ERINPOORAH DISPENSARY. A CASE OF AMPUTATION AT THE HIP-JOINT.
Meywar Bheel Corps. Brahmin, aged 30. when returning to his home from a distant village, was attacked by Meenas, who, he says, shot him By Surgeon
Lalla,
T. H. Hendley,
a
twice. Two balls are reported to have struck him at the outer part of the left thigh, and to have penetrated the limb, shattering the femtir and escaping by a wound on the inner side. He was taken to his home in a cart, and soon after his arrival it was noticed that the lower part of the shaft of the femur protruded through the outer wound. Hot irons were applied in twelve places over or near the seat of the injury ; burnt pilu and neem leaves were alternately applied locally ; and after a few day3 a bamboo splint in addition. After four montns of great suffering he was brought to the Erinpoorah Hospital on May 26th, 1873. When admitted, the patient was fearfully emaciated and feeble, both lower extremities, the abdominal, and chest walls, very oedeinatous; the penis and scrotum also distended to a painful degree. The left leg was shortened and everted, the thigh flattened out so much that the long axis of the limb seemed to be three or four inches outside a line drawn downwards from the anterior superior spinous process of the ilium. The opening through which the bullet entered, was on the outer side of the thigh about four inches below the above-named process; through it the sharp end of the lower part of the femur projected ; this, however, the man's brother returned into the wound with evident pride ; the wound of exit was rather lower down both openings; there on the inner side, pus welled out from where the cautery had been applied, on were numerous scars, The probe discovered the upper and inner part of the thigh. numerous large detached fragments of bone within the outer wound. Excision offered no hope of relief, the man was rapidly giving way; amputation below the hip-joint was impracticable. I therefore determined to perform that operation as 30011 as possible, as it afforded him the only chance of recovery. On June 2nd, at 7 a.m.?The man was placed on the operating table. One hospital assistant administered chloroform, a second pressed his thumbs upon the main artery as it crossed the edge of the pelvis, whilst a dresser feebly attempted to bring pressure to bear upon the abdominal aorta. Lieutenant Rennick kindly aided by holding the limb, and assisting afterwards in tying ligatures. The anterior flap was rapidly formed, but as the head of the bone was isolated from the shaft, and there might have been delay in getting it out from the acetabulum instead of at once forming the posterior flap. I tied the arteries in the upper one ; the capsule was then cut through, and the head of the bone turned out of its socket, though with difficulty, as there was no leverage to aid one; the posterior flap was rapidly The wound was well drenched with cut and the arteries tied. cold water; a solution, of tincture of iron applied, and the edges The hemorrhage was were brought together with silk ligatures. trifling; thanks to the able assitance at hand. "Water-dressing and a light bandage were adapted to the stump, and a little the pulse was not sp. ammon. aromat given to the patient; altered in any way. Upon examining the limb I found that the femur had been almost completely shattered in the upper part; about two inches long, a piece of the shaft in the upper third, there were numerous fragments scattered was quite isolated; of the original wound; the about; a large cavity in the track thigh was infiltrated with pus and serum. For the first much improved, the oedema almost four days the patient's health entirely subsided in the scrotum and trunk, and nothing to call the fourth On morning, the dressings were for alarm occurred. removed, the edges of the wound had healed by first intention in the middle three-fourths, a few small maggots escaped from the lower opening; the stump was washed with lotions of carbolic acid and sulphate of zinc water; sulphate of zinc and carbolic acid dressing were applied locally, and the patient placed on another bed. In the evening fever of an asthenic type set in, which continued throughout the case.?exacerbations coming on generally about twelve o'clock in the day, and ending at 5 or 7 p.m. Carbonate of ammonia and quinine always had a most beneficial effect, when givfen in the intervals ; fever mixtures were useful in the exacerbations. His pulse, on the whole, grew weaker day by day, the left chest wall was cedematous, but this subsided on the 6th June : the abdomen was also distended and painful, relief was speedily obtained by the use of an enema con* taining a little oil, and peppermint water; the oedema in the left limb was reduced by the use of sulphate of iron lotion and
whole'
THE INDIAN MEDICAL GAZETTE.
294
nitrate of silver, coupled with position. A few maggots came away when the wound was dressed, but none were noticed again throughout. On the 7th diarrhoea set in, which, although controlled by gallic acid (and this drng alone), proved troubleOn the 11th two or three small bed-sores were some to the end. seen; these were rendered of little moment by applying spirit and benzoated lotions from the second day. Liebig's extract and brandy were in constant requisition. The high caste of the patient, with the necessity of taking poor food, had been and was against the man from the receipt of his injury until death. On the 12th there was some difficulty in breathing, and pain in swallowing, with occasional vomiting (previously the patient had been sick once or twice); there were, however, no alterations in the chest so much. On the 15th I detected dulness in the right chest posteriorly; there was static congestion of the right lung, due to his enforced position and great weakI tried to remove this source of anxiety by arranging so ness. that he might be more upon the left side, which he could do as the wound was not painful. Three ligatufes came away on this morning (15th). Four more ligatures and most of the sutures were removed on the 19th. Two more on the 20th, and the last, from the femoral artery, on the 21st. The condition of the right lung much improved, but diarrhoea the very much weakened the patient, whose appetite was good to last. There was no cough, and no expectoration ; the man was On the an opium-eater, which would explain this, I apprehend. 22nd, the twentieth day after the operation, at my morning visit, the condition of the patient seemed to have much improved ; his left limb was almost of a natural size; there had been no diarrhoea during the night; the pulse was stronger than it had been for some days, and the man feeling so much better, had, eluding the care of his attendants, ate a most hearty meal, rather to the admiration of his friends, who thought he was now for the first time eating like a person in health. About an hour after I left the hospital, he suddenly fell back, clenched his teeth, refused to say a word?although at first he evidently understood what was going on around him?gradually became weaker and colder, and died at 4 p.m. the same day. Remarks.?I think that in this case it may be fairly considered that the operation did not at all hasten the approach of death. The wound was healing as well as could be desired; the local discomforts, such as oedema, disappeared almost with the removal of the source of irritation; there were various complications: for instance, the chest affection, Which, however, seemed amenable to treatment, and I have no doubt that had the man been more prudent, the diarrhoea and other troubles would have been checked. He had been reduced by months of suffering, without proper food; his blood had therefore become greatly impoverished, so that the sudden exertion of taking food immoderately had caused the dislodgeraent of a clot, which was too much for an already greatly embarrassed circulation to overcome. I do not think the operation had the slightest influence in hastening the end ; the irritation of the new wound was in fact less than that of the old. In cases of amputation near the trunk, I believe, a previously greatly exhausted condition of the patient, or an artificially produced exhaustion, at or near the time of operation, will be greatly in favor of recovery. I believe that there is a point, which might be almost reduced to a mathematical formula, to which a ought to be reduced, if nature have
patient already done the work, to ensure recovery. a table constructed by looking at append discover severe amputation, which I could
not
all the cases of in the Medical Gazettes for 1869-1870 and 1871, and in which the points of want of or presence of haemorrhage during the case or previous emaciation and exhaustion are made out. From this it will be seen that in 13 cases there were two deaths only; there were six cases of amputation at the hip with one death, and two at the shoulder with one death. In the first case of death little blood was lost at the operation, although there had been some haemorrhage ; in the second, very little blood was lost. Death resulted from pyaemia and osteo myelitis in four days. In 10 of the successful cases there was either profuse haemorrhage at the operation, or immediately before or after, or excessive exhaustion and emaciation. In several cases there was reported secondary haemorrhage; and in the thirteenth case the man had been exceedingly intemperate and had much weakened his constitution. At Jodhpore I had a C2se of amputation, at the upper third of the thigh, in which there was profuse haemorrhage, as my assistants became confused, and there were about thirty arteries to tie. In a case of fungus disease of the foot in which I amputated the leg, there was profuse I
liaemorrhago,
many
ligatures having been applied
as
the whole
surface seemed
one
artery.
[November 1, In both
cases
1873.
the limbs had been
kept up, and the main artery was well commanded by the tourniquet. In the latter case the patient was much emaciated, having lost large quantities of pus for two years. Both cases rapidly recovered. But the most instructive case was one of amputation very near the shoulder-joint. A boy, aged nine years, was brought in from a village one hundred miles from Jodhpore ; he was ten days on the journey. When admitted, his fore-arm and lower upper arm were seen rotting in a tile, the
ulna and radius were white and separated from as white a humerus. The limb to witbin four inches of the axilla was completely gangrenous, pulpy, and extremely fetid. It was so rotten that the tile had to be removed with the limb ; there was no line of demarcation. I amputated two inches above the gangrenous mass, everything had been prepared for the operation, and although no tourniquet could be applied, the subclavian artery was pressed upon, enough to prevent all pulsation in the axillary vessel. When I had removed the limb I found that an officious dresser had actually taken away all the artery forceps and locked them up in a chest. I pushed my Snger into the large artery, but the hospital assistant in the confusion had lost command of the subclavian, consequently there was great loss of blood before I could secure all the vessels. The boy went away cured in less than three weeks. In this instance one might almost be led to conclude that the blood had literally washed out the gangrene; and in all the cases it might almost be inferred that the blood in its flow washes out impurity from the stump. We must also remember that in removing a leg we take away almost a fourth of the body, which has in most instances had in it more than its share of blood. If we operate brilliantly in a " strong man losing scarcely an ounce of blood," what do we do ? We drive into the dismembered trunk more than its share of blood. What wonder, then, that we have a bounding full pulse, a burning skin, pya3mia, irritative fever, and so on. What wonder is it that we have stagnant, clot-forming blood, and finally, that our patient should succumb. On the other hand, if we turn to our weak patient, we have only his weakness to contend with; that we had before we removed his limb. Probably he had been struggling for months; another month then would be as nothing in the battle, but he would be the gainer as he has the source of irritation removed. The additional quantity of blood thrown upon his system would not be a difficulty, I apprehend, in his case, as the serum would easily find exit by the cellular tissue or natural channels, by osmosis and the accumulation of blood-cells and room. Osmotic matter would only improve his circulatory fluid; should he lose blood, he the more rapidly loses the serum with but a small expenditure of solids, and his stump is well washed out. Of course there are limits to their loss, and that will explain my remark.?" Can be reduced to a mathematical formula." I believe well washing the stump with streams of cold water also renders it more free from contamination and impurity. The use of steel lotions in cases where the patient is emaciated is, I believe, very advantageous. In my case of hip-joint amputation, there was great emaciation ; the excessive fluid was evacuated by various channels, oedema, diarrhoea, profuse micturition ; there wag, I apprehend, only the very excessive prostration to prevent success, but even here the patient lived through twenty days and died from imprudence ; he had gone beyond the point which my hypothetical formula would have determined. I have since making out the accompanying table examined a large number of copies of the Lancet and Medical Times, but without finding many cases in which the points mentioned above are alluded to. Three cases alone are to be added to my list. One of amputation in the upper third of the leg. The man was 60 years old; had suffered from abscess in the diseased limb for twenty months ; the leg was completely disorganized ; there was secondary haemorrhage, with gangrene ol the stump ; the arteries were tied with difficulty, being atheromatous.
(Lancet, 1863,
page 207.) Amputation.?I think of thigh or hip. The and emaciated, the radial pulse very weak ; feeble patient l6oz. of blood were lost at the operation; the pulse did not sink. He lived 14 days and died from carcinomatous disease of the lungs, not from the operation. (Lancet, 1866, Vol. 2, Case II. was
page 3.) Case III. Dr. Fayrer observes, with reference to a fearful case of injury from shark-bite, that the man lost very much blood at the time of the accident, but little during the operation; he died in three quarters of an hour. He bore the operation well. Dr. Fayrer adds?" That it is not necessary to wait long in serious injuries with collapse where imme-
November 1,
A MIRROR OF HOSPITAL PRACTICE.
1873.]
diate amputation is required," which I take to mean that the reduced condition is favorable to recovery. These cases Of course a great deal are very similar to those in the list. of blood is always contained in the removed limb, but not so much as in its natural condition in most instances, and especially where chloroform is given when much more blood remains in the internal organs. (Lancet, 18C8, page 658.) Erichsen says, that " patients who have lost much blood make slow recoveries," and are exposed to the after ''occurrence of pyaemia and low inflammations." But the above facts do not seem to illustrate his remark. I believe every surgeon of large experience has met with numerous cases of recovery after operations upon emaciated patients who have lost much blood, perhaps many more than after very successful and brilliant operations upon sound men. My remarks do not refer to cases of amputation without the The conditions are different. I have no use of chloroform. doubt that if attention were directed to the points briefly alluded to in this paper, many new and interesting facts might be made out. List
taken from the " Medical Gazette" for 1869-70-71.
of Operations
i!
Nature
op
Oper-
Result
ation.
and
Remarks.
OiO
510
Shoulder.
Lost very little blood. Death from pyffimia and osteo-myelitis in four
139
Junction of middle and upper third of thigh. Centre of arm.
Free
-HI
1871
178
1870
Hip-joint.
122
1870
122
1870
third Upper thigh.
of
The Below knee. arm was torn off by the same accident.
days.
haemorrhage. Rapid recovery.
Artery uncoiled after torsion, and bled freely. Recovery. Hardly any blood lost, the man was very intemperate Recovery. It was a dissecting operation. Lost much blood before the operation. Recovered.
Secondary haemorrhage after 13 days. Ligature of popliteal, fem-
oral and covery. man The
ext.
was
throughout.
123
1870
Fore-arm.
477
1871
Part of hand.
1870
Shoulder.
631
1870
Hip.
118
1870
Do.
1870
Do.
iliac arteries. ancemic
Re-
looking
Lost much blood before. Recovery inferred from table. Followed by secy, haemorrhage. Ligature of ulnar and brachial
arteries. Recovery. Boy extremely emaciated, not much loss of blood at operation. Recovery.
448
Ahoo, July 24th, 1873.
Excessively prostrated. Little blood lost. Recovery. Hsemorrhage at, time of accident some time before. Little loss of blood at operation. Died. Pale and emaciated. Pulse weak. Free flow of blood during operation. Secy. haemorrhage after two days ; yet he recovered. Much emaciated and sinking : little blood lost. Recovery.
295
Meywar Bheel Corps. Brahmin, aged 30. when returning to his home from a distant village, was attacked by Meenas, who, he says, shot him By Surgeon
Lalla,
T. H. Hendley,
a
twice. Two balls are reported to have struck him at the outer part of the left thigh, and to have penetrated the limb, shattering the femtir and escaping by a wound on the inner side. He was taken to his home in a cart, and soon after his arrival it was noticed that the lower part of the shaft of the femur protruded through the outer wound. Hot irons were applied in twelve places over or near the seat of the injury ; burnt pilu and neem leaves were alternately applied locally ; and after a few day3 a bamboo splint in addition. After four montns of great suffering he was brought to the Erinpoorah Hospital on May 26th, 1873. When admitted, the patient was fearfully emaciated and feeble, both lower extremities, the abdominal, and chest walls, very oedeinatous; the penis and scrotum also distended to a painful degree. The left leg was shortened and everted, the thigh flattened out so much that the long axis of the limb seemed to be three or four inches outside a line drawn downwards from the anterior superior spinous process of the ilium. The opening through which the bullet entered, was on the outer side of the thigh about four inches below the above-named process; through it the sharp end of the lower part of the femur projected ; this, however, the man's brother returned into the wound with evident pride ; the wound of exit was rather lower down both openings; there on the inner side, pus welled out from where the cautery had been applied, on were numerous scars, The probe discovered the upper and inner part of the thigh. numerous large detached fragments of bone within the outer wound. Excision offered no hope of relief, the man was rapidly giving way; amputation below the hip-joint was impracticable. I therefore determined to perform that operation as 30011 as possible, as it afforded him the only chance of recovery. On June 2nd, at 7 a.m.?The man was placed on the operating table. One hospital assistant administered chloroform, a second pressed his thumbs upon the main artery as it crossed the edge of the pelvis, whilst a dresser feebly attempted to bring pressure to bear upon the abdominal aorta. Lieutenant Rennick kindly aided by holding the limb, and assisting afterwards in tying ligatures. The anterior flap was rapidly formed, but as the head of the bone was isolated from the shaft, and there might have been delay in getting it out from the acetabulum instead of at once forming the posterior flap. I tied the arteries in the upper one ; the capsule was then cut through, and the head of the bone turned out of its socket, though with difficulty, as there was no leverage to aid one; the posterior flap was rapidly The wound was well drenched with cut and the arteries tied. cold water; a solution, of tincture of iron applied, and the edges The hemorrhage was were brought together with silk ligatures. trifling; thanks to the able assitance at hand. "Water-dressing and a light bandage were adapted to the stump, and a little the pulse was not sp. ammon. aromat given to the patient; altered in any way. Upon examining the limb I found that the femur had been almost completely shattered in the upper part; about two inches long, a piece of the shaft in the upper third, there were numerous fragments scattered was quite isolated; of the original wound; the about; a large cavity in the track thigh was infiltrated with pus and serum. For the first much improved, the oedema almost four days the patient's health entirely subsided in the scrotum and trunk, and nothing to call the fourth On morning, the dressings were for alarm occurred. removed, the edges of the wound had healed by first intention in the middle three-fourths, a few small maggots escaped from the lower opening; the stump was washed with lotions of carbolic acid and sulphate of zinc water; sulphate of zinc and carbolic acid dressing were applied locally, and the patient placed on another bed. In the evening fever of an asthenic type set in, which continued throughout the case.?exacerbations coming on generally about twelve o'clock in the day, and ending at 5 or 7 p.m. Carbonate of ammonia and quinine always had a most beneficial effect, when givfen in the intervals ; fever mixtures were useful in the exacerbations. His pulse, on the whole, grew weaker day by day, the left chest wall was cedematous, but this subsided on the 6th June : the abdomen was also distended and painful, relief was speedily obtained by the use of an enema con* taining a little oil, and peppermint water; the oedema in the left limb was reduced by the use of sulphate of iron lotion and
whole'
THE INDIAN MEDICAL GAZETTE.
294
nitrate of silver, coupled with position. A few maggots came away when the wound was dressed, but none were noticed again throughout. On the 7th diarrhoea set in, which, although controlled by gallic acid (and this drng alone), proved troubleOn the 11th two or three small bed-sores were some to the end. seen; these were rendered of little moment by applying spirit and benzoated lotions from the second day. Liebig's extract and brandy were in constant requisition. The high caste of the patient, with the necessity of taking poor food, had been and was against the man from the receipt of his injury until death. On the 12th there was some difficulty in breathing, and pain in swallowing, with occasional vomiting (previously the patient had been sick once or twice); there were, however, no alterations in the chest so much. On the 15th I detected dulness in the right chest posteriorly; there was static congestion of the right lung, due to his enforced position and great weakI tried to remove this source of anxiety by arranging so ness. that he might be more upon the left side, which he could do as the wound was not painful. Three ligatufes came away on this morning (15th). Four more ligatures and most of the sutures were removed on the 19th. Two more on the 20th, and the last, from the femoral artery, on the 21st. The condition of the right lung much improved, but diarrhoea the very much weakened the patient, whose appetite was good to last. There was no cough, and no expectoration ; the man was On the an opium-eater, which would explain this, I apprehend. 22nd, the twentieth day after the operation, at my morning visit, the condition of the patient seemed to have much improved ; his left limb was almost of a natural size; there had been no diarrhoea during the night; the pulse was stronger than it had been for some days, and the man feeling so much better, had, eluding the care of his attendants, ate a most hearty meal, rather to the admiration of his friends, who thought he was now for the first time eating like a person in health. About an hour after I left the hospital, he suddenly fell back, clenched his teeth, refused to say a word?although at first he evidently understood what was going on around him?gradually became weaker and colder, and died at 4 p.m. the same day. Remarks.?I think that in this case it may be fairly considered that the operation did not at all hasten the approach of death. The wound was healing as well as could be desired; the local discomforts, such as oedema, disappeared almost with the removal of the source of irritation; there were various complications: for instance, the chest affection, Which, however, seemed amenable to treatment, and I have no doubt that had the man been more prudent, the diarrhoea and other troubles would have been checked. He had been reduced by months of suffering, without proper food; his blood had therefore become greatly impoverished, so that the sudden exertion of taking food immoderately had caused the dislodgeraent of a clot, which was too much for an already greatly embarrassed circulation to overcome. I do not think the operation had the slightest influence in hastening the end ; the irritation of the new wound was in fact less than that of the old. In cases of amputation near the trunk, I believe, a previously greatly exhausted condition of the patient, or an artificially produced exhaustion, at or near the time of operation, will be greatly in favor of recovery. I believe that there is a point, which might be almost reduced to a mathematical formula, to which a ought to be reduced, if nature have
patient already done the work, to ensure recovery. a table constructed by looking at append discover severe amputation, which I could
not
all the cases of in the Medical Gazettes for 1869-1870 and 1871, and in which the points of want of or presence of haemorrhage during the case or previous emaciation and exhaustion are made out. From this it will be seen that in 13 cases there were two deaths only; there were six cases of amputation at the hip with one death, and two at the shoulder with one death. In the first case of death little blood was lost at the operation, although there had been some haemorrhage ; in the second, very little blood was lost. Death resulted from pyaemia and osteo myelitis in four days. In 10 of the successful cases there was either profuse haemorrhage at the operation, or immediately before or after, or excessive exhaustion and emaciation. In several cases there was reported secondary haemorrhage; and in the thirteenth case the man had been exceedingly intemperate and had much weakened his constitution. At Jodhpore I had a C2se of amputation, at the upper third of the thigh, in which there was profuse haemorrhage, as my assistants became confused, and there were about thirty arteries to tie. In a case of fungus disease of the foot in which I amputated the leg, there was profuse I
liaemorrhago,
many
ligatures having been applied
as
the whole
surface seemed
one
artery.
[November 1, In both
cases
1873.
the limbs had been
kept up, and the main artery was well commanded by the tourniquet. In the latter case the patient was much emaciated, having lost large quantities of pus for two years. Both cases rapidly recovered. But the most instructive case was one of amputation very near the shoulder-joint. A boy, aged nine years, was brought in from a village one hundred miles from Jodhpore ; he was ten days on the journey. When admitted, his fore-arm and lower upper arm were seen rotting in a tile, the
ulna and radius were white and separated from as white a humerus. The limb to witbin four inches of the axilla was completely gangrenous, pulpy, and extremely fetid. It was so rotten that the tile had to be removed with the limb ; there was no line of demarcation. I amputated two inches above the gangrenous mass, everything had been prepared for the operation, and although no tourniquet could be applied, the subclavian artery was pressed upon, enough to prevent all pulsation in the axillary vessel. When I had removed the limb I found that an officious dresser had actually taken away all the artery forceps and locked them up in a chest. I pushed my Snger into the large artery, but the hospital assistant in the confusion had lost command of the subclavian, consequently there was great loss of blood before I could secure all the vessels. The boy went away cured in less than three weeks. In this instance one might almost be led to conclude that the blood had literally washed out the gangrene; and in all the cases it might almost be inferred that the blood in its flow washes out impurity from the stump. We must also remember that in removing a leg we take away almost a fourth of the body, which has in most instances had in it more than its share of blood. If we operate brilliantly in a " strong man losing scarcely an ounce of blood," what do we do ? We drive into the dismembered trunk more than its share of blood. What wonder, then, that we have a bounding full pulse, a burning skin, pya3mia, irritative fever, and so on. What wonder is it that we have stagnant, clot-forming blood, and finally, that our patient should succumb. On the other hand, if we turn to our weak patient, we have only his weakness to contend with; that we had before we removed his limb. Probably he had been struggling for months; another month then would be as nothing in the battle, but he would be the gainer as he has the source of irritation removed. The additional quantity of blood thrown upon his system would not be a difficulty, I apprehend, in his case, as the serum would easily find exit by the cellular tissue or natural channels, by osmosis and the accumulation of blood-cells and room. Osmotic matter would only improve his circulatory fluid; should he lose blood, he the more rapidly loses the serum with but a small expenditure of solids, and his stump is well washed out. Of course there are limits to their loss, and that will explain my remark.?" Can be reduced to a mathematical formula." I believe well washing the stump with streams of cold water also renders it more free from contamination and impurity. The use of steel lotions in cases where the patient is emaciated is, I believe, very advantageous. In my case of hip-joint amputation, there was great emaciation ; the excessive fluid was evacuated by various channels, oedema, diarrhoea, profuse micturition ; there wag, I apprehend, only the very excessive prostration to prevent success, but even here the patient lived through twenty days and died from imprudence ; he had gone beyond the point which my hypothetical formula would have determined. I have since making out the accompanying table examined a large number of copies of the Lancet and Medical Times, but without finding many cases in which the points mentioned above are alluded to. Three cases alone are to be added to my list. One of amputation in the upper third of the leg. The man was 60 years old; had suffered from abscess in the diseased limb for twenty months ; the leg was completely disorganized ; there was secondary haemorrhage, with gangrene ol the stump ; the arteries were tied with difficulty, being atheromatous.
(Lancet, 1863,
page 207.) Amputation.?I think of thigh or hip. The and emaciated, the radial pulse very weak ; feeble patient l6oz. of blood were lost at the operation; the pulse did not sink. He lived 14 days and died from carcinomatous disease of the lungs, not from the operation. (Lancet, 1866, Vol. 2, Case II. was
page 3.) Case III. Dr. Fayrer observes, with reference to a fearful case of injury from shark-bite, that the man lost very much blood at the time of the accident, but little during the operation; he died in three quarters of an hour. He bore the operation well. Dr. Fayrer adds?" That it is not necessary to wait long in serious injuries with collapse where imme-
November 1,
A MIRROR OF HOSPITAL PRACTICE.
1873.]
diate amputation is required," which I take to mean that the reduced condition is favorable to recovery. These cases Of course a great deal are very similar to those in the list. of blood is always contained in the removed limb, but not so much as in its natural condition in most instances, and especially where chloroform is given when much more blood remains in the internal organs. (Lancet, 18C8, page 658.) Erichsen says, that " patients who have lost much blood make slow recoveries," and are exposed to the after ''occurrence of pyaemia and low inflammations." But the above facts do not seem to illustrate his remark. I believe every surgeon of large experience has met with numerous cases of recovery after operations upon emaciated patients who have lost much blood, perhaps many more than after very successful and brilliant operations upon sound men. My remarks do not refer to cases of amputation without the The conditions are different. I have no use of chloroform. doubt that if attention were directed to the points briefly alluded to in this paper, many new and interesting facts might be made out. List
taken from the " Medical Gazette" for 1869-70-71.
of Operations
i!
Nature
op
Oper-
Result
ation.
and
Remarks.
OiO
510
Shoulder.
Lost very little blood. Death from pyffimia and osteo-myelitis in four
139
Junction of middle and upper third of thigh. Centre of arm.
Free
-HI
1871
178
1870
Hip-joint.
122
1870
122
1870
third Upper thigh.
of
The Below knee. arm was torn off by the same accident.
days.
haemorrhage. Rapid recovery.
Artery uncoiled after torsion, and bled freely. Recovery. Hardly any blood lost, the man was very intemperate Recovery. It was a dissecting operation. Lost much blood before the operation. Recovered.
Secondary haemorrhage after 13 days. Ligature of popliteal, fem-
oral and covery. man The
ext.
was
throughout.
123
1870
Fore-arm.
477
1871
Part of hand.
1870
Shoulder.
631
1870
Hip.
118
1870
Do.
1870
Do.
iliac arteries. ancemic
Re-
looking
Lost much blood before. Recovery inferred from table. Followed by secy, haemorrhage. Ligature of ulnar and brachial
arteries. Recovery. Boy extremely emaciated, not much loss of blood at operation. Recovery.
448
Ahoo, July 24th, 1873.
Excessively prostrated. Little blood lost. Recovery. Hsemorrhage at, time of accident some time before. Little loss of blood at operation. Died. Pale and emaciated. Pulse weak. Free flow of blood during operation. Secy. haemorrhage after two days ; yet he recovered. Much emaciated and sinking : little blood lost. Recovery.
295
