pressure, especially when it can be applied against the bone. If the artery is of a larger class, and continues to bleed, it should be sufficiently exposed by enlarging the wound; a ligature should be applied above and below the opening in the vessel, which may or may not be divided between them at the pleasure of the surgeon. ”

“ The presence of a ball, rolling about on the diaphragm, can now be ascertained by means of the stethoscope at an early period, so as to admit of an operation being undertaken with confidence for its removal; while the knowledge acquired by auscultation or percussion, of the filling of the chest by fluid, whether serous, bloody, or purulent, is at the same time incontestibly demonstrated. The presence of a ball, or of any other foreign body, decides the question as to the place where the opening into the chest should be made. ”

“ 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. ”

“ If the limb should be swollen or inflamed to any distance, with some constitutional symptoms, in a doubtful habit of body, the termination will in general be unfavorable, whichever course be adopted, more particularly if the amputation must be done above the knee. The consideration of the circumstances in which the patient is placed, his age, and habit of body, should have great weight in forming a decision in the first instance, as to the propriety of attempting to save the limb, which ought only to be done in persons of good constitution and apparent strength. ”

“ The injury may not, perhaps, be quite so extensive. The bone may be merely fractured, and yet the soft parts will often be so much destroyed as not to be able to carry on their usual actions. A ruptured blood-vessel may, with an apparently slight external wound of this nature, pour out its blood between the muscles, and inject the arm to nearly double its size, all of which are causes rendering an operation necessary, and requiring decision, for inflammation will, and mortification may, ensue in a short time, when the most favorable moment for operation will have been lost. ”

“ When the thigh is carried off by a cannon-shot, the artery being torn across, there is so great a shock and so great a loss of blood at the moment, followed by fainting, or such faintness as leads to the belief that the sufferer is dying, and some do actually die without an effort at recovery. In such a case, or in one somewhat similar, Dr. Snow and others think chloroform would act as a stimulus, and that it would enable the patient to bear the operation of amputation with success, which he otherwise might not have done. ”

“ Persons so afflicted can bear no great exertion of any kind. They fall down under exposure to heat. They are easily inebriated, rendered furious by a small quantity of liquor, and often become stupefied, comatose, or even die suddenly. In addition to these evils, which may be avoided by care, many are subjected to fits, which are apparently epileptic; and others suffer from such intolerable pain in the part injured, as well as in the head generally, as to be desirous of seeking relief by an operation, even at the risk of life. ”

“ In young people, who have not been reduced in health and strength by privations and hard service, the bleeding should be repeated until the desired object has been effected; the quantity required to be drawn in inflammation, particularly after injuries, is often very great. It may almost become a question, in some cases, whether a patient shall be allowed to die of the disease, or from loss of blood; for convalescence is rapid in proportion as the inflammation is of small extent, and has been early subdued. ”