WOUNDS. 



tion ; for altlioiigli many patients would recorer from 

 either accider.t alone, none would furmount the two united, 

 and the higher the accident is in the thigh, the more im- 

 perious is the neceffity for amputation. 



Fourth cafe. A large bifcayen ftrikes the thick part of 

 a member, breaks the bone, divides and tears the mufclcs, 

 and deftroys the large nerves, without, however, touching 

 the main artery. According to M. Larrey, this is a fourth 

 cafe requiring immediate amputation. 



Mr. Guthrie alfo fays, that " if a cannon-fhot ftrike the 

 back part of the thigh, and carry away the mufcuiar part 

 behind, and with it the great fciatic nerve, amputation is 

 neceflary, even if the bone be untouched, &c. In this 

 cafe, I would not perform the operation by the circular 

 incifion, but would preferve a flap from the fore part or 

 fides, as I could get it, to cover the bone which fhould be 

 fhort." Guthrie on Gun-(hot Wounds of the Extremities, 

 p. 184. 



Fifth cafe. If a fpent cannon-lhot, or one that has been 

 reflefted, (hould ftrike a member obliquely, without pro- 

 ducing a folution of continuity in the Ikin, as often happens, 

 the parts which refift its aftion, fuch as the bones, mufcles, 

 tendons, aponeurofes, and vefTels, may be ruptured and 

 lacerated. The extent of the internal diforder is to be 

 examined ; and if the bones Ihould feel through the foft 

 parts as if they were fmalhed, and if there (hould be reafon 

 to fiifpeft from the fwelhng, and -a fort of fluftuation, that 

 the veffels are lacerated, amputation ought to be imme- 

 diately praftifed. We learn from M. Larrey, that this is 

 alfo the advice of M. Percy, an eminent French army fur- 

 geon. Sometimes, however, the veflels and bones have 

 efcaped injury, and the mufcles are almoil the only parts 

 difordered. In this circumftance, we are enjoined to follow 

 the council of M. La Martini^re, who recommended making 

 an incifion through the fldn. By this means, a quantity of 

 thick blackifh blood will be difcharged, and the prac- 

 titioner mull await events. According to M. Larrey, fuch 

 incifion is equally neceflary in the preceding cafe before 

 amputation, in order to afcertain the extent of the mifchief 

 which the parts have fuftained. 



It is to fuch injury done to internal organs, that we muft 

 afcribe the death of many individuals, which was for a long 

 while attributed to the commotion produced by the air put 

 in motion by the ball, when this, in grazing upon different 

 parts of the body, alters them, or cuts off the column of 

 air which is to ferve for refpiration, juft at the moment 

 when it is about to enter the cheft. See Ravaton's Traitc 

 des Plaies d'Armes a Feu. 



But to return to the objeft of our prefent confideration. 

 M. Larrey expreffes his belief, that what have been erro- 

 neoufly termed ivind contujions, if they are attended with 

 the mifchief above fpecified, require immediate amputation. 

 The leaft delay makes the patient's prefervation extremely 

 doubtful. The internal injury of the member may be 

 afcertained by the touch, by the lofs of motion, by the 

 little fenfibility retained by the parts which have been 

 ilruck, and, laftly, by praftifing an incifion, as already re- 

 commended. 



Sixth cafe. When the articular heads are much broken, 

 efpecially thofe which form the joints of the foot or knee, 

 and the ligaments, which ftrengthen thefe articulations, are 

 broken and lacerated by the fire of a howitzer or by a 

 bifcayen, or other kind of ball, immediate amputation, fays 

 M. Larrey, is indifpenfable. According to this expe- 

 rienced writer, the fame indication would occur, were the 

 ball lodged in the thicknefs of the articular head of a bone, 

 or were it fo engaged in the joint as not to admit of being 

 Vol. XXXVlfl. 



extrafted by fimple and ordinary means. ( See alfo Guthrie 

 on Gun-fhot Wounds, p. 197.) Putting out of confider- 

 ation cafes in which the injury has been done by a clean 

 cutting inftrumcnt, or in which a fmall ball has pafTed near 

 or partially injured a joint, another experienced army fur- 

 geon alio lays it down as a law in military furo-ery, that 

 no lacerated joint, particularly the knee, anile, or elbo'ws,Jhould 

 ever leave thefeld unamputated, 'where the patient is not obviotijly 

 finking, and confequently ivhere certain death 'would follotv the 

 operation. (Hennen's Military Surgery, p. 42.) And ih 

 another place he tells us : " In my own praftice, I have 

 met with only two cafes, where the limb was faved after a 

 ferious injury of tlie knee-joint ; and in one of them only 

 was the perfedl ufe of it reftored. I never met with an 

 inftance where the ankle or elbow-joint was perfeftly re- 

 ftored after fevere injury, though fome where the limb has 

 been faved. Of the fhoulder-joint the recoveries are more 

 frequent." P. 159. 



Fraftures extending into the joints, and accompanied 

 with great laceration of the ligaments, were cafes of gun- 

 fhot injuries pointed out by M. Faure as indifpenfably 

 requiring immediate amputation. (See Prix de I'Acad. de 

 Chir. torn. viii. ) Thus we fee, that this author was not fo 

 averfe to early aniputation as feveral modern writers have 

 reprefented. 



It is only in this manner, that the patients can be refcued 

 from the dreadful pain, the fpafmodic afFeftions, the violent 

 convulfions, the acute fever, the confiderable tenfion, and 

 the general inflammation of the limb, which, M. Larrey ob- 

 ferves, are the invariable confequences of bad fraftures of 

 the large joints. But, adds this author, if the voice of ex- 

 perience be not liftened to, and amputation be deferred, the 

 parts become diforganjzed, and the patient's life is put into 

 imminent peril. 



It is evident, fays he, that, in this cafe, if we wifh to pre- 

 vent the patient from dying of the confequent accidents, 

 aniputation fhould be performed before twelve or at moll 

 twenty-four hours have elapfed : even M. Faure himfelf 

 ppofefled this opinion, in regard to certain defcriptions of 

 injury. Mem. de Chir. Militaire, tom. ii. 



With refpeft to wounds of the knee, the fentiments of 

 Mr. Guthrie nearly coincide with thofe of M. Larrey. 

 " I moft folemnly protcft (fays Mr. G.) I do not remem- 

 ber a cafe do well, in which I knew the articulating end of 

 the femur, or tibia, to be fraftured by a ball that paffed 

 through the joint, although I have tried great numbers, 

 even to the laft battle of Touloufe. I know that perfons 

 wounded in this way have lived ; for a recovery it cannot 

 be called, where the limb is ufelefs, bent backward, and a 

 conftant fource of irritation and diftrefs, after feveral months 

 of acute fuffering, to obtain even this partial fecurity from 

 impending death ; but if one cafe of recovery fhauld take 

 place in fifty, is it any fort of equivalent for the facrifice of 

 the other forty-nine ? Or is the preferving of a limb of this 

 kind an equivalent for the lofs of one man ?" On Gun-fhot 

 Wounds, p. 196. 



Mr. Guthrie admits, that fraftures of the patella, with- 

 out injury of the other bones, admit of delay, provided the 

 bone is not much fplintered. 



Seventh cafe. According to M. Larrey, if a large 

 bifcayen, a fmall cannon-fhot, or a piece of a bomb-fhell, in 

 paffing through the fubftance of a member, fhould have ex- 

 tenfively denuded the bone, without breaking it, amputation 

 is equally indicated, although the foft parts may not appear 

 to have particularly fuffered. Indeed, the violent concuf- 

 fion produced by the accident has fhaken and diforganized 

 all the parts ; the medullary fubftance is injured, the veffels 

 5 A are 



