per, be supplied as a part of the regular and necessary outfit for hospital and field service. Expectant treatment has been practiced in all cases of penetrating wounds of the head. No cases have occurred in which the use of the trephine promised any advantage. In a penetrating would of the skill by a minie-ball the amount of injury inflicted is usually fatal in its nature. The prospects of recovery are seldom increased by the performance of a severe operation. The practice recommended is to remove spicula of bone and any foreign substance or clot that may be within reach, but not to probe the wound, or make too frequent examinations. Cold to the head, sedatives, and in some cases stimulants, rest, and expectancy, are the rules which have been observed.
The same law of expectancy is applied to wounds of the intestines. It is next to an impossibility, when a soldier is wounded in the abdomen, cutting the intestines, but that their contents should escape into the peritoneum. The necessity of lifting and handling, and the agitation of transportation to a considerable distance, render this result next to an infallible certainty. Some cases might be saved, perhaps, if they could be examined at the moment of reception of the wound, the edges pared and closed with silver wire.
The opportunity to do this has generally passed by the time the patient reaches the hospital. I think it admits of question whether greater effort should not be made to seek out the wound, close it by silver wire, and endeavor to obtain primary union, while peritonitis and constitutional disturbance are treated on general principles. Wounds of the chest, neck, and face have been frequent in proportion, from the troops come into position. Gunshot wounds of the chest have been treated by closing the wounds with ordinary dressing and on general principles. The insertion of morphine into wounds of the chest, attended by pain and dyspnoea, has been of the utmost advantage. I made the insertion of morphine into all painful wounds a standing order of the medical department, and it has acted so admirably as to enlist every surgeon in favor of the practice. Its good effects are especially remarkable in painful wounds of the joints, abdomen, and chest. From one to three grains are inserted on the point of the finger. I desire especially to call the attention of the profession to this practice, which is simply a generalization of the well recognized application of morphine hypodermically. The circular method has been the one almost universally adopted in amputations. One amputation through the knee has been performed with tolerably satisfactory result, in which the cartilages were not removed. In the majority of amputations at the lower third, the operation was performed just above the condyles, without opening the medullary canal. When practicable, I give my decided preference for amputation through the knee joint. A series of cases has been reported to me in another department, in which the cartilage was left, the flaps being brought smoothly over the ends of the polished condyles. These cases are reported as having done exceedingly well. The case in my own department, just referred to, was doing well when last heard from, with the exception that abscesses had formed on the stump, undoubtedly depending on the ulceration of cartilage. I would advise the removal of the condyles in all cases in which the surroundings were favorable. In operations which become necessary under circumstances indicating danger from erysipelas or gangrene, I would allow the cartilage to
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