June 1,
A MIKEOE OF HOSPITAL PEACTICE.
1871.]
CASES ILLUSTRATIVE OF TWO COMMON DEATH AFTER AMPUTATION.
By
W. E.
Allen, F.E.C.S., Offg.
CAUSES OF
Civil Surgeon,
Cliittagong.
?
to.
The chief question of interest in this case is, I apprehend, ?at what point should the amputation have been performed? Surgery lays down the law that, with but two exceptions, in traumatic gangrene amputation should be performed without waiting for the formation of a line of demarcation, but it is left to the discretion of the surgeon to determine the precise point at which the operation should be done, and he has to balance the danger of the recurrence of gangrene in the stump from the operation having been performed too near the seat of injury, against tlie increased risk to life from the shock caused by removal of a larger portion of the limb, and this more especially in the lower extremity, for the records of surgery show that tlie chances of recovery are diminished the higher the amputation is performed. It is possible that in the above case the chance of recurrence of the gangrene would have been less had the amputation been performed at the knee-joint or iu the lower third of the thigh.
II-?Chubamon, aged 35, a native in the employ of tlie E. I. Railway Company, on the 19th December, 1867, was stooping the line to pick up some money he had dropped, when an engine came upon him unawares and passed over his left foot, completely crushing it. I saw him soon afterwards, and amputated by flap operation at junction of middle and lower third of the leg; he progressed favourably up to the 24th instant, near
when all the sutures stump having healed
were
and
3rd?Would the chance of recovery bo a higher spot ?
increased by amputation at
in the employ of April \\th, 1866.?J. M. ?, a guard the E. I. Railway Company, was thrown between two carriages of a train moving slowly, and his right ankle was severely squeezed between the rail and the flange of a wheel. I saw him about four hours after the accident, and found the ankle and surrounding parts greatly contused and swollen, and found that there was a clean cut wound, about four inches long, across the dorsum of the foot, and another of less extent above the outer ankle; no crepitation and no appearance of synovia. The foot was placed comfortably on a cushion, and cold water directed to be assiduously applied; next day swelling had greatly increased. On the 6th day signs of gangrene were very manifest over the inner ankle. 1th day.?All the bruised parts over inner and outer ankle had sloughed, there was great constitutional disturbance, necessity for amputation urged. 8th day.?Amputation by flap operation performed at junction of middle and lower third of leg. Examined the ankle joint, and found that the gangrene had extended through the joint, from side to side, all the soft structures in the neighbourhood being involved; no fracture of any of the bones. 9th day.?Stump showing tendency to slough. 10th day.?Stump one mass of sloughs j all sutures removed, charcoal poultices to be applied. 13th day.?Died. During the course of the case the usual routine treatment? bark and ammonia, chlorate of potash, occasional purgation, beef-tea and wine, to the extent of a bottle daily, was had recourse
enlargements ?
removed, the greater part of the
by 1st intention, there being only one or two sloughy points remaining ununited. 23th?(6th day after the accident).?He was attacked by trismus during the night; swallows with great difficulty ; complains of great pain in the masseter muscles. To have a grain of opium every 2nd hour, chloroform by inhalation occasionally, and as much nutritious soup as he can be got to swallow. The symptoms increased in severity; he became generally tetanic, exhibiting marked opisthotonos, and died on the 29th not I had an instant,?10 days after the accident. opportunity of examining the condition of the stump after death, and I do not know whether there was that nodular enlargement of the cut extremities of the nerves which is, unquestionably, frequently, if not always, found in cases of death from tetanus after amputation. In this case there were no neuralgic pains or other symptoms attracting attention to the stump, which, as above stated, had united most satisfactorily. In thinking over this and similar cases which I have met with, the following questions have frequently suggested themselves to mo :?l.y??Ilave these nodular enJargements and tetanic symptoms really a relation of cause and ellect? 2nd?What conditions favor the formation of these
221
A MIKEOE OF HOSPITAL PEACTICE.
1871.]
CASES ILLUSTRATIVE OF TWO COMMON DEATH AFTER AMPUTATION.
By
W. E.
Allen, F.E.C.S., Offg.
CAUSES OF
Civil Surgeon,
Cliittagong.
?
to.
The chief question of interest in this case is, I apprehend, ?at what point should the amputation have been performed? Surgery lays down the law that, with but two exceptions, in traumatic gangrene amputation should be performed without waiting for the formation of a line of demarcation, but it is left to the discretion of the surgeon to determine the precise point at which the operation should be done, and he has to balance the danger of the recurrence of gangrene in the stump from the operation having been performed too near the seat of injury, against tlie increased risk to life from the shock caused by removal of a larger portion of the limb, and this more especially in the lower extremity, for the records of surgery show that tlie chances of recovery are diminished the higher the amputation is performed. It is possible that in the above case the chance of recurrence of the gangrene would have been less had the amputation been performed at the knee-joint or iu the lower third of the thigh.
II-?Chubamon, aged 35, a native in the employ of tlie E. I. Railway Company, on the 19th December, 1867, was stooping the line to pick up some money he had dropped, when an engine came upon him unawares and passed over his left foot, completely crushing it. I saw him soon afterwards, and amputated by flap operation at junction of middle and lower third of the leg; he progressed favourably up to the 24th instant, near
when all the sutures stump having healed
were
and
3rd?Would the chance of recovery bo a higher spot ?
increased by amputation at
in the employ of April \\th, 1866.?J. M. ?, a guard the E. I. Railway Company, was thrown between two carriages of a train moving slowly, and his right ankle was severely squeezed between the rail and the flange of a wheel. I saw him about four hours after the accident, and found the ankle and surrounding parts greatly contused and swollen, and found that there was a clean cut wound, about four inches long, across the dorsum of the foot, and another of less extent above the outer ankle; no crepitation and no appearance of synovia. The foot was placed comfortably on a cushion, and cold water directed to be assiduously applied; next day swelling had greatly increased. On the 6th day signs of gangrene were very manifest over the inner ankle. 1th day.?All the bruised parts over inner and outer ankle had sloughed, there was great constitutional disturbance, necessity for amputation urged. 8th day.?Amputation by flap operation performed at junction of middle and lower third of leg. Examined the ankle joint, and found that the gangrene had extended through the joint, from side to side, all the soft structures in the neighbourhood being involved; no fracture of any of the bones. 9th day.?Stump showing tendency to slough. 10th day.?Stump one mass of sloughs j all sutures removed, charcoal poultices to be applied. 13th day.?Died. During the course of the case the usual routine treatment? bark and ammonia, chlorate of potash, occasional purgation, beef-tea and wine, to the extent of a bottle daily, was had recourse
enlargements ?
removed, the greater part of the
by 1st intention, there being only one or two sloughy points remaining ununited. 23th?(6th day after the accident).?He was attacked by trismus during the night; swallows with great difficulty ; complains of great pain in the masseter muscles. To have a grain of opium every 2nd hour, chloroform by inhalation occasionally, and as much nutritious soup as he can be got to swallow. The symptoms increased in severity; he became generally tetanic, exhibiting marked opisthotonos, and died on the 29th not I had an instant,?10 days after the accident. opportunity of examining the condition of the stump after death, and I do not know whether there was that nodular enlargement of the cut extremities of the nerves which is, unquestionably, frequently, if not always, found in cases of death from tetanus after amputation. In this case there were no neuralgic pains or other symptoms attracting attention to the stump, which, as above stated, had united most satisfactorily. In thinking over this and similar cases which I have met with, the following questions have frequently suggested themselves to mo :?l.y??Ilave these nodular enJargements and tetanic symptoms really a relation of cause and ellect? 2nd?What conditions favor the formation of these
221
