No. 1032.

SATURDAY, JUNE 10, 1843.

KING’S COLLEGE HOSPITAL.

CASES IN WHICH AMPUTATIONWAS PERFORMED ;

WITH

CLINICAL REMARKS.

BY

MR. FERGUSSON.

IN a clinical lecture, delivered on the 16thof February, 1843, Mr. Fergusson statedthat he would take the opportunity whichthen presented of making some observationson amputation and the mode of dressingstumps, as some of the cases which hadbeen lately under treatment enabled him todo so in a much more satisfactory and usefulmanner than during the systematic lectureson such subjects.CASE 1.-David Owen, ætat. 7, of a stru-

mous habit, admitted lOth of December,1842 ; had suffered from disease of the kneesince he was eighteen months old. Fromtime to time the affection (gelatinous altera-tion of the synovial capsule, abscesses,chronic inflammation of bones, &c ) had

seemingly yielded to treatment, and abouttwelve months ago the hamstrings were di-vided to facilitate the extension of the limb,which had become much bent at the knee

during the progress of the case. In thecourse of several months the limb was madealmost straight, but acquired no additionalstrength, and the apparatus which had beenused for extension was still kept on to aidthe patient in his attempts to support thebody on this limb. About six months sinceinflammation again attacked the joint, andere long an abscess burst on the outside ofthe knee. His health now suffered con-siderably, and the discharge was profuse.A probe passed into the opening came in con-tact with bare bone.

22. To-day amputation was performed inthe lower third of the thigh, with an anteriorand posterior flap. Four arteries were tied,and all bleeding having apparently ceased,the stump was stitched and strapped.About three hours after some blood wasobserved to trickle from the wound, and a

clot protruded between the stitches. Thesewere cut, and a large mass of blood havingbeen removed, a small artery, which bledfreely, was secured, when cold cloths wereapplied, to check the oozing from othervessels which did not seem to require liga.tures. In the evening, the haemorrhagehaving ceased, the cut surfaces, beingcovered with lymph, were brought againinto apposition, and retained by stitches,straps, and a bandage.

23. Has passed a good night.24. Child doing well; stump not dis-

turbed.26. Dressings of stump removed; looking

well; slight swelling; scarcely any dis-

charge ; edges united. New straps applied.A strip of lint, covered with spermaceti oint-ment, laid along the course of the wound,and a bandage put on.

27. Stitches removed to-day. Straps, lint,and bandage applied as before. At each

dressing the bandage is carried from thepelvis to the end of the stump, great carebeing taken to bring the soft parts well overthe cut surface of the femur.

Jan. 16, 1843. A similar mode of treat.ment as that above described has been pur.sued. The stump is now almost healed,and the patient is about to quit the house,having rapidly improved in appearance andhealth.Immediately after the operation Mr. Fer-

gusson stated that this case had been underhis notice for more than twelve months, andfrom what had occurred within the last six,as also from the disease having been presentso long, he had resolved to recommend am-putation. He believed that had he allowedthe limb to remain there was great risk ofthe patient sinking under the constant irrita-tion ; and as by the process of extension thehead of the tibia had been in a manner dis-located behind the condyles of the femur,it was very doubtful if the limb would everhave been of service; even in the event of alldisease ultimately ceasing, he had no doubtthat the course which he had pursued wouldbe most to the advantage of the patient. Thiswas the second instance in which he hadamputated in the thigh some time after at-tempts had been made to extend the lim

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by division of the hamstrings and the appli- after, but there was no further cause ofcation of apparatus. One of these cases alarm ; the wound healed rapidly, and onhad been treated by himself, and in the case the 25th of February was entirely cica-above related he had sanctioned the mode trised.of practice. In both cases he had imagined With reference to this case it was statedthat the original disease had ceased, and al- by Mr. Fergusson that when the amputationthough he could not admit that in either of was performed there was no greater urgencythem the recurrence had been induced by in the condition of the foot than there hadthe treatment, yet they bore out the general been for years before. He had himself seenview that he had on sucha question, viz., that the boy two years previously, and had thenthe practitioner should be very cautious in recommended the operation, for it appearedadopting anything like force to effect the ex- to him that there was no probability of thetension, for whether the reappearance of in- disease getting well, and that its continuedflammation was attributable to the surgeon’s presence would in many respects be preju-interference, the patient or his friends would dicial to the patient. The parents, however,be too apt to think so, and thus both the would not listen to the proposal, and he hadsurgeon and his profession might sufler in not seen the case during the interval. Acharacter. The mode of amputation with a few days before the boy came into the houseshort anterior flap and a long posterior one, he had been brought to him, with a requesthe had frequently alluded to on other occa- that he would now perform the operation, assions; and he would now request the pupils both the parents and patient himself nowto watch the future progress of the case and despaired of a cure. Considering that asthe mode of treatment,-subjects on which he the disease had been present for seven years;would dwell at greater length on another that it was in no respect better than it hadoccasion. been two -years before ; that this constant

CASE 2.-Thomas Kallord, aetat. 10, ad- source of irritation was checking the boy’smitted 26th Jannary, 1843. Has had dis- growth, retarding his education, and theease in the right tarsus since he was three cause of much trouble and anxiety to hisyears old. At present the part is more than parents, he had not hesitated about the stepdouble the natural size, and there are three which he had taken, more especially as heorifices on the surface from which there is a could perceive no means of treatment likelyconstant discharge of matter, and through to save the foot. Amputation had been per.which a probe can be thrust upon bare por- formed in the middle of the leg with thetions of the tarsal bones. The boy is small view that an artificial support should beand weakly, but at present is in as good afterwards used, which should permit thehealth as he ever enjoys at any time. He free use of the knee-joint.has entered the hospital for the purpose of CASE 3.-Alfred Allen, aetat. 7, admittedhaving the foot removed. December 16,1842. Was always a healthy

28. Amputation was performed to-day in boy, though thin and weak-looking, untilthe middle of the leg. A small anterior flap four months ago, when he was observed towas formed by sweeping the knife in a semi, limp in his walk, and complained of pain in-lunar direction from one side to the other, the left knee, which gradually became muchand then a large posterior one was made by swollen. An abscess at last pointed in fronttransfixing in the usual manner. Three ar- of the head of the tibia, which was openedteries were secured; the surfaces were held about two months ago, and the aperturetogether by stitches ; lint, moistened with through which bare bone can be felt, hascold water, was laid over the wound, and never closed since. The swelling dimi.straps were ordered to be applied in a few nished for a time after the evacuation of thehours, after all bleeding had ceased. In the matter, but has again become very conspicu.evening the edges between the stitches were ous, more especially on the upper and outercarefully approximated with straps, and a side of the knee, where fluctuation is veryroller was then carried round the stump. distinct. He has now constant pain in theThe subsequent dressings were similar to joint, and is much disturbed in his sleep.

those used in the preceding case. On the The cartilages do not seem very tender whenfifth day after the operation, at the period of they are pressed, but there is so much in-

dressing, there was an escape of arterial blood, flammation around the joint that the partsto the extent of an ounce or somewhat more, can scarcely be touched without causing ad-when the wound was partly opened by the ditional distress.finger, for the purpose of exposing the bleed. 22. Abscess has been opened and a largeing vessel. There was no occasion, how- quantity of pus evacuated. It does not seemever, for either pressure or ligature, as the that the matter has communicated with theblood immediately ceased to flow. Cold joint; the cavity of the abscess, however, ex-cloths were applied, and in the evening, as tends above the patella, from one side of thethere had been no recurrence of the haemor- knee to the other. At a consultation to-dayrhage, the surfaces were again approximated it has been decided not to amputate at pre.by straps. A constant watch was kept on sent, as hopes are entertained that the jointthe stump for several days and nights there- is not seriously affected.

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Feb. 4. Since last report the symptoms have then one or more arteries which had beenbecome more severe, and, as the patient’s overlooked throw out their blood, and neces-health is giving way, it has been determined to sitate the further interference of the sur-remove the affected part. Thishasaccordingly geon. Such had been the case here, and sobeen done at the hour of visit to-day, by a often did it happen that in the estimation ofmethod similar to that pursued in Owen’s some it formed a good reason for not dress-case. Eight arteries required to be secured; ing the stump until all chance of bleeding atfour interrupted sutures were used ; lint and this period had ceased. In the other in-cold water were applied for four hours, and stance of haemorrhage (Kallord’s case) thethen straps and bandages were used, as in the occurrence had come on at a more unusual

preceding cases. period. Secondary haemorrhage seldom7. Stump dressed to-day ; looks well, and took place until the ninth or twelfth day, but

apparently has healed by the first intention. here it had appeared on the fifth. The11. All the ligatures have come away to- mode in which it ceased was somewhat sin-

day, and the stump is nearly healed, The gular. It happened, fortunately, at ’ theboy’s general health improving rapidly. time when he (Mr.F.) was dressing the

17. Stump quite healed, and the patient is wound, and for an instant it seemed so pro-about to leave the hospital. fuse that he had applied pressure with theWith reference to this case it was observed fingers upon the popliteal artery, which was

that so long as hopes were entertained that kept up until he had gone the round of thethe joint was not irrecoverably effected the ward, under the hope that by thus checkingamputation was delayed, but at last it be- the current for a time it might cease to flowcame so apparent that the patient’s health from the open vessel when the fingers wereould not long bear up against such irri- removed. This, however, was not the case,atton: hat further delay would have been for it again flowed freely, and it then becameculpable. a question what course should be followed.

In speaking of both of these instances of Considering that the union of the wound wasamputation in the thigh, Mr. Fergusson took still so recent, he had resolved, on the spur ofparticular notice of the shape of the flaps, the moment, to open it up again, with the in-the posterior being purposely made consider- tention of exposing the open vessel and ap-ably longer than that in front. From which- plying a ligature ; but the latter was notever side the flaps are taken, and whether found necessary, for the bleeding ceased asthe operation be by fiaps or circular irici- soon as the surfaces were separated. Thissions, the posterior or lower side of the was different from his anticipation, as thestump invariably, in the course of time, re- current seemed at first too impetuous to betracts much more than the anterior or upper arrested by the mere exposure to the air; heportion, and ultimately the cicatrix is so was, therefore, inclined to suppose that thedrawn upwards and backwards as to give explanation, under the circnmstances, wasthe stump a most unseemly appearance,- this,-that during the dressing some adhe-havingthe bone projecting in front, with a sions had been broken, and thus a vesselscanty covering of soft textures. If, however, sufficient to yield a tolerable stream of bloodcare be taken to leave the textures on the had been partially laid open, the remainingback of the thigh longer than those in front, adhesions preventing its retraction, and thatthe retraction only brings the cicatrix to when these had been broken up by the finger’about the centre of the stump, and then the the vessel had retracted, and the hasmor-bone seems properly protected on all sides, rhage had then ceased in the usual manner.and the part has that full and rounded ap- With such a warning he had placed a con-pearance which is so characteristic of a well- stant watch on the patient for the next twoformed stump, days, as the bleeding might have recurredIn all these examples great care had been during the night, and the consequences might

taken to secure every vessel which seemed have proved fatal.unlikely to close spontaneously. It would In all these cases he had been careful atbe remarked, however, that bleeding had each operation to secure by ligature everyoccurred afterwards in two of them. In the artery that seemed unlikely to cease bleed-first (Owen, amputation in the thigh) it had ing. Eight had required to be tied intaken place within a few hours after the Allen’s case, while three appeared sufficientoperation, and this was a period when it in Owen’s, although another was afterwardswas extremely apt to come on, however found necessary. Both of these thighs weremindful the surgeon might be whilst the pa- nearly of a size, yet eight ligatures weretient was on the operating table. The shock required in one and only four in another!of the operation, exposure of the patient’s This, however, was easily accounted for, asbody, and of the cut surfaces to the cold air, in Allen’s case there was much greaterall tended to lessen the heart’s action ; but in swelling, more active disease, more inflam..the course of a short time after the person mation, than in Owen’s, and it was alwaysis put to bed, has probably had some cordials found in such cases that the smaller arteriesadministered, and got warm under the bed- of the thigh yielded more blood than in in.clothes, the circulation becomes excited, and stances where amputation was required for

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accidents, or for diseases where the knee wasnot much enlarged.

It was his general practice not only tosecure all vessels likely to bleed for anylength of time, but also to apply all theusual dressings which he was in the habit ofusing on these occasions whilst the patientwas on the table. On the latter point theremight occasionally be reason for certainmodifications, for instances would occur

from time to time where the surgeon mightapprehend further bleeding, or where, fromthe continued oozing from small vessels, it

might be deemed most advisable to exposethe surfaces for a time to the air; but in byfar the greater number of instances he wasstill of the opinion that he had always enter-tained, that the best plan was to dress thestump at the period of the operation.With reference to the means of keeping

the surfaces in apposition, he gave the pre-ference to stitches, straps, and bandages, asthe pupils had seen them used on these occa-sions ; the stitches were introduced in suchnumbers as he thought necessary-in one

case four or five sufficing, whilst in anotherseveral more might seem requisite; these lieallowed to remain on the stump for eightand forty hours at least, and where they ap-peared to cause little irritation he preferredretaining them for one or two days longer.The common adhesive strap he applied be-tween the stitches, so as to cause the mostaccurate apposition ; along the line of thewound he generally put a piece of lint,covered with simple dressing, and over allput a common roller. Sometimes, instead ofthe two latter, he applied lint, with cold

water, especially where he was afraid ofoozing of blood, or a high degree of inflam-mation, but generally the ointment and ban-dage were to be preferred.The second dressing was usually on the I

second day from the operation, but if therewas little discharge and no apparent excite-ment in the stump he often delayed this steptill the third, or, occasionally, even the fourth.On such occasions, after removing the ban-dage and strips of lint, he generally cut twoor three of the stitches, and perhaps took offseveral of the straps, especially if the latterwere soiled and stretched, and then appliednew straps, clean lint, and a fresh roller.In four and twenty hours similar steps wererepeated, and then generally all the stitchesand original straps were taken away. Fromfirst to last the dressings were as simple asthey could possibly be. The straps androller were of great service in givingsupport and form to the stump, whose ulti-mate condition depended greatly on the skillwith which they were used ; and the simpleointment was solely intended to facilitate theremoval of the portion of lint with whichthe wound was covered. At first, both

straps and bandage were applied loosely,but in the course of ten or fifteen days, i. e.,

after the separation of the ligatures, theywere so adjusted as to give both firm sup’port and form to the part. In the thigh,unless the surgeon attended to the mode inwhich a stump was dressed, the part mightassume a most discreditable appearance,however well it may have been made at first.Usually, in such cases, it was most easy forthe patient to keep the stump bent upwardsto the pelvis, and therefore it was generallypropped up with cushions in this attitude; it was a dangerous one, however, if not pro.perly attended to, as the weight of the softparts, besides the natural tendency to con. traction, caused them to descend towards

the pelvis, and then the end of the bonemight appear but scantily covered, or mightproject-even in instances where the flapshad originally appeared of most abundantlength. In these cases, then, he carefullyinculcated the propriety of holding the soft

parts well up towards the end of the stump,before applying the straps and bandage,andalso the advantage of beginning the applica-tion of the latter close to the pelvis, andbringing it by successive turns up to the endof the stump. After the lapse of three weeksthere was little use for straps, but the ban.dage should not be given over for manyweeks more-it was still useful in givingform to the stump, and was of much greaterservice in these cases than many seemed toimagine. Towards the final closing of thewound it might occasionally be deemed ad.visable to use an astringent lotion or stimu’lating ointment. Such practice had beenpursued in some of these cases where thewounds had assumed the appearance of

simple sores, but no particular comments onthese points seemed necessary on the presentoccasion.

DUMOULIN, a celebrated French practi.tioner of former times, never lost sight of thefact that the payment of the fee is au essen-

tial part of the visit to a patient. If asked," Shall you come again, doctor?" he wouldreply, " Yes, if you pay me."

· Mast I

pay you now ?" " Yes, if you wish me tocome again !" Having, with a brother-ph).sician been called to attend a nobleman whowas dangerously ill, both doctors arrived atthe house one day when the patient was iiiarticulo mortis. The servants in the hallwere full of invectives, and audibly threat-ened the disciples of Æsculapius with sum-mary punishment in case their master shoulddie. This catastrophe having taken place,Dumoulin’s colleague, terrified at the im.

pending penalties, anxiously inquired ofhim by what door they should get out," By the door they pay at," said Dumoulin,and followed by the other, he boldly tra

versed the hall, and went to demand hisfee.