ON THE STRUCTURE OF THE SMALL-POX PUSTULE;
391 lesions ; Secondary abscesses, phlebitis, shock, tetanus-either as complications of fever, or existing as the most prominent diseased actions—are the leading dangers and causes of death in primary ampullttioll, The conclusion from these facts is sufficiently clear : primary amputation is liable to all the causes of danger and of death which are observed to supervene in all the other classes. This without an exception. The most dangerous causes in character here, as in the intermediary
... intermediary amputations, predominate in largest proportion, and in proportionately nearly equal numbers in primary and intermediary. Between the supervening actions of primary and intermediary amputations, there is, in truth, but little essential difference of cha-, racter. In the series before us of primary ' , amputation, we have death directly following I operation: cholera destroying 2, and tetanus supervening in 1 ; phlebitis and metastatic abscess each occurring in 1, not as complications of a peculiar type of fever, but as specific diseases, unconnected with febrile origin. These are points of difference between the two classes, which would seem to indicate a greater proneness to these actions, or to any others prevailing at the time, in primary amputations ; and such I believe to be the fact. I The actual inflammatory and febrile action commenced before intermediary amputations, seems counterbalanced in unfavourable effects by the quickness of succession in the two separate shocks of injury and amputation, suffered in cases operated primarily. And that they are two separate and distinct, and not two solved into one, as the warmest advocates of the advantages of primary amputation have occasionally sustained against all reason and evidence, no one can doubt, who has had the opportunity of observing for himself. Conclusions founded on such an error, one which, I repeat, must seem palpable and evident on investigation, is a cause of the long unsettled and, I will venture to assert, the still unsettled opinion as to the relative advantages and disadvantages of primary and secondary amputation. These are some of the more important conclusions to which I have been led by careful study, not only of the cases while under treatment, but of the results, classified and maturely considered. Some observations yet remain on the nature of the leading actions I have thustraced as supervening upon the four classes of cases defined and proving causes of mortality, as also upon the agents influencing their development, their progress, and termination. A few cases may also be required to illustrate by definite facts the whole subject, and conclude the relation of data and views connected with the treatment and mortality of severe injuries, and of amputations performed for their relief at different periods from the date of the accident. These views, and the facts on which they rest, I have felt anxious, not hastily or without mature consideration, but at the end of four years after the materials were collected in the field and at the bedside, to bring forward in a clear and practical manner for the assistance and instruction of those commencing their professional career. I have been anxious, from a firm conviction that, even should I fail in carrying the conviction of others with me as to the truth and importance of those facts and views, I might, nevertheless, contribute some little to our knowledge of the complicated questions bearing upon our practice in amputations; and that the effort would also tend to produce a more philosophical, accurate, and therefore satisfactory system of investigation, whenever the questions to which these lectures are devoted shall be the subject of inquiry. I found, at the commencement, that I must appeal to statistics for proofs, and by the same means test both my own opinions and those of others. It became immediately evi. dent, also, that for the due understanding of the facts in immediate connection with amputation, it was essential that there should be a comprehensive knowledge of the facts connected with the progress and mortality of diseased actions supervening on similar injuries where amputation was not performed. These facts, therefore, I furnished rather as indispensable to the proper appreciation of the questions of amputation, than as a mere collateral series which might be consulted or not, according to the taste of the inquirer. Having now concluded the consideration not only of these, but of the statistical results generally, the few remaining lectures will be devoted to the investigation of the nature of the diseased actions supervening on amputation, the chief agents in their development, and the means by which they may be modified, or their worst results averted. Lastly, I shall have a few practical observations to offer on the influence of different modes of operation and dressing, with a view to determine how far these may modify the results of amputations.