, 1867-01-11

Nc late Amputallon--lo Anesceuen.A
rn,-o, SrArKsNAK :-Ihav read with cons
.,a.,.hle interest the account which in your
Last issue, you gave the public of the eircum-
,,.,.., amending the demise Of the late Mrs. I
Athaliah Lancaster.
A there Is q statement or two in the aeeount
whieh refscts unfavorably on the professional
character OF one of the three physicians who
,ueeesuiyely attended the patient previous to the
gentleman who performed the amputation and
Also ,Ome pcihts Of importance to the public
nth r.ferenss to the operation itself, which de-
mad notice; request space in your columns
tor 4 brief review Of the main points Of the
ease. Befofe doing 30, however, visa to state
nv arm cdhvietion that your account was
.rus reflection Of the information which you re-
eeived /; nor have any evidence that there has
been any wilful mistatsmsnt BY any person.
But the general public, who know but little Of
surgical matters, are consequently, liable at all
dm.s to come to wrong conclusions, in refer
eucs to what is right and p.oper in the treat
meut Of cases requiring surgical skill. 1t is,
think, to be regretted, that knowledge Of this
| kind Is not more generally possessed, both for
| the interests of the profession and the public.
Space does not permit me, however at this
time to say anything further on this point.
There is = line somewhere which directs US
To treat a delicate subject delicately. 10 treat.
| inr Of this subject, which lie delicate enough,
| 1haIl endeaVor to observe the adage, but shall
| aIso act on the belief that the truest delieacy
often consists in the use of the plainest words.
Taking the general history Of the case as re-
ported in the Statesmdn, as being in the main
| correct. | shall consider firstly the disloca-
l b kaw rrad AT IL me- nj
fall from the crutch secondly, the disease
which followed, and lastly the smputation.
| DEDICATION Of the knee joint may be partial or
| complete. Ifthe reader will imagine, straight,
| somewbat rounded stick Of wood, about three
| inches In diameter sawed across, and then the
sawed ends moved until they overlap, be will
| have an Dea of q complete dislocation Of the
knee. The deviation from . straight line will
| be As much in the one case as in the other.
| Therefora 10 the case under consideration, the
disIocation could not have been complete or it
would have been seen by everybody. lfthe saw
cd ends of the stick are replaced and one Of them
moved quarter of an inch or so lsterally, tneu
the idea Of partial dslOcation will be formed.
1 But there was a partial dislocatiou discovered
some considerable time afterwards, which is
easily accounted for by the ravAges Of ulcera-
ton ADD modification, destroying and relaxing
| to q great extent the ligaments and other soft
parts in and around the joint, making it mere
incident of the disease. Bat, If we admit the
occurrence of the partial dislocaIion at the
time Of the fall and its continuing unreduced, 1t
would be altogether insufficient to cause the
modification Of the limb. The effects of such
diSlocations being confined to the oint consists
ing of inflammation which subsidies after
while, scarcely ever ending even in the forma-
tion Of common ''mattsr" (pus). So much for
the dislecation.
Now for the modification and Amputation.
| III L. 4, af
and itutienal." The term 'local" has
been applied to modification arising from local
injury, such as mechanical violence Of severe
character-Such as fracture of the bones with
tearing or other injury Of the flesh, etc,
and other similar causes.
The term t'coustitutional" has been apPlied to
modification arising from some unhealthy state
of the general system. 1t may develop itself
spontaneously attacking an apparently healthy
part, or may follow some slight injury of the
part. The "local" variety is generally very
rapid in its course. 1t may prove fatal in few
hours or days The CONSTITUTIONAL is not so
rapid 10 its course. To which class then does
our case belong? 1t was undoubtedly "constitu
tiOnAl." The disease was not confined 10 the
leg. The whole system was at fault. This
point 10 Of great import lnce, as will be soon
seen. The existence of the disease cannot be
accounted for by the simple fall from the crutch
TO the floor, but it was aggravated t;by.
We are told that the knee was attacked by in
6anlAtioH, said to be rheumatic but rheumatic
inflammation scarcely ever ends in the formation
of 'mAtter." 1t was, probably, common infla-
nation, for matter WAS formed considerable
time elapsed before medical aid was sought.
The joint became dstended with fluid.
So it will be seen that the leg was attack,
ed at The knee by destructive Inflammation,
some time before any injury rds received by the
fall. Nov forthe amputatiOu. And may re.
| mark here for inf fornati0n hat he I'M,
putation Of limb is one OF the simplest opera
tionI in surgery Its reputation for being difficult
is owing to its seriousness as regards its conse.
quences, and the circumstances which render
necessary. OF course if it was right to ampu-t
tate at all, it would have been better to have
done so early. But it was not right to anputate
either early or late. More than this, it WAS de-
eidsdy wrong. 1t was wrong not only because,
a. shall presently show, common sense afirms
il, or because ], 90 my own experience say so.
But it WAS wrong because that the recorded expe-
ence Of the best authorities on the subject, 10
England and America unanimously pronounce 1t
so, among whom may mention the names oil
Druit, Gross and Miller. Druit, says In his
Modern Surgery" that the sold rule in cases
Of constitutional modification is still good, viz;
TO wait until the modification is arrested and
line Of demarcation formed, otherwise the dis
ease may form tue stump. But even after
the morti6caIion has stopped, it is necessary to
| tAke care tnAt tno pAueut uhs NlBOI ehOuBu "
bear the loss Of blood which must IN some de-
gree necessarily snsue." Miller, in his "Princi-
Piles Of Surgery" says; olive amputate during
progress [of the modification it is most likely
that We shall be cutting in parts foredoomed.
Therefore we wait not only
until the line Of demarcation has been made,
and separation begun but until the latter has
been in good measure completed, assisting Ma
tuFo . -amputation, rather than operating ours
selves" ETC., etc. Gross, in his 'System Of
Surgery" says ''In constitutional modification
the rule now is never TO amputate until the snr
gson is assured BY the establishment Of line
Of dsmArcatiOn that both the part aud system
are in . condition TO bear the shock Of the ope.
ration, aud the modification has been complete
ly arrested" Even further delay may be de-
mandsd, IL upon careful investigation 1t be
fonnd that the patient is still feeble from the
effects Of the modification. To amputate un.
der such circumstances would greatly endsnger
the result, If not positively destroy the patient.
Even If We consider the case as arising from
msehanical injury, and therefore '1ocal," great