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

If inflammation, accompanied by pain, should take place, cold or iced water should be applied, particularly in primary amputations. In secondary ones, warm fomentations or light warm poultices will be more advantageous, all constriction by sutures or plasters being removed, the parts being simply approximated to each other. Attention should be paid to the directions in aphorism 61.

AMPUTATION AT THE HIP-JOINT.

77. This amputation essentially owes its existence to the wars of the French Revolution. M. Bourgery says Blandin performed it three times in 1794; once successfully. Baron Larrey did it seven times during his different campaigns, and he says one or two persons who had survived were seen during their cure by an officer in Russian Poland, but they never reached France. Nevertheless, I always assume that one at least did recover, whether he was really seen or not, being a compliment and a reward justly due to the zeal and ability of my old friend the Baron, to whom the surgery of France is so much indebted. This operation was first done in Spain by the late Mr. Brownrigg, at Elvas, in 1811, and by myself after the siege of Ciudad Rodrigo, but none of our patients ultimately recovered. I operated on a French soldier at Brussels soon after the receipt of the injury at Waterloo; he survived; and he was the first and the only man seen for a long time afterward in either London or Paris. The biographer of Baron Larrey says he was present at, and advised the operation to be done; but that is an error, as the Baron did not visit Brussels until after I had left it for Antwerp; neither had I any knowledge of the Baron’s writings in 1811 or 1812, when my first operation was done in Portugal. Eighteen or twenty ways have been suggested for doing this operation, and twenty persons are believed to have survived its performance, several of whom may be living at the present time.

A very extensive destruction of the soft parts, the femur remaining entire, does not authorize the removal of the limb in the first instance, unless the main artery be also injured. Captain Flack, of the 88th Regiment, was struck by a large cannon-shot at Ciudad Rodrigo, on the outside and anterior part of the left thigh, which tore up and carried away nearly all the soft parts from the groin, or bend of the thigh, below Poupart’s ligament, to within a hand’s-breadth of the knee. It was an awful affair. He was supposed to be dying, was returned dead, and his commission was given to another. Left to die in the field hospital after the town was stormed, and finding himself thus deserted by his own friends, he claimed my aid as a stranger. I took him five leagues to my hospital at Aldea del Obispo. The femoral artery lay bare for the space of nearly four inches, in a channel at the bottom of the wound; the whole, however, gradually closed in, and he recovered.

If the injury is on the back part, a flap should be made in amputation from the fore part. If the wound should be on the outside, the flap is to be made from the inside, and vice versa, the object being to make the stump as long as possible. A wound of the artery, accompanied by a fracture of the femur, requires amputation, for although many would survive either injury alone, none would, it may be apprehended, surmount both united.

If after a fracture in course of treatment, the principal artery should be wounded by some accidental motion of the bone, amputation should in general be resorted to. A ligature on the artery higher up would fail, and the operation of seeking for both ends of the injured vessel would cause so much mischief in an unsound part that the consequences would in all probability be fatal.

78. When the femur is suffering from a malignant disease, commencing in the periosteum, or in its cancellated internal structure, I am reluctantly obliged to say, from experience, that the removal of the whole bone at the hip-joint offers the best, perhaps the only chance of success. In such cases, the operator has in general the power of selecting his mode of proceeding.

It may be laid down as a principle in all cases of accident, whether from shot, shell, or railway carriages, that no man should suffer amputation at the hip-joint when the thigh-bone is entire. It should never be done in cases of injury when the bone can be sawn through immediately below the trochanter major, and sufficient flaps can be preserved to close the wound thus made. An injury warranting this operation should extend to the neck, or head of the bone, and it may be possible, as I have proposed, even then to avoid it by removing the broken parts.

79. The principle being established, as a general rule in all cases of recent injury, that the femur must be broken at least as high as the trochanter to constitute an imperative case for this operation, the next point of importance relates to the manner of forming the first incisions. The instructions and recommendations to be found in books for the performance of this operation are frequently inapplicable, and are not to be depended upon; the errors occurring from the operation having been considered and performed on the dead body and not on the living; on the normal and not on the injured state of parts. Thus, for instance, it is recommended that an assistant should rotate the knee outward or inward, to show the head of the femur; to which recommendation there is the insuperable objection, that no person should suffer this operation who has a knee, or half a thigh, or even a third of one, to move by the rotary process. Pure theorists in surgery have decided upon having a large flap made on the fore part of the thigh, and a smaller one behind, regardless of the fact that this cannot be done in many cases requiring a primary operation from the nature of the injury; although it may be done in many secondary cases, in which this severe operation would not have been required if the limb had been amputated in the first instance. It is the mode recommended by Mr. Brownrigg, who in his operations, which were secondary ones, had a choice of integument, and it is, perhaps, under these circumstances, the best.

Baron Larrey tied the femoral artery in the first instance, and then made two lateral flaps; but this operation, dependent on the fear of hemorrhage, was never performed in the British army.