Show COMMON GATED I THE PRESIDENTS WOUND Aa it is now three weeks since President Pres-ident Garfield was wounded and aa his progress toward an ultimate recovery re-covery has been eo steady and constant i I con-stant we naturally turn to an analysis analy-sis of his symptoms in order to determine deter-mine aa nearly aa possible the nature of the injury The many differences of opinion that have arisen were the natural consequenees resulting from a wound such as he received It ia an easy matter to be mistaken where difficulties of diagnosis such as existed ex-isted in the present instance necessarily neces-sarily arose Probable penetrating wounds of any one of the large cavities cavi-ties of the bidy do not admit of the i use of the probe nor indeed of any considerable amount of exploration It is only then by a careful analysis of the succeeding symptom or as it were an a posteriori demonstration that as nearly as may be the extent of toe injury may be arrived at While Burgeons may arid do differ iu their opinions as to the ultimate result re-sult of a given case during its earliest stage the resultant symptoms tend I steadily to clear up the obscurity as well as to develop such theories as were based upon the most probable amount of injury done for theories they must of necessity be until proved or disproved by the light of subsequent subse-quent facts The facts as recorded in the daily papers go to show that three examinations of the wound were made OE the day of the shooting shoot-ing two of these showing but a flesh wound while one was thought to demonstrate the fact of a probable wound of the liver Surgeon General Wales in exploration with the finger fin-ger was satisfied that he could feel the wound in the liver while Dr 11 Bliss from the use of a > > probe to a depth of three inches arrived at the samo conclusion Doctor Townshend Health Officer of the District made probably the first examination of the wound also with his finger and only states that some bleeding followed Each fails to give either the exact or probable direction of the bullet excepting ex-cepting that the liver was wounded and that the ball had passed through this organ and was lodged somewhere in the anterior abdominal wall The natural inference from these brief statements would be that the bell struck the injured man at right angle to the vertical plane of the body and that it had been true to its original course not being at all deflected de-flected by any substance with which it came in contact Such an inference would be perfectly natural in the absence ab-sence of an accurate knowledge of the track of the wound and upon this inference a surgeon would base his ideas as to the ultimate result of the case In addition to this imperfect im-perfect knowledge of the extent of the wound there has as yet been given to the public no accurate description of the relative positions of the two parties which would go a great way in determining the probable course and deflection of the ball if such a deflection had occurred There is still another evidence upon the body near a gunshot wound which will always al-ways give a pretty accurate idea of the general direotiou of the wound and the probable track of the same and that is a beveled and bruised condition con-dition of the skin where the bullet first came in contact with it This will be found in all cases where the wound is not at right angles to one of the vertical planes of the body There has been in all the descriptions ol this case a lack of what might seem to be minor symptoms but which when collected go to make amore a-more probable caae than could be done without them Therefore in deciding upon the probable extent of the Presidents injury and also as to niB possible recovery many facts must be supplied by the symptoms as they arise in his oase from day today to-day Before advancing our own theory of the case let us eee how well the first opinions have been borne out by the subsequent progress of the case As we before remarked the differences in opinion were but natural aDd therefore all that we may say need not at all reflect upon the judgment of the learned gentlemen in charge The symptoms at the end of the first eight hours were vomiting bleeding to a moderate extent of first a pulse of 60 per minute and then steadily rising to 132 respirations a little accelerated and a temperature of 968 or a falling oft of nearly 2 ° There was with this come pain and restlesness but with the mental faculties facul-ties unclouded This is the period of shock and the period of complete reaction was anxiously awaited The manifest and almost invariable result of a penetrating wound ef the abdomen abdo-men complicated with a wound of the liver or kidney and probably one or more of the intestines would be either death during the period of shock or subsequently from peri tonites or fatal inflammation If now we notice the bulletins of the next four days we observe a gradual and steady recovery from the shock and also an entire absence i of all inflammatory symptoms nothing noth-ing remains but a little surgical fever and the wound which is beginning to discharge eome pue Now then we hve the first evidence that the ball has not penetrated the cavity of the abdomen and that the important organs i or-gans therein contained have i escaped injury Ot wounds of the liver reported re-ported in the surgical history of the war there were eight recoveries in thirtytwo reported cases but it must be remembered that while this is a mortality of only 25 per cent the numbers of fatal cases upon the field of wounds of this character would greatly swell the death rate Exceptional Excep-tional cases in all clashes of wbat would seem to be mortal wounds do occur bat when considered with the great mass thev are too few to merit serious consideration Though one man had lived for eleven das with a pistol ball in the wall of the heart it would hardly warrant a surgeon in giving anything like a favorable opinion opin-ion in a similar case Having passed the inflammatory stage there still runs through the case one symptom that tenda further to ahow that the ball has not passed into the cavity of the abdomen and that is pain in one and sometimes both legs This would go to show that the ball had taken one of two directions TIZ Either to the left and toward the spinal 1 column or downward behind the important viscera in the right side and was lodged upon or near the important nerves that go to supply sup-ply the leg The first hypothesis can reasonably be left out because the symptoms are not strongly enough marked nor daea paralysis to any extent ex-tent exist in the eztremtiea The second is the more probable one for several reasons First the character of the pain is such AS would result from any injury to the oaoral plexus of nerves and would cause in addition the prominent soreness or sensibility of the skin of the right leg especially such indeed as the President complains of second the ball struck and partially fractured he eleventh rib This rib from its Ii known mobility it3 rounded surface and from the fact that when pressed I upon it rises would easily deflect a II large ball whose initial vslocity was not very great and consequently I turn the bullet downwards in the direction di-rection of the pelvis and behind the peritoneum The bullet would encounter en-counter but little opposition after leaving the rib until it had expended its force in the loose fat of the pelvis or had buried itself in the tenderloin muscle If in addition to these facts it is remembered that the wouldbe assassin was the taller of the two men and that under any circumstances cir-cumstances the muzzle of the pistol would be directed a little downward it will be readily eeen bow the course of the wound would be downward toward to-ward the pelvis and not on a straight line into the cavity of the abdomen Again if the line of fire wag from behind be-hind forward and little to the right as indeed would seem probable then the doubleconvexity of the rib would exert a still greater power in deflecting ball from its onward course and thereby make the injury lees serious than it at first seemed There is still another fact which would jzo to support this view of thecae the-cae find that ia that the pistol had but little penetrating power owing to its quality and the taot that the cartridge car-tridge contained only twenty grains of powder The wounded man was also a wellbuilt heavy person and the natural thioknes3 of the posterior wall of the abdomen at this point would offer a better resistance to a ball than if the patient had been more sparely built II now the subsequent reports of the casebave been noticed it will be seen that while there has been a steady subsidence of the surgical fever with perhaps a few exacerbations exacerba-tions due to outside influences there has existed this constant pain in the leg and tingling sensation in the foot morphine has been necessary iu greater or leas quantities daily in order to quiet and relieve the patient from the effects of this pain It may be said in reply to this theory that the temporary jaundice which occurred was an evidence of tha truth of the first theory that the liver had been wounded Had the liver been wounded anti indeed traversed by a ball making a wound in the organ fully as large in diameter ag a mans finger the jaundice redgling would not only have been mord marked but it would have remained for days and weeks and would not have disappeared disap-peared spontaneously and without assistance as-sistance There is no doubt but that the impact of the bull upon the rib of sufficient force to fracture it and immediately over the right lobe of the liver might cause just such temporary jaundice as occurred but that would be ail The liver being also one of the organs beat supplied with blood in fact a mass of blood vessels itself would have poured forth into the cavity of the peritoneum such a quantity of blood at once as would have given the case an entirely en-tirely different aspect The additional addi-tional absence of all inflammatory symptoms the condition of the pulse respiration and temperature as well as the fact that there was appetite and a condition of the stomach to retain re-tain food go to make up a negative neg-ative to the proposition of a penetrating pene-trating wound of the abdomen at thai point It is unfortunate in view of a clear appreciation ot the case that a more accurate description of the external wound has not been given by the at tending surgeons as this would tend to throw light at least upon the probable 1 prob-able result of the injury In this connection too mncb praise cannot be said of those in charge of the case for the care and prudence they have exhibited in not endanger j i ing the patients life in probing and hunting for the ball The natural I I euppuration resulting from the I i I wound will daily demonstrate its direction i 1 I rection and extent while at the same time it carries the patient farther E from the danger point Healthy pus I must be the natural result of such an injury and be the means of pushing or carrying out such particles of clothing or bone as may lie in its course This need not be the source of any alarm to the reading public as it is a natural consequence of natures way of repairing the damage done In the light of the daily progress of the case therefore it would seem that the injury in-jury to President Garfield was not so serious as at first supposed and that his ultimate recovery is well assured There is however an element in the case which may cause him touch trouble during his lifetime even if it does not materially interfere with the use of his right leg If it is a fact as seems very probable that the sacral plexus of nerves has been injured in-jured or is being pressed upon by the ball a greater or leas permanent trouble with the leg may be expected It is probable that the ball will become I be-come encased in a little sack and there remain causing no more trouble than the same would do in other parts of the body Time I can only give farther light in the caaa tf and the scientific investigations which 1 it has brought about will add another fact to the great catalogue of surgical injuries A surgeons work ia not all easy and while in like cases to the j inquiries of anxious friends and the public he is compelled to speak of I I probabilities it becomes a matter of f necessity with him until nature I com II I l plates a cure or a post mortem clears I away all doubt It is to be hoped 4 t I however that the progress and study of thia will be continued until the I President is again able to resume ha duties and the nation settles down to its usual confidence in the safety of its chief officers Doctors will differ i while cases occur but it is in this this j I comes and the best results are obtained ob-tained A complete unanimity of I I sentiment would not be productive of j investigation nor give any new facts I i to the world Great credit is due to the surgeons in charga of the case I and though they may have seemed I lover sanguine the result in their I favor will be all the more satisfactory |