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

185. Thomas Carryan, of the 3d Regiment, was wounded at Albuhera, on the 16th of May, 1811, on the inside of the calf of the right leg, the ball passing out on the fore and outside of the tibia: it bled considerably for some minutes, when it ceased, and the hemorrhage did not return until the 15th of June, on which day a little blood followed the dressings, and increased on the patient making any exertion; so that on the 4th, the gentleman under whose care he was tied the femoral artery on the outside of the sartorius muscle, which suppressed the hemorrhage for that day, the limb continuing with little or no interruption of the same temperature to the hand as the other. On the 5th, the original wound had a bad appearance, and some coagulated blood was readily pressed out of it; on the 6th, a greater quantity came away; and on the 7th, the exertion of using the bed-pan was followed by a stream of arterial blood, which ceased on tightening the precautionary tourniquet.

The limb was amputated above the ligature on the artery. Its dissection showed the anterior tibial artery to have been destroyed for some distance, and the muscles on the back part of the leg nearly in a gangrenous state. The patient died a few days afterward.

Remarks.—If an incision had been made in the leg so as to expose the artery, and ligatures had been placed on it above and below the wound, the man, in all probability, would not have died.

Sergeant William Lillie, of the 62d Regiment, aged thirty-two, was wounded in the right thigh, on the 10th of April, at the battle of Toulouse, by a musket-ball, which passed through, in an oblique direction downward and inward, close to the bone, describing a track of seven inches. The ball was extracted behind on the field. He said he had bled a good deal on the receipt of the injury, which he had stopped by binding his sash round the limb. The discharge from the wound was considerable; it appeared, however, to be going on well until the 20th of the month, when, on making a sudden turn in bed, dark-colored blood flowed from both orifices of the wound in considerable quantity. I had given an order, as the Deputy Inspector-General in charge of all the wounded, that no operation should be performed on a wounded artery without a report being sent to me, and an hour at least granted for a reply, unless the case were of too urgent a nature to admit of it. It appeared to be so in this instance, and before I arrived Mr. Dease had performed the operation for aneurism at the lower part of the upper third of the thigh. I could only express my regret that it had been done, and point out the probability of the recurrence of the hemorrhage from the lower end of the artery, which took place on the 7th of May, when the limb was amputated, and the man subsequently died. On examination the artery was found to have been divided exactly where it passes between the tendon of the triceps and the bone. The upper portion of the artery thus cut across was closed. A probe introduced into it from above would not come out at the face of the wound, although the impulse given to this part on moving it was observable in the middle of a large, yellowish-green spot, which I had previously declared to be the situation of the extremity of the artery which had contracted behind this, in the shape of a claret bottle, for about an inch, having within it a small coagulum. The lower end of the artery from which the hemorrhage had taken place was marked by a spot of a similar character; but on passing a probe upward from the popliteal space, it came out at a very small hole in the extremity of the artery, in the center of the yellow spot, the canal of the artery not being contracted and diminished, but only apparently closed by a layer of the yellowish-green matter laid over it, and adhering to its circumference.

Sergeant Baptiste Pontheit, of the French 64th Regiment, was wounded by a musket-ball at the battle of Albuhera, on the upper and fore part of the thigh; it passed out behind, in the direction of the femoral artery. He lost a great quantity of blood before the hemorrhage ceased, but the wound went on well until the 26th, ten days after the battle, when he felt something give way in his thigh, and found himself bleeding from the wound, which, however, soon ceased on pressing his hand upon it. In the afternoon, on again moving, he lost about half a pint of florid blood, which induced the surgeon on duty to place a tourniquet on the limb. When at leisure (in the course of two hours) I removed the tourniquet, and as no hemorrhage occurred, and there was no swelling in the vicinity of the wound, I replaced the dressing with a precautionary screw tourniquet, explaining to him its use, and the probable nature of his wound, together with the operation requisite to be performed in case of further bleeding.

On turning in bed at night he lost a little more blood, which ceased on his tightening the tourniquet, which was shortly after loosened. In the morning, everything being removed, there appeared some swelling about the wound, the opening of which was filled up by a coagulum: gentle pressure being made, it readily turned out, and was followed by a stream of arterial blood, leaving little doubt of the femoral artery being wounded. Compression being effected in the groin, I made an incision three inches and a half in length, taking the wound as a central point, and exposed the femoral artery and vein: both were wounded, the former being half destroyed in its circumference, surrounded with coagulated blood, and appearing as if it had sloughed from being touched by the ball, the course of which was directly past it, and would have carried it away if it had not been for the elasticity of the artery. A ligature placed above, and another below the wound, secured both artery and vein; the incised wound was brought together by adhesive plaster, and the limb placed in a relaxed position. The operation was of short duration; he lost little or no blood, but, the circulation was very languid, and the man exceedingly low. The warmth of the leg and foot was soon below the standard of the other; warm flannels were applied, and some brandy was given to him. In the evening the heat was more natural, and the man returned thanks for the humanity and kindness shown to him, congratulating himself and me upon the success of an operation which he had supposed would be infinitely more severe. The next morning he ate a tolerable breakfast, but felt a pricking sensation in the calf of the leg, which was as warm to the hand as the other, but the foot was cold. The second day the swelling of the limb, its appearance, and discoloration on the under part, indicated approaching mortification, which on the third was evident, and on the fourth, at mid-day, he died, the limb up to the wound being nearly all in a gangrenous state. No adhesion had taken place in the wound, or in the artery, which showed the inner coat cut, the ligatures being firm, and no coagulum behind them.

Captain St. Pol, of the 7th or Royal Fusiliers, was wounded in the ham from behind, while in the ditch at the foot of the great breach at Badajos. He fell instantly, and lost, as he thinks, a considerable quantity of blood. On recovering he was raised from the ground, and walked a few paces prior to his being carried to his tent, where I saw him in the afternoon of the next day, the 7th. The leg had ceased to bleed before his arrival in camp. A substance could be felt on the inner side of the patella, which, by the sensation communicated to the finger on moving, appeared to be the ball, which was extracted. Some dark-colored blood issued from the cavity; the ball was lying loose and unconnected; the finger, on being passed into the joint, which was swollen, discovered no splinters of bone, and the entrance of the ball behind would not admit the finger. His having walked some distance on the leg, and the absence of any splinters between the articulating extremities of the bones, induced Dr. Armstrong, the surgeon of his regiment, and myself to think that the ball had entered with little injury to the bone; and after stating to the patient the little hope we had of ultimately saving the limb, independently of the great danger to which he was exposed, compared to the certainty of the operation of amputation at the moment, we recommended its being done, but he would not consent. The next day he was removed to Badajos on a litter, the heat of the tent being unsupportable.

On the morning of the 9th I saw him early, when the want of circulation in the foot was evident from its having lost its natural color and warmth; the knee was swollen, but not painful, and I had no doubt that the artery had been divided by the ball. The marbled appearance and tallow-white color soon indicated the loss of the leg above the calf; and vesications had formed on the foot, already of a green color.

On the 12th, the extent of the gangrene was defined on the back of the knee up to the original wound at its lower edge, gradually receding as it advanced to the fore part of the leg, which for three inches below the knee was apparently sound; the uneasiness of the knee being moderate, and the incised wound looking perfectly healthy, although the latter had not united.

On the 16th, the separation of the dead from the living parts having taken place behind, and being well marked and commencing on the fore part, the limb was amputated as low down as possible. Sixteen vessels were tied; the parts were gently brought together, without any hope of union. According to subsequent experience, this operation should not have been performed. The dead parts only should have been removed, and the stump left to nature until the health was perfectly restored.