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.