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.
41. An amputation of the upper extremity may almost always be done from
the shoulder-joint downward, without much risk to life. When necessary,
the sooner it is done the better.
42. An amputation of any part of the lower extremity below the knee
may be done forthwith, with nearly an equal chance of freedom from
any immediate danger, as of the upper extremity at or near the
shoulder-joint.
43. It is otherwise with amputations above the middle of the thigh, and
up to the hip-joint. They are always attended with considerable danger.
44. There can be no doubt that if the knife of the surgeon could in all
cases follow the ball of the enemy or the wheel of a railway carriage,
and make a clean good stump, instead of leaving a contused and ragged
wound, it would be greatly to the advantage of the sufferer; but as
this cannot be, and an approach to it even can rarely take place,
the question naturally recurs,--At what distance of time, after the
receipt of the injury or accident, can the operation be performed most
advantageously for the patient?
45. In order to answer this question distinctly, it should be
considered with reference to distinct places of injury:--
1st. When injuries require amputation of the arm below the
shoulder-joint, or of the leg below the knee, these operations may
be done at any time from the moment of infliction until after the
expiration of twelve or twenty-four hours, without any detriment being
sustained by the sufferer with regard to his recovery; although every
one, under such circumstances, must be desirous to have the operation
over. The surgeon having several equally serious cases of injury of
the head or trunk brought to him at the same time as two requiring
amputation of the upper extremity, may defer the latter more safely
perhaps than the assistance he is also called upon to give to the other
cases, the postponement of which may be attended with greater danger.
2d. This state embraces those great injuries in which the shoulder is
carried away with some injury to the trunk; or the thigh is torn off
at or above its middle, rendering an amputation of the upper third,
or at the hip-joint, necessary. It is this or nearly this state which
alone implies a doubt as to the propriety of immediate amputation, and
demands further investigation. It is the state to which attention is
earnestly drawn for future observation.
46. It has been implied, if not actually maintained, that a man could
have his thigh carried away by a cannon-shot without being fully aware
of it, or, if aware of it, that it did not cause much alarm--in fact,
that it did not materially signify as to his apprehension, whether the
ball took off his limb or the tail of his coat, or only grazed his
breeches. An instance of this kind has not fallen under my observation.
47. A surgeon on the field of battle can rarely have a patient brought
to him, requiring amputation, under less time than from a quarter to
half an hour; a surgeon in a ship may see his patient in less than
five minutes after the receipt of the injury; and to the surgeons of
the navy we must hereafter defer for their testimony as to the absence
or presence of the constitutional alarm and shock to which I have
alluded, and to what degree they follow, immediately after the receipt
of such injury. The question must not be encumbered and mystified by
a reference to all sorts of amputations after all sorts of injuries,
but to the one especial injury, viz., that of the _upper third of the
thigh_.
48. My experience, which may be erroneous, like everything human,
has taught me, that when a thigh is torn, or nearly torn off, by a
cannon-shot, there is always more or less loss of blood, suddenly
discharged, which soon ceases in death, or in a state approaching to
syncope. When the great artery has been torn, this fainting saves life,
for an artery of the magnitude of the common femoral does not close its
canal by retracting and contracting in the same manner as a smaller
vessel; it can only diminish it; and the formation of an external
coagulum is necessary to preserve life, which the shock, alarm, and
fainting, by taking off the force of the circulation, aid in forming;
and without which the patient would bleed to death. An amputation, in
this state of extreme depression, might destroy life, although aided by
the exhibition of chloroform.
49. If the cannon-shot, or other instrument capable of crushing the
upper part of a thigh, should not divide the principal artery, and
the sufferer should not bleed, it is possible he may be somewhat in
the state alluded to in which the patient, for he may not be called
sufferer, is said to be just as composed as if he had only lost a
portion of his breeches. Nevertheless few have seen a man lose even
a piece of his skin and of his breeches by a cannon-shot, without
perceiving that he was indisputably frightened. Dr. Beith, surgeon
of the _Belleisle_, hospital ship, in the Baltic, informs me that
Mr. Wrottesley, of the Engineers, was struck by a cannon-shot, at
Bomarsund, on the upper part of his right thigh, which shattered it
and his hand, which was resting upon it. His leg was also broken by a
splinter from the gun which the ball had previously struck. The femoral
artery was not injured, and it was said he lost but little blood. He,
however, never rallied from the blow, but sank in twenty minutes after
he was brought to Dr. Beith. The constitutional shock and alarm were
great; countenance sunk and pallid, pulse scarcely perceptible.
“An East Indian, twenty-two years of age, of healthy aspect, in the
month of October, 1854, when proceeding on a shooting excursion, at
Moulmein, in Burmah, was most severely wounded by the accidental
explosion of his gun, the entire charge of large shot lodging in the
center of the left thigh, and causing a bad compound fracture, with
fearful laceration of the soft parts. I was asked to see the patient
by Dr. Reynolds, the staff-surgeon of the station, at half-past seven
A.M., an hour after the injury had been inflicted, and found him
laboring under most urgent collapse and great nervous depression. It
was of course impossible to save the limb, but I suggested delay for
some hours, and the moderate use of stimulants, till the system had
in some degree recovered its equilibrium. Such was the case at five
P.M., and the flap operation was done while the man was under the
full influence of chloroform, (three drachms being required for that
purpose.) When placed in bed, he became conscious, but never rallied,
and died in half an hour.
“Very little blood was lost during the operation, and the impression
on my mind was, that it would have been wiser to have steadily but
carefully continued the use of stimulants during the operation, and
thus have counteracted the shock of the latter following on that of the
injury, from which the system had only partially recovered.”--_Case by
Dr. Dane, Surgeon to the Forces._
Deputy Inspector-General Taylor informs me that “a young muscular man,
of the siege-train, had his left thigh nearly carried off at its middle
by a cannon-shot at Sebastopol. The soft parts on the inside, including
the artery, escaped laceration; the remaining soft parts and large
pieces of bone were entirely carried away, the injury extending above
the middle of the bone. The muscles on the fore part of the other thigh
were extensively laid bare and injured. The prostration was great;
pulse feeble; the man’s spirits were good, and he desired amputation
under chloroform. The left thigh was amputated at the upper third. The
chloroform, administered on a pocket-handkerchief, lightly folded, and
held over the nose and mouth, speedily took effect. I am under the
impression that the chloroform not only caused insensibility to pain,
but supported the system during the operation, although the man died an
hour after its completion. Nevertheless, I think the chloroform enabled
the man to bear the operation better than he would have done without
it.”
This case does not quite meet my proposition as to the effect of
chloroform when the thigh has been carried off nearer the hip-joint,
with rupture of the principal artery; cases which have hitherto been
usually lost, whether amputation is performed or not.
50. While some persons, under the loss of a thigh high up, are reduced
to a state of syncope, or nearly approaching to it, which renders them
almost or even entirely speechless, others are said to suffer extreme
pain, and earnestly entreat assistance, under which circumstances
amputation should be performed forthwith. In the former, the
administration of stimulants may render the operation less immediately
dangerous. In the latter, they will be beneficial, and may save life.
51. Chloroform, or other similar medicaments, may produce an effect in
such cases as yet unknown. Its careful administration may not destroy
the ebbing powers of life, and may render an amputation practicable,
which could not otherwise be performed without the greatest danger. It
may be otherwise; the point, however, is to be ascertained, although in
all cases of great suffering its use should be unhesitatingly adopted.
Much difference of opinion having taken place on the subject of
chloroform, I requested Dr. Snow, who has superintended its use in many
of our hospitals, and in almost all the cases of serious operation in
private life, to draw up his observations and opinions in the most
compendious form possible, which he has been so good as to do, in the
following terms:--
“Chloroform may be given with safety and advantage to every patient
who requires, and is in a condition to undergo, a surgical operation.
A state of great depression, from injury or disease, does not
contra-indicate the use of chloroform. This agent acts as a stimulant
in the first instance, increasing the strength of the pulse, and
enabling the patient, in a state of exhaustion, to go through an
operation much better than if he were conscious.
“Persons who have died from the effects of chloroform had disease of
the heart, or of some other vital organ, but the majority had a sound
state of constitution; and it seems probable that the average health
of persons who have been the subject of accident has been at least as
good as that of those who have taken chloroform without ill effects.
From these and other considerations I am of opinion that accidents from
chloroform are to be prevented by care in its administration, and not
by the selection or rejection of cases for its employment.
“When animals are made to breathe air containing not more than four
or five per cent. of the vapor of chloroform till death ensues, the
breathing ceases very gradually, being first rendered laborious and
then feeble, and the heart continues to beat for a minute or two after
respiration has ceased. During this interval, while the heart is still
beating, the animal can be easily restored by artificial respiration.
This mode of death from chloroform might undoubtedly take place in
the human subject, if a person were to go on giving it regardless of
the symptoms; but a careful examination of all the recorded cases of
death from this agent shows that it has not occurred in this manner.
On the contrary, the symptoms of danger have in every instance come on
suddenly, and the action of the heart has been arrested at the same
moment as the breathing, or even before it. This is precisely the way
in which the lower animals die when they are compelled to breathe air
containing eight or ten per cent. of the vapor of chloroform. It is
therefore evident that the cause of death is the inhalation of the
vapor of chloroform not sufficiently diluted with common air.
“It requires more chloroform to suspend the functions of the ganglionic
nerves, which preside over the contractions of the heart, than to
suspend the functions of the medulla oblongata and the nerves of
respiration; but the action of the heart may be arrested by the direct
effect of this agent. Chloroform, when inhaled, is absorbed by the
blood in the lungs, passes at once to the left cavities of the heart,
and is immediately sent through the coronary arteries to every part of
that organ, in less time, probably, than it can reach the brain; or,
supposing the respiration to be suddenly arrested by the action of the
chloroform on the brain, the vapor, not being sufficiently diluted,
is present in large quantities in the lungs at the moment when the
breathing ceases; and becoming absorbed, in addition to that which was
already in the blood, has the effect of paralyzing the heart.
“Twenty-five minims of chloroform produce only twenty-six cubic inches
of vapor, and as one hundred cubic inches of air, at 60° Fahr., will
take up fourteen cubic inches of vapor, and at 70° will take up
twenty-four cubic inches, if fully saturated, it is quite possible
that the air during inhalation may contain ten per cent. of the vapor,
if means be not taken to prevent it. Under these circumstances,
each hundred cubic inches of air would contain nearly ten minims
of chloroform, and this might be taken into the lungs at once by a
rather deep inspiration. The average quantity of chloroform present
in the blood of an adult, when sufficiently insensible for a surgical
operation, is eighteen minims, while twenty-four minims are as much as
can be present in the system at one time with safety. The absorption
of a little more than thirty minims would have the effect of causing
death, even if it were equally diffused throughout the circulation. It
must be evident, therefore, that to take ten minims of chloroform into
the lungs at one inspiration, when insensibility is almost complete,
must be attended with danger.
“Robust persons, accustomed to hard work or violent exercise, are very
apt to become affected with rigidity of the muscles and struggling,
when nearly insensible from chloroform; and they often hold the breath
for a time, and then draw a deep inspiration. It is under these
circumstances that several of the accidents from chloroform have taken
place, and extreme care is required to give the chloroform more than
usually diluted with air, when this state of unconscious struggling and
rigidity occurs.
“The most important point to attend to, in the exhibition of
chloroform, is to insure that the vapor shall be sufficiently diluted
with air during the whole process of inhalation. This may be effected
with a suitable apparatus and proper attention, or if an inhaler be
not at hand, the chloroform should be diluted with one or two parts
by measure of rectified alcohol. One or two drachms of this may be
placed on a hollow sponge, and repeated when required. The spirit
has the effect of limiting the quantity of chloroform which rises in
vapor, while very little of the diluent is inhaled, since, from its
lower volatility, the greater part of it remains on the sponge or
handkerchief employed to exhibit the chloroform.
“When the chloroform vapor is so diluted that it does not constitute
more than four or five per cent. of the respired air, its effects
become developed very gradually and regularly. The suspension of the
sensibility of the conjunctiva at the border of the eyelids is the best
sign that the patient will bear the operation without flinching, and
the inhalation should immediately be left off if the breathing become
stertorous. The pulse is not a very important guide in the exhibition
of chloroform, for the two following reasons: 1st, if the vapor be
sufficiently diluted with air, the pulse cannot be seriously affected
by it; and 2d, if it be not so diluted, the pulse may cease suddenly,
without previous warning of danger.
“If the vapor of chloroform be sufficiently diluted with air, it is
practically impossible that any accident, really due to this agent,
should occur. In case of accident, however, artificial respiration,
very promptly and efficiently performed, is the only means which
affords a prospect of restoring the patient--at all events, this is
the only means found to restore animals when it was obvious they would
not recover spontaneously. The prospect of success from artificial
respiration will depend on the greater or less extent to which the
heart is affected by the direct action of the chloroform.”
Mr. Syme, in his “Clinical Observations,” delivered in the Royal
Infirmary in Edinburgh, recommends, in cases of approaching death
from the use of chloroform, that the tongue should be drawn forward
by means of a pair of artery forceps, by which it is presumed the
epiglottis is raised, and a greater facility afforded for the admission
of atmospheric air, the inconvenience resulting from two small holes in
the tip of the tongue being amply compensated by the preservation of
life.
Nevertheless, I am of opinion that attention should be paid to the
pulse, and whenever it begins to fail or flutter, the inhalation of
chloroform should be arrested; for respiration and the pulse often
cease almost simultaneously, and in some instances have done so
irrecoverably.
I formerly said that chloroform might be used with advantage in all
cases of injury requiring amputation, save one, and in that one
experience was wanting to decide the point. It is when a thigh has
been carried off by a cannon-ball, or destroyed at its upper part by
any other means, such as the wheels of a railway carriage or other
weighty machine. When the thigh is carried off by a cannon-shot, the
artery being torn across, there is so great a shock and so great a
loss of blood at the moment, followed by fainting, or such faintness
as leads to the belief that the sufferer is dying, and some do
actually die without an effort at recovery. In such a case, or in one
somewhat similar, Dr. Snow and others think chloroform would act as a
stimulus, and that it would enable the patient to bear the operation
of amputation with success, which he otherwise might not have done. It
may be so; but, as I believe nothing in surgery until fairly tried and
found to answer, I refrain, for the present, from expressing a positive
opinion, save that the trials should be made with great caution,
inasmuch as the observations which have been made in the Crimea have
not been sufficiently numerous or so decisive as to settle the point
in favor of the chloroform, although they confirm all the others to
which allusion has been made. In these cases a tourniquet cannot be
applied, and the sudden loss of blood saves the life of the sufferer
for the time, by suppressing the bleeding; which suppression, I have
long since pointed out, is effected in the artery at the groin, by the
formation of a coagulum, and not by the contraction and retraction of
the vessel into the shape of the neck of a claret bottle, which would
take place at the lower third of the same artery in the thigh under
a similar injury; in which case, also, the bleeding would cease by
the unassisted efforts of nature. If the artery, there or elsewhere,
should, on the contrary, be only partially divided, the person would
bleed to death, unless surgery of some kind should come to his aid.
52. When the sufferer is brought to the surgeon at the end of half an
hour, having lost a limb below the thigh or shoulder by a cannon-shot,
he will often be found in a state of such great depression as to be
likely to be destroyed by the infliction of a serious and painful
operation like amputation, unless chloroform should relieve it. This
has occurred to me so often as to induce me formerly to recommend delay
for four, six, or even eight hours, if the unfortunate person did not
suffer much, and appeared likely to be revived by the proper use of
stimulants. If he should be in great pain, the limb should be removed
under chloroform.
53. This recommendation originated from the fact that, as one seriously
wounded man has as much claim as another to the attention of the
surgeon, all could not be attended to at the same time; and the
success following the deferred cases of amputation was as great, if
not greater, than in those on which the operation was more immediately
performed.
54. The advantageous results of _primary_ amputations, or those done
within the first twenty-four, or at most forty-eight hours, over
_secondary_ amputations, or those done at the end of several days, or
of three or four weeks, have been so firmly and fully established as no
longer to admit of dispute.
55. When an amputation is deferred to the secondary period, a joint is
often lost. A leg which might have been cut off below the knee in the
first instance is frequently obliged to be removed above the knee when
done in the second.
56. In the secondary period after great injuries, the areolar and
muscular textures near the part injured are often unhealthy, the
bones are in many instances inflamed internally, and their periosteal
membranes deposit on the surrounding parts so much new ossific matter
as frequently to envelop in a few days the ligatures on the vessels,
and render them immovable, necrosis of the extremity of the bone
following as a necessary consequence, thus protracting the cure for
months.
57. Sloughing of the stump, accompanied by inflammation of the vein
or veins leading to the cava, frequently takes place. This state of
stump is often followed by purulent deposits in and upon the different
viscera, and principally in the cavities of the chest. Where febrile
diseases are endemic, they often prevail; the constitutional irritation
is great; the stumps do not unite, or, if apparently united, open out
and slough, and frequently after a few days implicate the veins.
58. In the first edition of my work on Gunshot Wounds, and on the
great operations of Amputation, published in 1815, I said, alluding
to secondary operations: “In the most favorable state of the stump,
the diseased parts do not extend very deep; yet inflammation is
frequently communicated along the vein, which is found to contain
pus, even as far as the vena cava.” “When I have met with this
appearance, I have always considered the vessels as participating
in (not originating) the disease, which had existed some days, and
thereby more quickly destroying the patient.” I further said that
after secondary amputations, the febrile irritation, allayed by the
operation, sometimes returns, and more or less rapidly cuts off the
patient by an affection of some particular internal part or viscus,
especially of the lungs. “If it be the lungs, and they are most usually
affected, the breathing becomes uneasy; there is little pain when the
disease is compared with pneumonia or pleuritis; the cough is dry and
not very troublesome; the pulse having been frequent, there is but
little alteration; the attention of the surgeon is not sufficiently
drawn by the symptoms to the state of the organ, and in a very short
time all the symptoms are deteriorated: blisters are employed, perhaps
blood-letting, but generally in vain; and the patient dies in a few
hours, as in the last stage of inflammation of the lungs, in which
effusion or suppuration has taken place.” “My attention was drawn to
it after losing several cases in this way, as a circumstance of more
than common accident, from its having happened to a young officer to
whom I was paying considerable attention, (at Salamanca.) Since that I
had one well-marked case at Santander, of a sudden and fatal affection
of the lungs after amputation of the thigh, which was under the
immediate care of Dr. Irwin,” and of myself as the principal medical
officer. The late Mr. Rose, of the Guards, communicated a case, after
amputation of the arm, to Sir James M’Grigor, who forwarded it to me;
and my old friend, the late Mr. Boutflower, who served frequently
under me during the latter part of that war, and aided me in all my
labors and views, forwarded to me, at the same time, two cases from
Fuenterabia, which terminated fatally after amputation of the arm,
from the deposition of a considerable quantity of pus in the cavity of
the thorax. “So insidious,” he said, “was the approach of the disease,
that, except a difficulty of breathing which supervened a few hours
before death, there were no symptoms indicating the existence of such a
morbid affection.” No further notice was taken of this disease by any
one in any of the hospitals on entering France in 1813, neither at St.
Jean de Luz, nor Bayonne, nor Pau, St. Sever, Tarbès, or Orthez, until
after the battle of Toulouse, where the following cases occurred, which
I published previously to any one else in 1815.
A soldier suffered amputation of the thigh five weeks after the injury,
in consequence of a gunshot fracture at Toulouse, he being in a very
reduced state, the discharge profuse, the pain great, hectic fever
severe. The third day after the operation, from which he scarcely
rallied, he complained of difficulty in swallowing, and pain in the
situation of the thyroid gland, which was found next morning to be
inflamed. In spite of the means employed, he died on the fourth day of
this attack, or the seventh after the amputation, in a state of great
emaciation. On dissection, the whole substance of the thyroid gland was
destroyed, a deposit of good pus occupying its place, which descended
by the sides of the trachea and œsophagus to the sternum, and had all
but found its way into the larynx, between the cricoid and thyroid
cartilages on the right side.
Daniel Lynch, wounded through the knee-joint at the battle of
Toulouse, on the 12th of April, 1814, had his thigh amputated by
the late Mr. Boutflower, on the 8th of May. The night succeeding
the operation he passed comfortably. Next day, the 9th, the febrile
symptoms were augmented. On the 10th he was worse; pulse 150. On the
11th he was better. On the 16th he was considered to be in a state
of convalescence, and went on improving until the 22d, when fever
recurred. On the 28th his stomach became very irritable; the stump
appeared to be nearly healed, the discharge being small, and of good
quality; one ligature remained. 30th: Pulse 110; tongue of a brownish
hue. During the 31st and 1st of June he got worse, and died. The stump
appeared to have united externally, except where the ligatures came
out; but, on cutting through the line of adhesion, the muscular parts
within were evidently unhealthy; the bone was surrounded for some
distance by a case of osseous matter, including the remaining ligature,
which could not be removed by any force short of breaking it. The femur
was bare, and showed marked signs of absorption having commenced; three
inches of it must have come away if the man had lived. The extremity of
the vein was in a sloughing state.
Having dissected the other extremity for a clinical lecture I
was occasionally in the habit of giving on particular cases, a
semi-transparent membranous bag, containing good pus, was found
accidentally on the tibialis posticus muscle. The blood in the perineal
vein outside of it was coagulated; there were little or no marks of
inflammation, and the matter appeared to have been deposited without
any. The inner side of the soleus muscle seemed simply to be discolored.
The first edition, containing these facts, which were before unknown,
and which furnish another laurel to the surgery of the Peninsular war,
having been published before the battle of Waterloo, the opinions
and facts stated therein became matters for public discussion, and
the reports made by my friends from Brussels, Antwerp, Yarmouth, and
Colchester, confirmed all the facts, and, I may add, all the opinions
of the slightest importance. They were published in the second edition
in 1820, and again more pointedly in the third, published June 18, 1827.
59. Forty years have passed away since I stated my opinion, that
inflammation of the veins is of two kinds--the adhesive or healthy,
from which the sufferers usually recover, as in the cases of women
laboring under the disease called phlegmasia dolens, and the
irritating or unhealthy, occurring after operations; the disease being
communicated by continuity to the vein, rather perhaps than originating
in it. I then said I did not believe that pus is carried from the
inside of the vein to the general circulation, the office of the vein
as a carrier of blood ceasing on the inflammation taking place in
its internal tissue, although I admit that the blood in a vitiated
state, from the commencing disease in the stump, or in the system, may
have for some time passed along it into the general circulation. The
inflammation thus commencing may extend upward and downward, and across
to the opposite side of the body, as I first demonstrated in 1825, in
the case of Jane Strangemore, p. 47. I never saw it actually in the
heart, the sufferers dying by the time it had reached as high as the
diaphragm, and in general before it had got so far.
60. When a person, after undergoing amputation, is about to suffer
from unhealthy inflammation of the veins, the pulse quickens, and
continues above 90, usually rising from 100 to 130. The stomach
becomes irritable; there are frequent attacks of vomiting, generally
of a bilious character, accompanied by the usual symptoms of fever. A
few days after the commencement of the complaint, there is usually a
well-marked rigor, followed perhaps by others, but exacerbations and
remissions of fever are common. The skin gradually assumes a yellowish
tinge, the perspiration is excessive, the bowels irregular, the pulse
becomes weaker and more irritable, the emaciation is considerable, and
the patient gradually sinks; or the febrile symptoms may subside, with
the exception of the frequency of the pulse, the patient rallies a
little, but while he says he is better, and the appetite even returns,
the deterioration in appearance becomes more marked, more deathlike,
even while eating, and an accession of fever rapidly closes the scene.
The stump is often not more painful than under ordinary circumstances,
neither is there any remarkable pain or tenderness in the course of the
vessels.
61. The practical points are, to draw blood with caution, on the
_accession_ of fever, provided a remittent or typhoid form does not
prevail; to open out the stump as soon as possible, even by a division
of the external adhesions, the inner parts being usually unsound; to
envelop it in a large warm poultice; to apply cold above, even ice if
procurable, in the course of the great vessels, and to soothe the
system by calomel, opium, and saline diaphoretic remedies, followed by
stimulants, cordials, quinine, and acids.
Private A. Clarke, 79th Regiment, had his thigh broken by a musket-ball
a little above the knee-joint, at Waterloo, and was admitted into the
clinical ward of the York Hospital, in London, in November, 1816. The
bone being in a state of necrosis, Mr. Guthrie amputated the thigh high
up, on the 20th of January, 1817. Pulse before and after the operation
104. On the 25th, pulse 120; skin cool; tongue moist; appeared weak
and irritable. During the 26th and 27th, symptoms of low fever came
on. 28th, suffered severely from vomiting, general fever, greater
prostration of strength; stump had not united, but discharged good pus.
30th, skin assumed a yellow tinge.
On the 1st of February, had a rigor resembling a fit of ague, and Mr.
Guthrie declared his suspicion of the formation of matter, probably in
the liver, and of inflammation of the veins of the stump. The symptoms
gradually assumed the character of typhus gravior, and on the 8th he
died. On dissection the liver was found enlarged, and weighing six
pounds; the other viscera were sound. On examining the stump an abscess
containing four ounces of good pus was found in the under part, near
the bone. The femoral vein and those going to that part of the stump
were inflamed, and contained coagulated blood, lymph, and purulent
matter, the disease extending from the femoral to the vena cava. The
rigors on the 1st February marked the formation of matter, the typhoid
symptoms its continuance, and the inflammation of the veins. Union was
discouraged from the first dressing.
The following case is so highly instructive on all points, that it is
transcribed from the _London Medical and Physical Journal_ for 1826:--
Jane Strangemore, aged twenty-eight, was admitted into the Westminster
Hospital, September 24, 1823, with an elastic swelling of the whole
of the knee-joint, measuring twenty-seven inches and a half in
circumference. The thigh was amputated by Mr. Guthrie on Saturday,
the 27th, the bone being sawn through just below the trochanter. She
suffered a good deal from pain after the operation. An opiate was
administered and repeated, and she passed a good night.
28th.--The pulse, which previous to the operation was 80, has increased
to 100; there is, however, little heat of skin, and she appears easy.
Some aperient medicine, and saline draughts to be given every four
hours. Toward the evening, she vomited a quantity of bilious matter;
pulse 120. Three grains of calomel and one of opium, followed by the
common aperient mixture, were ordered, and an enema. Equal parts of
ether and laudanum to be applied to the region of the stomach, to which
part pain was referred.
October 1st.--Better in all respects, but looking irritable and ill; no
pain anywhere; no sickness; appetite good; pulse still quick.
8th.--Two ligatures have come away; the wound looks well; the edges
have nearly healed; eats meat, and with a good appetite.
9th.--Not so well; pulse 120; skin hot; feels ill; complains of pain in
the other leg and thigh, which disturbed her rest. Was well purged, and
the leg fomented; the pain was principally felt in the calf and in the
heel.
10th.--Pulse 130; tongue furred; vomiting again of bile; the pain in
the thigh, extending upward to the groin and downward to the heel,
is intolerable, particularly in the latter part; the thigh and leg
much swelled, and tender to the touch, although without redness; the
swelling elastic, yet yielding to the pressure of the finger, but
not in any manner like an œdematous limb. Mr. Guthrie pronounced the
disease this morning to be inflammation of the veins, extending from
the opposite side; but after a careful examination, and on pressure,
no pain was felt in the course of the iliac vessels of that side, and
the stump looked well, save at one small point corresponding to the
termination of the femoral vein.
17th.--The symptoms continued nearly the same during the week, the
sickness of stomach and purging of bilious matter abating at intervals.
20th.--Less pain in the limb, which is swollen and tender to the touch,
the superficial veins being all very much enlarged. The groin more
swollen and tender; sickness gone, and her appetite returning; she is
allowed good nourishing simple diet. The stump has been poulticed since
the 9th, to promote suppuration.
25th.--During these five days it was interesting to see the patient
eat, and desire solid food, and, in her extremely emaciated state,
seem to enjoy it. The bowels occasionally deranged. Pulse always from
125 to 136. Is slightly jaundiced in color, but declares that she is
better, and will get well.
27th.--Gradually sank in the evening, and died; the limb having
everywhere diminished in size, except at the groin, where the swelling
was more circumscribed, resembling the appearance of a chronic abscess
approaching the surface. On examination after death, the termination
of the vein on the face of the stump was open, and in a sloughy
state; above that, for the distance of four inches, and as high as
Poupart’s ligament, the inside of the vein bore marks of having been
inflamed, but the inflammation seemed to have been of an adhesive
character; above that point, the inflammation appeared to have been
of an irritative or erysipelatous kind, had gone on to suppuration,
and the vein was filled with purulent matter, lymph, and blood, partly
coagulated and partly broken down. These appearances extended up the
cava as high as the diaphragm, and traces of inflammation could be
distinctly observed almost in the auricle. The disease had passed along
the right external iliac and its branches; it had descended along the
left iliac vein and its branches in the pelvis to the uterus, and along
the limb to the sole of the foot. At the left groin the iliac vein,
becoming femoral, was greatly distended with pus, apparently of good
quality, and, if the patient had lived a day or two longer, it would
have been discharged by a natural effort, as in chronic abscess; the
viscera were healthy.
During the last days of this woman’s life, no blood was returned from
the lower half of the body, unless by the superficial veins; yet she
was comparatively easy, although of a yellow hue, emaciated to the
utmost, so as to represent a living skeleton; in this state, with a
pulse at 130, craving for and eating a whole mutton-chop and more at a
time, with the most deathlike countenance it is possible to conceive.
These two cases mark the course, the symptoms, and the termination of
inflammation of the veins after amputation, in as clear (if not a more
clear) and distinct manner as any which have since been published,
and which they preceded; nevertheless, most authors of more modern
date overlook the first, and some appear to avoid as much as possible
noticing the second.
62. After the battle of Waterloo, the wounded of the same regiment were
sent indiscriminately, some to Brussels, others to Antwerp. Those who
remained at Brussels suffered principally from inflammatory fever after
amputation; those at Antwerp, from the epidemic fever prevailing at the
time, beginning us an intermittent and ending often in typhus; facts of
great importance to recollect, as showing the influence of malaria. The
following are instances of endemic fever after secondary amputation,
ending in subacute inflammation of the lungs and effusion into the
chest:--
Charles Brown, 92d Regiment, forty years of age, at that time a healthy
man, was wounded on the 18th June by two musket-balls in the right hand
and wrist; he was admitted into the hospital at Antwerp on the 25th
June. On the 5th July, the arm was swollen above the elbow; discharge
profuse and fetid; countenance sallow and dejected; fever. 8th: Arm
amputated above the elbow. 9th, 10th, 11th: A little increase of
fever. 12th: A paroxysm of intermittent, to which he had been subject
occasionally since he had been at Walcheren. On removing the dressing,
the edges of the stump were retorted; discharge copious and fetid;
respiration hurried; thirst; skin hot and yellowish; pulse 90. 14th:
Intermittent returned; head affected in consequence of long continuance
in the hot bath. 15th: Complains to-day of fullness and pain in the
left side; pulse 100; skin of a deeper tinge of yellow; a sense of
suffocation when in the horizontal position. A blister was applied to
the whole of the side of the chest. 16th: Was delirious during the
night; vomited frequently; became insensible at the hour when the
paroxysm of intermittent fever was expected to return; and died in the
evening. On opening the chest, the lungs were found adhering to the
pleuræ costales in several places, and were hepatized; a quantity of
serum and lymph was contained in the left pleura, so as to compress
the lung, in which there was a small abscess. The liver was twice the
natural size.
J. Lomax, of the Guards, was wounded at Waterloo, suffered amputation
of the right arm on the 23d August, and arrived at the General
Hospital, Colchester, on the 27th, in a state of high fever, and unable
to give any distinct account of himself. He had had the ague, he said,
for many days, which left him for a short time, but returned when on
board ship; on the 25th he was attacked by pain in the side, which
was very severe on the 26th, on which day a blister was applied, which
greatly relieved him. The stump had an unhealthy appearance, the edges
of the wound evincing a disposition to separate. On the 28th he was
free from pain; fever unabated, with a tendency to delirium. He sank
rapidly on the 30th, and died on the 31st, notwithstanding the use of
the most powerful stimuli. A quantity of serum was found on dissection
in the left side of the chest, and the pleura pulmonalis on each side
was covered with a thick layer of coagulable lymph. The pericardium was
distended with fluid. The liver was enormously enlarged, pushing up the
diaphragm, and displacing the lung, having in its substance a large
abscess containing at least a quart of pus. The stump did not exhibit
any peculiar appearance.
O. Sweeney, 90th Regiment, aged nineteen, was wounded in the hand on
the 18th of June, 1815, and taken to Brussels. On the 5th of July he
left for England, and arrived at Colchester on the 14th. The wound
shortly after assumed an unhealthy appearance; hemorrhage took place,
and the arm was amputated on the 30th. The day after, he had severe
rigors for fifteen minutes, followed by fever. The next day he was
better, and appeared to be doing well until the 6th of August, when
fever recurred. Stump quite healthy in appearance. On the 7th, he was
attacked by vomiting and purging, which lasted several hours, and
reduced him much, returning at intervals until the evening of the 8th.
Small quantities of wine and opium agreed best, and a blister was
applied to the scrobiculus cordis. On the 9th, he complained of pain
and tenderness in the abdomen, which were relieved by fomentations and
an enema. The stump looked well, and discharged healthy pus in small
quantity; the ligature on the brachial artery came away. On the 10th,
his strength failed, and the tongue and teeth were covered with a dark
sordes. The adhesions of the stump appeared disposed to separate. At
night he was restless, with low delirium; and on the 11th died, with
the complete facies Hippocratica. On raising the sternum, the pleura of
the left lung was found adhering to that of the ribs, and covered by a
thick layer of coagulable lymph. The lung was highly inflamed; and on
cutting into its substance, a number of small tubercles was observed.
The pericardium and left cavity of the thorax contained more than the
usual quantity of fluid. During the progress of this case, eleven
days from the amputation no one symptom existed which could induce a
suspicion of inflammation going on in the thorax. The stump was in a
sloughing state, but the disease did not extend along the brachial
veins.
Thomas Haynes, 23d Light Dragoons, aged nineteen, was wounded by a
spear on the back of the left forearm, at Waterloo; the wound appeared
to do well until he left Brussels for England, when it assumed an
unfavorable appearance, and on his arrival at Colchester, on the 14th
of July, it was in a sloughing state. The pain was excessive, and the
tenderness around the whole circumference of the sore was so great that
he could not suffer the slightest pressure with the finger. He was
largely bled, and a solution of sulphuric acid, one drachm to twelve
ounces of water, was applied twice a day to the whole surface, and the
whole kept wet with cold water; this treatment was continued until
the 21st, during which period he was bled five times, to about twenty
ounces each time. The acid solution was increased in strength from one
drachm to an ounce, and care was taken that the sloughing portions
only were touched with it. His health was considerably amended, and
on the whole a favorable result was expected. At two on the 22d,
however, a sudden hemorrhage took place, to the amount of three pints;
a second ensuing on the 23d, the arm was amputated. The pulse continued
quick; in other respects he was doing well, until the 25th, when some
accession of fever took place, and increased. He was bled to ten
ounces, and purged. On the 26th, the line of incision in the stump
appeared to be healed; and with the exception of the pulse at 140, he
had no unpleasant symptom on the 27th, and was free from pain of every
kind. On removing the center strap, which had been allowed to remain,
a large collection of matter of good quality issued. On the 28th, he
was much the same. On the 29th, the countenance had assumed a deathlike
paleness; pulse 120, intermitting every fifth pulsation; breathing
short and laborious, with some pain in the chest, and every symptom of
effusion having taken place. He died at two P.M., six days after the
amputation.
The only morbid appearance found on dissection was a large quantity of
serous fluid in the pericardium, which was distended by it, and on both
sides of the chest. The heart and lungs, with their membranes, were
quite sound. On examining the stump, the sanative process was found
to have been entirely confined to the integuments. No appearance of
granulation could be perceived on the muscular surface.
This last case is worthy of especial observation, on account of the
manner in which sulphuric acid was used for the sloughing state, from
one drachm to one ounce of the acid to twelve ounces of water, not
as something new, but as an ordinary application; and I am doubtful
whether there is any case on record of such use, anterior to it. Is the
external use of strong acids in sloughing cases also due to the war in
the Peninsula? Delpech says Yes,--a testimony I shall confirm in its
proper place.
I have departed, in some degree, in the foregoing observations, from
the aphorismal form I had prescribed for myself in the commencement
of these Commentaries. I have done so as an act of justice to those
officers who served at Toulouse, Brussels, Antwerp, and Colchester, in
1814 and 1815, who are all now no more, and who labored hard in the
then early investigation of these different states of disease, and have
not received the reward they merited of public acknowledgment. I have
endeavored, as the late Chancellor of the Exchequer says in his life of
Lord George Bentinck, to preserve for them the chastity of their honor.
63. Mr. Hunter, in 1793, described the appearances and the fatal
results of inflammation of the veins, as a consequence of injuries
inflicted on the surrounding parts, but I apprehend I was the first
person to point out the prevalence of this complaint after secondary
amputation, and its intimate connection with certain low inflammatory
attacks, attended by destructive purulent depositions, particularly in
the chest, and their more chronic deposit in other parts. Mr. Rose,
of the Guards, published some observations in the fourteenth volume
of the _Medical and Chirurgical Transactions_, in 1828, confirming
the remarks made by me in print thirteen years before, but without
referring to them. Mr. Arnott has an able paper on that subject in the
fifteenth volume. M. Sedillot thinks he has detected globules of pus
in different parts of the circulating system in persons who had died
of this disease. Mr. Henry Lee, 1850, one of the last English writers
on the subject, professedly doubts the accuracy of the observation;
this point remains among others for further investigation. He admits,
however, that in cases where, from long-continued disease, there have
been repeated introductions of vitiated fluids into the circulation,
the blood loses much of its coagulating power, which prevents the
admission of purulent matter by the veins, by forming coagula with it
in them, thus constituting he thinks the essential disease. When the
coagulating power of the blood is thus lost, he thinks it possible that
pus-globules may then be found circulating in it. Other late writers,
and lastly Dr. Hughes Bennett, think these diseases are dependent on
the introduction of a peculiar animal poison. Attention should be
paid by the medical officers of the public service, whenever there
is a war, to the state of the blood, and to the inner lining of the
diseased veins under the microscope;[2] and all those gentlemen, when
in London, should study its use, under Mr. Quekett, at the College of
Surgeons, to whose lectures they have the right of admission, and to
whose kindness they will all soon feel greatly indebted. I am not aware
that the writers referred to have added anything to the practical facts
I had related so long before, which is much to be regretted. It is of
little use, although it is a step in the right direction, to describe a
disease, or even to show why and wherefore it destroys, unless a means
of prevention or of cure can also be indicated.
[Footnote 2: The India Company have supplied the principal hospital of
each presidency with one good microscope at least; one of these, with a
person who understands its use, should be attached (but is not) to the
principal hospitals during the present war in the East.]
64. In the irritable and sloughing state of stump alluded to,
hemorrhages frequently take place from the small branches, or from the
main trunks of the arteries, in consequence of ulceration; and it is
not always easy to discover the bleeding vessel, or, when discovered,
to secure it on the face of the stump; for as the ulcerative process
has not ceased, and the end of the artery which is to be secured is not
sound, no healthy action can take place; the ligature very soon cuts
its way through, and the hemorrhage returns as violently as before, or
some other branch gives way; and under this succession of ligatures and
hemorrhages the patient dies.
Some surgeons have, in such cases, preferred cutting down upon the
principal artery of the limb, in preference to performing another
amputation, even when it is practicable; and they have sometimes
succeeded in restraining the hemorrhage for a sufficient length
of time to allow the stump to resume a more healthy action. This
operation, although successful in some cases, will generally fail,
and particularly if absolute rest cannot be obtained, when amputation
will become necessary. The same objection of want of success may be
made to amputation; on a due comparison of the whole of the attending
circumstances, the operation of tying the artery in most cases is to be
preferred in the first instance, and if that prove unsuccessful, then
recourse is to be had to amputation; but this practice is by no means
to be followed indiscriminately. The artery ought to be secured with
reference to the mode of operating, as in aneurism, but the doctrines
of this disease are not to be applied to it, because it is still a
wounded vessel with an external opening.
To obviate all doubts, the part from which the bleeding comes should
be well studied, and the shortest distance from the stump at which
compression on the artery commands the bleeding carefully noted; at
this spot the ligature should be applied, provided it be not within the
sphere of the inflammation of the stump. In case the hemorrhage should
only be restrained by pressure above the origin of the profunda, and
repeated attempts to secure the vessel on the surface of the stump have
failed, amputation is preferable to tying the artery in the groin, when
the strength of the patient will bear it.
When hemorrhage takes place after amputation at or below the
shoulder-joint, it is a dangerous occurrence. An incision should then
be made through the integuments and _across_ the great pectoral muscle,
when the artery may be readily exposed, and a ligature placed upon it
without difficulty anywhere below the clavicle.
If the state of the stump in any of these cases should appear to depend
upon the bad air of the hospital, the patient had better be exposed to
the inclemency of the weather than be allowed to remain in it.
In crowded hospitals, hemorrhages from the face of an irritable stump
are not unfrequent, and often cause a great deal of trouble and
distress. It is not a direct bleeding from a vessel of sufficient size
to be discovered and secured by ligature, but an oozing from some
part of the exposed granulations, which are soft, pale, and flaccid.
On making pressure on them the hemorrhage ceases, but shortly after
reappears, and even becomes dangerous. This hemorrhage is usually
preceded by pain, heat, and throbbing in the surface from which it
proceeds. There is irritation of the habit generally, and a tendency to
direct debility. The proper treatment consists in the removal of the
patient to the open air, with an antiphlogistic regimen in the first
instance, followed by the use of quinine and acids; cold to the stump,
in the shape of pounded ice or iced water. Escharotic and stimulating
applications should be used with caution. If any of the styptics which
are sometimes announced as infallible could be relied upon, their
application in these cases would be most advantageous. The solution of
the perchloride of iron is the best.