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.
[2] The India Company have supplied the principal hospital of each presidency with one good microscope at least; one of these, with a person who understands its use, should be attached (but is not) to the principal hospitals during the present war in the East.
64. In the irritable and sloughing state of stump alluded to, hemorrhages frequently take place from the small branches, or from the main trunks of the arteries, in consequence of ulceration; and it is not always easy to discover the bleeding vessel, or, when discovered, to secure it on the face of the stump; for as the ulcerative process has not ceased, and the end of the artery which is to be secured is not sound, no healthy action can take place; the ligature very soon cuts its way through, and the hemorrhage returns as violently as before, or some other branch gives way; and under this succession of ligatures and hemorrhages the patient dies.