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.

    66/1282 (page 54)
    not increase the patient’s danger, and, as for the momentary augmentation of pain, which he suf- fers, he is amply compensated by all the benefits resulting from the operations See Gunshot Wounds. 4, Mortification. Mortification is another cause, which, when advanced to a certain degree, renders amputation indispensably proper. We have noticed, that bad compound fractures, and wounds, often ter- minate in the death of the injured limb. Such surgeons as have been determined, at all events, to oppose the performance of amputation, have pretended, that the operation is here totally use- less. They assert: that when the mortification is only in a slight degree, it may be cured, and that when it has spread to a considerable extent, the patient will perish, whether amputation be per- formed or not. But this way of viewing things is so contrary to facts, and the experience of every impartial practitioner, that I shall make no attempt to refute the assertion. While it is allowed that it would be very bad practice, to amputate on every slight appearance of gangrene, it is equally a fact, that when the disorder affects the substance of a member, the operation is ge- nerally the safest and most advantageous measure, Nay, there are, as we shall presently see, certain forms of mortification, in which the early per- formance of amputation is the only chance of saving the patient. Practitioners have entertained very opposite opinions, concerning the period when one should operate in cases of mortification. Some pretend, that whenever the disorder presents itself, and especially when it is the effect of external vio- lence, we should amputate immediately the mor- tification has decidedly begun to form, and while the mischief is in a spreading state. Others be- lieve, that the operation should never be under- taken, before the progress of the disorder has stopped, even not till the dead parts have begun to separate from the living ones. The advocates for the speedy performance of amputation declare, that the further progress of the mortification may be stopped, and the life of the patient preserved, by cutting above the parts affected. However, according to the reports of the greater number of eminent surgical writers, this practice is highly dangerous, and undeserv- ing of confidence. Whatever pains may be taken in the operation, only to divide sound parts, there is no certainty of succeeding in this object, and the most skilful practitioner may be deceived. The skin may appear to be perfectly sound and free from inflammation, while the muscles which it covers, and the parts immediately surrounding the bone, may actually be in a gangrenous state. But even when the soft parts are found free from apparent distemper, on making the incision, still, if the operator should not have waited till the mortification has ceased to spread, the stump will almost always be attacked by gangrene. Surgeons who have had opportunities of fre- quently seeing wounds which have a tendency to mortify, entertain the latter opinion. Such was the sentiment of Pott, who says, that he has often seen the experiment made, of amputating a limb in which gangrene had begun to show itself, but never saw it succeed, and it invariably hastened the patient’s death. The operation may be postponed, however, too long. Mr. S. Sharp, in particular, recommended too much delay, advising the operation never to ‘be done, till the natural separation of the mortified parts had considerably advanced. Mr. Sharp was a surgeon of immense experience, and his au- thority carries with it the greatest weight. But, perhaps, he was too zealous in his opposition toa - practice, the peril of which he had so often be- held. When the mortification has ceased to spread, there is no occasion for further delay. We now obtain, just as certainly, all the benefits of the operation, and get rid of a mass of putridity, the exhalations from which poison the atmosphere which the patient breathes, and are highly detri- mental to his health. Nay, according to the re- ports of writers, patients in these circumstances may actually fall victims to the absorption of the putrid matter which is suffered to remain too long. However, this danger would not be so considera- ble as that which would arise from too precipitate an operation; and it is better to defer amputation a little more than is absolutely requisite, than run any risk of doing the operation before it is cer- tain, that the parts have lost their tendency to gangrene. In the article Mortification, we have noticed particular cases of gangrene, where, according to Larrey’s experience, the surgeon is not to'wait for the line of separation being formed, but have recourse to the immediate performance of am- putation. The experience of Mr. Lawrence tends also to confirm the propriety of such practice. (See Medico-Chir. Trans. vol. 6, p. 156, &c.) In an example, where a large part of the arm was deeply affected with gangrene from external violence, and the disorder was yet making rapid progress, I once recommended the performance of amputation at the shoulder-joint. On the whole, this instance was favourable to the prac- tice; for, though the patient died at the end of a fortnight, probably he would not have lived twenty-four hours, had the operation not been done ; nor was the stump attacked with mortifi- cation, a circumstance worthy of attention, be- cause it is a danger particularly insisted upon by the opponents of amputation, under the preceding circumstances ; and, had it not been for a large — abscess, which formed in the back, as was sup- posed, from a violent blow received in the fall, which produced the original injury, there were | well-grounded hopes of recovery. The patient, here spoken of, was attended by Dr. Blicke, of W althamstow. There is likewise a species of gangrene, which is pointed out by Mr. Guthrie, as requiring early amputation. ‘* A soldier (says he) shall receive a flesh-wound from a musket-ball in the middle of the thigh, which passed through the limb ap- parently, on a superficial inspection, without in- juring the main artery; or it shall pass close be= hind the femur, where the artery turns to the back part of the bone ; or it may go ‘through the middle of the bone, from behind forwards, be- tween the condyles of the femur into the knee-~ joint, and the patient shall walk to the surgeon with little assistance, be superficially dressed, and, in many cases, considered slightly wounded 5 yet, the femoral artery and vein, of the whole of these cases, and, indeed, in many others, shall be wounded, or cut across, and the local inflamma-