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.