Part 7
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.
LECTURE IV.
APHORISMS FOR AMPUTATIONS, ETC.
65. Amputation of a limb is the last resource and the opprobrium of surgery, as death is of the practice of physic; it being, notwithstanding, impossible to do impossibilities, and save a limb or a life which can no longer be preserved. Art and science at that point cease to be useful.
66. At the commencement of the war in the Peninsula, all surgeons believed it to be impossible to compress in an effective manner the artery of the thigh against the bone, as it passes over the edge of the pubes, and that the loss of blood on its division must be so formidable as to be murderous. This was merely a surgical delusion, which maintained its ground in London until the end of 1815, when the French soldier, whose thigh I had successfully taken off at the hip-joint, after the battle of Waterloo, without first tying the femoral artery, was shown to all disbelievers. It was the great point in advance in English and European surgery, and one great result of the practice of that war.
67. This great, indeed most important fact, having been established, the surgery of amputation was deprived of nearly all its terrors. Confidence, and with it coolness, were obtained; and many young surgeons diligently sought for an operation on the hip-joint as the _ne plus ultra_ of operative boldness and dexterity, much after the fashion of the young lady _pianistes_, who do not consider themselves in any way advanced on the road to perfection until they can play at least the overture to _Guillaume Tell_, if not the _Galop Chromatique_ of Listz, nearly as well as the composer himself.