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ON THE RESULTS AND TREATMENT OF THE CASES OF AMPUTATION PERFORMED AT THE CORK NORTH INFIRMARY.
720 possesses
an
affinity
for chlorine.
The discoverer of this
substance, Dulong, paid dearly for his discovery, with the loss of
one eye and of three fingers of his left hand. Dulong, on saturating a solution of ammonia with chlorine, obtained an unknown oily fluid mixed with water; he proceeded to separate this fluid from the water by means of a moistened filter. Moist paper is not pervious tooil; a mixture of oil and water may, therefore, be separated by means of a moistened filter; the water iiows
filter whilst the oil remains upon it. The very moment when the oil which Dulong had obtained came into contact with the filter, a fearful explosion took place, and mutilated him in the manner I have stated.
through the
with three obtain three atoms of hydrochloric acid, which, with three atoms of ammonia,. form sal ammoniac ; there remains sulphuret of nitrogen, containing, to one equivalent of nitrogen, three equivalents of sulphur and two atoms of free ammonia. The sulphuret of nitrogen formed in this manner must speedily be separated from the fluid, because it decomposes with exceeding rapidity in contact with water, and forms, with the free ammonia, hvDosulohlte of ammonia. One
equivalent of
atoms of chloride of
ammonia
sulphur;
decomposes
we
Notwithstanding this, he subsequently examined and analysed the new compound. With iodine, ammonia Sulphuret of nitrogen, when heated, decomposes with produces a similar compound. All these nitrogen com- feeble detonation. pounds are decomposed with amazing facility. I must here still mention the capacity of ammonia It is very remarkable that phosphorus forms with nitro- for entering into combination with a number of chlorides, gen a compound possessing quite diflerent properties. and also with oxygen salts, forming compounds of which This compound was first observed by Davy, and after- we have no more definite notion than that the ammonia wards investigated by H. Rose. It is produced by satuperforms in them the same part as the water of crystalrating protochloride of phosphorus (P Cl 3,a compound lisation in the salts which crystallise with water. corresponding to phosphorous acid) with ammonia. It Chloride of calcium absorbs four equivalents of amabsorbs five equivalents of ammonia ; a dry, white powder monia, in a dry state. This property of the chloride of is obtained which has the following compositioncalcium has already given rise to many errors. You see from this, for instance, why ammoniacal gas cannot be and which, upon being heated to redness, yields phospho- dried by means of chloride of calcium, for this substance rus, sal ammoniac, and water, whilst phosphuret of nitro- absorbs ammonia as readily as it absorbs aqueous gen, P N2, remains in the form of a snowy-white powder. vapour-one hundred parts of dry chloride of calcium This phosphuret of nitrogen may be heated to white- absorb one hundred and nineteen parts of dry ammonia. ness, in close vessels, without undergoing any alteration; Chloride ot’ silver possesses the same property-one it is, moreover, incombustible to a high degree ; it may hundred parts of chloride of silver absorb seventeen be exposed to a red heat for hours, with free access of air, parts of ammonia. Faraday has taught us to obtain without change. Alkalies and acids do not alter it, but ammonia in a fluid state from this compound. For this in contact with metallic oxides, especially with oxide of purpose dry chloride of silver saturated with ammonia is mercury, it becomes readily oxidised. If a wide glass introduced into a double-limbed tube, and the latter then tube be filled with large pieces of sal ammoniac, and the closed by fusion ; the one limb is then heated and the latter be then heated to evaporation and the vapour of other cooled ; the ammonia which escapes from the one protochloride of phosphorus transmitted through the limb collects and condenses into a clear fluid in the tube, pure phosphuret of nitrogen will likewise be ob- other. tained. You have, in these instances, protochloride of One hundred parts of protosulphate of manganese phosphorus, P Cl3 ; imagine, added to this, one equiva- absorb forty-three parts of ammonia ; one hundred parts lent of ammonia, N H3, and you have hydrogen and of sulphate of zinc absorb fifty-one parts of ammonia. chlorine in the same proportion as in hydrochloric acid ; That the ammonia performs the part of water of you hpve, further, one equivalent of nitrogen and one crystallisation in many of these compounds, seems to be equivalent of phosphorus; the result, therefore, ought to confirmed by its deportment with the salts of copper. be hydrochloric acid and phosphuret of nitrogen, P N ;; Salts of copper are blue, but most of them only when in but the phosphuret of nitrogen produced has not the a state of crystallisation and containing water. Sulphate formula P N, but the formula P N2, thus containing, to of copper, from which the crystallisation-water has been one atom of phosphorus, double the quantity of nitrogen expelled, is perfectly white. If this latter salt is satuit could obtain by this mutual decomposition ; in this rated with dry ammoniacal gas, it assumes the same blue decomposition, therefore, the one half of the phos- colour as it would were water added instead of ammonia ; it absorbs one equivalent of ammonia. phorus is liberated. Ammonia enters, likewise, into combination with perchloride of phosphorus, forming a compound which has ON THE not yet been minutely examined. If perchloride of RESULTS AND TREATMENT phosphorus is saturated with ammonia, then drenched OF THE with water, and the mixture subjected to distillation, a volatile camphor-like substance passes over, which contains chlorine, phosphorus, and nitrogen. Sulphuret of nitrogen was obtained in a similar manner, a few years since, by Soubeiran. This chemist found that if sulphur is completely saturated with chlorine, chloride of sulphur is obtained, Cl S, corresponding to hyposulphurous acid. This chloride of sulphur combines with ammonia, and this in such a manner that one equivalent of chloride of sulphur absorbs two fBf1nivalents of ammonm.
The ammonia must be perfectly dry, and must he transmitted through the chloride of sulphur gradually, so that the mass does not become heated ; a yellow greenish powder is obtained. If water be poured upon this, a yellow powder i.3 formed, cOllsistil1g of sulphuret of nitrogen, S3 N, and water, Eal ammoniac, and free ammonia, are obtained.
CASES OF AMPUTATION PERFORMED AT THE CORK NORTH INFIRMARY. (Read before the Cork Medical Society.) By D. B. BULLEN, M.D., one of the Surgeons of the Cork North
Infirmary.
THERE are several circumstances connected with the modes of performing amputations upon which practical surgeons entertain opposite opinions, and fixed rules are still wanted to determine the selection of particular operations for special cases. Some surgeons warmly advocate flap operations, while others advance strong
arguments in favour of the circular amputation. Again, operators of eminence are reluctant to amputate in
some
joints, and others select joints for effecting the separation of the limb whenever it can be done. The conclusion may, therefore, be drawn from this diversity of opinions, that each plan of operating has merit in certain cases, while it may not be eligible in others, and we should fairly weigh the advantages and disadvantages of each mode of amputating in order to arrive at some grounds upon which to make a preference,-when to the
721 the flap operation and when the circular,-what may safely be made the point of separation, and which- are those that ought to be avoided. For pursuing such an inquiry accurate statistical information is much wanted, not only with regard to the manner in which the several operations are executed, but also in showing the principles upon which the subsequent treatment is conducted. When we consider the extraordinary mortality which follows the amputations in the French hospitals, we must admit something radically wrong in their practice; and the difference which prevails between the results of surgical operations in several British hospitals is sufficiently startling to demand investigation. However, the successful issue of operations must depend upon many circumstances connected with the physical and moral condition of the local population over which the In this part of the surgeon can have no control. country the poorer classes bear severe operations extremely well. Their strong religious feeling gives them that passive courage which does not fear death, and the vegetable diet upon which the greater numbers live renders them less liable to subsequent inflammation. The following table gives the results of fifty-eight cases of amputation performed in the North Infirmary, by my colleague, Dr. Howe, and myself.
adopt joints
The removal of the leg below the knee by the circular amputation is generally a safe and good operation in primary cases, and where the integuments are vascular and healthy. When, however, the subject is feeble and
emaciated, with the circulation
in the cutaneous vessels there is reason to apprehend that separating a sufficient extent of skin to cover in the extremities of the divided bones may destroy the vitality of the part, and sloughing be the consequence. In such cases, operating with the posterior flap presents decided advantages. Primary amputations do not heal as rapidly as operations performed upon persons who have been some time in hospital; and if the stump of the leg, made with a flap, The case of goes wrong, it is very hard to manage. Daniel Mahony was one of this description. He was a labourer, forty years of age, and was brought into the infirmary with compound fracture of the ankle-joint. The bones were crushed and the flesh of the leg extensively lacerated by a heavily-laden cart having gone over it. The injury was of such a nature as to leave no hope of saving the limb, and amputation was proposed. The patient at first refused his consent, but at the end of sixty-four hours he solicited the performance of the operation. Inflammation had then commenced. The limb was considerably swollen, and severe irritative fever had set in. Anxious to give the poor man a chance for his life, I consented to remove the limb, and being much pleased with the results of the flap operations I had performed, I determined, contrary to my conviction, to operate in the same manner in this case. Although this
languid,
of a spare habit of body, his leg was rather and I therefore tried, in making the flap, to cut out and remove a good deal of the great posterior muscles, so as to avoid too fleshy a flap. On cutting through the muscles they did not retract, but yielded before the knife. When the flap was brought over the ends of the bones, the divided edges of the muscles protruded beyond the integuments and forced their way out between the uniting sutures. Union did not take place in this case. On the third day the stump put on a gangrenous appearance, and on the eleventh day after the operation he died. This was the first death after amputation in twenty consecutive cases. The life of this man would very probably have been saved had he consented to the operation when it was first proposed to him. In amputations of the thigh the same rule appears to hold good as in amputations below the knee, that we should be guided by the muscularity of the limb. In doing the flap operations upon the lower third of the thigh, the external flap should be made first, because if the internal flap is made first, the strong fascia which sheaths the outer part of the thigh makes it very difficult to carry the knife fairly round the bone so as to transfix the limb in the angles of the cut before dividing the parts. There is one objection against this operation, which is, that the great vessels are cut obliquely, and if caution is not used in securing them, as soon as reaction takes place arterial haemorrhage may occur. Another precaution which ought to be attended to is to dissect the bone freely from the surrounding parts, so as to saw it well above the angles of the flaps, for though the flaps may be cut very large, the bone will be apt to protrude at the external angle of the wound even after the lapse of several days, and after considerable union has taken place. The sharp edge of the femur easily makes its way through the recently formed cicatrix, and keeps up a troublesome sore until a circle of bone exfoliates, and is thrown off. When amputating the arm above the elbow and below the lower third, the circular operation seems preferable ; at least it is the one I have always performed, and the cases turned out well. The brachial artery lies so superficially and is in such close contact with the bone that it is not easy to cut flaps so as to leave the vessel sufficiently imbedded in the surrounding parts. The same objection holds good with regard to the position of the great nerves. If the flaps are cut posteriorly and anteriorly the artery and nerves will be in the internal angle, and there is great risk of transfixing them in passing the knife through the limb. On the other hand, in making lateral flaps, the knife must cut its way for a considerable space between the bone and the artery and nerves, with the danger of wounding the vessel when transfixing the limb, at a point much higher up than where it is cut across. When it is necessary to amputate in the upper third of the arm, above the insertion of the deltoid muscle, it is better to operate at the articulation and remove the head of the bone, The operation is much easier and avoids some very difficult complications. If the arm is to be removed so high up as not to allow the use of a tourniquet, nor pressure upon the artery in the axilla, in order to command the bleeding, the operator must depend upon an assistant to press on the subclavian artery either under the clavicle or at the place where it emerges from between the scaleni muscles above the middle part of the clavicle. Continued pressure above the clavicle to stop the pulsation of the artery becomes so intensely painful that if the patient is a strong person his struggles displace the compression, and when the operator proceeds to secure the vessel the blood dashes in his face. The artery retracts into the loose cellular tissue of the axilla amongst the great axillary nerves, and there is great difficulty in seizing it. In the case of John Barry, a very powerful man, whose arm was amputated at the infirmary very high up, the artery retracted into the axilla, and every effort to check the bleeding by pressure above the clavicle was unavailing. By a vigorous plunge deep into the axilla the mouth of the bleeding vessel was grasped between the two thumbs of the operator, but the loss of blood was very formidable before it could be secured. So far from any advantage being gained by leaving the head of the bone it may give rise to man was
fleshy,
722
d<
Names.
c:I
0
Grant....
Disease of ankle ...... Caries of foot ......... Gangrene of foot ...... Gangrene of foot...... Compound fracture ....
6 John Vivian......
Frostbitten in both feet.
7Patrick
Scannell.... Leary....
Necrosis of leg ........ Caries of foot......... Compound fracture ....
10 Thomas Drew .....
Disease of bones of leg..
11 John Reily....... 12 David Cremin...... 13 James Donovan...... Anne Robertson.. 15 John Barry .......
Compound fracture
8
Peggy
Fitzgerald .
9 Patrick
14 g18
o 16 17
Mary Murphy .... Margaret Burke.. David
Crowly
19 Daniel
CL.
20
21 22 24 25
...
Cornelius Connor..
Hymes.... Leary..
2826
Timothy Callaghan L29 John Leahy...... I Hallisy 1 2denims Mary Driscoll ....
..
3 John
Daly........
j 4 Mary Ryan....... 5 Cornelius Deloury .
.
Williams.... 6Eliza 7 Daniel Flynn...... 8 John Sullivan .... 9 John Scanlon .... 10 John Delany ......
w
11 William
:3s7-
I
ll
12 13 14 15 16 17
18L19
.... Scrof. disease of ankle.. Caries of foot.......... Gangrene of foot...... Disease of ankle ...... Compound fracture .... Humid gangrene ...... Caries of foot ........
Morgan..
NomyMeade...... John Brian........ Maurice Fitzgerald Catharine Long.... Andrew Courtney.. John Burns ......
Richard
Shephard.
Edward Land ....
Donovan .
Murphy .... g..0::<( 1Timothy L Barry ...... .
2 James 3 John
1 William Leahy.... Coffee ...... 3 John Long........ 4 Michael Desmond. 5 Daniel Connell.... 6 6 Florence Neale....
y i 2 Denis oi
Shoulder-joint.
Owen Cline
Total 58.
Remarks.
Complications or consequences causing death.
Partial amputation of the second foot............
since ) secondin leg South tated
ampu-
Infirmary
< SubsequentuponChopart’s operation .............. S Refused
Mahony....
James Daniel Murphy... 23 Patrick Brian..... Cornelius Eliza Driscoll..... Ellen Cashman.... 27 Judith Regan.....
]
injury requiring amputation. or
2 Denis Mary Clifford.... 3 David Farrell...... .. 45 PatrickMurphy Brian.....
1 Stephen
*
K
Disease
to allow
operation
for four days .......... Exostosis of tibia...... Compound fracture .... Gangrene of foot ...... Compound fracture .... Diseased ankle ........ Compound fracture .... Compound fracture .... Gangrene of foot ...... Compound fracture ..;.
Compound fracture
....
Compound fracture
....
Subsequent upon typhus.... Effusion
White White
swelling ........ swelling ........ Gangrene White swelling ........ Necrosis of leg........ Comp. fracture of knee White swelling........ Necrosis of bones of leg. White swelling ........ ............
fracture of knee..........
Compound the
White swelling ........ White swelling........ Scrofulous disease of leg White swelling ........ Compound fracture .... Diseased knee ........ Compound fracture of the knee..........
)
Compound
fracture ....
on
the
lungs after
the stump had healed....
The
became stumpnates
grenous
Happened at sea
before.
Sunk
haustion
gan-
sloughed
two
days
from ex-
..............
Accident at sea fifteen days
before .................
survived the inj ury ninetyfive days ..............
Compound fracture.... Compound fracture.... Sabre-wound of elbow..
Compound fracture .... Compound fracture .... Compound fracture .... Compound fracture .... Scrof. disease of hand.. Compound fracture ....
Diseased
os
brachii
....
........
723 much inconvenience. Some months ago a man applied to me at the infirmary, whose arm had been amputated at St. Sebastian, during the late civil war in Spain. He complained of being frequently attacked with sudden and violent paroxysms of pain in the side of the breast and parts adjoining the axilla, which at times were so severe as to produce nausea and faintishness. The arm had been removed very close to the head of the os brachii, above the insertion of the deltoid muscle, and below the insertion of the pectoralis major and latissimus dorsi. The wound was perfectly cicatrised, and there was no heat, redness, nor appearance of inflammation in the surrounding parts. On examination it appeared that whenever he made any unusual exertion of the thoracic muscles, the pectoralis and latissimus dorsi being attached to the short portion of the os brachii, and not having any antagonists, were thrown into spasmodic action, and, turning the extremity of the bone directly towards the body, dragged it with great force against the axillary plexus. The agony he endured obliged him to request me to cut out the head of the bone. Before consenting to do this, I wished to try what could be done by applying a compress in the axilla, and, by means of bandaging, to keep the end of the bone turned from the body. After some days he said he felt a good deal relieved by the treatment, and has not applied since at the infirmary. If, however, he should again complain of a recurrence of his sufferings I shall disarticulate the head of the bone. Amputation at the shoulder-joint is not only a safe operation, but one very easy of accomplishment. Owen Clive is an East Indian pensioner, and served in the Burmese war. Having been attacked with the intermittent fever of the country he was confined for a long time in the hospital at Rangoon. Being discharged an invalid he returned to this country, and for several years has struggled under the effects of a shattered constitution. He was received into the North Infirmary for extensive erysipelas phlegmonodes of the lower extremities. An abscess formed beneath the fascia of the right thigh, which contained the largest quantity of matter I ever saw discharged from the body of a living person. His recovery was very protracted, and he left the infirmary in a state of great debility. Some weeks after he applied again for admission, having fallen when walking across the room, and broken the os humeri at the upper third. Erysipelatous inflammation immediately attacked the broken limb, and suppuration formed between the muscles and along the fractured bone. After extensive incisions down the arm the abscesses healed, but no union took place in the extremities of the broken bone. He was sent into the country with the hope that improvement of his general health may bring about consolidation of the fracture. After undergoing much suffering he returned again to the hospital, with abscesses extending from the shoulder to the extremities of the fingers, and the os brachii still disunited. At his own request I proceeded to remove the limb, and were the aspect of a patient to be taken as a guide in determining upon operation no prospect could be more disheartening on account of his wretched and emaciated appearance when placed upon the table. The humerus being diseased throughout its whole extent there was no option but to disarticulate the bone. The operation was performed in accordance with the instructions of my old preceptor, M. Lisfranc, and the patient did not lose six ounces of blood. The wound healed rapidly, and at the end of one month he was able to take exercise in the open air. This man has enjoyed very good health since the operation. It is important, in wounds of the hand, to save every portion of the member that we can, as the parts that remain may be brought after a time to do very useful service. To preserve even one finger and the thumb is an object for which it is worth risking a good deal. Where the integuments are lacerated we should not cut them away, for portions of flesh, which, at a first examination, may appear to be quite destroyed, often preserve a considerable degree of vitality, and after having sloughed to a certain extent granulate kindly, and afford a good covering to the subjacent bones. Even when the wristjoint is torn open, and parts of the bones which form it carried away, the hand may be saved by judicious treat-
Mr. B., a young gentleman from the neighbourhood of Dublin, was on a visit at the house of a clergyman some miles from this city. Having returned in the evening from shooting, he stood close before a large kitchen fire leaning with the left hand on the muzzle of his gun, which was loaded and the hammer down. The heat of the fire, exploded the detonating cap and the whole charge of the gun, which was rather heavy shot, passed right through the carpus. The shot entered close to the head of the ulna, and, taking an oblique direction outwards and a little forwards, carried away large portions of the carpal bones and the heads of the metacarpal bones of the little, ring, and middle fingers. Some grains of shot struck the eyebrow, and lodged beneath the skin of the forehead. The flexor and extensor tendons of the little and ringfingers were quite destroyed, but the power of moving the other fingers remained. The wound was completely charred by the explosion of the gunpowder, and although the ulnar branch of the palmar arch must have been divided there was no haemorrhage. The hand was laid upon a large splint, and treated with cold water dressings. For ten days there was scarcely any pain or inflammation, but when the eschar began to be detached matter formed about the wrist and along the fascia of the forearm. A large incision was made along the radius, and keeping the wound open drained the hand. At the end of a few weeks this gentleman was able to return to Dublin. Since then the exfoliation of parts of the carpal bones has given rise to fresh suppuration, but on the removal of the detached pieces the abscess healed, and he has regained in a great degree the use of the hand. A man was brought into the infirmary last summer with the left hand shattered by the explosion of a blunderbuss. The middle, fourth, and little fingers, with the corresponding metacarpal bones, were torn away, large portions of the carpal bones were destroyed, the wristjoint opened, and head of the ulna fractured. Every part of the hand, except the forefinger and thumb, were removed, and the broken head of the ulna taken out. The wound was treated by water dressings, and when matter formed underneath the fascia of the forearm free vent was given to it by proper incisions. The arm was saved, and this man finds the one finger and thumb very useful members. In amputating the phalanges of the fingers there is a circumstance which is sometimes overlooked, and subsequently gives rise to a good deal of trouble. The tendons of the extensors of the fingers are attached to the dorsum of the third phalanx, while the tendons of the flexors pass in a sheath upon the inferior surface of the third phalanx, and are inserted into the inferior surface of the first and second phalanx. If the removal is effected either at the point of the third and second phalanges, or in the middle of the third phalanx, the flexor tendon retracts into the sheath, beneath the palmar fascia, and leaves the stump without any power of flexion. Now, the extensor tendon being attached to the dorsum of the bone, the extensor muscle is left without an antagonist, and the little stump is dragged upwards and backwards. If you hold up the middle or third finger, and prevent it from bending, you will find it impossible to shut the other fingers of the hand. The same action takes place when the third phalanx, or part of it, is left, and the power of closing the hand is lost. In two cases I was obliged to remove the stumps at the of the third phalanx, with the metacarpal articulation after amputation, had been performed by otherpersons in the middle of the third phalanx. , Much of the success of modern operations is due to the use of small ligatures in securing the blood-vessels, and the very simple manner in which the wounds are dressed. Alanson’s 11 Practical Observations on Amputation" were published in 1782, and dressing to effect union by the first intention soon became the general practice of the surgeons of these countries. The cure, however, was greatly retarded by the large flat ligatures, the use of which were still retained. In 1800 my father amputated the thigh of Mr. Meany, an eminent tea-merchant of this city, in the presence of the right Rev. Dr. Murphy, our present Roman Catholic Bishop, his brother, Mr. N. Murphy, and Dr. Gibbins. He tied the arteries with ment.
bone,
724 I
small single silk threads, cutting short one end of them.The Union by the first intention was so rapid in this case that the
tourniquet, by causing venous congestion, increases flowing of blood, and even the compression of a the gentleman was able to be removed into the open air bandage brings on a recurrence of venous bleeding for on the eleventh day after the operation. Soon after he hours after the operation. On carefully examining the adopted the same practice in an amputation performed condition of the limb the muscles are found to be purple, above the knee upon Mr. Ross, brother to the distributor isoft, and do not retract, and the integuments are flabby, of stamps, and on Mr. Quill, brother to the celebrated and inclined to a bluish colour. There is a manifest Maurice Quill, of facetious memory. Recovery in each atony in the parts, a deficiency of the vital energy, which of these cases was equally rapid. It is a pity for the is requisite to set up and carry on the reparative action, fame of the surgery of the south of Ireland that my father did not publish the results of his cases at the time, for Dr. Hennen, in his work, ascribes the credit of this improvement to Mr. James Veitch, a naval surgeon, in April, 1806, published some valuable precepts relative to the mode of tying the arteries in amputation. Mr. Cooper, in his 11 Surgical Dictionary," also says, " Mr. Veitch, however, seems to merit the honour of having been perhaps the first to set the example of tying every vessel, the femoral, as well as the smaller arteries, with a single silk tlaread, taking care to include, as far as was possible, nothing but the artery ; and when this had been done he took off one half of each ligature, as near as possible to the knot, so that the foreign matter introduced was a mere trifle compared to what I had been accustomed to see." In dressing and treating stumps with a view to obtaining union by the first intention the great object is to avert inflammation. When inflammatory action sets in, and the parts become painful, hot, and swollen, union does not take place, and if adhesion has taken place during the first two or three days subsequent to the operation, as soon as the parts become inflamed the adhesions break up and the stump becomes a large suppurating sore. The chief aim, therefore, in making up a limb after amputation is to remove every source of irritation, and to guard against any circumstance likely to interfere with the quiet process of reparation. To effect this, after the bleeding has entirely ceased, and the parts have been brought into contact, a sufficient and well-regulated support must be given to the stump to prevent the tendency to sudden and convulsive startings, which cause great suffering, and sometimes burst open the newly-formed adhesions. Some surgeons are favourable to the use of sutures for keeping the edges of the wound together, while others think that they act as causes of irritation, and give rise to suppuration. It is not well to depend upon sutures alone when extensive surfaces are to be
who,
held in position, but a few, judiciously placed, give great steadiness and prevent the opposite surfaces of the stump from gaping when it is placed upon the pillow. Besides the sutures some adhesive straps should be applied, but the whole face of the stump should not be bound down by bands of sticking-plaster. The continued constriction of adhesive plaster too freely and carelessly put on causes a great deal of pain, and in amputations below the knee, and of the forearm especially, by compressing the integuments against the surfaces of the divided bones, brings on ulceration of the covering of the stump and protrusion of the bones-a strip of lint over the face of the stump and a light bandage are all that is requisite. From the time the patient is placed in bed the dressing should be kept wet by the continuous irrigation of cold water over the limb. This is very soothing and keeps in check the tendency to increased vascular action ; besides, by keeping the dressings constantly moist, when the time comes for changing them, which should not be before the sixth day, unless the smell of the wound should have become offensive, they can be easily removed without tearing asunder the slight and newly-formed adhesions. Although it is the general practice of British surgeons, in the treatment of all incised wounds, to bring the edges of the wound together, so that they may unite by the first intention, yet some cases occasionally present themselves which require a different mode of proceeding. In operating upon old subjects, in which the lower extremity has been for a long time the seat of chronic inflammation, we sometimes find the veins of the leg enormously enlarged and varicose, and the arteries few and much diminished in size. When the limb is removed the venous hsemorrhage is profuse and difficult to check.
of which a sound union can be effected. From the moment of operating the torpid and relaxed state of the blood-vessels demand stimulation. The first object is to arrest the haemorrhage; for that purpose the tourniquet, and whatever may cause pressure upon the limb, should be immediately removed, the thigh bent upon the pelvis, so that the stump may be thrown up, and kept in a perpendicular position, and a stream of cold water should be poured from a height over the face of the stump. These means generally check the more profuse discharge of blood, but a venous oozing continues, which is increased by closing up the wound, and putting on a bandage. Should they fail, however, dossils of lint, dipped in a hot saturated solution of alum, applied to the bleeding surface, and leaving the limb exposed in a current of cool air, will generally succeed. It is useless to attempt to obtain union by the first intention in cases of this description; for, if after some hours, when the danger of haemorrhage has ceased, the edges of the wound are brought together, and the usual dressings applied, it generally happens that at the end of three or four days the stump becomes gangrenous. Gangrene following amputation, in old and enfeebled constitutions, is generally fatal, and we should, therefore, endeavour to avert it by the immediate use of proper local stimulants, and by sustaining the constitutional powers with an invigorating course of treatment. Pressing the surface of the stump with pledgets of lint, dipped in warm elemi ointment and turpentine, soon excites healthy suppuration, and an abundant growth of florid granulations, together with the steady use of opium, carbonate of ammonia, wine, and nutritious broths. The successful result of amputations, like most other surgical operations, depends more upon the medical management afterwards than upon any mechanical dexterity in their performance. The pain and excitement of the operation, accompanied by the sudden loss of blood, is followed by a degree of constitutional disturbance, which is more dangerous to persons who have been heretofore healthy than to those who have long suffered under some painful disorder, and who have been suddenly relieved from a previous source of irritation. Hence primary amputations, performed immediately after recent injuries, are more often fatal than the removal of limbs for chronic and long-continued local diseases. But secondary amputations, in cases of extensive injuries, are more fatal than primary, because they are generally done during the existence of irritative fever, and when the powers of the system have been impaired by the shock consequent upon the injury. The hectic fever which results from suppuration in joints, or from diseased bones, does not contra-indicate operation ; on the contrary, upon the removal of the cause of the constitutional irritation, the return to health is often surprisingly rapid. But in determining the propriety of amputating in the secondary stage of extensive injuries, we must be guided by the extent to which inflammation spread along the limb and disorganised the tissues, and by the nature and degree of the irritative fever. There are two dangers to be apprehended and guarded against after operation. The failure or loss of constitutional power to bear up against the shock, and the reaction consequent upon rallying, which may lead to a state of dangerous excitement, ending in active inflammation. Immediately after the patient has been placed in bed a large opiate should be given and repeated in proper doses at regular intervals. And here it may be observed, that where the stimulating and cordial influence of opium is required laudanum and crude opium are the forms most to be relied on. Some of the salts of morphia, and particularly the acetate, when given in large doses, produce so much depression and collapse,
by means
has
725 that it is hazardous to give them in cases where we have to contend with symptoms of great exhaustion. When reaction has fairly set in, the tongue become foul and dry, skin hot, and pulse quick, we must then deal with the case as one of irritative fever. A mild mercurial given at bedtime, followed by an aperient draught in the morning, and the regulated exhibition of some opiate, combined with tartarised antimony, as the circumstances may require. The diet, for the first few days, should be nutritious though not stimulating, and unless there be strong reasons to the contrary, more generous aliment should be given early, for after severe losses of blood withholding animal food often induces an irritability of the system which disposes strongly to inflammatory action.
comparatively small if the patient has jn[.;t made water, although, as she cannot completely empty the bladder, the tumour will not entirely disappear; but any
PRACTICAL FACTS AND OBSERVATIONS ON DISEASES OF WOMEN, AND SOME
SUBJECTS CONNECTED WITH MIDWIFERY. By G. OAKLEY HEMING, M.D., F.L.S., PhysicianAccoucheur to St. Pancras Infirmary and to the Western Dispensary. (Continued from p. 697.) ON
PROLAPSUS ARE
UTERI,
AND
SOME
AFFECTIONS
WHICH
FREQUENTLY MISTAKEN FOR IT.
[The following lines were accidentally omitted in the eleventh case of Dr. Heming’s last paper :-" The vagina was very tender, and I gave her considerable pain in removing the pessary; it was not replaced ; she was advised to remain in bed for a few days, and to use an injection of cold water ; the uterus has continued in its normal situation, and she has not experienced, since, any inconvenience from her complaint."]
-
PROCIDENTIA VESICLE. doubt as to the real nature of the case, which may arise THIS affection is of much more frequent occurrence from this cause, may be at once removed by the introducthan is generally supposed, and it is, undoubtedly, often tion of a catheter (Case 1), which will not only remove confounded with procidentia uteri. It is probable that ’, any urine which may be contained in the pouch of the Madame Boivin did not thoroughly understand this affee- bladder, but we shall be enabled to feel the point of the tion, or suspect its frequent occurrence, as she has given instrument with the fingers applied to the surface of the no delineation of it in her atlas, devoted only a few lines tumour, the parietes of the vagina and bladder interto the subject, and omitted two of its most characteristic vening’. The tumour formed by procidentia vesicse symptoms,-" the pain referred to the navel, with sense proceeds from the anterior part of’ the vagina, and the of tightness there," and the" altered state of the os displaced bladder is covered by the anterior paries of that uteri." The diagnosis is so plain that it is only by a canal ; so that we cannot pass our finger between it and careless examination that we can account for its ever the pubes to touch the os uteri, which is within the being mistaken for prolapsus uteri. The constitution is vagina above it. This orifice will be found to be disfar less disturbed in procidentia of the bladder than in torted in a manner peculiar to this displacement of the that of the uterus ; the stomach does not sympathise bladder. with the protruded bladder unless there be a diseased In the natural situation of the bladder the cervix of state of the displaced viscus ; nor is the nervous system so the uterus is strongly connected by a strong cellular disturbed in this affection as in cases of prolapsus uteri. membrane ; in procidentia of the bladder of long standA mucous discharge usually attends this affection, which ing, this cellular membrane and the anterior lip of the In this altered os uteri becomes very much lengthened. greatly varies in quantity. Sir Charles Clarke has mentioned a symptom upon state of the parts, the os uteri is no longer found in the which he places great reliance, as regards the diagnosis; centre of the pelvis, but opens directly backwards, and he observes,lies in contact with the posterior parts of the vagina. It is the posterior and inferior part of the bladder that " The peculiar symptom which marks this complaint is a pain referred to the navel, with a sense of tightness descends in this affection; first a kind of pouch is formed, there. This pain is the greatest when the bladder cor.- covered by the anterior part of the vagina, filling up tains the largest quantity of urine, and as it parts with that canal, till at length it protrudes through the os exits contents the uneasiness diminishes, till, at last, ternum, and shows itself externally. when it is empty, or nearly so, the symptom goes off CASE 1.-Mrs. -, fifty years of age, consulted me in altogether." consequence of a tumour protruding from the vagina, The superior ligament of the bladder runs from the with which she had suffered for the last four years. Since fundus of the bladder to the navel, to which it is the birth of her youngest child, which was seven years attached, and, perhaps, an elongated state of the liga- old, she has had leucorrhcea; she attributes the first proment (the remains of the umbilical arteries) or the effect trusion of the tumour to a frequent and long-continued produced by the dragging upon the navel itself, may ac- cough. Upon examination, I found a roundish tumour, count for this symptom." about the size of a cricket-ball, proceeding by a broad On examination of the tumour, the os uteri will not be base from the anterior part of the vagina, and protruding found at its lowest part, as in prolapsus uteri ; it is still through the os externum ; this was rendered very tense within the vagina; transverse rugae may be observed, when the patient coughed, and there could be little especially at the upper part of the tumour, and these are doubt, from the sensation of fluctuation, that it contained more or less marked, in proportion to the degree of disa fluid, there was no opening to be felt in any part of it; tention of the bladder, and upon this also will depend I could not pass my finger into the vagina at its anterior the size of the tumour (see annexed cut), which will be part between the pubes andit, butcould do this at its pos-
an
affinity
for chlorine.
The discoverer of this
substance, Dulong, paid dearly for his discovery, with the loss of
one eye and of three fingers of his left hand. Dulong, on saturating a solution of ammonia with chlorine, obtained an unknown oily fluid mixed with water; he proceeded to separate this fluid from the water by means of a moistened filter. Moist paper is not pervious tooil; a mixture of oil and water may, therefore, be separated by means of a moistened filter; the water iiows
filter whilst the oil remains upon it. The very moment when the oil which Dulong had obtained came into contact with the filter, a fearful explosion took place, and mutilated him in the manner I have stated.
through the
with three obtain three atoms of hydrochloric acid, which, with three atoms of ammonia,. form sal ammoniac ; there remains sulphuret of nitrogen, containing, to one equivalent of nitrogen, three equivalents of sulphur and two atoms of free ammonia. The sulphuret of nitrogen formed in this manner must speedily be separated from the fluid, because it decomposes with exceeding rapidity in contact with water, and forms, with the free ammonia, hvDosulohlte of ammonia. One
equivalent of
atoms of chloride of
ammonia
sulphur;
decomposes
we
Notwithstanding this, he subsequently examined and analysed the new compound. With iodine, ammonia Sulphuret of nitrogen, when heated, decomposes with produces a similar compound. All these nitrogen com- feeble detonation. pounds are decomposed with amazing facility. I must here still mention the capacity of ammonia It is very remarkable that phosphorus forms with nitro- for entering into combination with a number of chlorides, gen a compound possessing quite diflerent properties. and also with oxygen salts, forming compounds of which This compound was first observed by Davy, and after- we have no more definite notion than that the ammonia wards investigated by H. Rose. It is produced by satuperforms in them the same part as the water of crystalrating protochloride of phosphorus (P Cl 3,a compound lisation in the salts which crystallise with water. corresponding to phosphorous acid) with ammonia. It Chloride of calcium absorbs four equivalents of amabsorbs five equivalents of ammonia ; a dry, white powder monia, in a dry state. This property of the chloride of is obtained which has the following compositioncalcium has already given rise to many errors. You see from this, for instance, why ammoniacal gas cannot be and which, upon being heated to redness, yields phospho- dried by means of chloride of calcium, for this substance rus, sal ammoniac, and water, whilst phosphuret of nitro- absorbs ammonia as readily as it absorbs aqueous gen, P N2, remains in the form of a snowy-white powder. vapour-one hundred parts of dry chloride of calcium This phosphuret of nitrogen may be heated to white- absorb one hundred and nineteen parts of dry ammonia. ness, in close vessels, without undergoing any alteration; Chloride ot’ silver possesses the same property-one it is, moreover, incombustible to a high degree ; it may hundred parts of chloride of silver absorb seventeen be exposed to a red heat for hours, with free access of air, parts of ammonia. Faraday has taught us to obtain without change. Alkalies and acids do not alter it, but ammonia in a fluid state from this compound. For this in contact with metallic oxides, especially with oxide of purpose dry chloride of silver saturated with ammonia is mercury, it becomes readily oxidised. If a wide glass introduced into a double-limbed tube, and the latter then tube be filled with large pieces of sal ammoniac, and the closed by fusion ; the one limb is then heated and the latter be then heated to evaporation and the vapour of other cooled ; the ammonia which escapes from the one protochloride of phosphorus transmitted through the limb collects and condenses into a clear fluid in the tube, pure phosphuret of nitrogen will likewise be ob- other. tained. You have, in these instances, protochloride of One hundred parts of protosulphate of manganese phosphorus, P Cl3 ; imagine, added to this, one equiva- absorb forty-three parts of ammonia ; one hundred parts lent of ammonia, N H3, and you have hydrogen and of sulphate of zinc absorb fifty-one parts of ammonia. chlorine in the same proportion as in hydrochloric acid ; That the ammonia performs the part of water of you hpve, further, one equivalent of nitrogen and one crystallisation in many of these compounds, seems to be equivalent of phosphorus; the result, therefore, ought to confirmed by its deportment with the salts of copper. be hydrochloric acid and phosphuret of nitrogen, P N ;; Salts of copper are blue, but most of them only when in but the phosphuret of nitrogen produced has not the a state of crystallisation and containing water. Sulphate formula P N, but the formula P N2, thus containing, to of copper, from which the crystallisation-water has been one atom of phosphorus, double the quantity of nitrogen expelled, is perfectly white. If this latter salt is satuit could obtain by this mutual decomposition ; in this rated with dry ammoniacal gas, it assumes the same blue decomposition, therefore, the one half of the phos- colour as it would were water added instead of ammonia ; it absorbs one equivalent of ammonia. phorus is liberated. Ammonia enters, likewise, into combination with perchloride of phosphorus, forming a compound which has ON THE not yet been minutely examined. If perchloride of RESULTS AND TREATMENT phosphorus is saturated with ammonia, then drenched OF THE with water, and the mixture subjected to distillation, a volatile camphor-like substance passes over, which contains chlorine, phosphorus, and nitrogen. Sulphuret of nitrogen was obtained in a similar manner, a few years since, by Soubeiran. This chemist found that if sulphur is completely saturated with chlorine, chloride of sulphur is obtained, Cl S, corresponding to hyposulphurous acid. This chloride of sulphur combines with ammonia, and this in such a manner that one equivalent of chloride of sulphur absorbs two fBf1nivalents of ammonm.
The ammonia must be perfectly dry, and must he transmitted through the chloride of sulphur gradually, so that the mass does not become heated ; a yellow greenish powder is obtained. If water be poured upon this, a yellow powder i.3 formed, cOllsistil1g of sulphuret of nitrogen, S3 N, and water, Eal ammoniac, and free ammonia, are obtained.
CASES OF AMPUTATION PERFORMED AT THE CORK NORTH INFIRMARY. (Read before the Cork Medical Society.) By D. B. BULLEN, M.D., one of the Surgeons of the Cork North
Infirmary.
THERE are several circumstances connected with the modes of performing amputations upon which practical surgeons entertain opposite opinions, and fixed rules are still wanted to determine the selection of particular operations for special cases. Some surgeons warmly advocate flap operations, while others advance strong
arguments in favour of the circular amputation. Again, operators of eminence are reluctant to amputate in
some
joints, and others select joints for effecting the separation of the limb whenever it can be done. The conclusion may, therefore, be drawn from this diversity of opinions, that each plan of operating has merit in certain cases, while it may not be eligible in others, and we should fairly weigh the advantages and disadvantages of each mode of amputating in order to arrive at some grounds upon which to make a preference,-when to the
721 the flap operation and when the circular,-what may safely be made the point of separation, and which- are those that ought to be avoided. For pursuing such an inquiry accurate statistical information is much wanted, not only with regard to the manner in which the several operations are executed, but also in showing the principles upon which the subsequent treatment is conducted. When we consider the extraordinary mortality which follows the amputations in the French hospitals, we must admit something radically wrong in their practice; and the difference which prevails between the results of surgical operations in several British hospitals is sufficiently startling to demand investigation. However, the successful issue of operations must depend upon many circumstances connected with the physical and moral condition of the local population over which the In this part of the surgeon can have no control. country the poorer classes bear severe operations extremely well. Their strong religious feeling gives them that passive courage which does not fear death, and the vegetable diet upon which the greater numbers live renders them less liable to subsequent inflammation. The following table gives the results of fifty-eight cases of amputation performed in the North Infirmary, by my colleague, Dr. Howe, and myself.
adopt joints
The removal of the leg below the knee by the circular amputation is generally a safe and good operation in primary cases, and where the integuments are vascular and healthy. When, however, the subject is feeble and
emaciated, with the circulation
in the cutaneous vessels there is reason to apprehend that separating a sufficient extent of skin to cover in the extremities of the divided bones may destroy the vitality of the part, and sloughing be the consequence. In such cases, operating with the posterior flap presents decided advantages. Primary amputations do not heal as rapidly as operations performed upon persons who have been some time in hospital; and if the stump of the leg, made with a flap, The case of goes wrong, it is very hard to manage. Daniel Mahony was one of this description. He was a labourer, forty years of age, and was brought into the infirmary with compound fracture of the ankle-joint. The bones were crushed and the flesh of the leg extensively lacerated by a heavily-laden cart having gone over it. The injury was of such a nature as to leave no hope of saving the limb, and amputation was proposed. The patient at first refused his consent, but at the end of sixty-four hours he solicited the performance of the operation. Inflammation had then commenced. The limb was considerably swollen, and severe irritative fever had set in. Anxious to give the poor man a chance for his life, I consented to remove the limb, and being much pleased with the results of the flap operations I had performed, I determined, contrary to my conviction, to operate in the same manner in this case. Although this
languid,
of a spare habit of body, his leg was rather and I therefore tried, in making the flap, to cut out and remove a good deal of the great posterior muscles, so as to avoid too fleshy a flap. On cutting through the muscles they did not retract, but yielded before the knife. When the flap was brought over the ends of the bones, the divided edges of the muscles protruded beyond the integuments and forced their way out between the uniting sutures. Union did not take place in this case. On the third day the stump put on a gangrenous appearance, and on the eleventh day after the operation he died. This was the first death after amputation in twenty consecutive cases. The life of this man would very probably have been saved had he consented to the operation when it was first proposed to him. In amputations of the thigh the same rule appears to hold good as in amputations below the knee, that we should be guided by the muscularity of the limb. In doing the flap operations upon the lower third of the thigh, the external flap should be made first, because if the internal flap is made first, the strong fascia which sheaths the outer part of the thigh makes it very difficult to carry the knife fairly round the bone so as to transfix the limb in the angles of the cut before dividing the parts. There is one objection against this operation, which is, that the great vessels are cut obliquely, and if caution is not used in securing them, as soon as reaction takes place arterial haemorrhage may occur. Another precaution which ought to be attended to is to dissect the bone freely from the surrounding parts, so as to saw it well above the angles of the flaps, for though the flaps may be cut very large, the bone will be apt to protrude at the external angle of the wound even after the lapse of several days, and after considerable union has taken place. The sharp edge of the femur easily makes its way through the recently formed cicatrix, and keeps up a troublesome sore until a circle of bone exfoliates, and is thrown off. When amputating the arm above the elbow and below the lower third, the circular operation seems preferable ; at least it is the one I have always performed, and the cases turned out well. The brachial artery lies so superficially and is in such close contact with the bone that it is not easy to cut flaps so as to leave the vessel sufficiently imbedded in the surrounding parts. The same objection holds good with regard to the position of the great nerves. If the flaps are cut posteriorly and anteriorly the artery and nerves will be in the internal angle, and there is great risk of transfixing them in passing the knife through the limb. On the other hand, in making lateral flaps, the knife must cut its way for a considerable space between the bone and the artery and nerves, with the danger of wounding the vessel when transfixing the limb, at a point much higher up than where it is cut across. When it is necessary to amputate in the upper third of the arm, above the insertion of the deltoid muscle, it is better to operate at the articulation and remove the head of the bone, The operation is much easier and avoids some very difficult complications. If the arm is to be removed so high up as not to allow the use of a tourniquet, nor pressure upon the artery in the axilla, in order to command the bleeding, the operator must depend upon an assistant to press on the subclavian artery either under the clavicle or at the place where it emerges from between the scaleni muscles above the middle part of the clavicle. Continued pressure above the clavicle to stop the pulsation of the artery becomes so intensely painful that if the patient is a strong person his struggles displace the compression, and when the operator proceeds to secure the vessel the blood dashes in his face. The artery retracts into the loose cellular tissue of the axilla amongst the great axillary nerves, and there is great difficulty in seizing it. In the case of John Barry, a very powerful man, whose arm was amputated at the infirmary very high up, the artery retracted into the axilla, and every effort to check the bleeding by pressure above the clavicle was unavailing. By a vigorous plunge deep into the axilla the mouth of the bleeding vessel was grasped between the two thumbs of the operator, but the loss of blood was very formidable before it could be secured. So far from any advantage being gained by leaving the head of the bone it may give rise to man was
fleshy,
722
d<
Names.
c:I
0
Grant....
Disease of ankle ...... Caries of foot ......... Gangrene of foot ...... Gangrene of foot...... Compound fracture ....
6 John Vivian......
Frostbitten in both feet.
7Patrick
Scannell.... Leary....
Necrosis of leg ........ Caries of foot......... Compound fracture ....
10 Thomas Drew .....
Disease of bones of leg..
11 John Reily....... 12 David Cremin...... 13 James Donovan...... Anne Robertson.. 15 John Barry .......
Compound fracture
8
Peggy
Fitzgerald .
9 Patrick
14 g18
o 16 17
Mary Murphy .... Margaret Burke.. David
Crowly
19 Daniel
CL.
20
21 22 24 25
...
Cornelius Connor..
Hymes.... Leary..
2826
Timothy Callaghan L29 John Leahy...... I Hallisy 1 2denims Mary Driscoll ....
..
3 John
Daly........
j 4 Mary Ryan....... 5 Cornelius Deloury .
.
Williams.... 6Eliza 7 Daniel Flynn...... 8 John Sullivan .... 9 John Scanlon .... 10 John Delany ......
w
11 William
:3s7-
I
ll
12 13 14 15 16 17
18L19
.... Scrof. disease of ankle.. Caries of foot.......... Gangrene of foot...... Disease of ankle ...... Compound fracture .... Humid gangrene ...... Caries of foot ........
Morgan..
NomyMeade...... John Brian........ Maurice Fitzgerald Catharine Long.... Andrew Courtney.. John Burns ......
Richard
Shephard.
Edward Land ....
Donovan .
Murphy .... g..0::<( 1Timothy L Barry ...... .
2 James 3 John
1 William Leahy.... Coffee ...... 3 John Long........ 4 Michael Desmond. 5 Daniel Connell.... 6 6 Florence Neale....
y i 2 Denis oi
Shoulder-joint.
Owen Cline
Total 58.
Remarks.
Complications or consequences causing death.
Partial amputation of the second foot............
since ) secondin leg South tated
ampu-
Infirmary
< SubsequentuponChopart’s operation .............. S Refused
Mahony....
James Daniel Murphy... 23 Patrick Brian..... Cornelius Eliza Driscoll..... Ellen Cashman.... 27 Judith Regan.....
]
injury requiring amputation. or
2 Denis Mary Clifford.... 3 David Farrell...... .. 45 PatrickMurphy Brian.....
1 Stephen
*
K
Disease
to allow
operation
for four days .......... Exostosis of tibia...... Compound fracture .... Gangrene of foot ...... Compound fracture .... Diseased ankle ........ Compound fracture .... Compound fracture .... Gangrene of foot ...... Compound fracture ..;.
Compound fracture
....
Compound fracture
....
Subsequent upon typhus.... Effusion
White White
swelling ........ swelling ........ Gangrene White swelling ........ Necrosis of leg........ Comp. fracture of knee White swelling........ Necrosis of bones of leg. White swelling ........ ............
fracture of knee..........
Compound the
White swelling ........ White swelling........ Scrofulous disease of leg White swelling ........ Compound fracture .... Diseased knee ........ Compound fracture of the knee..........
)
Compound
fracture ....
on
the
lungs after
the stump had healed....
The
became stumpnates
grenous
Happened at sea
before.
Sunk
haustion
gan-
sloughed
two
days
from ex-
..............
Accident at sea fifteen days
before .................
survived the inj ury ninetyfive days ..............
Compound fracture.... Compound fracture.... Sabre-wound of elbow..
Compound fracture .... Compound fracture .... Compound fracture .... Compound fracture .... Scrof. disease of hand.. Compound fracture ....
Diseased
os
brachii
....
........
723 much inconvenience. Some months ago a man applied to me at the infirmary, whose arm had been amputated at St. Sebastian, during the late civil war in Spain. He complained of being frequently attacked with sudden and violent paroxysms of pain in the side of the breast and parts adjoining the axilla, which at times were so severe as to produce nausea and faintishness. The arm had been removed very close to the head of the os brachii, above the insertion of the deltoid muscle, and below the insertion of the pectoralis major and latissimus dorsi. The wound was perfectly cicatrised, and there was no heat, redness, nor appearance of inflammation in the surrounding parts. On examination it appeared that whenever he made any unusual exertion of the thoracic muscles, the pectoralis and latissimus dorsi being attached to the short portion of the os brachii, and not having any antagonists, were thrown into spasmodic action, and, turning the extremity of the bone directly towards the body, dragged it with great force against the axillary plexus. The agony he endured obliged him to request me to cut out the head of the bone. Before consenting to do this, I wished to try what could be done by applying a compress in the axilla, and, by means of bandaging, to keep the end of the bone turned from the body. After some days he said he felt a good deal relieved by the treatment, and has not applied since at the infirmary. If, however, he should again complain of a recurrence of his sufferings I shall disarticulate the head of the bone. Amputation at the shoulder-joint is not only a safe operation, but one very easy of accomplishment. Owen Clive is an East Indian pensioner, and served in the Burmese war. Having been attacked with the intermittent fever of the country he was confined for a long time in the hospital at Rangoon. Being discharged an invalid he returned to this country, and for several years has struggled under the effects of a shattered constitution. He was received into the North Infirmary for extensive erysipelas phlegmonodes of the lower extremities. An abscess formed beneath the fascia of the right thigh, which contained the largest quantity of matter I ever saw discharged from the body of a living person. His recovery was very protracted, and he left the infirmary in a state of great debility. Some weeks after he applied again for admission, having fallen when walking across the room, and broken the os humeri at the upper third. Erysipelatous inflammation immediately attacked the broken limb, and suppuration formed between the muscles and along the fractured bone. After extensive incisions down the arm the abscesses healed, but no union took place in the extremities of the broken bone. He was sent into the country with the hope that improvement of his general health may bring about consolidation of the fracture. After undergoing much suffering he returned again to the hospital, with abscesses extending from the shoulder to the extremities of the fingers, and the os brachii still disunited. At his own request I proceeded to remove the limb, and were the aspect of a patient to be taken as a guide in determining upon operation no prospect could be more disheartening on account of his wretched and emaciated appearance when placed upon the table. The humerus being diseased throughout its whole extent there was no option but to disarticulate the bone. The operation was performed in accordance with the instructions of my old preceptor, M. Lisfranc, and the patient did not lose six ounces of blood. The wound healed rapidly, and at the end of one month he was able to take exercise in the open air. This man has enjoyed very good health since the operation. It is important, in wounds of the hand, to save every portion of the member that we can, as the parts that remain may be brought after a time to do very useful service. To preserve even one finger and the thumb is an object for which it is worth risking a good deal. Where the integuments are lacerated we should not cut them away, for portions of flesh, which, at a first examination, may appear to be quite destroyed, often preserve a considerable degree of vitality, and after having sloughed to a certain extent granulate kindly, and afford a good covering to the subjacent bones. Even when the wristjoint is torn open, and parts of the bones which form it carried away, the hand may be saved by judicious treat-
Mr. B., a young gentleman from the neighbourhood of Dublin, was on a visit at the house of a clergyman some miles from this city. Having returned in the evening from shooting, he stood close before a large kitchen fire leaning with the left hand on the muzzle of his gun, which was loaded and the hammer down. The heat of the fire, exploded the detonating cap and the whole charge of the gun, which was rather heavy shot, passed right through the carpus. The shot entered close to the head of the ulna, and, taking an oblique direction outwards and a little forwards, carried away large portions of the carpal bones and the heads of the metacarpal bones of the little, ring, and middle fingers. Some grains of shot struck the eyebrow, and lodged beneath the skin of the forehead. The flexor and extensor tendons of the little and ringfingers were quite destroyed, but the power of moving the other fingers remained. The wound was completely charred by the explosion of the gunpowder, and although the ulnar branch of the palmar arch must have been divided there was no haemorrhage. The hand was laid upon a large splint, and treated with cold water dressings. For ten days there was scarcely any pain or inflammation, but when the eschar began to be detached matter formed about the wrist and along the fascia of the forearm. A large incision was made along the radius, and keeping the wound open drained the hand. At the end of a few weeks this gentleman was able to return to Dublin. Since then the exfoliation of parts of the carpal bones has given rise to fresh suppuration, but on the removal of the detached pieces the abscess healed, and he has regained in a great degree the use of the hand. A man was brought into the infirmary last summer with the left hand shattered by the explosion of a blunderbuss. The middle, fourth, and little fingers, with the corresponding metacarpal bones, were torn away, large portions of the carpal bones were destroyed, the wristjoint opened, and head of the ulna fractured. Every part of the hand, except the forefinger and thumb, were removed, and the broken head of the ulna taken out. The wound was treated by water dressings, and when matter formed underneath the fascia of the forearm free vent was given to it by proper incisions. The arm was saved, and this man finds the one finger and thumb very useful members. In amputating the phalanges of the fingers there is a circumstance which is sometimes overlooked, and subsequently gives rise to a good deal of trouble. The tendons of the extensors of the fingers are attached to the dorsum of the third phalanx, while the tendons of the flexors pass in a sheath upon the inferior surface of the third phalanx, and are inserted into the inferior surface of the first and second phalanx. If the removal is effected either at the point of the third and second phalanges, or in the middle of the third phalanx, the flexor tendon retracts into the sheath, beneath the palmar fascia, and leaves the stump without any power of flexion. Now, the extensor tendon being attached to the dorsum of the bone, the extensor muscle is left without an antagonist, and the little stump is dragged upwards and backwards. If you hold up the middle or third finger, and prevent it from bending, you will find it impossible to shut the other fingers of the hand. The same action takes place when the third phalanx, or part of it, is left, and the power of closing the hand is lost. In two cases I was obliged to remove the stumps at the of the third phalanx, with the metacarpal articulation after amputation, had been performed by otherpersons in the middle of the third phalanx. , Much of the success of modern operations is due to the use of small ligatures in securing the blood-vessels, and the very simple manner in which the wounds are dressed. Alanson’s 11 Practical Observations on Amputation" were published in 1782, and dressing to effect union by the first intention soon became the general practice of the surgeons of these countries. The cure, however, was greatly retarded by the large flat ligatures, the use of which were still retained. In 1800 my father amputated the thigh of Mr. Meany, an eminent tea-merchant of this city, in the presence of the right Rev. Dr. Murphy, our present Roman Catholic Bishop, his brother, Mr. N. Murphy, and Dr. Gibbins. He tied the arteries with ment.
bone,
724 I
small single silk threads, cutting short one end of them.The Union by the first intention was so rapid in this case that the
tourniquet, by causing venous congestion, increases flowing of blood, and even the compression of a the gentleman was able to be removed into the open air bandage brings on a recurrence of venous bleeding for on the eleventh day after the operation. Soon after he hours after the operation. On carefully examining the adopted the same practice in an amputation performed condition of the limb the muscles are found to be purple, above the knee upon Mr. Ross, brother to the distributor isoft, and do not retract, and the integuments are flabby, of stamps, and on Mr. Quill, brother to the celebrated and inclined to a bluish colour. There is a manifest Maurice Quill, of facetious memory. Recovery in each atony in the parts, a deficiency of the vital energy, which of these cases was equally rapid. It is a pity for the is requisite to set up and carry on the reparative action, fame of the surgery of the south of Ireland that my father did not publish the results of his cases at the time, for Dr. Hennen, in his work, ascribes the credit of this improvement to Mr. James Veitch, a naval surgeon, in April, 1806, published some valuable precepts relative to the mode of tying the arteries in amputation. Mr. Cooper, in his 11 Surgical Dictionary," also says, " Mr. Veitch, however, seems to merit the honour of having been perhaps the first to set the example of tying every vessel, the femoral, as well as the smaller arteries, with a single silk tlaread, taking care to include, as far as was possible, nothing but the artery ; and when this had been done he took off one half of each ligature, as near as possible to the knot, so that the foreign matter introduced was a mere trifle compared to what I had been accustomed to see." In dressing and treating stumps with a view to obtaining union by the first intention the great object is to avert inflammation. When inflammatory action sets in, and the parts become painful, hot, and swollen, union does not take place, and if adhesion has taken place during the first two or three days subsequent to the operation, as soon as the parts become inflamed the adhesions break up and the stump becomes a large suppurating sore. The chief aim, therefore, in making up a limb after amputation is to remove every source of irritation, and to guard against any circumstance likely to interfere with the quiet process of reparation. To effect this, after the bleeding has entirely ceased, and the parts have been brought into contact, a sufficient and well-regulated support must be given to the stump to prevent the tendency to sudden and convulsive startings, which cause great suffering, and sometimes burst open the newly-formed adhesions. Some surgeons are favourable to the use of sutures for keeping the edges of the wound together, while others think that they act as causes of irritation, and give rise to suppuration. It is not well to depend upon sutures alone when extensive surfaces are to be
who,
held in position, but a few, judiciously placed, give great steadiness and prevent the opposite surfaces of the stump from gaping when it is placed upon the pillow. Besides the sutures some adhesive straps should be applied, but the whole face of the stump should not be bound down by bands of sticking-plaster. The continued constriction of adhesive plaster too freely and carelessly put on causes a great deal of pain, and in amputations below the knee, and of the forearm especially, by compressing the integuments against the surfaces of the divided bones, brings on ulceration of the covering of the stump and protrusion of the bones-a strip of lint over the face of the stump and a light bandage are all that is requisite. From the time the patient is placed in bed the dressing should be kept wet by the continuous irrigation of cold water over the limb. This is very soothing and keeps in check the tendency to increased vascular action ; besides, by keeping the dressings constantly moist, when the time comes for changing them, which should not be before the sixth day, unless the smell of the wound should have become offensive, they can be easily removed without tearing asunder the slight and newly-formed adhesions. Although it is the general practice of British surgeons, in the treatment of all incised wounds, to bring the edges of the wound together, so that they may unite by the first intention, yet some cases occasionally present themselves which require a different mode of proceeding. In operating upon old subjects, in which the lower extremity has been for a long time the seat of chronic inflammation, we sometimes find the veins of the leg enormously enlarged and varicose, and the arteries few and much diminished in size. When the limb is removed the venous hsemorrhage is profuse and difficult to check.
of which a sound union can be effected. From the moment of operating the torpid and relaxed state of the blood-vessels demand stimulation. The first object is to arrest the haemorrhage; for that purpose the tourniquet, and whatever may cause pressure upon the limb, should be immediately removed, the thigh bent upon the pelvis, so that the stump may be thrown up, and kept in a perpendicular position, and a stream of cold water should be poured from a height over the face of the stump. These means generally check the more profuse discharge of blood, but a venous oozing continues, which is increased by closing up the wound, and putting on a bandage. Should they fail, however, dossils of lint, dipped in a hot saturated solution of alum, applied to the bleeding surface, and leaving the limb exposed in a current of cool air, will generally succeed. It is useless to attempt to obtain union by the first intention in cases of this description; for, if after some hours, when the danger of haemorrhage has ceased, the edges of the wound are brought together, and the usual dressings applied, it generally happens that at the end of three or four days the stump becomes gangrenous. Gangrene following amputation, in old and enfeebled constitutions, is generally fatal, and we should, therefore, endeavour to avert it by the immediate use of proper local stimulants, and by sustaining the constitutional powers with an invigorating course of treatment. Pressing the surface of the stump with pledgets of lint, dipped in warm elemi ointment and turpentine, soon excites healthy suppuration, and an abundant growth of florid granulations, together with the steady use of opium, carbonate of ammonia, wine, and nutritious broths. The successful result of amputations, like most other surgical operations, depends more upon the medical management afterwards than upon any mechanical dexterity in their performance. The pain and excitement of the operation, accompanied by the sudden loss of blood, is followed by a degree of constitutional disturbance, which is more dangerous to persons who have been heretofore healthy than to those who have long suffered under some painful disorder, and who have been suddenly relieved from a previous source of irritation. Hence primary amputations, performed immediately after recent injuries, are more often fatal than the removal of limbs for chronic and long-continued local diseases. But secondary amputations, in cases of extensive injuries, are more fatal than primary, because they are generally done during the existence of irritative fever, and when the powers of the system have been impaired by the shock consequent upon the injury. The hectic fever which results from suppuration in joints, or from diseased bones, does not contra-indicate operation ; on the contrary, upon the removal of the cause of the constitutional irritation, the return to health is often surprisingly rapid. But in determining the propriety of amputating in the secondary stage of extensive injuries, we must be guided by the extent to which inflammation spread along the limb and disorganised the tissues, and by the nature and degree of the irritative fever. There are two dangers to be apprehended and guarded against after operation. The failure or loss of constitutional power to bear up against the shock, and the reaction consequent upon rallying, which may lead to a state of dangerous excitement, ending in active inflammation. Immediately after the patient has been placed in bed a large opiate should be given and repeated in proper doses at regular intervals. And here it may be observed, that where the stimulating and cordial influence of opium is required laudanum and crude opium are the forms most to be relied on. Some of the salts of morphia, and particularly the acetate, when given in large doses, produce so much depression and collapse,
by means
has
725 that it is hazardous to give them in cases where we have to contend with symptoms of great exhaustion. When reaction has fairly set in, the tongue become foul and dry, skin hot, and pulse quick, we must then deal with the case as one of irritative fever. A mild mercurial given at bedtime, followed by an aperient draught in the morning, and the regulated exhibition of some opiate, combined with tartarised antimony, as the circumstances may require. The diet, for the first few days, should be nutritious though not stimulating, and unless there be strong reasons to the contrary, more generous aliment should be given early, for after severe losses of blood withholding animal food often induces an irritability of the system which disposes strongly to inflammatory action.
comparatively small if the patient has jn[.;t made water, although, as she cannot completely empty the bladder, the tumour will not entirely disappear; but any
PRACTICAL FACTS AND OBSERVATIONS ON DISEASES OF WOMEN, AND SOME
SUBJECTS CONNECTED WITH MIDWIFERY. By G. OAKLEY HEMING, M.D., F.L.S., PhysicianAccoucheur to St. Pancras Infirmary and to the Western Dispensary. (Continued from p. 697.) ON
PROLAPSUS ARE
UTERI,
AND
SOME
AFFECTIONS
WHICH
FREQUENTLY MISTAKEN FOR IT.
[The following lines were accidentally omitted in the eleventh case of Dr. Heming’s last paper :-" The vagina was very tender, and I gave her considerable pain in removing the pessary; it was not replaced ; she was advised to remain in bed for a few days, and to use an injection of cold water ; the uterus has continued in its normal situation, and she has not experienced, since, any inconvenience from her complaint."]
-
PROCIDENTIA VESICLE. doubt as to the real nature of the case, which may arise THIS affection is of much more frequent occurrence from this cause, may be at once removed by the introducthan is generally supposed, and it is, undoubtedly, often tion of a catheter (Case 1), which will not only remove confounded with procidentia uteri. It is probable that ’, any urine which may be contained in the pouch of the Madame Boivin did not thoroughly understand this affee- bladder, but we shall be enabled to feel the point of the tion, or suspect its frequent occurrence, as she has given instrument with the fingers applied to the surface of the no delineation of it in her atlas, devoted only a few lines tumour, the parietes of the vagina and bladder interto the subject, and omitted two of its most characteristic vening’. The tumour formed by procidentia vesicse symptoms,-" the pain referred to the navel, with sense proceeds from the anterior part of’ the vagina, and the of tightness there," and the" altered state of the os displaced bladder is covered by the anterior paries of that uteri." The diagnosis is so plain that it is only by a canal ; so that we cannot pass our finger between it and careless examination that we can account for its ever the pubes to touch the os uteri, which is within the being mistaken for prolapsus uteri. The constitution is vagina above it. This orifice will be found to be disfar less disturbed in procidentia of the bladder than in torted in a manner peculiar to this displacement of the that of the uterus ; the stomach does not sympathise bladder. with the protruded bladder unless there be a diseased In the natural situation of the bladder the cervix of state of the displaced viscus ; nor is the nervous system so the uterus is strongly connected by a strong cellular disturbed in this affection as in cases of prolapsus uteri. membrane ; in procidentia of the bladder of long standA mucous discharge usually attends this affection, which ing, this cellular membrane and the anterior lip of the In this altered os uteri becomes very much lengthened. greatly varies in quantity. Sir Charles Clarke has mentioned a symptom upon state of the parts, the os uteri is no longer found in the which he places great reliance, as regards the diagnosis; centre of the pelvis, but opens directly backwards, and he observes,lies in contact with the posterior parts of the vagina. It is the posterior and inferior part of the bladder that " The peculiar symptom which marks this complaint is a pain referred to the navel, with a sense of tightness descends in this affection; first a kind of pouch is formed, there. This pain is the greatest when the bladder cor.- covered by the anterior part of the vagina, filling up tains the largest quantity of urine, and as it parts with that canal, till at length it protrudes through the os exits contents the uneasiness diminishes, till, at last, ternum, and shows itself externally. when it is empty, or nearly so, the symptom goes off CASE 1.-Mrs. -, fifty years of age, consulted me in altogether." consequence of a tumour protruding from the vagina, The superior ligament of the bladder runs from the with which she had suffered for the last four years. Since fundus of the bladder to the navel, to which it is the birth of her youngest child, which was seven years attached, and, perhaps, an elongated state of the liga- old, she has had leucorrhcea; she attributes the first proment (the remains of the umbilical arteries) or the effect trusion of the tumour to a frequent and long-continued produced by the dragging upon the navel itself, may ac- cough. Upon examination, I found a roundish tumour, count for this symptom." about the size of a cricket-ball, proceeding by a broad On examination of the tumour, the os uteri will not be base from the anterior part of the vagina, and protruding found at its lowest part, as in prolapsus uteri ; it is still through the os externum ; this was rendered very tense within the vagina; transverse rugae may be observed, when the patient coughed, and there could be little especially at the upper part of the tumour, and these are doubt, from the sensation of fluctuation, that it contained more or less marked, in proportion to the degree of disa fluid, there was no opening to be felt in any part of it; tention of the bladder, and upon this also will depend I could not pass my finger into the vagina at its anterior the size of the tumour (see annexed cut), which will be part between the pubes andit, butcould do this at its pos-