Volume 1

A dictionary of practical surgery / [Samuel Cooper].

  • Samuel Cooper
Date:
1825
Catalogue details

Licence: Public Domain Mark

Credit: A dictionary of practical surgery / [Samuel Cooper]. Source: Wellcome Collection.

    64/1282 (page 52)
    H2 bad symptoms to commence, but amputate ere they originate, and, when the operation has been done early enough, most of my patients have been saved. However, when some days had trans- pired, and inflammation, swelling, and fever had come on, I must candidly confess, that the issue was not always fortunate. Yet the operation should not, on this account, be dispensed with ; for, if only a few can thus be saved out of many, some benefit is obtained, as, without this step, such few would also perish.” (Vermischte Chir. Schriften, B. 1. p.42.) What I saw of com- pound fractures of the thigh, after the assault on Bergen-op-Zoom, we may remark, coincides with the results of Schmucker’s ample experience; for the only two patients, who survived the bad symp- toms proceeding directly from the fracture, were, one whose femur was broken near the knee; and another, whose iimb I took off, on account of a fracture of the middle of the bone, accompanied with abscesses of surprising extent. The latter was a case, however, in which the limb ought to have been removed earlier. The following re- marks, by Mr. Guthrie, I consider judicious and correct. ‘«« The danger and difficulty of cure, attendant on fractures of the femur from gunshot wounds, depend much on the part of the bone injured ; and, in the consideration of these circumstances, it will be useful to divide it into five parts. Of these, the head and neck included in the capsular ligament, may be considered the first; the body of the bone, which may be divided into three parts, and the spongy portion of the lower end of the bone exterior to the capsular ligament, forming the fifth part. Of these, the fractures of the first kind are, I believe, always ultimately fatal, al- though life may be prolonged for some time. The upper third of the body of the bone, if badly fractured, generally causes death at the end of six or eight weeks of acute suffering. I have seen few escape, and then not with a useful limb, that had been badly fractured in the middle part. Fractures of the lower or fifth division, are in the next degree dangerous, as they generally affect the joint ; and the least dangerous are fractures of the lower third of the body of the bone. Of these eyen I do not mean to conceal, that when there is much shattered bone, the danger is great, so, that a fractured thigh by gunshot, even with- out particular injury of the soft parts, is one of the most dangerous kinds of wounds that can oc- cur.” (See Guthrie on Gunshot Wounds, p.190.) In compound fractures, as Mr. Pott has cor- rectly pointed out, there are three points of time when amputation may be proper. The first of these is immediately, or as soon as possible after the receipt of the injury. ‘The second is, when the bones continue for a great length of time without any disposition to unite, and the dis- charge from the wound has been so long, and is so large, that the patient’s strength fails, and general symptoms foreboding dissolution come on. The third is, when a mortification has taken suth complete possession of the soft parts of the inferior portion of the limb, quite down to the bone, that upon the separation of such parts, the bone or bones shall be left bare in the interspace. The first and ‘second of these are matters of very serious consideration. The third hardly requires any. When a compound fracture is caused’ by the passage of a very heavy body over a limb; such; for instance, as the broad wheel of a waggon or loaded cart, or by the fall of a very ponderous body on it, or by a cannon shot, or by any other means so violent as to break the bones into many fragments, and so to tear, bruise, and wound the soft parts, that there shall be good reason to fear, that there will not be vessels sufficient to carry on the circulation with the parts below the fracture, it becomes, as Mr. Pott observes, a an attempt to save such a limb will not occasion loss of life. This consideration must be before any degree of inflammation has seized the part, and therefore must be immediately after the ac- cident. When inflammation, tension, and a dis- position to gangrene in the limb have arisen, the period is highly disadvantageous for operating, and the patient’s chances of being saved by am- putation, under these circumstances, are much smaller than before the changes here spoken of had taken place. At the same time, there are certain examples of mortification from external causes, where, as far as one can judge from the results of later experience than that of Mr. Pott, the surgeon should not defer amputation, even though the disorder be yet in a spreading state, attended with considerable swelling and tension reaching far up the limb. ‘This is a subject, how- ever, which will require more explanation here- after. (See what is presently said on Mortijica- tion.) Nor are the cases, to which reference is made, meant to affect the general truth of the observation, delivered by the most experienced surgeons of every age, that when a limb is ex- tensively swelled and inflamed, with a part of it’ either in a state of spreading mortification, or ready to become gangrenous, the period is so unfavourable for amputation, that very few pa- tients, so. circumstanced, ever recover after the operation. Nor is it meant to be insinuated, that in the very cases, which form exceptions to the general rule of not amputating before the tendency to gangrene has ceased, the patient might not have had an infinitely better chance of his life, had the operation been done immediately after the first receipt of the injury, before any dis- position to gangrene had had time to be produced. The necessity of immediate or very early de- cision, in this case, makes it a very delicatg , part of practice ; for, however pressing the case_ may seem to the surgeon, it will not, in general, appear in the same light to the patient, to the relations, or to bystanders. ‘They will be in- clined to regard the proposition as arising from ignorance, or an inclination to save trouble, or a desire to operate; and it will often require more resignation and confidence on the part of the patient, than is generally met with, to submit to and upon so little apparent deliberation ; and yet time to pass, decides the patient’s fate. quick tendency to mortification, which ensues in the injured limb, and too often ends in the patient’s in those whose constitutions, previous to the acs we | | } {