Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

36. Wounds or injuries of nerves, which do not entirely divide the trunk, or a principal branch given off from a plexus of nerves, may give rise to general as well as to local symptoms; that is, by sympathy, connection, or continuity of disease, other nerves and organs of the body are affected. This applies also to the spinal marrow, when the injury does not destroy at once. General Sir James Kempt was wounded at the storming of the castle of Badajoz, on the inside of the left great toe, by a musket-ball which, from the appearance of a slit-like opening, was supposed to have rebounded from the bone, but was discovered a fortnight afterward flattened and lying between it and the next toe. Inflammation had ensued, followed by great irritability and numerous spasmodic attacks, appearing to render locked-jaw probable. The spasms soon became general, extending from the foot to the head, but tetanus did not take place. On his return to England, they gradually subsided, but he did not sleep at night for a year. After the battle of Waterloo the spasms became more frequent and troublesome, attacking the muscles at the back of the neck and throat, causing considerable anxiety. The attack was often traced to exposing the foot to cold or to undue pressure, and frequently to derangement of stomach, although he was most regular in diet. After the lapse of six or seven years these severe symptoms subsided; but during the last forty years of his life he suffered occasionally from them.

Admiral Sir Philip Broke received a cut with a sword on boarding the Chesapeake, on the left side of the back of the head, which went through his skull, rendering the brain visible; the wound healed in six months, although splinters of bone came away for a year. A second cut on the right side did not penetrate the bone. After a temporary paralysis of the right side, he recovered, with a loss of power and a disordered sensation in the second, third, and little fingers of the right hand, aggravated by cold weather and by mental anxiety.

Seven years afterward, he fell from his horse, and suffered from concussion of the brain, which added to his former sensations by rendering the left half of his whole person incapable of resisting cold, or of evolving heat. In a still atmosphere abroad, at 68° Fahr., he said, “the left side requires four coatings of stout flannel, which are augmented as the thermometer descends every two degrees and a half, to prevent a painful sense of cold; so that when it stands at the freezing point the quantity of clothing of the affected side becomes extremely burdensome. When exposed to a breeze, or even in moving against the air, one or even two oilskin coverings are necessary in addition, to prevent a sensation of piercing cold driving through the whole frame. Moderate horse exercise and generous diet improved the general health; the warm bath caused a distressing effect; the shower bath, cold or tepid, increased the paralytic affection. Frictions, with remedies of all kinds, increased it also, and so did sponging with vinegar and water, as well as any violent, stimulating, quick excitement, or earnest attention to any particular subject. The Admiral died unrelieved, twenty-six years after the receipt of the injury, of disease of the bladder.”

37. Brigade-Major Bissett was wounded on horseback, in the Kaffir war, by a musket-ball, which entered on the outside of the lower part of the left thigh, passed upward across the perineum, wounding the rectum within the anus—from which part he lost a quantity of blood—and came out through the pelvis on the opposite side. The course of this ball was accounted for by the fact that he saw the Kaffir who shot him standing some yards below him when he fired. The ball, in its passage upward and across the thigh, injured the great sciatic nerve, and the consequence is continued pain in the toes, instep, and foot, with contraction of the muscles, and lameness, together with the usual incapability of bearing heat or cold, particularly the latter, against which he is peculiarly obliged to guard. The skin shows no sign of discoloration or derangement. Position gives the explanation why the ball took such a peculiar course; the symptoms show the nature of the injury. From other effects he has perfectly recovered, but his leg is comparatively useless, while it is a constant source of suffering.

38. The cases related in the Lectures on wounds of arteries, of mortification taking place in the foot and leg, after the division of the principal artery in the thigh, show that the maintenance of the life of a part depends on the blood. The cases now related show that neither an injury nor the division of the principal nerve, nor, perhaps, of all the nerves going to a part, will destroy that life. The complete failure of the circulation, in a part such as the foot, impairs, but does not totally destroy, the sensibility imparted by the nerves, until after the loss of life has taken place, or until decomposition is about to occur. An injury then to the nerve causes great pain, not usually at the part injured, but in the extreme parts supplied by it; some loss of the power of motion; some deprivation of its ordinary sensibility, as shown by a feeling of numbness, and an incapability, to a certain extent, of resisting heat or cold. When all the nerves have been divided, the power of moving the limb is lost, as well as its sensibility in a general sense. The temperature remains at a natural standard under ordinary circumstances, but no extra evolution of heat can take place by which cold is resisted, nor any absorption of it, which perhaps renders the application of a high temperature, particularly when combined with moisture, dangerous. The circulation is capable of maintaining the ordinary heat of a part, although it is deprived of the influence of the special nerves of sensation and of motion; but a greater evolution of heat appears to depend on something communicated by the nerves in a state of integrity. In the case of Sir P. Broke, this something appeared to be derived from the brain, on which part the wound was inflicted, and the transmission of which was interrupted by the injury. The evolution of animal heat has of late been supposed to be dependent on electricity, from the resemblance which exists between it and the nervous power, although the attempts to identify them have not been successful. That the evolution of heat is the result of nervous power, appears to be indisputable; in what that power consists, physiologists have yet to ascertain.

39. The best means of mitigating the pain, independently of the application of warmth—and cold rarely does good, as the sufferer soon finds out—is by the application of stimulants to the whole of the extremity affected, followed by narcotics. The tinctures of iodine and lytta, the oleum terebinthinæ, the oleum tiglii or cajeputi, the liquor ammoniæ or veratria, may be used in the form of an embrocation, of such strength as to cause some irritation on the skin, short, however, of producing any serious eruption. After the parts have been well rubbed, opium, belladonna, or henbane may be applied in the form of ointment; or the tincture of opium, henbane, or aconite may in turn be applied on linen. Great advantage has been derived in many neuralgic pains from the application of an ointment of aconitine, carefully prepared, in the proportion of one grain to a drachm of lard, at which strength it will sometimes irritate almost to vesication, as well as allay pain.

When the pains return from exposure to cold, particularly in the lower extremity, great advantage has been derived from cupping on the loins, from purgatives, opiates, and the warm bath. Benefit has been obtained occasionally from quinine, and from belladonna, aconite, and stramonium, administered internally in small doses frequently repeated, but not suffered to accumulate without purgation; as the accumulated effects are sometimes dangerous.

LECTURE III.

AMPUTATIONS, ETC.

40. When the wound of an extremity is of so serious a nature as to preclude all hope of saving the limb by scientific treatment, it should be amputated as soon as possible.