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

28. Whenever the main artery of a limb is injured by a musket-ball, mortification of the extremity will frequently be the result, particularly if it be the femoral artery; it will be of certain occurrence if both artery and vein are injured, although they may not be either torn or divided. There may not then be such a sudden loss of blood, in considerable quantity, as to lead to the suspicion of the vessel being injured. The fact is known from the patient’s soon complaining of coldness in the toes and foot, accompanied by pain, felt especially in the back part or calf of the leg, or in the heel, or across the instep, together with an alteration of the appearance of the skin of the toes and instep, which, when once seen, can never be mistaken. It assumes the color of a tallow candle, and soon the appearance of mottled soap. Although there may be little loss of temperature under ordinary circumstances of comfort, there is a feeling of numbness, but it is only at a later period that the foot becomes insensible. This change marks the extent of present mischief. The temperature of the limb above is somewhat higher than natural, and some slight indications of inflammatory action may be observed as high as the ham, and the upper part of the tibia in front; it is at these parts that the mortification usually stops when it is arrested. The general state of the patient, during the first three or four days, is but little affected, and there is not that appearance of countenance which usually accompanies mortification from constitutional causes. In a day or two more, the gangrene will frequently extend, when the limb swells, becomes painful, and more streaked or mottled in color; the swelling passes the knee, the thigh becomes œdematous, the patient more feverish and anxious, then delirious, and dies.

An extreme case will best exemplify the practice to be pursued. A soldier is wounded by a musket-ball at the upper part of the middle third of the thigh, and on the third day the great toe has become of a tallowy color and has lost its life. What is to be done? Wait with the hope that the mortification will not extend. Suppose that the approaching mortification has not been observed until it has invaded the instep. What is to be done? Wait, provided there are no constitutional symptoms; but if they should present themselves, or the discoloration of the skin should appear to spread, amputation should be performed forthwith, for such cases rarely escape with life if it be not done. Where in such a case should the amputation be performed? I formerly recommended that it should be done at the part injured in the thigh. I do not now advise it to be done there at an early period, when the foot only is implicated; but immediately below the knee, at that part where, if mortification ever stops and the patient survives, it is usually arrested; for the knee is by this means saved, and the great danger attendant on an amputation at the upper third of the thigh is avoided. The upper part of the femoral artery, if divided, rarely offers a secondary hemorrhage. The lower part, thus deprived by the amputation of its reflex blood, can scarcely do so; and if it should, the bleeding may be suppressed by a compress. The blood will be dark colored. If the upper end should bleed, the blood will be arterial, and by jets, and the vessel must be secured by ligature.

29. When from some cause or other amputation has not been performed, and the mortification has stopped below the knee, it is recommended to amputate above the knee after a line of separation has formed between the dead and the living parts. This should not be done. The amputation should be performed in the dead parts, just below the line of separation, in the most cautious and gentle manner possible, the mortified parts which remain being allowed to separate by the efforts of nature. A joint will be saved, and the patient have a much better chance for life.

30. A wound of the axillary artery rarely leads to mortification of the fingers or hand. If it should do so, the principle of treatment should be similar, although the saving of the elbow is not so important as that of the knee: neither is the amputation in the axilla, below the tuberosities of the humerus, as dangerous as that above the knee.

31. Mortification after the sudden application of intense cold or heat is to be treated on similar principles.

32. When a nerve or plexus of nerves conveying sensation and motion, and going to a part, or an extremity of the body, is divided, the part or limb is deprived of three great qualities: motion, sensation, and the power of resisting with effect the application of a degree of heat or of cold, which is innocuous when applied in a similar manner to the opposite or sound extremity. In other words, it will be scalded by hot water and frost-bitten by iced or even cold water, which are harmless when applied to another and a healthy part.

An officer received, at the battle of Salamanca, two balls, one under the left clavicle, which was supposed to have divided the brachial plexus of nerves, as the arm dropped motionless and without sensation to the side. The other ball passed through the knee-joint, which suppurated. The left side of the chest became affected; he suffered from severe cough, followed by hectic fever, and was evidently about to sink. As a last chance, I amputated his leg above the knee, after which he slowly recovered. Fourteen years afterward he showed me his arm in the same state, and told me he had been indicted for a rape, but that the magistrates, seeing the wooden leg and the useless arm, while admitting the attempt, would not assent to the committal of the offence.

33. When one nerve only of several going to an extremity such as the arm and hand, is divided, the loss sustained is confined to the extreme part more immediately supplied by the injured nerve. Thus, if the ulnar nerve only be divided, the little finger and the adjacent side of the ring finger suffer, perhaps in some degree the inner side of the thumb and the adjoining fingers; if the median nerve, the thumb and other fingers; if the radial, the back of the hand next the thumb. In some instances there seems to be a kind of collateral communication by which a degree of sensibility is after a time recovered.

34. If any foreign substance should lodge in and continue to irritate the nerve, the wounded part often becomes so extremely painful as not to be borne; the nerve at that part forms a tumor of a most painful character, requiring removal, or in extreme cases even the amputation of the extremity.

35. After an ordinary amputation, the extremity of a nerve enlarges so as to resemble a leek, and if this should adhere to the cicatrix of the wound, painful symptoms, referred to the toes and other parts of the removed leg, are experienced often to an almost unbearable degree; the end of the nerve should be removed. The pain apparently felt in and referred to the toes is merely the effect of irritation of the extremity of the nerve.