Part 5
When a large shot or other solid substance has injured a limb to such an extent only as admits of the hope of its being possible to save it, this hope is sometimes found to be futile, at the end of three or four days, from a failure of power, in the part below the injury, to maintain its life for a longer time: mortification is obviously impending. In military warfare, uncontrollable events often render amputation unavoidable in such a case. Under more favorable circumstances, the surgeon should be guided by the principle laid down of _constitutional_ and _local_ mortification; and, although the line cannot perhaps be distinctly drawn between them at the end of three, four, or more days, it will be better to err on the side of amputation than of delay. If the limb should be swollen or inflamed to any distance, with some constitutional symptoms, in a doubtful habit of body, the termination will in general be unfavorable, whichever course be adopted, more particularly if the amputation must be done above the knee. The consideration of the circumstances in which the patient is placed, his age, and habit of body, should have great weight in forming a decision in the first instance, as to the propriety of attempting to save the limb, which ought only to be done in persons of good constitution and apparent strength.
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.
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.
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._