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Show 200 A MP UTA TION. AIJPUTATION. jury on which the tendency to gangrene will operate. 261' The gangrene will appear on the stump%. The next diificult question to be settled, on the instant of an accident, occurs in the complication of wounded arteries, and broken bones ; or in gun-shot wounds, or when joints are laid open. A fracture apparently the most dreadful, when seen first, with the limb distorted, and the bones sticking out, and which" we are tempted to condemn, does yet, when reduced, lose favorable to expect from a shattered state of the limb and knee-joint. Yet in this very instance we must confess the in sufficiency of these general rules, since a ball has passed through the knee-joint, and the limb has been saved. As important an observation as I know for the young army surgeon, is, that he take care in operating for gunshot wound, ‘with a shattered tibia, that the fissures of the bone do not reach up into the joint ; for in this case there will be inflammation of the joint. It is better in all cases of doubt to am- its frightful aspect -, and often by bringing the parts toputate above the knee. gether, we can procure adhesion of the skin, and reduce it to a simple fracture. But when a great artery is at the same time. Wounded, when operations deep in the flesh of a limb, and amongst broken bones, are necessary-the case is altered ; we cannot reduce the fracture to a simple form. Here also we gain a point, however, if we can save the limb for a little; " lfiFfilH « ,, although suppuration, and a discharge too profuse for the system to bear, is to be the consequence; for then amputation will be safe. It may in this case happen, that we are enabled to tie the _.\.‘ "-I,‘ ,.‘.. ...:' l , artery above the part wounded, which reduces the wound to a simple compound fracture, if I may use the expression ; and if in any way we can restrain the hmmorrhagy, and check the rismg inflammation, we ought to defer amputation. ‘ Perhaps the accident the most fully licensed for amputar tron, is where the knee-joint is laid open with fracture and la- cerated integuments. The inflammation of this great joint is in itself pregnant with danger, and will produce fever and irri- tation to a most alarming degree. But if these consequences may arise from a mere puncture of the joint, we have nothing * When gangrene has seized a limb, the limb generall y lies an immorta- blc mass ; and when the gangrene has been stopped and cured still itlics unmoveable ; and often by its insensibility the effect of the pres'sure on the prejectmg processes of the bone, as of the heel or anele or head ofthe fibu~ 1a, destroys the skin, and makes the bones carious. Fi'om such a cause, I have seen it necessary to amputatc a limb ; when otherwise the gangrened parts being of small extent, would have sloughcd off ' But I refrain from further remarks on the general question of amputation, suspecting that they may be to my readers not more satisfactory than the advice which I myself have received from books. The reason of this unsatisfactoriness is, that each case, as it occurs in practice, is attended with circum- stances so peculiar, that it will seldom class with our general aphorisms; and frequently in the discussion of this subject, the first surgeons are left in doubt and perplexity. The question of amputation is not to be discussed, I conceive, in a sex parate dissertation. It will always remain to be determined by our general knowledge, by the consideration of the effect of age and constitution, and of the powers of the system, on the peculiar circumstances of the case. Our decision must be the result of our combined knowledge, of the symptoms of con: stitutional affections ; of the effect of circumstances on the constitution or disease ; of the effect of disease on the local in- jury; and of the probable effect of the operation. At any rate, the question embraces so extensive a range of the princi~ pics of pathology, that it is foreign to the object of this little Work to enter fully into the subject, 5 Mom M05912} , |
