Volume 1

Cooper's dictionary of practical surgery and encyclopaedia of surgical science.

Samuel Cooper

Date:: 1861-1872

Credit: Cooper's dictionary of practical surgery and encyclopaedia of surgical science. Source: Wellcome Collection.

Provider: This material has been provided by The University of Glasgow Library. The original may be consulted at The University of Glasgow Library.

62/1104 page 50

$60 fractvired, amputation is, beyond qxiestion, the best practice in the maiority of instances, not because the human system is at that period in the best stale for meeting tJie consequences of the double shocic, moral or phy- sical — not because these present such decidedly more favourable results than secondary amputa- tions, under every condition of circumstances (when the latter are not compulsorily performed), but because many will be the forced amputations in an intermediate and still less favourable period ; many more the death before the favourable pcfriod arrives; and a large number even then remain who arrive at that period, but offer no reasonable chance of surviving the shock of an operation if superadded on tlte diseased and exlmisting actions to ivMch the original injury had given rise. Add all these deaths to those from secondary amputation (properly 80 called) and he must be a bigot indeed to the adverse opinion, who can have one moment's hesita- tion as to which side of the question the amount of human suffering and the loss of human life pre- ponderates (loc. cit. p. 292). M. Velpeau says, The fundamental argument of the partizans of temporization, to wit, that a multitude of mutilated persons would have been enabled to save their limbs, if the surgeon had delayed, is more specious than solid ; for we can reply to them, that a goodly number of the other cases would be living with three limbs, if, in delaying the operation they had not suffered them to die with four. {Elem. of Op. Surg. vol. ii. p. 469. Mott's Translation.) The opinions of Mr. Alcock, as quoted above, embody, we believe, as nearly as possible, the doctrine of the great majority of surgeons of the present day, and that doctrine may be briefly stated as follows: when the injury is such that it is obvious that there is no chance for the ultimate preservation of the limb, primaiy amputation should always be preferred ; but when the surgeon has doubts on this point, which will very frequently be the case, for the question is often one of the greatest possible difficulty and delicacy, he should give the limb the benefit of the doubt, holding the alternative of se- condary amputation in reserve in case of need ; the results of this latter, if not equal to those of the former, being yet sufficiently favourable, in civil practice especially, to wari'ant the delay. Primary amputation, however, is not always to be immediate in the literal sense of the word, but the state of collapse, or shock, which is often the immediate effect of a serious injury, must be allowed to pass off before the operation is attempt- ed. The surgeon may often wait with advantage, as Mr. Guthrie recommends (see article Gunshot Wounds), for six or eight hours or even longer, cordials being administered at intervals until reac- tion has duly taken place. A still longer delay is in many cases admissible, although Mr. Skey per- haps goes too far in thinking that the condition of the patient is as favourable for amputation at the expiration of thirty-six, or even forty-eight hours, as at the expiration of three or four. On the question of reaction after serious accidents, the last named author thinks sufficient distinction is not made between the consequences of violence done to the circulating and that to the nervous svstem A man receives a severe Wow on the abdomen or elsewhere ; his nervous system sustains the first effect of the shock ; h.s pulse sinks till it becomes almost in.perceptib e, but he has lost no blood To amputate a limb which may have been uaui-uicu, or crushed, or otherwise severely or hopelessly mutilated, in this condition of his sys- tem, is to hurry him on to his death. The cause is a shock which time can, and under favourable circumstances will, remedy. We give him stimu- lants, and his circulation rallies; his physical powers revive, and in the course of one or more hours, we amputate, with success. Contrast this case with that of a man reduced to an equal degree of prostration by toss of blood, consequent on severe compound fracture or mutilation of aiij' kind. In such a case how can we expect reaction to take place with the circulation reduced^ by a large diminution from its standard quantity. Mr. Skey thinks that in the former case we should postpone the operation until reaction has taken place, but in the latter (that is, if there exist good grounds for believing the hemorrhage to have been considerable) we must attribute the prostration primarily to that cause, and resort to immediate amputation. {Skey, Op. Surg. p. 315.)] For the consideration of a variety of compli- cated circumstances affecting the question of am- putation in compound fracture, I must refer to Gunshot Wounds. 2. Extensive Contused and Lacerated Wounds. These form the second class of general cases requiring amputation. Wounds without fracture are not often so bad as to require this operation. When a limb, however, is extensively contused and lacerated, and its principal blood-vessels are injured, so that there is no hope of a continuance of the circulation, the immediate removal of the member should be recommended, whether the bones be injured or not. Also, since no effort on the part of the surgeon can preserve a limb so in- jured, and such wounds are more likely to mortily than any others, the sooner the operation is un- dertaken the better. In these cases, as in those of compound frac- tures, though amputation may not always be ne- cessary at first, it often becomes so afterwards. The foregoing observations, relative to the second period of compound fractures, are equally appli- cable to badly lacerated wounds, unattended with iniury of the bones. Sometimes a rapid mortifi- cation comes on ; or a profuse suppuration, which the system can no longer endure. _ For information on the proper period of am- mitatuig in traumatic gangrene, see Mortifica- tion, and the section on this disorder in the present article. 3. Cases in which part of a Limb has been carried away by a cannon-ball. Wlien part of a limb has been torn off by a cannon-ball, or any other cause capable of pro- ducing a similar effect, the formation of a good and serviceable stump; the greater fe^jl' ^^^'^ ing the clean, regular wound of amputation ; and he benefit ofa for more expeditious, as well as o a sounder cure, are the principal reasons which here make the operation advisable. ThTs was an instance, in which some former surg ns disputed the necessity of. amputation Tl>ev urRed as a reason for their opinion, that the liSlS^g already removed, it is bc«er to en e - vour to cure the wound as speedily as pos ible than increase the patient's sufferings and dangei,$

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