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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.

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.