Part 6
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.