WOUNDS. 



are lacerated, the nerves immoderately ftretched, and thrown 

 into a ilate of ftupor ; the mufcles are deprived of their 

 tone ; and the circulation and fenCbility in the limb are 

 obftrufted. Before deciding, however, M. Larrey cautions 

 us to obferve attentively the fymptoms which charafterize 

 this kind of diforder. This cafe can be fuppofed to happen 

 only in the leg, where the bone is very fuperficial, and 

 merely covered at its anterior part with the flcin. 



The following are defcribed as the fymptoms : the limb 

 is infenfible, the foot cold as ice, the bone partly expofed, 

 and on careful examination, it will be found that the integu- 

 ments, and even the periofteum, are extenfively detached 

 from it. The commotion extends to a confiderable dif- 

 tance ; the funftions of the body are difordered ; and all 

 the fecretions experience a more or lefs palpable dilturb- 

 ance. The intelleftual faculties are fufpended, and the cir- 

 culation is retarded. The pulfe is fmall and concentrated, 

 the countenance pale, and the eyes have a dull moift ap- 

 pearance. The patient feels fuch anxiety, that he cannot 

 long remain in one pofture, and requefts that his leg may 

 be quickly taken off, as it incommodes him feverely, and he 

 experiences very acute pain in the knee. When all thefe 

 charafteriflic fymptoms are conjoined, fays M. Larrey, we 

 fhould not hefitate to amputate immediately ; for the leg 

 would be attacked with fphacelus the fame day, and the 

 patient would certainly perifh. 



M. Larrey next adduces feveral interefting cafes in fup- 

 port of the preceding obfervations. 



Eighth cafe. When a large gynglimoid articulation, fuch 

 as the elbow, or efpecially the knee, has been extenfively 

 opened with a cutting iriftrument, and blood is extravafated 

 in the joint, M. Larrey deems immediate amputation ne- 

 ceflary. In thefe cafes, the fynovial membranes, the liga- 

 ments, and aponeurofes, inflame, the part fwells, and 

 erethifmus rapidly takes place ; and acute pains, abfcefles, 

 deep finufes, caries, febrile fymptoms, and death, are the 

 fpeedy confequences. M. Larrey has feen numerous fub- 

 jefts die of fuch injuries, on account of the operation having 

 been poftponed with a hope of faving the limb. In his 

 Memoires de Chirurgie Militaire, torn. ii. fome of thefe are 

 detailed. 



Although a wound may penetrate a joint, yet if it be 

 fmall and unattended with extravafation of blood, M. Larrey 

 informs us, it will generally heal, provided too much com- 

 preflion be not employed. This gentleman believes in the 

 common doftrine of the pernicious effeft of the air on the 

 cavities of the body ; yet, in this place, a doubt feems to 

 affeft him : fpeaking of the lefs danger of fmall wounds of 

 joints, he fays, " a quoi tient cette difference, puifque Pair 

 pen^tre dans I'articulation dans I'un comme dans I'autre 

 cas ?" 



When two limbs have been at the fame time fo injured 

 as to require amputation, we fhould not be afraid of am- 

 putating them both immediately, without any interval. We 

 have, fays M. Larrey, feveral times performed this double 

 amputation with almoft as much fuccefs as the amputation 

 of a Angle member. He has recorded an excellent cafe in 

 confirmation of this ftatement. Mem. de Chirurgie Mili- 

 taire, torn. ii. p. 478. 



When a limb is differently injured at the fame time in two 

 places, and one of the wounds requires amputation, (fup- 

 pofe a wound of the leg with a fplintered frafture of the 

 bone, and a fecond of the thigh, done with a ball, but with- 

 out any frafture of the os femoris, or otlier bad accident, ) 

 M. Larrey recommends us, firft to drefs the fimple wound 

 uf the thigh, and amputate the leg immediately afterwards, 

 if the knee be free from injury. When it is neceffary to 



amputate above this joint, the lefs important wound need 

 not be dreffed till after the operation, provided it can be 

 comprehended in the fedlion of the member, or be fo near 

 the place of the incifion as to alter the indication. When 

 the wound demanding amputation is the upper one, the 

 operation of courfe is to be done above it, without paying 

 any regard to the injury fituated lower down. 



M. Larrey, however, approves of deferring the operation, 

 when delirium, convulfions, and inflammation, prevail on the 

 firft receipt of the injury. In this circumftance, we are 

 advifed to take meafures for appeafing thefe accidents ; the 

 progrefs of nature is to be carefully obferved ; and the 

 firft moment of quiet is to be taken advantage of for the 

 performance of the operation. See Larrey'i Mem. de 

 Chirurgie MiUtaire, torn. ii. p. 45 1, &c. 



Ninth cafe. To the foregoing fpecics of gun-fhot 

 wounds, pointed out by M. Larrey as urgently requiring 

 immediate amputation, are to be added compound fraftures 

 of the thigh from gun-fhot violence. 



" Gun-fhot fraflures of the thigh," fays Dr. J. Thomfon, 

 " have been univerfally allowed to be attended with a high 

 degjree of danger ; indeed, till of late years, very few in- 

 ftances have been recorded of recovery from thefe injuries. 

 Ravaton acknowledges, that in his long and extenfive ex- 

 perience, he had never feen an example of recovery from a 

 gun-fhot frafture of the thigh ; and Bilguer, in his calcu- 

 lations with regard to thofe who recover from gun-fhot 

 fraftures, fets afide thofe of the thigh-bone, as being of a 

 nature altogether hopelefs. In the prefent improved ftate 

 of military furgery, inftances not unfrequently occur of 

 recovery from this frafture ; but of thefe, the number will 

 be found, I believe, to be exceedingly fmall, in comparifon 

 with thofe who die, particularly when the frafture has had 

 its feat above the middle of the bone, &c." 



According to the obfervation of Percy, fcarcely two of 

 ten recover of thofe who have fuffered gun-fhot fraftures of 

 the thigh-bone. Mr. Guthrie fays, that " upon a review of 

 the many cafes which I have feen, I do not believe that more 

 than onc-fixth recovered fo as to have ufeful limbs ; two- 

 thirds of the whole died either with or without amputation ; 

 and the limbs of the remaJning fixth were not only nearly.' 

 ufelefs, but a caufe of much uneafinefs to them for the re-<^ 

 mainder of their lives." See Guthrie on Gun-fhot Wounds,! 

 p. 191. 



" In fraftures by mufliet-bullets of the lower part of the 

 thigh-bone (fays Dr. Thomfon), recovery not unfrequently 

 takes place ; and both Schmucker and Mr. Guthrie con-j 

 ceive, that they are injuries in which amputation may be 

 delayed with fafety. It would be very agreeable, that this 

 opinion fhould be confirmed by future experience ; but ie 

 appears to me, that before it can be received as a maxim in 

 military furgery, much more extenfive and accurate obferva^ 

 tion than we yet poffefs wUl be required, with regard to 1 

 the proportion of thofe who recover without amputation, 

 or after fecondary operations, and of thofe who recover 

 after primary amputation. Of thofe who iiad fuffered 

 this injury, we favv, comparatively, but a fmall number 

 recovering in Belgium, and they had been attended with 

 fevere local and conllitutional fymptoms." See Report of 

 Obfervations made in the Military Hofpitals in Belgium, 

 p. 247, etfiq. 



Balls often produce fiffures of fgveral inches in length in 

 the thigh-bone. This is a ftate, obferves Dr. Thomfon, 

 which muit be very unfavourable to recovery ; and his con- 

 clufion is, that in general, even in fraftures o,f the lower 

 part of the thigh-bone, a greater number of lives will be 

 preferved in military praftice by immediate amputation, 



6 than 



