Lectures on Hospitalism: And the Causes of Death after Operations

J. E. Erichsen
1874 BMJ (Clinical Research Edition)  
IN the last lecture, I pointed out to you the percentage of mortality that still prevails after the major amputations. The figures that I laid before you admit of no doubt or cavil, as they have been drawn from the statistical reports which are now annually published by the officers of many of our hospitals: their accuracy cannot, therefore, be questioned. They prove incontestably that the average mortality after amputations in general hospitals in this country, taken as a whole, is from 35 to
more » ... ole, is from 35 to 40 per cent., whilst the available continental returns show a much higher rate. I also pointed out to you the important fact, that there has been no diminution in this rate of mortality during the last thirty-five years; that it is, in fact, higher than that furnished by statistics then published. If the figures are correct-and for the reason given I have no doubt of their accuracy-the deductions I have made from them are legitimate. To-day we will proceed to inquire into the most important question of all-viz, the causes that have led to the production, and are still leading to the perpetuation, of so lamentable and unsatisfactory a result. These causes may, by a reference to any published statistical table of Hospital Reports, be found to arrange themselves under four distinct heads. First, there are certain conditions inherent in the operation itself which dispose to, or directly determine, a fatal result; as, for instance, the exposure of the membranes of the brain in trephining, the opening of the peritoneum in operations for hernia, or the deep cellular planes of the pelvis in lithotomy. To these conditions it is sufficient to advert, and no description of them is rendered -necessary, as they explain themselves. But it is well to bear in mind that the ipfluence of such direct conditions as these is much increased by the complication of septic agencies. Secondly, we have a series of causes which exercise a very minute influence upon the general rate of mortality, although they are individually serious and important; such, for instance, as tetanus, secondary hsemorrhage, etc. But undoubtedly the two principal causes that determine death after the greater operations, such as amputations, ovariotomy, and others of the more important operations, are-Shock and Septic Disease. -The influence of these in amputations is well marked. Out of the 8o cases occurring at University College Hospital, which form the basis of these observations, I find that there were 3 deaths from shock (all primary), and Io from pysemia and erysipelas; leaving oDly 8 deaths to be accounted for by exhaustion and the other minor and more varied causes that I have mentioned. On referring to Table B , we shall find that of a total of 63I amputations, IIO died from shock and py:emia together, or 17.5 per cent. of the whole operated on; whilst of the 239 deaths, 48 per cent. were from the combined influence of these two causes-and this is irrespective of those that are reported as dying of "exhaustion", which is closelyallied to shock, or from " erysipelas", " low cellulitis", and other forms of septic disease than pyaemia. This terrible disease proved fatal in as nearly as possible 36 per cent. of all the deaths, and shock in about lo per cent. of the deaths, or in 3.8 per cent. of all amputations. But the respective influences of these two great causes of death after amputations will be found not only to vary very greatly according as the operation is primary, secondary, or for disease, but also to exercise very different degrees of influence in different hospitals, as may be seen by Table B. Shock was most felt in primary amputations, in the proportion of 25 per cent. of the deaths; was but little fatal in secondary amputations, 6 per cent.; and was entirely absent as a cause of death in pathological amputations. Pysemia was fatal in about one-third, or 33 per cent., of the pnrmary amputations; in 44.4 per cent. of the secondary; and in those for disease it again acquired nearly the level of the primary-viz., 34.6 per cent. We shall proceed to consider these two conditions more in detail; and, first, with regard to shock. The influence of shock is necessarily most felt in primary amputations. Indeed, I believe that its fatal results are almost entirely confined to amputations performed within twenty-four hours of the inflic. tion of the injury; at least, I have never known a case of intermediate or secondary amputation, or amputation for disease, in which the patient died from this cause. Fatal shock, in fact, is the result of the combineddepressing influence of the injury and of the operation. It is the more likely to occur in the exact proportion of the severity of the injury and the age of the patient. It is often rather referable to the injury than to the operation, and it becomes a question whether, in many cases of serious and almost hopeless smash of a limb, it might not be better to let the patient expire in peace, than subject him to the repetition of a shock which his nervous system will be utterly unable to endure. This is more especially the case in extensive crush and disorganisation of the lower extremity up to, or above the middle, of the thigh, such as are not unfrequent at the present day from railway accidents, in which the mangling of the limb rather resembles that produced by cannon-shot than by an ordinary injury of civil life. In these cases, amputation through the upper third of the thigh, or at the hip-joint, is the only available operation. It is usually done in such cases. But is it ever successful? That is a question which deserves the serious consideration of hospital surgeons. I am not acquainted with a single case in which such an operation has succeeded in general hospital practice. The three cases in which it was done, out of the eighty University College cases, all died of shock. The same catastrophe has happened in every other case on record with which I am acquainted. It is an operation that has been abandoned by military surgeons in cases of compound comminuted fracture of the femur from bullet-wound in this situation; ought it not to be equally discontinued by civil surgeons, in those more hopeless cases of utter smash of the limb that occur in their practice? For my own part, I shall never again amputate in that situation for such injuries-hopeless alike, whether left or subjected to the knife; but surely better left to die in peace than again tortured by amputation, which all experience has shown to be useless. It is of importance to observe, in reference to these cases of death from shock after primary amputations, that the fatal result happens a few hours, usually within twenty-four, of the performance of the operation. Hence, although it may be disposed to by the previous condition of the patient as to his power of endurance, his age, etc. (for death from shock necessarily occurs more frequently under similar conditions of injury at advanced than at early periods of life), or even by season of year, yet it cannot in any way be affected by the conditions to which the patient is exposed subsequently to the performance of the operation, so far at least as hospital or other external influences are concerned. We must therefore look upon death from shock as a part of the general accident to which the patient has been exposed and of the injury that he has sustained, aggravated, doubtless, by the further depressing influence exercised by so serious an operation as an amputation possibly high up in one of the limbs. It is interesting to observe that season exercises an influence on the liability to death from shock after primary amputations. According to Hewson of Philadelphia, it is most common in winter. The reason is obvious; the cold, to which the sufferer has been exposed at the time of the occurrence of the accident for which he has to undergo an amputation, is an additional cause of vital depression. If, therefore, we want to improve our statistics of amputations-in other words, to lessen the mortality consequent on these operations-the first point to look to is not to amputate needlessly in hopeless cases of smash of the thigh high up, in order to give "a last chance" to a patient whose vital powers have already been depressed to the lowest ebb by a fearful mutilation. Such amputations, which often consist in little more than the severance of a limb still attached to the trunk by shreds of muscle, ought scarcely to find their way into a statistical table professing to give the general results of operations the majority of which are.more deliberately performed, and THE BRITISH MEDICAL -7 0URNAL. 97 Jan. 24, 1874.]
doi:10.1136/bmj.1.682.97 fatcat:vv3droz2cbajvfnquiwyx6fwk4