Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

41. An amputation of the upper extremity may almost always be done from the shoulder-joint downward, without much risk to life. When necessary, the sooner it is done the better.

42. An amputation of any part of the lower extremity below the knee may be done forthwith, with nearly an equal chance of freedom from any immediate danger, as of the upper extremity at or near the shoulder-joint.

43. It is otherwise with amputations above the middle of the thigh, and up to the hip-joint. They are always attended with considerable danger.

44. There can be no doubt that if the knife of the surgeon could in all cases follow the ball of the enemy or the wheel of a railway carriage, and make a clean good stump, instead of leaving a contused and ragged wound, it would be greatly to the advantage of the sufferer; but as this cannot be, and an approach to it even can rarely take place, the question naturally recurs,—At what distance of time, after the receipt of the injury or accident, can the operation be performed most advantageously for the patient?

45. In order to answer this question distinctly, it should be considered with reference to distinct places of injury:—

1st. When injuries require amputation of the arm below the shoulder-joint, or of the leg below the knee, these operations may be done at any time from the moment of infliction until after the expiration of twelve or twenty-four hours, without any detriment being sustained by the sufferer with regard to his recovery; although every one, under such circumstances, must be desirous to have the operation over. The surgeon having several equally serious cases of injury of the head or trunk brought to him at the same time as two requiring amputation of the upper extremity, may defer the latter more safely perhaps than the assistance he is also called upon to give to the other cases, the postponement of which may be attended with greater danger.

2d. This state embraces those great injuries in which the shoulder is carried away with some injury to the trunk; or the thigh is torn off at or above its middle, rendering an amputation of the upper third, or at the hip-joint, necessary. It is this or nearly this state which alone implies a doubt as to the propriety of immediate amputation, and demands further investigation. It is the state to which attention is earnestly drawn for future observation.

46. It has been implied, if not actually maintained, that a man could have his thigh carried away by a cannon-shot without being fully aware of it, or, if aware of it, that it did not cause much alarm—in fact, that it did not materially signify as to his apprehension, whether the ball took off his limb or the tail of his coat, or only grazed his breeches. An instance of this kind has not fallen under my observation.

47. A surgeon on the field of battle can rarely have a patient brought to him, requiring amputation, under less time than from a quarter to half an hour; a surgeon in a ship may see his patient in less than five minutes after the receipt of the injury; and to the surgeons of the navy we must hereafter defer for their testimony as to the absence or presence of the constitutional alarm and shock to which I have alluded, and to what degree they follow, immediately after the receipt of such injury. The question must not be encumbered and mystified by a reference to all sorts of amputations after all sorts of injuries, but to the one especial injury, viz., that of the upper third of the thigh.

48. My experience, which may be erroneous, like everything human, has taught me, that when a thigh is torn, or nearly torn off, by a cannon-shot, there is always more or less loss of blood, suddenly discharged, which soon ceases in death, or in a state approaching to syncope. When the great artery has been torn, this fainting saves life, for an artery of the magnitude of the common femoral does not close its canal by retracting and contracting in the same manner as a smaller vessel; it can only diminish it; and the formation of an external coagulum is necessary to preserve life, which the shock, alarm, and fainting, by taking off the force of the circulation, aid in forming; and without which the patient would bleed to death. An amputation, in this state of extreme depression, might destroy life, although aided by the exhibition of chloroform.