[(1) HENNEN says:-"If, however, the bone is splintered to the very joint, or so close as to excite our fears as to future consequences, we operate beyond it on the upper part of the limb. If the head of the humerus itself is injured, or the shaft splintered, with much destruction of the soft parts, or if the head of the bone alone is left in the glenoid cavity, the rest being carried off, we forthwith take it out of the socket; an operation as simple, if properly planned, as any in surgery; and one which, on all occasions where the bone is injured, is infinitely preferable to amputation lower down. It not unfrequently occurs, that the arm is carried completely out of the socket; and, in this case, very little more remains for the surgeon than to pass a ligature round the arteries, even though they do not bleed, as often happens, and to cut short the leash of nerves, which in this case usually hangs far out of the wound, to bring the lips towards each other by adhesive straps, and to support them by proper compress and bandage." (pp. 38, 9.)

(2) HENNEN mentions "a species of the comminuted compound Gun-shot Fracture, which, although at first of but little consequence in appearance, is of most serious importance in its results. This occurs where a musket-ball has perforated a cylindrical bone without totally destroying its continuity, and consequently without producing any distortion of the limb, or other symptoms which characterize a fracture. The foundation of infinite mischief is, however, laid; for not only is the shaft of the bone injured, but fragments are carried into and lodged in the medullary canal; and if the limb has been in an oblique position, or the ball has taken an oblique course, these fragments are often driven in to a great distance, and fairly impacted in its cavity, there keeping up a constant and uncontrolable irritation, and destroying both the medulla and its membraue, together with the cancelli, which naturally support it. I have repeatedly seen this separated portion of bone lying in the medullary canal, at the distance of from four lines to an inch and a half from the circular hole formed by the passage of the ball, retaining its shape, its colour, its solidity, while all the surrounding osseous parts were diseased, and formed a spongy discoloured mass of bony granulations around it, the periosteum, for some way, both above and below the wound, being entirely separated from the bone. To attempt to save such a limb is imposing a task upon the powers of nature, which, nineteen times in twenty, she is unable to effect, even under the most favourable circumstances. If a ball has passed through without carrying in any fragments of bone, a case which sometimes happens in the thigh, when the man is standing erect, and the ball has struck the bone fairly and directly, the case is more favourable, than when the wound is oblique as in the arm, which is so often thrown into a variety of postures; and consequently, where there is a greater chance that the channel of the ball should be formed obliquely, and the spicular fragments forced up into the medullary cavity. But even of this favourable variety I have seen only two cases cured, both of persons struck on the centre of the femur, the wound admitting a finger to be passed into the bony ring or perforation, and there to find a clear, unembarrassed, and comparatively simple loss of parts. By far the most frequent result is the loss of the limb sooner or later, after a very tedious and distressing train of symptoms, exhausting to the patient and baffling every endeavour of his attendants." (pp. 133, 34.)

(3) "Balls often pass through or along the bones of the hand or foot, and, except in very severe cases attended with great loss of substance, amputation," says HENNEN "is not immediately necessary. The strength of the fascia covering those parts, and the number of minute bones composing them, will, however, render extensive openings peculiarly requisite. These bones never suffer from necrosis, nor do they ever become regenerated as far as my experience goes; but if the aid of an appropriate supporting splint, assisted by proper bandages, is had recourse to, their loss is soon supplied by a new formation of soft parts, approaching to a cartilaginous nature; and by the approximation of the sound bones to each other. However desirable it may be to save a hand or foot, yet, in severe lacerations, the frequency of tetanic affections should at once lead us to adopt immediate amputation. Gun-shot injuries of the joint of the great toe are always extremely troublesome, and accompanied with excruciating pain, often giving rise to severe nervous affections, and often terminating in tetanus. Amputation of the toe will therefore be the safest mode of treatment, and it should be a general rule to amputate all lacerated toes and fingers, in preference to attempting their preservation.” (pp. 154, 55.)]

349. The earlier in these cases amputation is had recourse, to the more successful is the result; but in very severe general shock, or in complete numbing from cold, the wounded person must be first revived with stimulants. When the secondary symptoms have once set in, before amputation is performed, it must be delayed, till after proper treatment the patient

is in a quiet condition at the period of suppuration, at which time amputation should be immediately performed.

[Immediate amputation after severe gun-shot injuries has long been the practice of English army and navy Surgeons, for it would seem in the way it is spoken of by WISEMAN that even in his time it was a settled proceeding. He says:-" Experience judgeth it commendable, if it be necessary; and in such shattered limbs where there is no hope of preserving the patient's life otherwise. And then it must be done in its proper time, that is to say, suddenly upon the receipt of the wound, before the patient's spirits be overheated, either with pain, fever, &c. *** But amongst us aboard, in that (the naval) service, it was counted a great shame to the chirurgeon if that operation was left to be done the next day, when symptoms were upon the patient and he spent with watchings, &c. Therefore you are to consider well the members, and if you have no probable hope of sanation, cut it off quickly, while the soldier is heated and in mettle. But if there be hopes of cure, proceed rationally to a right and methodical healing of such wound; it being more for your credit to save one member than to cut off many." (p. 396.) The celebrated French surgeon, Le DRAN, who published on gun-shot wounds a few years after WISEMAN, also advocated the early amputation, and lays it down as a rule, "that when the amputation of a limb is indispensably necessary, in the case of a gun-shot wound, it ought to be done without delay." (p. 163.)

RANBY, (a) who was serjeant-surgeon to GEORGE the SECOND, and whom he accompanied in the wars in Flanders, adhered to WISEMAN'S practice, and says:-" If a wound be of such a desperate nature as to require amputation, (which is always the case when it happens in any principal joint,) it would certainly be of consequence could the operation be performed on the spot, even in the field of battle; lest, by deferring it, an inflammation may come on, which one may very reasonably expect should obstruct a work that ought rarely to be entered upon during the continuance of so calamitous a circumstance. The neglecting this critical juncture of taking off a limb, frequently reduces the patient to so low a state, and subjects the blood and juices to such an alteration, as must unavoidably render the subsequent operation, if not entirely unsuccessful, at least exceedingly dubious." (p. 29.)

It is probable that about this time some dispute had occurred as to the propriety of this practice; for, in 1756, the French Academy of Surgery proposed it as the subject for the prize essay in that year, and in consequence of the paper of FAURE, an army Surgeon, to which they assigned the reward, they decided in favour of delaying the operation wherever practicable, although from the first it were absolutely necessary. Soon after, this, BILGUER, Surgeon-general to the Prussian army, wrote against amputation in general, and permitted no amputation in that service. But although his statements were "much applauded, and in some countries held up as doctrines to be followed," yet, from carefully sifting them, and from his own practical experience, GUTHRIE says, that "BILGUER on this subject ought never to be quoted as an authority for modern times." .205.)

But neither the recommendation of the French Academy nor BILGUER'S anathema eem to have had much influence on the medical officers of the British service, for HUNTER Says:-"In general, surgeons have not endeavoured to delay it (amputation) till the patient has been housed and put in the way of cure; and therefore it has been a common practice to amputate on the field of battle." But to primary amputation HUNTER was decidedly averse, for he proceeds :

"Nothing can be more improper than this practice, for the following reasons. In such a situation it is almost impossible for a surgeon, in many instances to make himself sufficiently master of the case, so as to perform so capital an operation with propriety; and it admits of dispute, whether at any time and in any place amputation should be performed before the first inflammation is over. When a case is so violent as not to admit of a cure in any situation, it is a chance if the patient will be able to bear the consequent inflammation, therefore, in such a case it might appear, at first sight, that the best practice would be to amputate at the very first; but if the patient is not able to support the inflammation arising from the accident, it is more than probable that he would not be able to support the amputation and its consequences; on the other hand, if the case is such as will admit of its being brought through the first inflammation,

(a) The Method of treating Gunshot Wounds. 8vo. London, 1774. TO RANBY the profession of Surgery in this country is much indebted, as it is believed that mainly by his interest and exertions the Surgeons were in 1745 (18 Geo. II.) separated

from their connexion with the barbers, and established as a distinct corporation, of which he was the first master, although not a member of the old court, and probably not even a member of the Company of Barbers and Surgeons.

although not curable, we should certainly allow of it, for we may be assured that the patient will be better able to bear the second. If the chances are so even, where com. mon circumstances in life favour the amputation, how must it be where they do not? how must it be with a man whose mind is in the height of agitation, arising from fatigue, fear, distress, &c.? These circumstances must add greatly to the consequent mischief, and cast the balance much in favour of forbearance. If it should be said that, agreeable to my argument, the same circumstances of agitation will render the accident itself more dangerous; I answer that the amputation is a violence superadded to injury; therefore heightens the danger, and when the injury alone proves fatal, it is by slower means. In the first case it is only inflammation; in the second, it is inflammation, loss of substance, and most probably loss of more blood, as it is to be supposed that a good deal has been lost from the accident, not to mention the awkward manner in which it must be done. The only thing that can be said in favour of amputation on the field of battle is, that the patient may be moved with more ease without a limb than with a shattered one." HUNTER, however, doubts any advantage being obtained even on that point. He admits, "it is of less consequence whichsoever way it is treated if the part to be amputated is an upper extremity." And he even goes on to say, "If the parts are very much torn, so that the limb only hangs by a small connexion, then the circumstance of the loss of so much substance to the constitution cannot be an objection, as it takes place from the accident, and indeed every thing that can possibly attend an amputation; therefore, in many cases, it may be more convenient to remove the whole. In many cases it may be necessary to perform the operation to get at blood vessels, which may be bleeding too freely; for the searching after them may do more mischief than the operation." (pp. 561, 63.)

HUNTER'S objections to primary amputation do not, however, appear to have had much weight, at least with the army surgeons of his own or the immediately subsequent period, for HENNEN states, on the authority of Dr. PITCAIRN, who served in the expe dition to Egypt," that whenever the surgeons could operate on the field in that country they did so; and for himself, he only lamented that he could not remove more limbs in that situation, having never had a doubt upon the point, and being still more confirmed in the justice of his opinion by the results of the deferred operations." To this HENNEN adds:"On the first landing of our troops in Portugal, the propriety of the practice was impressed upon the surgeons, as I have been informed, by Mr. GUNNING, then senior Surgeon upon the staff, and subsequently Surgeon-in-chief of the Peninsular army; the practice was constantly followed, and the precept orally delivered from surgeon to surgeon, during the whole period that I served in that country." (p. 43.)

GUTHRIE has ably advocated the practice of early amputation after gun-shot injuries, and makes the following judicious observations, which equally apply to this operation when required by any other accident, and which should never be lost sight of. "The anxiety (shown by the soldiers) to have these operations executed with as little delay as possible, has sometimes been prejudicial; for as much attention must be paid, in my opinion, to avoid operating too soon as too late, and perhaps for a reason quite contrary to that usually received as legitimate for not operating, viz., that the sufferer may have time to recover from the shock of the injury, and approach as near as possible to a state of health; and the farther he is from this state, the greater the chance of a fatal termination. If a soldier at the end of two, four, or six hours after the injury, has recovered from the general constitutional alarm occasioned by the blow, his pulse becomes regular and good, his stomach easy, he is less agitated, his countenance revives, and he begins to feel pain, stiffness, and uneasiness in the part; he will now undergo the operation with the greatest advantage; and if he bears it well, of which there will be but little doubt, he will recover in the proportion of nine cases out of ten in any operation on the upper extremity, or below the middle of the thigh, without any of the bad consequences usually mentioned by authors as following such amputation. If, on the contrary, the operation be performed before the constitution has recovered itself, to a certain degree, from the alarm it has sustained, the additional injury will most probably be more than he can bear, and he will gradually sink under it and die." (p. 216.)

Upon the same point HENNEN also observes:-"The propriety of amputation on the field being admitted, the question naturally suggests itself, what is the proper period? instantly on the receipt of the wound, or consecutively? The practical reply is, with as little delay as possible." But when "an army surgeon finds a patient with a feebleness and concentration of the pulse, fainting, mortal agony, loss of reason, convulsions, hiccup, vomiting, irregular chills, stiffening of the whole body, universal feeling of cold and numbness, sense of weight, change of colour, and other symptoms of collapse, so well described by LE CONTE, he waits patiently for a return towards life: he administers

wine, warmth, volatiles; he soothes and he encourages; and when due reaction is established, he performs that humane operation, the utility and necessity of which are now confirmed beyond the possibility of doubt or the influence of cavil." (pp. 45, 6.)

"Inflammation in the seat of the injury," GUTHRIE further observes, "comes on at an indeterminate period, varying in different people. When the injury is high in the thigh, it commences sooner than in the leg or arm, and the symptomatic fever accompanying it is proportionally severe. If, then, after an injury where the alarm has been very great, and the powers of life considerably diminished, so as to have prevented an operation shortly after the accident, some little reaction should take place, the patient should become restless, the pulse quickened, the parts injured painful, the operation should be no longer delayed; for the removal of the diseased parts can only moderate this nervous commotion and prevent delirium and death. * *If the operation be delayed beyond the first twenty-four hours in some persons, and in others thirty-six hours, pain, heat, tumefaction, and the other constituents of inflammation come on rapidly, attended by increased arterial action, severe nervous twitchings, thirst, heat of skin, general restlessness, delirium, and the patient is soon carried off if the injury has been extensive. Many very severe wounds do not terminate so quickly; the symptoms exist in a less degree, and may be moderated by the antiphlogistic treatment until suppuration is established, and the primary high excitement reduced within the limits of hectic fever depending upon the irritation of incurable parts.

"In any period from the time inflammation has commenced in the seat of injury, and symptomatic fever is established, amputation is performed under very different circumstances than when it has been done prior to their supervention; the parts to be divided are no longer in a healthy state; they have taken on inflammatory action tending to suppuration, and will not unite by adhesive inflammation, as they would have done if they had been divided forty-eight hours sooner. The operation, instead of relieving the symptomatic fever, greatly increases it. It is now really a violence superadded to the injury; and the patient dies, unless very active means are employed for his relief, and even under the most vigorous and attentive treatment it frequently proves fatal, although his life may be prolonged for some days." (pp. 219, 20.)]

350. If amputation be not indicated by the nature of the wound, it is impossible to determine whether and by what consecutive symptoms it may be at a later period required. These symptoms may be: 1. Mortification of the limb.-2. Nervous symptoms, convulsions of the stump, tetanus, when the cause remains in the wound, and cannot in any way be removed.-3. Exhausting suppuration.-4. Bleeding from the whole surface of the wound, which cannot be stanched.

As to the indications for amputation after shot-wounds, and the time at which it should be performed, the following writers are to be especially compared:

BILGUER, Dissert. de membrorum amputatione rarissimè administranda aut quasi abroganda. Hallæ, 1761. 4to.

The Treatises of FAURE, LECONTE and GRILLION upon the question, L'amputation étant absolument nécessaire dans les plaies compliquées de fracas des os, et principalement celles qui sont faites par armes à feu, déterminer le cas où il faut faire l'amputation sur le champ, et ceux où il convient de le différer, et en donner les raisons; in the Prix de l'Académie de Chirurgie.

LARREY, Mémoire sur les Amputations; in Mém. de Chirurg. Milit., vol. ii. p. 451. SCHNEIDER, Ueber die Amputation grösser Glieder nach Schuss wunden. Leipz., 1807.

8vo.

WAGNER, Versuch einer näbern Bestimmung der Indicationen zur Amputation der grösseren Gliedmassen, besonders nach Schusswunden, in VON GRAËFE und WALTHER'S Journal für Chirurgie und Augenbeilkunde, vol. i. p. 139.

HUTCHISON, COPELAND, Some further Observations on the subject of the proper period of amputating in Gunshot Wounds. London, 1818.

Ibid. Practical Observations in Surgery. 2nd Edit. London, 1826.

RUST, Ueber die Amputation grösserer Gliedmassen; in his Magazin, vol. vii. p. 337. GUTHRIE, G. J., A Treatise on Gunshot Wounds, etc., quoted at head of Article.

V.-ON POISONED WOUNDS.

RANBY, JOHN, The Anatomy of the Poisonous Apparatus of the Rattlesnake; together with an account of the quick Effects of its Poisons. Phil. Trans., vol. xxxv. p. 377.

1726.

HALL, CAPTAIN, Experiments on the effects of the Poison of the Rattlesnake; in Phil. Trans., vol. xxxv. p. 309. 1727.

PORTAL, LE BARON A., Observations sur la Nature et le Traitement de la Rage; suivies d'un Précis historique et critique des divers remèdes qui ont été employés jusqu'ici contre cette Maladie. Paris, 1779. 8vo.

LEROUX, L. C. P., Observations sur la Rage suivies de Réflexions sur les Spécifiques de cette Maladie, couronnées par l'Académie de Dijon. 1780. 8vo.

FONTANA, F., Traité sur le Vénin de la Vipère, sur les Poisons Américains, sur la Laurier-Cérise, et sur quelques autres Poisons végétaux. On y a joint des Observations sur la Structure primitive du Corps animal différentes Expériences sur la Réproduction des Nerfs, et la Description d'un nouveau Canal de l'Eil. 2 vols. Florence, 1781. 4to.

FOTHERGILL, JOHN, M.D., A case of Hydrophobia, and additional Directions for the Treatment of Persons bit by Mad Dogs; in the Complete Collection of his Medical and Philosophical Works, by JOHN ELLIOT, M.D. London, 1781.

MEDERER, Syntagma de rabie caninâ. Friburg, 1783. 8vo.

KRUSE, W., (ROUGEMONT,) Dissert. de Vulneribus quæ virus habent. Bonnæ, 1784. 8vo. ENEAUX, Méthode de traiter les Morsures des Animaux Enragés et de la Vipère; suivie d'un précis sur la Pustule Maligne. Dijon, 1785. 8vo.

HAMILTON, ROBERT, M.D., Remarks on the means of obviating the fatal effects of the Bite of a Mad Dog or other rabid animal, and on the mode of cure when Hydrophobia occurs, etc. Ipswich, 1785.

8vo.

MOSELY, BENJ., Dr., Treatise on Tropical Diseases, and on the Climate of the West Indies in which are included the Treatment of the Stings of Scorpions, and of the Stings and Bites of other Poisonous Insects; of the Bites of deadly Venomous Serpents; of the Bites of Mad Dogs; of the Dysentery; of the Yellow Fever; of the Tetanus or Lock-jaw, &c. London, 1788. 8vo.

BARTON BENJ. SMITH, M.D., An Account of the most effectual means of preventing the deleterious consequences of the Bite of the Crotalus horridus, or Rattlesnake; in the Transactions of the American Society, vol. iii. p. 100. 1793.

ANDREY, C. L. F., Recherches sur la Rage. Paris, 1779. 8vo.

BARDSLEY, S.A., M.D., An Enquiry into the Origin of Canine Madness, &c.; in Memoirs of the Literary and Philosophical Society of Manchester, vol. iv. 1793; and also in Medical Reports. London, 1807. 8vo.

BENEDICT, Ideen zur Begründung einer rationalen Heilmethode der Hundswuth; nebst einer Vorrede VON ROSENMÜLLER. Leipzig, 1808. 8vo.

HOME, EVERARD, The case of a man who died in consequence of the Bite of a Rattlesnake; with an account of the effects produced by the Poison; in Phil. Trans., vol. c. p. 75.

1810.

TROLLIET, Nouveau Traité de la Rage; observations cliniques, recherches d'anatomie pathologique et doctrine de cette maladie. Lyons et Paris, 1820. 8vo.

BARDSLEY, J. L., M.D., article Hydrophobia; in Cyclopædia of Practical Medicine. London. royal 8vo. 1833.

VON LENHOSSEK, M., die Wuthkrankheit, nach bisherigen Beobachtungen und neueren Erfahrungen dargestellt. Pesth und Leipzig, 1837.

YOUATT, WILLIAM, On Rabies; in his work, The Dog. London, 1845. 8vo.

RUST, Aufsätze und Abhandlungen aus dem Gebiete der Medicen, Chirurgie, und Staatsarzneikunde, vol. ii. p. 805.

351. In poisoned wounds, not merely is the connexion of the part divided, but at the same time a peculiar matter is introduced into it, which gives rise to special symptoms. Here belong the stings of bees and wasps,