Imatges de pàgina
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The objections made to this appear to have been founded chiefly on theoretical grounds;-these are examined and refuted in a very luminous and satisfactory manner by Mr Guthrie; but the argument drawn from actual, extensive, and general experience is so paramount, as to render all other exposition of the merits of the question most unnecessary in this place.

At first sight, indeed, it is obvious that, if a man must lose a limb, he had better lose it immediately, than after three or four weeks of pain, and suffering, and fever, and inflammation, suppuration, gangrene, and danger. It is certain also, that, in this struggle, many would die before the period of his last chance for recovery by amputation could arrive; but even this period, when the patient has survived and attained it, is less favourable for the operation than the moment when the accident was received; and, of any equal numbers of operations performed, the one number on the field of battle, and the other at the secondary period, it appears in evidence, that a far greater proportion of the former recover than of the latter. As the most satisfying proof of this leading fact, we shall content ourselves with exhibiting the following tables from the book now before

us:

Return of the capital operations performed at the hospital stations, between the 21st of June and the 24th December, 1813, of the army under the command of his Excellency Field-Marshal the Duke of Wellington; being a period of six months, from the advance of the British army from Portugal, until its establishment in winter quarters in front of Bayonne.

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75

Amputation of the upper extremities, 296 116 105
Lower extremities.......

255 149 65 41

Total number of operations..........

The operations at the shoulder-joint not included.

551 265 170 116

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"Return of the capital operations performed in the same period on the field of battle, and for the most part kept in regimental and divisional hospitals.

5

Amputation of the upper extremities. 165
Lower extremities............................. 128 19 43

Number operat

ed upon.

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Upper extremities........
Lower extremities..........................................

Of which died.

Discharged,
cured.

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Total number of operations...........

291

24 107 160

"The cases marked "under cure," in both statements, having passed the period of danger, are considered as recovered; and from this it will appear that the comparative loss, in secondary or delayed operations, and primary or immediate operations, is as follows:

3

to 1

..............................................................

Secondary. Primary. Upper extremities ............... 12 to 1 Lower extremities "This difference is certainly very remarkable, and it is so well known to all the surgeons of the British army, as a constant occur. rence, that there is no longer among them any doubt on the subject; and the following statement of operations performed on officers and soldiers, in consequence of the battle of Toulouse, will probably be even more satisfactory; as the medical duties both in the field on the day of action, and in the hospitals afterwards, until the final evacuation of Toulouse, were more immediately under my observation and controul.

"Primary Operations on the Field of Battle.

Number operat

ed upon.

7

40

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64

Of which died.

18

Under cure.

Cured.

94

66

6

32

Total of primary amputations....... 47 9 38

"Of the eight that died of amputation of the lower extremity, three were shortly after the operation; which was performed as high as possible in the thigh by the circular incision, and one officer.

"Secondary or delayed operations in General Hospital.

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Number operated

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upon.

15

Upper extremities......
Lower extremities............

36 18

Total of delayed, or secondary amputations. 51 21

Of which died.

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from

Discharged cnred,
or considered out
of danger when
transferred

Toulouse.

12

18

30

The reasons of this difference of success are, that, in the primary operations, the amputations have been performed on a healthy subject, and on sound soft parts; and hence the stump generally heals by the first intention, and without accidents. In the secondary amputations, on the contrary, the health has been broken by much suffering for three weeks, or more; and the soft parts which are cut by the surgeon have been altered by inflammation; hence the stumps seldom heal without suppuration; often they ulcerate; and sometimes the limb becomes gangrenous, or the patient is attacked with fever, and dies from internal suppurations.

On the subject of gangrene we have also some excellent and judicious observations from Mr Guthrie; and especially from one kind of gangrene peculiar to gun-shot wounds of the extremities, that which is the consequence of the wound of the principal arteries of a limb. The gangrene in this case commonly begins in the lower part of the limb, below the wound, perhaps in the toes and fingers, and spreads upwards; and the experience of Mr Guthrie leads him to conclude, that this case forms an exception to the general rule of waiting in gangrene for the line of separation, before proceeding to amputate.

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Hlaving lost all the cases of gangrene succeeding to wounds of arteries, and other cases of greater injury, in which it supervened on the third or fourth day without much previous inflammation; I be gan to think it an error to wait for the line of separation, when there appeared but little prospect of its formation. Iu two cases after the battle of Salamanca, in which I had reason to think the gangrene was of this kind, I amputated with success; a third died after amputation, but not of gangrene affecting the stump; and a fourth and fifth, which I left for the appearance of the line of separation, or the cessation of the gangrene, very soon died. This practice, in cases of

severe injury, after gun-shot wounds, has succeeded in the hands of others, even in England."

After discussing all the questions and points of practice connected with amputations, generally as connected with gun-shot wounds, Mr Guthrie proceeds, in distinct sections, to the consideration of the particular operations.

Under each head he not only describes the modes of operat ing, but, with a freedom and ability which experience alone can give, he points out the nature, variety, and extent of those wounds and accidents which require the operations in question. These observations are most valuable and instructive, but scarcely admit of abridgment or analysis; and this is a book which we are most unwilling to save any one the trouble, we ought rather to say, the pleasure and profit of perusing. The account of the operations performed at the hip and shoulder-joint, are especially interesting. The former operation has been more than once performed by Mr Guthrie, and other British surgeons; we regret to add, that in one case only has it been completely successful. But this one is sufficient to justify an operation from which surgeons in general have shrunk. The operation of the shoulder-joint has become as perfect and as successful as any other operation.

A surgeon in private practice, who performs a few annual great operations, is still timid and apprehensive, compared to the military surgeon; and there is nothing more worthy of a passing remark, than that confidence and intrepidity which the military surgeon acquires, and which is in truth so necessary for him to have in the discharge of his important and arduous du ties. Mr Guthrie has no silly fears of hæmorrhagy and uncompressed arteries, in cases where experience has taught him confidence. He cares not, indeed, in most cases, whether he has a tourniquet or not; an instrument which in some cases is, indeed, useless, as in operations at the great joints. In these he trusts with the most perfect confidence to the manual compression of the artery above the clavicle, and on the brim of the pelvis.

"The fear usually entertained by surgeons, is that of incontrollable hæmorrhage; and Mr John Bell (whose works have done so much good in the surgery of arteries), has here done much mischief, in persuading many young men that hæmorrhage from large arteries is not to be restrained by any pressure; which is, in my opinion, one of the principal errors of his work, in relation to military surgery, and is indeed almost as great an error as any he has laboured so effectually

to overturn.

"He says, p. 415 of his Principles of Surgery, 'I will repeat with VOL XII. NO, 46.

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confidence what I have frequently affirmed, that it is one thing to suppress the pulse in the lower part of the limb, and another thing to stop the pulse in the great artery. I have tried in great operations, near the trunk of the body, to stop the blood by pressure; but though I could suppress the pulse of the femoral artery with my fore-finger, I could not command its blood with the whole strength of my body.' And in a note he says, the fact which I have here affirmed is of too much importance for me not to maintain it with more than common earnestness. I affirm then, that, though the throbbing of an aneurism, or the pulse in the lower part of a limb, be quite suppressed, yet the circulation is not stopped; and I entreat the young surgeon never to trust to any such mark of the compression being effectual.'

"If he wish it to be understood, that the inguinal, or the subclavian artery, cannot be commanded by any pressure, so as to prevent hæmorrhage on their division, it is merely advancing an opinion, that hardly needs a comment; for almost all the medical officers of the British army have, on many occasions, seen both vessels so effectually compressed by moderate pressure, that not one drop of blood has escaped from the orifice of the artery, after it has been divided. I am, therefore, willing to believe that this cannot be his meaning, but that he supposes a certain degree of pressure may stop the pulsation of the artery without suppressing the circulation; an opinion equally as dangerous, and erroneous, as the other; for it tends to keep the mind of the young surgeon in alarm, and thereby obstructs the free exercise of his judgment, during the whole course of many serious operations, when he often requires the greatest firmness to enable him to surmount the difficulties that present themselves. This alarm is most unnecessarily raised, for I have no hesitation in declaring, and I am supported in the assertion by all the surgeons of extensive practice in the British army, that when the pulse is suppres sed in a great artery, that the flow of blood is completely restrained for every purpose in military surgery. I will even say, that the flow of blood shall be entirely suppressed, and yet the pressure upon the subclavian artery above the clavicle, shall be so moderate, that the instrument will not leave a mark upon the skin discoverable after twenty-four hours. I do not assert this without solid foundation, for I have seen the inguinal and subclavian arteries compressed and divided very many times, and I have had the femoral and axillary arteries as often between my fingers; but I never saw blood projected one inch from the orifice of these vessels without the pulsation or motion of the artery taking place; and I never saw blood flow in a stream from the orifice of any large artery. I have seen, when the sides of these vessels have not been pressed exactly together, so that the inner coats have not been in contact, that a little blood has oozed to the mouth of the artery, and that it has even dropped from it; but the moment this drop became a stream, the pulsation of the artery was sensible to the fingers, and the blood thrown out, came per saltum. I have never found any difficulty in holding the divided end

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