WOUNDS. 



than by attempting the cure without that operation. 

 " When the bone appears, on a careful examination, to be 

 broken without being much fplintered, and when the patient 

 can be removed eafily to a place of reft and fafety, it may 

 be right to attempt to preferve the limb ; but if the bone be 

 much fplintered, or if the conveyance is to be long or un- 

 certain, it will, in mod inltances, I am convinced, be a 

 much fafcr praftice, even in fraftures of this part of the 

 thigh-bone, to amputate without delay. 



" Mullvet-bullets, in paffing through the femur, near to 

 the knee-joint, produce fifTures of the condyles, which 

 generally communicate with the joint. Thcfe cafes, like 

 thofe in which the bullets have paffed direftly through the 

 joint, require immediate amputation. 



" The writings of military furgeons contain but few 

 hillories of cafes in which the thigh-bone had been fraftured 

 above its middle by the paflage of mu.Ovet-buUets. Thefe 

 are cafes, I believe, which have generally had a fatal ter- 

 mination ; and the danger attendant upon the amputation 

 which they require, feems long to have deterred furgeons 

 from attempting to afcertain what advantages might be 

 derived from the employment of that operation. Schmucker 

 recommends and ftates, that he had praftifed with fuccefs 

 immediate amputation in thofe cafes, in which a fufEcient 

 fpace was left below the groin for the application of the 

 tourniquet. It is curious to remark, in the hillory of am- 

 putation, how long furgeons were in difcovering the eafe 

 and fafety with which the femoral artery may be com- 

 preffed by the fingers, or pads, in its paflage over the brim 

 of the pelvis. Boy, from the immediate danger, protrafted 

 fuffering, and ultimate want of fuccefs, which he had ob- 

 ferved to follow this kind of injury, urges ftrenuoufly the 

 propriety of immediate amputation : Mr. Guthrie's opinion, 

 with regard to the dangerous nature of thefe injuries, and 

 the advantages to be derived in them from immediate am- 

 putation, coincides in every refpeft with thofe of Schmucker 

 and Boy. He obferves, that thofe whofe thigh-bone has 

 been fraftured in its upper part by a mufliet-bullet, gene- 

 rally die with great fuffering before the end of the fixth or 

 eighth week ; and that few even of thofe efcape, in whom 

 that bone has been fraftured in its middle part. Of the 

 few whom we faw, who had furvived gun-fliot fraftures in 

 the upper part of the thighbone in Belgium, fcarcely any 

 one could be faid to be in a favourable condition. In all, 

 the limbs were much contrafted, dillorted, and fwollen, 

 and abfcefles had formed round and in the neighbourhood of 

 the fraftured extremities of the bones. In feme inftances, 

 thefe abfcefles had extended down the thigh ; but more 

 frequently they pafled upwards, and occupied the region of 

 the hip-joint and buttocks. In feveral inftances in which 

 incifions had been made for the evacuation of matter, the 

 fraftured and exfoliating extremities of the bones fometimea 

 comminuted, and fometimes forming the whole cylinder, 

 could be felt bare, rough, and extenfively feparated from 

 the foft parts vsrhich furrounded them. In otlier iiillances, 

 thefe extremities were partially inclofed in depofitions of 

 new bone, which, from the quantity thrown out, feemed to 

 be prefent in a morbid degree. It was obvious, that in all 

 of thefe cafes, feveral months would be required for the 

 re-union of the fraftured extremities ; that in fome much 

 pain and mifery were fl;ill to be endured from the procefles 

 of fuppuration, ulceration, exfoliation, and ejcftion of 

 dead bone ; that in fome cafes, the patients were incurring 

 great danger from heftic fever, and from diarrhoea ; that 

 the ultimate recovery in moft of them was doubtful ; and 

 that of thofe in whom this might take place, there was but 

 little probability that any would be able to ufe their limbs ! 



The fight of thefe cafes (fays Dr. Thomfon) made a deep 

 impreffion upon my mind, and has tended to increafe my 

 convidtion, that this is, of all others, the clafs of injuries ui 

 which immediate amputation ia moft indifpenfably re- 

 quired." See Report of Obfervations made in the Military 

 Hofpitals in Belgium, p. 254—258. 



Dr. Thomfon adds, that what has been faid of the danger 

 of fraftures produced by muficet-bullets in the upper part 

 of the femur is true, in a ftill greater degree of thofe which 

 have their fL;at in the neck or head of that bone. In fuch 

 inftances. Dr. Thomfon joins the generality of modern army 

 furgeons, in ftroagly recommending amput-ation at the hip- 

 joint. 



Of Gun-Jl}ot Wounds in 'which Amputation may be deferred. 

 — If, fays M. Larrey, it be poffible to fpecify the cafes in 

 which amputation ought to be immediately performed, it is 

 impoffible to determine h priori thofe which will require 

 the operation fubfequently. One gun-(hot wound, for ex- 

 ample, will be cured by ordinary treatment, while another, 

 that is at firft kfs fevere, will afterwards render amputation 

 indifpenfable, whether this be owing to the patient's bad 

 conftitution, or the febrile complaints which are induced. 

 However this may be, the fafe rule for fulfilling the indica- 

 tion that prefents itfelf, is to amputate confecutively only iu 

 circumftances in which every endeavour to fave the limb is 

 manifeftly in vain. Upon this point, M. Larrey's doftrine 

 differs from that of M. Faure. 



The latter praftitioner admits cafes, which he terms cafes 

 of the fecond kind, in which he delays amputation, not with 

 any hope of faving the limb, but in order to let the firft 

 fymptoms fubfide. The operation done between the 

 fifteenth and twentieth day, appears to him lefs dangerous 

 than when performed immediately after the receipt of the 

 injury. At the above period, according to M. Faure, the 

 commotion occafioned by the gun-(hot injury is difpelled ; 

 the patient can reconcile himfelf to amputation, the mere 

 mention of which fills the pufiUanimous with terror in a 

 greater or leffer degree ; the debility of the individual is no 

 objedlion ; and it is laid down as an axiom, " that the con- 

 fequences of every amputation, done in the firft inilancc, 

 are in general extremely dangerous." In fupport of this 

 theory, M. Faure adduces ten cafes of gun-fliot injuries, in 

 which, after the battle of Fontenoy, the operation was 

 delayed, in order that it might afterwards be performed 

 with more fuccefs ; a plan which, according to the author, 

 proved completely fuccefsful. See Prix de I'Acad. de 

 Chirurgie, tom. viii. edit, in i2mo. 



This divifion of the cafes for amputation into two clafTes, 

 not confiftent with nature, obferves M. Larrey, has been 

 the caufe of a great deal of harm. Very often the partifans 

 of M. Faure have not dared to refort in the firft inilance to 

 amputation, the dangers of which they exaggerate ; while, 

 on other occafions, they amputate confecutively, without 

 any fuccefs. 



The effefls of commotion, inftead of increafing, gradually 

 diminifti and difappear after the operation. It is proved, 

 fays he, that the commotion, fo far from being a counter- 

 indication to immediate amputation, is a reafon that Jhoald 

 incUne the furgeon to operate. Such was the fentiment of 

 La Martini^re and Boucher. 



Neither ought the patient's alarm to be a reafon for 

 poftponing the operation ; for according to M- Larrey, the 

 patient juft after the accident will be much lefs afraid of 

 the rifl{ which he has to encounter, than after the expiration 

 of the firft four-and-twenty hours, when he has had time to 

 rcfleft upon the confequences of the injury, or of amputa- 

 tion. This remark lias been made by the illuftrious Pare. 

 5 A 2 " Espe- 



