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diff --git a/44089-8.txt b/44089-8.txt deleted file mode 100644 index 4a15d2f..0000000 --- a/44089-8.txt +++ /dev/null @@ -1,3038 +0,0 @@ -The Project Gutenberg EBook of A dissertation on the inutility of the -amputation of limbs, by Johann Ulrich Bilguer - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org/license - - -Title: A dissertation on the inutility of the amputation of limbs - -Author: Johann Ulrich Bilguer - -Translator: S. A. D. Tissot - -Release Date: November 1, 2013 [EBook #44089] - -Language: English - -Character set encoding: ISO-8859-1 - -*** START OF THIS PROJECT GUTENBERG EBOOK A DISSERTATION *** - - - - -Produced by Fay Dunn and the Online Distributed Proofreading -Team at http://www.pgdp.net (This file was produced from -images generously made available by The Internet Archive) - - - - - -Transcriber's Note - - -In this plain text version of A Dissertation on the Inutility of the -Amputation of Limbs: - - Words in italics are marked with _underscores_. - Small capital letters are shown in upper case. - The oe ligature is represented by [oe]. - -Original spellings, punctuation, inconsistencies and all apparent -printers' errors are retained (see note at end of book for exceptions). - -Footnotes have been moved to the end of sections. - - - - - A DISSERTATION ON THE INUTILITY OF THE - - Amputation of Limbs. - - - Written in Latin, by M. BILGUER, Surgeon General - to the Armies of the King of PRUSSIA. Augmented - with the Notes of Mr. TISSOT, Physician at - LUSANNE. - - Now first Translated into ENGLISH, - - By a SURGEON. - - LONDON: - - Printed for R. BALDWIN, at the Rose, in - Paternoster-Row, and T. BECKET and P. A. DE - HONDT, in the Strand. - - MDCCLXIV. - - - - -ADVERTISEMENT, - -By the ENGLISH Translator. - - -It is with particular pleasure I present the English reader with a -translation of Mr. Bilguer's celebrated performance: It will meet, I -doubt not, with the approbation of those, who have the true honour of -surgery at heart, and are at the same time friends to humanity. After -what is said by so eminent a judge as Dr. Tissot, as well as many -others who are an ornament to the profession, I shall not launch out -into any eulogium on the author: there is a spirit of modesty, candour -and ingenuity runs through the whole, that to every sensible reader -will prove a sufficient recommendation of the work.----If it in the -least contributes to check the cruel and precipitate practice of taking -off limbs that might be saved, thereby preserving the lives, as well as -preventing the mutilation of numbers of our fellow creatures, I shall -think myself amply recompenced for the labour I have taken in thus -endeavouring to render Mr. Bilguer's beneficent design more extensively -known. - - - - - _Speedily will be published_, - - A - - Translation of Dr. TISSOT'S last Work, - - ENTITLED, - - Avis au Peuple sur sa Santé. - - By JAMES KIRKPATRICK, M. D. - - - - - TO - - DR. PRINGLE, - - Physician in Ordinary to Her Majesty, Fellow of the Royal Society, &c. - - - SIR, - -Your excellent work on the _Diseases of the Army_, so useful to -physicians in general, will always be considered as a standard for -the practice of those in particular, who are intrusted with the -important office of superintending the health of the soldiery. Mr. -Bilguer has performed, on his part, what you have so ably done on -yours, in pointing out to his colleagues and successors, the plan -which they ought to follow. It has given me pleasure to translate his -Dissertation, and you must derive a peculiar satisfaction from the -perusal of it, because, from the extensive and painful experience you -have had of the bad consequences resulting from the operation this able -Surgeon so warmly opposes, you can more readily perceive the usefulness -and value of this little work. It is therefore my duty to address it -to you, and I eagerly embrace so favourable an opportunity of thus -publicly declaring the sentiments of esteem and particular respect, -with which I have the honor to be, - - SIR, - Your most humble, and - Most obedient Servant, - - TISSOT. - - Lausanne, - 1 April, 1764. - - - - -PREFACE, - -By DR. TISSOT. - - -An extract of the Dissertation, of which I now publish a Translation, -had given me a very high opinion of it; but on a perusal of the whole, -I found it still better than I had imagined: It seemed to me one of the -most useful and best executed performances on Surgery, and I hoped it -would very soon be translated into French. - -Eighteen months having elapsed without any such translation appearing, -I thought of procuring one. I then endeavoured to find a translator, -but failing in that, I determined to do the office my self. I imagined, -that, in thus dedicating a few hours of my time to this work, I should -do a considerable service to many unfortunate people. I shall rest -well satisfied if, by rendering this excellent book more common, I -prove the means of adding to its influence, and of inducing a great -number of surgeons, who may now read it, to quit the cruel and fatal -practice of amputation, for the method which Mr. Bilguer proposes, with -a degree of sincerity and precision which leaves no room for doubt. - -The title of the original is, _Dissertatio inauguralis -medico-chirurgica, de membrorum amputatione, rarissime administranda aut -quasi abroganda, quam, pro gradu doctoris medecinæ et precipue chirurgiæ -rite consequendo, die vigesima una Martii, A. S. 1761. In alma Regia -Fridericiana speciminis loco, publicæ eruditorum censuræ submisit_, -JOHANNES ULRICUS BILGUER, curia-rh[oe]tus _generalis præfectus -chirurgorum exercitûs regii Borussici_. - -This work contains a much greater variety of matter than its title -implies, for it not only shews the inutility and danger of amputation, -by several arguments, to which many others might be added; but not -satisfied with levelling a tottering edifice, Mr. Bilguer frames and -describes a plan for preventing and curing those accidents, which -oblige surgeons to have recourse to amputation; and this is properly -the most considerable and most essential part of the performance, which -is, in fact, a treatise on gunshot wounds. - -I have scarcely done Mr. Bilguer justice with regard to style: I -hope, however, I have given his meaning, without depriving it of its -perspicuity or strength. This work will begin a new æra in Surgery, and -will reach posterity. I should have been sorry in any shape to have -disfigured it. - -It will give me very great pleasure, if the pains I have taken, and the -notes I have added, prove agreeable to the author. He may be convinced -that, being engaged in business as I am, his performance must have -appeared to me extremely well executed, and much wanted, before I -undertook to translate it. - -I am informed he has lately published a work on Surgery, in the German -language; I am persuaded it contains much valuable matter: He seems -to me to have a genius for discovering new expedients to lessen the -sufferings of human kind. I would have given this book the title of a -_Manual for the Surgeons of the Army_, which it deserves to be, were -there not already another so called[1], which, although very little -known, is by no means contemptible. The author had, even at that time, -remarked that wounds of the tendons are not troublesome, owing to -their want of sensibility, that the actual cautery is seldom proper; -and some other facts, almost forgotten since that time. He describes -wounds near the articulations with dislocation and fracture, he points -out the accidents attending gunshot wounds, and, what deserves notice, -he only admits of amputation in one case; namely, that of an incurable -mortification, and mentions it as a cruel and doubtful expedient. I -shall here cite his own words; they plainly shew that, if he lived in -our time, he would be one of the most zealous encouragers of the new -method, since he was so sensible of the defects, and grieved at the -barbarity of the old. "If, unfortunately," says he, "a mortification, -from whatever cause it proceeds, gains ground in such a manner as -to baffle all our care and applications, there is then no expedient -left but that of taking off the limb; the success of which is very -uncertain, for if it be dubious in a healthful subject, it must be -much more so in one which is otherwise: It is, however, the only -method, dreadful as it is, of putting astop to the ailment, and saving -the rest of the body. This nevertheless ought not to be done, except -when the consent, age and strength of the patient permit us to try so -dangerous an experiment." - -This author's manner of thinking is very far from being established as -might be wished, amputations being still too frequent. Mr. Bilguer's -work ought at this time to be so much the more favourably received, -as a celebrated company, whose decisions ought to have great weight -in matters relating to surgery, has formally declared, about seven -years ago, _That amputation is absolutely necessary in gunshot wounds, -complicated with fracture of the bones_; and have left unfortunate -wounded men no other alternative, but that of losing the injured limb -on the spot, or a few hours later. That line of Juvenal seems very -applicable on the occasion: - - _Nulla unquam de morte hominis cunctatio longa est._ - -FOOTNOTES: - -[1] _Le Manuel du Chirurgien d'Armée_; or, The Art of methodically -curing Gunshot Wounds, &c. By L. L. M. C. Printed for Houry, at Paris. -My edition is the second, published 1693. - - - - -A TABLE OF THE SECTIONS. - - - _Inutility of amputation of the limbs._ - - I. _The author's design in this treatise._ _Page_ 1 - - II. _What afforded him the first hints._ 2 - - III. _What encouraged his inquiries._ 3 - - IV. _Motives which induced him to write this treatise._ 4 - - V. _Subject of the dissertation._ 6 - - VI. _Accidents which are supposed to render amputation - necessary, viz. mortification, shattered limbs, - violent contusion, wounds of the large vessels, caries - of the bone, cancer._ 7 - - VII. _Internal medicines; remarks on the use of the bark - in mortifications. Questions by M. Tissot with respect - to two cases._ 9 - - VIII. _External applications; incisions on the parts - affected, manner of performing them._ 12 - - IX. _Separation of the dead from the sound flesh, - without cutting to the quick; nicety of this - operation._ 15 - - X. _Manner of dressing the wounds, and the bones, when - affected._ 17 - - XI. _Continuation._ 19 - - XII. _Scarifications round the mortified Part._ Ibid. - - XIII. _Doctrine of the ancients and several moderns - with respect to fomentations, confirmed. Forms - answering to different intentions._ Ibid. - - XIV. _Alteration of the condition of wounds; time to - administer the bark._ 25 - - XV. _Manner of giving it._ Ibid. - - XVI. _Sequel of the external treatment; formation - of pus._ 27 - - XVII. _Conjecture on S. G.'s manner of performing - cures._ 30 - - XVIII. _Reflections on the abuse of amputation, its - inexpediency when the mortification proceeds from an - internal cause._ 31 - - XIX. _Of a mortification in consequence of an external - accident; impropriety of amputation demonstrated; the - proper treatment._ 33 - - XX. _Shattered limbs the second case, fracture of the - bone; common treatment._ 39 - - XXI. _Method proposed by Mr. Bilguer; external - applications._ 42 - - XXII. _Remarks on the same subject; internal medicines._ 46 - - XXIII. _Fevers, their cause, danger, method of cure._ 47 - - XXIV. _Gunshot wounds, wounds of the joints._ 50 - - XXV. _Sequel of the method of cure._ 54 - - XXVI. _Success of the author's method._ 57 - - XXVII. _Calculation in his favour._ 59 - - XXVIII. _Sequel of the calculation._ 63 - - XXIX. _Of the amputation of the thigh._ Ibid. - - XXX. _Of contusion, the third case._ 68 - - XXXI. _Sequel of contusion._ 69 - - XXXII. _Method of cure._ 74 - - XXXIII. _Continuation of the method of cure._ 75 - - XXXIV. _Impatience of the sick under the new method; - steady perseverance of the surgeon requisite; care of - his Prussian Majesty to prevent useless mutilations of - the soldiers[2]._ 77 - - XXXV. _Limbs carried off; wounds of the large blood - vessels, the fourth case requiring amputation._ 78 - - XXXVI. _Cases which confirm Mr. Bilguer's method._ 91 - - XXXVII. _Continuation._ - - XXXVIII. _Caries of the bone, fifth case; the cure._ 92 - - XXXIX. _Different ways of relieving this ailment._ 96 - - XL. _Cancer of the parts, sixth case; inutility of - amputation._ 98 - - XLI. _Conclusion of the work._ 102 - -FOOTNOTES: - -[2] It was rumoured at Paris during the war, that the King of Prussia -forbid the mutilation of his soldiers from other motives than those -of humanity. Idle people spent their time in declaiming against such -barbarity, and thus ignorantly prejudiced the minds of people against -Mr. Bilguer's method. I have heard able surgeons hint this objection, -when I spoke to them concerning the present work. They acknowledged, -nevertheless, that amputations had been too common in the French -armies. I hope the publication of this little book will have two -effects; the first is, to re-establish the truth, and the second is, to -awaken in those surgeons, the feelings of humanity. - - - - -A DISSERTATION ON THE Inutility of Amputation. - - -Having resolved some little time since to publish in this learned -university a Dissertation which might serve as a specimen of my Medical -Acquirements, the subject which appeared the most suitable to my -purpose, is one, that may improve the art of surgery, which I practised -for several years during the heat of the late bloody wars, and may -at the same time wipe away the old aspersion, first broached at Rome -against Archagates, and so often repeated since, that surgeons are -executioners, who cut and burn without mercy. - -The cutting off a limb being the severest means employed in surgery -for the relief of mankind, an operation which every one beholds with -horror, I cannot, I imagine, more effectually accomplish my design, or -do a greater service, than by demonstrating, _that the cases wherein -amputation is necessary, are much less frequent than has been hitherto -supposed, and that it may even be almost totally dispensed with_. - - -SECT. II. - -My first thoughts on this subject arose from observing what passed -under my own inspection in the military hospitals. - -In the first place I remarked, that in a very great number of cases, -where amputation was judged necessary by the physicians and surgeons -of the army, and even by the wounded themselves, in order to preserve -life, it seldom or almost never answered the end. - -In the second place, I saw and had under my immediate care, a great -number of patients whose limbs had been carried off by cannon balls, -and in such a manner too, that all those who adhere to, and are afraid -to deviate from established rules, would have performed a fresh -amputation on the remaining stumps, whom I cured, as far as they were -capable of being cured, without having recourse to such disagreeable -means. - -And lastly; many others, whose limbs were not intirely separated -off, but so much detached, wounded, shattered and contused, that the -ablest surgeons deemed it necessary to take them wholly off, were -nevertheless, by my endeavours, contrary to the general opinion, cured -without amputation. - - -SECT. III. - -This success, partly owing to the efforts of nature, and partly to the -means employed by art, strongly encouraged me almost never to have -recourse to amputation, but to try every kind of remedy, internal as -well as external, calculated to preserve the lives as well as the -limbs of the unfortunate sufferers. My first attempts, so far from -being unfavourable, confirmed me more and more in the opinion, that -parts which have sustained the most considerable injuries, will much -oftener get well than what is commonly believed: And although this -opinion does not seem to be countenanced by many eminent physicians and -surgeons; although I do not flatter myself I shall be able to induce -them to alter their sentiments, I hope nevertheless, that some others, -encouraged by my example, and this account of my success, will have -the courage to follow the same method, and that their authority may -afterwards contribute to convince the most incredulous. - - -SECT. IV. - -But supposing, what I do not apprehend can be the case, that all -the gentlemen of the profession should agree in declaring my method -absolutely useless, the rest of mankind at least, will be obliged to -me for my endeavours to mutilate the wounded as little as possible; as -most people are shocked at the mention of any amputation, or at the -sight of a poor creature who has lost an hand, an arm, a foot or leg, -wretchedly crawling along upon crutches or a wooden leg; and consider -the total privation of a limb, as a much greater misfortune than when -it is preserved, though perhaps unshapely, and uncapable of performing -several of its primitive functions. If one reflects how much every body -dreads the pain occasioned by the slightest incision, he will easily -conceive the degree of horror a person must feel at the thought of -amputation, and why many patients chuse rather to die than to submit -to it[3]. Hence it is so uncommon to find men, like count Mansfeld, -so famed in the war that lasted thirty years, who caused his wounded -arm to be taken off amidst the sound of trumpets and beating of drums; -or like the country fellow, whom Dr. Schaarschmid, late an eminent -physician at Berlin, mentions in his collection of observations and -remarks on physic and surgery, who cut off his own mortified leg with a -saw, very unfit for such an operation[4]. - -FOOTNOTES: - -[3] I would not chuse to lay much stress on this argument; for if -one weighs the circumstances of pain, the amount of what the patient -suffers from the treatment necessary for saving the limb, will often be -equal to that arising from amputation. But the two strongest reasons -for prefering Mr. Bilguer's method is, the saving the limb as well -as the life of the patient; the loss of which is often occasioned by -amputation, but never by the pain of an incision. It is also true, that -pain when slighter, though longer continued, is more easily supported -by the patient. TISSOT. - -[4] To these instances may be added, that of the son of Thomas -Koulichan, a captain in the Austrian service, who, being wounded in the -leg, and the bones shattered, in one of the latter battles of the war, -held a candle with one hand and extracted the splinters with the other. -He exhibited many other proofs, not only of courage in the field, but -also of that fortitude in bearing pain which is very different from the -other, and much more seldom met with. TISSOT. - - -SECT. V. - -But lest I should be charged with being weakly influenced by the cries -of the patient, and with wanting that kind of fortitude which Celsus[5] -thinks requisite in a surgeon, in treating of this operation, I shall -take it for granted that the patients are men like those I have just -now mentioned, and that an inordinate desire of life, an uncommon -strength of mind, religion, and other moral reasons, induce them to -consider pain as nothing, when it affords them any hope of preserving -life. - -It is foreign to my plan to inquire who was the first who attempted -this operation, or to trace the history of it in the works of the -ancients. I shall only take notice, that such wounded men as recovered, -after having lost a limb by some accident, without doubt, shewed the -possibility, and suggested the first hint of trying this operation. -Neither shall I dwell upon the various methods of performing it from -the infancy of the art to the present time; they are described in -other books[6], and I do not purpose giving a compleat treatise on -amputation. I shall not even touch upon what is already generally known -on this subject, but as little as I possibly can: This is the best way -of handling any particular point; and I hope all those who pay more -regard than I do to scholastic form, will pardon my inattention to -regularity of method and stile, when they are informed how much my time -is engaged; others will excuse me, when they call to mind the remark of -Celsus, that diseases are cured by proper remedies, not by a display of -eloquence. - -FOOTNOTES: - -[5] _Celsus de re medica_, l. 7. præf. Nevertheless Mr. Dionis, in -his course of operations, (_Demonstr. 2, Art. 9._) acknowleges, that -even the most intrepid surgeons tremble at the instant they are going -to perform this operation. Of all the operations, says he, that which -occasions the greatest horror, is the amputation of a thigh, a leg -or an arm. When a surgeon is about to take off a limb, and reflects -on the cruel means he must employ, he cannot help feeling a tremour, -and pitying the misfortune of the poor patient, who is under a fatal -necessity of being deprived, for life, of a part of his body. And in -another place he says, This operation ought rather to be performed by a -butcher than by a surgeon. - -[6] Memoirs of the Royal Academy of Sciences, 1732. Art. 7. - - -SECT. VI. - -To prove what I have advanced, I shall begin with enumerating those -accidents for which amputation has been hitherto deemed necessary. I -shall reduce them to six. - -First, A mortification, which spreads till it reaches the bone. - -Secondly, Any limb so greatly hurt, whether by fracture or -dilaceration, that there is room to dread the most fatal consequences, -a mortification and death. - -Thirdly, A violent contusion of the soft parts, which has at the same -time shattered the bones. - -Fourthly, Wounds of the larger vessels, which convey the blood into the -limb, either, as the only means of stopping the hemorrhage, or through -the apprehension the limb should perish for want of nourishment. - -Fifthly, An incurable caries of the bone. - -Sixthly, If any part is either attacked with a cancer, or is in danger -of being so, it is customary to take it off. - -I shall treat of these different accidents more or less particularly, -in proportion to the number of observations I have made on each of -them, as no method of cure, however doubtful and alarming, should -be rejected, till a better can be pointed out. Thus, this treatise -contains only, in effect, an account of the methods I successfully -employed in the military hospitals, for the relief of the above -disorders; together with a few observations, and still fewer -hypothetical reasonings, which induced me to condemn the use of -amputation. - - -SECT. VII. - -I shall begin with an account of the means I make use of, internal -as well as external, when a limb is mortified, the effects of which -have convinced me, that in such cases amputation is not necessary; -and here I shall first gratify the curiosity of those readers who, -doubtless, are desirous to know what I have learned from the extensive -opportunities I must necessarily have had, with respect to the use of -the Peruvian bark. - -Experience has taught me, that this admirable medicine is possessed of -a singular and specific virtue in mortifications. - -I know that several physicians and surgeons only recommend it in -those which proceed from weakness. I have heard it reported by -others, that they found it of little service after the famous battle -of Dettingen[7]. But perhaps the other circumstances, with regard to -the treatment of the patient, did not contribute to promote those -good effects which I always observed attended it when judiciously -administered. And I make no doubt, but every practitioner who, in -prescribing it in cases of mortification, observes the rules laid -down by Dr. Pringle, Dickins, Wade, Cheselden, Douglas, Rushworth, -Amyand, Shipton and some others, will find it very efficacious. I -do not mean, nevertheless, that it should be considered as the only -internal medicine; there are, doubtless, other bitters which are -sometimes extremely proper on these occasions. I must add, that the -bark appears to me to possess that quality which Celsus requires in -medicines, whether in a solid or liquid form, adapted to the cure of -a mortification, to bind the belly moderately, and brace the whole -system. After having treated of the external applications, I shall -point out the method in which I administered the bark. - -FOOTNOTES: - -[7] Mr. Ranby, however, who was one of the surgeons of the British -troops at the time of the battle of Dettingen, lays great stress upon -the bark: It is true, that in one of his cases, having ordered it to -an officer of seventy years of age, whose leg had been amputated, _on -account of his ancle, with the neighbouring parts, having been terribly -shattered by a cannon ball_, it did not keep the sore from growing -worse, or prevent the patient's death. But that we may form a just -estimate of the merit of the bark, and the effects of amputation at -the same time, it will be necessary to compare this case with the one -which precedes it. This comparison will, I imagine, be of use.----I -shall quote the author's own words. "An Austrian officer, who had his -hand miserably shattered by a cannon ball, was, by some accident, left -in a wood near the field of battle, destitute of any manner of help, -from Thursday till the Sunday following, when he was brought to Hanau. -The next morning I was carried to see him, and to assist in taking off -his arm. On viewing it, I found it mortified almost to the elbow, with -a great swelling and inflammation quite up to the shoulder. As it was -by no means adviseable to attempt an amputation in such circumstances, -I proposed giving him the bark; which being no ways objected to, he -entered upon immediately. The next day he was rather better: But, on -the third, was evidently so. The inflammation was less, the swelling -began to subside, and the edges of the mortification were separating. -The arm was fomented and wrapped up in the oatmeal and stale beer -poultice, with theriaca: And the dreadful symptoms which forbad the -operation, were now so much abated, that his surgeons did not at all -hesitate to take it off. But this was done to very little purpose; -for three or four days after the amputation, being attacked with -convulsions, he expired." - -I shall here subjoin five questions. - -Would Mr. Bilguer have amputated in these two instances? - -Would not his method have saved both these patients, especially the -last? - -Does not amputation seem to have contributed to their death? - -Does it not evidently appear, that in the latter of these two cases, -amputation destroyed the good effects of the bark, which seemed to -conduct the patient to a speedy cure; and that in the former case, the -bark had not power sufficient to repair the mischief occasioned by the -amputation? - -Does it not follow from these two observations, that however salutary -the effects of the bark may be, those of amputation are hurtful in a -greater degree? TISSOT. - - -SECT. VIII. - -Whenever a mortification attacks any part of the body, whether it be -owing to an outward hurt, or proceeds from an internal cause, as often -happens in persons afflicted with the scurvy, dropsy, a vitiated state -of the blood, phagedenic sores, or very aged people, who begin, as it -were, to die in the extremities: Whenever, I say, the mortification -begins to appear, it requires immediate help. We must begin by making -incisions on the part affected, in order to procure a discharge of -the corrupted matter, and to assist the action of the medicines. I -make long incisions, not only on the mortified parts, but on those -adjacent, which would soon be so; I make several of them, as nearly as -the large trunks of the blood vessels, and more considerable branches -of nerves will allow, not above an inch distant from each other. We -ought always to cut to the quick; and if the bone be affected, the -periosteum must be cut through, and the bone laid bare. These incisions -should follow the direction of the greater number of fibres of the -muscles that happen to be thus cut upon; but when the gastrocnemii, -the glutei or deltoid muscles have been wounded by a ball, they must -be cut cross-ways, otherwise convulsions, particularly the spasmus -cynicus, will probably ensue. Several aponeuroses, especially that of -the biceps, ought likewise to be cut transversally: It is true, if the -longitudinal incisions are sufficiently long and numerous, they take -off the tension of these membranes so much as to render the transversal -ones unnecessary. - -Neither ought the tendons to be spared; they must be boldly cut through -transversally. - -If a wound, or any other ailment, happens near the articulations, I -also, without fear, make large incisions through the ligaments. - -It will easily be understood that these incisions must differ from -each other in length and depth; they must be longer in those parts -of the sore where the disease has spread the widest, and shorter in -others. Both must be more superficial at their extremities, and deeper -in the middle, in the place where the complaint began, and where the -mortification reaches deepest. - -The number of incisions, and their distance, must also vary, as they -may be found necessary; so that a skilful surgeon may make three, four, -six or eight, as the case may require. - -It is obvious, that in an operation of this kind, a surgeon should not -be too precipitate; and when he does not know the depth of the ailment, -he should not go too deep with his incision: he may repeat it if he -finds he has not reached the quick. - - -SECT. IX. - -After these incisions are made, we must carefully examine how far the -part which is absolutely mortified, and which it is impossible to -restore to life, may reach. This may be distinguished by the stench -which exhales from it, by its change of colour, and want of feeling. -These mortified parts ought immediately to be separated from the sound, -and removed by means of a bistory in the same manner as one muscle is -divided from another in an anatomical dissection. In order to do this, -the dead flesh must be cut through cross-ways, which puts the patient -to no kind of pain. But care must be taken in this operation, not to -separate such parts as may be somewhat affected by the mortification, -yet not totally corrupted, as it often happens, after the removal of -what is entirely dead, that they recover, by proper assistance, their -natural state. - -In making these incisions, we should take all imaginable care, as I -have already remarked, not to wound the larger blood vessels or more -considerable nerves; for this purpose, the gangrened parts which -lie near them, should be separated with great caution: It is even -better to leave behind a small portion of the mortified flesh which -may adhere to them, and to trust for its separation to the ensuing -dressings, which they will not fail to accomplish. The reason for this -rule is, that we often see the vessels remain sufficiently sound, -while the other parts are very much corrupted. We find for example, -in the arm, near the joint of the elbow, near the wrist, and even in -the lower extremities, the vessels intire, although the mortification -of the parts which surround them be so considerable, as to oblige us -to make our incisions to the bone; and it is these vessels, after the -extirpation of the dead parts, that must keep up life in those which -remain: We ought to preserve the greatest number we can, not only of -the larger vessels, but even of the smaller ones: It was with a view to -this particular, that I recommended not to make our incisions rashly, -but with a good deal of caution, both with respect to the place where -they were made, their direction and their distance. In operating with -this circumspection, we shall avoid incurring the censure of Platnerus, -who remarks, that we ought not to separate the dead from the sound -parts with violence, "Because," says he, "incisions which cause an -effusion of blood, often renew the inflammation." Now in my method, -there is neither any violence, nor incisions attended with blood. - - -SECT. X. - -When the incisions are made, if the neighbouring parts appear somewhat -tainted, we must, by gentle compression, squeeze out the corrupted -humour which may harbour there, and wipe it off with a bit of soft -linnen rag. Afterwards, whether it may have been necessary to extract, -either with the fingers, a scalpel, or with the instrument called a -myrtle leaf[8], any bony splinters too much detached from the substance -of the bone itself to hope for a re-union, a circumstance which often -requires a considerable dilatation of the fleshy parts; or whether -the bones appear carious, or spoiled in any other shape; or, lastly, -whether we may have been obliged to make deep incisions, even to -the bone: In all these cases, we must at first employ such external -applications as are proper for the bones, and for the soft parts that -have a tendency to mortification, although they may have discharged a -sufficient quantity of blood during these operations. - -The bone, whether the periosteum be sound or destroyed, must be dressed -with the following medicine: _Of frankincense, mastick, sarcocolla and -myrrh finely pounded, true balsam of Peru, and genuine essential oil -of cloves, of each equal parts; of balsam of Fioraventi, as much as -may, in mixing all the ingredients over a very gentle fire, form a thin -liniment_; which must be warmed when used, and which must be poured -plentifully into the wounds I am speaking of, so that the bone may be -well moistened therewith. - -This medicine is of service in all cases where the bone is affected. -When the bone is covered with it, some dry lint may be laid over it, -and the soft parts dressed by sprinkling upon this lint a powder -composed of _an ounce of myrrh finely pounded, half an ounce of sal -ammoniac, camphor and nitre, each a dram_. After the first layer of -lint is thus covered, fresh lint must be applied, and again sprinkled -with the powder, till in this manner the cavity of the wound is quite -filled up with alternate layers of lint, and this vulnerary powder. - -FOOTNOTES: - -[8] See Dionis's surgery, page 18. 4th edition. - - -SECT. XI. - -If the bone is not affected, or the periosteum laid bare, the balsam or -thin liniment may be omitted. And the dressings may only consist of the -layers of dry lint and vulnerary powder applied alternately. - - -SECT. XII. - -Besides the dressings I have mentioned (§ X. and § XI.) for these -kinds of wounds, we must likewise make slight scarifications upon the -neighbouring parts, and sprinkle them with the powder; after this -treatment, embrocate all the sores with oil of turpentine, and then -lightly bandage up the whole with plain linnen cloth, which must be -kept moistened, night and day, with warm fomentations. - - -SECT. XIII. - -It is in following this method only, (§ X, XI, XII.) that these -fomentations, so much recommended both by the antients and moderns, -will be found truly serviceable and efficacious. Mr. Heister has -collected a sufficient number of these forms, in treating of -mortifications, in his excellent system of surgery, which is in every -body's hands. It will be an easy matter for a surgeon, who understands -the nature of the ailment and the quality of the medicines, to select -such as will be most suitable to the case he happens to treat. Thus, -for example, the fomentation consisting of a _pint of lime water, -three ounces of camphorated spirit of wine, and an ounce or half an -ounce of sal ammoniac_, is very useful in mortifications which are -the consequences of high inflammation, as it relieves the inflamed -parts that lie round those which are already mortified. The same -effect may be obtained from the fomentation made with the _balsam of -life_; namely, _soap, salt of tartar, and oil of turpentine, mixed and -dissolved in lime-water_; and from the _cataplasm_, composed of the -herbs called _species pro cataplasmate_, and _venice soap and saffron_ -added thereto[9]. - -If, without any considerable inflammation preceding, a part is found -mortified, or a beginning mortification appears attended with a -swelling, which frequently happens to dropsical people, to those -afflicted with [oe]dematous tumours, and to aged persons, and whenever -the ailment proceeds from a defect rather than an excess of the vital -motions; the following fomentations are more proper. - - 1. _Take of water germander, wormwood, southernwood, rue, of each two - handfulls; chamomile flowers, one handfull: Boil them together, and to - two pints of the strained liquor add four ounces of treacle spirit, - two ounces of venice soap, and half an ounce or even an ounce of sal - gem._ - - 2. _Take of water germander, wormwood, feverfew, of each two - handfulls; of mint and southernwood, of each a handfull: Boil them - together in oxycrate, so as to have four pints of the strained liquor, - to which may be added half an ounce of sal gem, and afterwards from - two to four ounces of treacle spirit._ - - 3. _Take of martial ball[10] two ounces, sal ammoniac one ounce; - dissolve them in about eight pints of spring water, and add two pints - of rectified spirit of wine._ - - 4. _Take of crude alum, and white vitriol, each two ounces and two - drams; lytharge of silver and myrrh, each an ounce; Aleppo galls, two - ounces; juniper and bay berries, each an ounce; savin and rue, each - two pugils; oak leaves, a handfull and a half; verdegris, half an - ounce; camphor, two drams; calamin, six drams[11]. After having mixed - and reduced all these ingredients to powder, let two ounces of the - composition be boiled with four pints of water, or with two of water - and two of vinegar._ - -The following embrocations applied to parts already mortified, will -stop the further progress of the mortification; where it is just -beginning they will prevent it, and will also help nature to separate -the dead parts from the sound. - - 1. _Spirit of wine, three ounces; myrrh and aloes powdered, of each - half an ounce; Ægyptian ointment, three drams[12]._ - - 2. _Vinous decoction of scordium, twelve ounces; vinegar of rue and of - roses, of each four ounces; spirit of treacle, three ounces; and one - ounce of sal ammoniac._ - - 3. _Lime water, four pints; treacle spirit, or that of feverfew, two - pints; white wine vinegar, one pint; elixir proprietatis, six ounces; - Ægyptian ointment, two ounces._ - - 4. _Decoction of elder flowers, six ounces; wine, eight ounces; - vinegar, camphorated spirit of wine, treacle spirit, or that of - feverfew, each two ounces; spirit of salt, two drams._ - -Lastly, in order to soften the parts, separate the sloughs, and promote -suppuration, the following application may be used. - - _Water germander, two handfulls; mallows and marshmallows, each - a handfull; flower of linseed, three ounces; Venice soap and sal - ammoniac, of each two ounces; linseed oil, an ounce. Let these - ingredients be boiled together, in vinegar and water, to the - consistence of a poultice._ - -It may be in general observed with regard to fomentations, that such -as are emollient are serviceable, when hard dry crusts prevent a -discharge; those which abound with acid, when there is a considerable -degree of putrefaction; and, lastly, those which are spirituous, saline -or strengthening, are most proper when swellings are flabby, and the -body abounds with aqueous humours. - -FOOTNOTES: - -[9] These two last applications are not in Heister: The _species -pro cataplasmatic_, consists of _yarrow, wormwood, water germander, -southernwood, chamomile, sage, hysop, rue, elder, St. John's wort, and -red roses_. - -It is quite unnecessary to make use of all these ingredients at one -time. TISSOT. - -[10] As the composition of the martial ball may not be generally known, -I shall describe it in this place: _Take of filings of iron one part; -white tartar two parts: Let them be reduced to a fine powder, and put -into a matrass with as much French brandy as will swim about an inch -above the powder; exhale to dryness, either in the heat of the sun or -in that of a water bath. Pour fresh brandy upon the remainder, and -evaporate them in this manner several times successively, till the mass -appears resinous; then form it into balls nearly of the bigness of an -egg._ - -I do not exactly know what quantity Mr. Bilguer means by _sextarius_; -that measure, among the ancients, contained twenty four ounces, but -here I believe it denotes somewhat less. If we suppose it to be about a -pint, the medicine will be extremely good. - -[11] This composition is commonly called _species pro decocto nigro_, -or the species for the black decoction. - -[12] In using the external vulnerary medicines, in which aloes is an -ingredient, it must be remembered, what Mr. Bilguer remarks in another -place, that they often prove purgative. - - -SECT. XIV. - -The diligent use of these fomentations will alter, in the space of -twelve hours, the condition of gangrened wounds for the better; at -the end of which, the lint and vulnerary powder, with which they were -filled, may be removed, and at the same time, all the detached pieces -of mortified flesh may be extracted, and the same dressings (§ X, XI, -XII.) applied, which must be renewed every twelve hours. The third -or fourth dressing, the wound will discharge matter of a favourable -aspect, so as to afford hopes of a cure: Then it will only be necessary -to give the bark internally, and to dress the sore in the manner I -shall mention by and bye. § XVI. - - -SECT. XV. - -The bark may be given by itself, in powder, or made into an electuary -with rob of elder, or with the syrup of quinces, cinnamon, orange-peel, -or any other cordial syrup; if it purges when taken in substance, it -must be administered in the infusion or extract. If the fever be -strong, the heat considerable, and the patient thirsty, the bark will -be of no service[13]; but recourse must be had to medicines which -may abate the fever and allay the heat, such as are commonly called -temperants. - -If the bark be judged necessary, it may be given in doses of half a -dram or two scruples, at first every hour, afterwards every two hours, -and at length, once every three or four hours: To each dose may be -added a few drops of spirit of sea salt, or of dulcified spirit of -vitriol, or a few grains of alum or catechu. If the patient be very -weak, a small glass of some acid wine may be ordered with the medicine, -such as Rhenish, Neckar or Moselle wine, &c. When it is thought proper -to promote perspiration, an infusion of chamomile may be drank, as is -recommended by Dr. Pringle. Let the strength be supported by the plain -regimen, directed by that physician in the same treatise. - -Let the drink be water and vinegar, weak veal and chicken broth, gruels -of barley or oatmeal, acidulated with vinegar or juice of lemons, -&c. I have not room, in this place, to enter into a more particular -discussion. - -FOOTNOTES: - -[13] Mr. Bilguer might have even said hurtful; the only true temperants -are, repeated bleedings and the acids, which are preferable to nitre, -which is not very proper wherever there is reason to apprehend a -mortification. Absorbents, which in some parts of the country where Mr. -Bilguer writes, are still ranked in the class of temperants, are very -hurtful in the present case, and never afford any relief to wounded -patients. - - -SECT. XVI. - -I now return to the external treatment. When the dressings described, -§ X, XI, XII. have begun to procure a discharge of matter, the use of -the vulnerary powder and oil of turpentine must be laid aside; but -we must continue to assist and promote the suppuration for several -days, sometimes even to the eighth; by dressing with the digestive, -I shall hereafter mention, by keeping the parts constantly covered -with emollient fomentations, and by avoiding to cleanse the wound -too much, either by too strong compression, or by wiping it with -too much exactness each time of dressing. We ought to be very much -on our guard with respect to these two last points, till there be a -sufficient suppuration; afterwards a somewhat stronger compression may -be allowed, and the sore may be wiped with more exactness, but still, -nevertheless, but very gently. For suppuration is the work of nature, -an effort of the sound parts, by which they throw off whatever is -vitiated and noxious; and it is the business of the surgeon to assist -this salutary operation, by removing, with his instruments, such parts -as are intirely corrupted; but this ought to be done, at least as much -as possible, without causing any discharge of blood[14]. He must not, -however, confine his attention to the soft parts only, but must have an -eye likewise to the bones; and, after having examined them carefully, -and even made what dilatations may be necessary for this examination, -he must remove, at each dressing, whatever is carious, and all the -splinters that can be extracted without violence; after which they -may be covered with the balsam for the bones, § X. and the soft parts -dressed, as circumstances may indicate, either with dry lint, or with -some digestive ointment, especially that which I shall describe bye and -bye, quickened with a little essence of myrrh. - -All these dressings should be finished as expeditiously as possible, -in order not to leave the sore too long exposed to the air, especially -the cold air, which may be avoided by dressing the patient in a room -moderately warm, and by holding a few live coals near the part which is -dressed. - -When there is a large suppuration the wound must be dressed twice a -day, beginning always, as I said before, with carefully examining -the state of the bone, with removing such shivers as are separable, -with rasping and trepanning where there may be occasion; leaving to -nature, assisted by the balsam, § X. what cannot be extracted by manual -assistance. - -The digestive ointment for the fleshy parts, which I commonly use, and -which I have already recommended, is the following; _Oil olive, half -a pint, and an ounce of red saunders boiled together, till the oil -acquire a deep red colour; when it is strained, add a pound of yellow -wax, and a pound and a half of turpentine; when the whole is mixed -and melted together over a gentle fire, a little balsam of Peru may be -added._ - -This medicine is principally of service in cases where, on account -of the proximity of the bones, we would not chuse too plentiful a -suppuration. - -FOOTNOTES: - -[14] This precept, of which the very reverse is but too frequently -practised, is of very great consequence: It is founded upon this, that -a discharge of blood proves that an incision has reached the quick; -now every such incision produces an inflammation, which retards the -suppuration already begun, and hence we interrupt this operation of -nature which we meant to promote, and, as it is the means of preventing -a mortification, whatever interrupts it contributes to the disease: It -cannot, therefore, be too often repeated, that in general, incisions -which cause a discharge of blood, ought never to be practised after a -suppuration is begun. TISSOT. - - -SECT. XVII. - -It was probably by some such application, that S** G**** cured a man -whose arm was mortified, and whom the physicians and surgeons had -given up; a cure which appears to me much less wonderful than what -is imagined. The physicians and surgeons despaired of his recovery, -and quitted him, because he would not submit to amputation, at the -very time when, doubtless, the separation of the sound and mortified -parts began to take place, owing either to the force of nature or the -medicines they had administered, and when granulations of new flesh -began to shoot. It was easy for S** G****, called in at this instant, -to effect a cure, by means of his quieting powders and balsam. What is -most astonishing in this case, and deserves at the same time to excite -our indignation, is the obstinacy and the cruelty of the physicians; -but they were sufficiently punished for it. - - -SECT. XVIII. - -This is not the only instance of patients in whose cases physicians -and surgeons have pronounced amputation to be unavoidable, and who, -upon their refusing to submit to it, have afterwards been cured by very -simple treatment. This ought to be a lesson for us never to be too -precipitate in having recourse to this operation. - -But what must be done, they will say, when every medicine has failed? -Is it not better, in such a situation, to try a doubtful remedy, as -Celsus expresses it, than to do nothing? - -As what is called a doubtful remedy, is for the most part no remedy at -all, I look upon such an argument as very fallacious; I shall explain, -what I think on this point. Every mortification is the consequence -either of some internal morbid cause, or an external accident. In the -first case, amputation can be of no service while the morbid cause -remains; and who can hope, in so short a time, to remove a consumption, -the scurvy, a decay from old age, a dropsy, or cachexy? And if these -cannot be removed before amputation, it is to very little purpose to -operate on the sound part, as it would only be killing the patient. Is -there a physician or surgeon but would conclude he occasioned the death -of a dropsical person, were he to cut his mortified leg off above the -knee? What is true in a dropsical case, is equally so with respect to -others: To amputate, is only to give needless pain, and to accelerate -the patient's death. It may be further asked, Must we then in such a -situation intirely abandon the patient? I answer, No; but we ought to -direct our efforts against the morbid cause, and at the same time, -employ the most effectual applications externally, lopping off whatever -is absolutely mortified, without cutting to the quick, lest the pain, -and other accidents which are the consequence of such incisions, should -hasten death. After this treatment, the remainder may be left to -nature, assisted with the most efficacious medicines, internal as well -as external; and if the patient dies, we may rest satisfied that the -disease was beyond the resources of art. - -FOOTNOTES: - -[15][15] I hardly ever knew any old officers who have not been witnesses -of some examples of this kind; and I have seen several people who have -themselves been in such a situation. - - -SECT. XIX. - -When a mortification in a healthy constitution is the consequence of -an external accident, the point is not so easily determined; I will -venture, nevertheless, to remove the difficulty. - -It must first be inquired into, if the ailment has been properly -treated at the begining, and if sufficient care has been taken with -respect to the cause. If there appears any default in these points, we -must first endeavour to repair it, before we think of amputation. If, -on the contrary, the treatment has been judicious, we must examine if -the mortification continues to spread, or if it be stopt, and its edges -begin to discover themselves. - -If it continues to spread, it is improper to amputate, for several -reasons. In the first place, because the whole habit is in a bad -state, and there must be a fever and general inflammation, which would -be greatly increased by an operation which, of itself, is sufficient -to bring on the death of the healthiest man. In the second place, -amputation cannot be performed on the sound part, in the manner as is -generally imagined, as the infection is very often more deeply seated -than it appears to be: We may judge of this by observing what happens -very frequently in whitlows of a bad kind, where the matter quickly -insinuates itself along the arm, and is pent up there, inflaming -sometimes even the axillary glands; as an inflammation of the toes, -in a short time, brings on that of the glands in the groin: Thus -the disease having taken root in the place where the operation is -performed, would of course be increased by the ligatures, which are -indispensably necessary in this operation, unless we would suffer the -patient to perish by an hemorrhage. In such a case then, amputation -is not a dubious remedy, but it is no remedy at all[16]; and if the -patient sometimes does escape, it must be acknowledged that nature has -effected the cure; that she has got the better both of the disease and -of the bad treatment, and has thus overcome a double enemy. - -It is evident, from what I have said, that while the mortification -gains ground, the method I have proposed, § VII. XVI. should be -followed. When its progress is stopt, it must be considered whether -the limb can be preserved or not. We may entertain hopes[17] of its -preservation, if all the corrupted parts cast off, and the sound parts, -and even the bones, begin to produce granulations of new flesh. I -cannot here omit remarking, that Mr. Haller's late experiments, which -prove to the satisfaction of many eminent anatomists, the insensibility -of the periosteum, render the sign of a mortification derived from such -insensibility very doubtful. My experiments on this subject agree with -his, excepting in this, that I always found the pericranium extremely -sensible[18]. Whatever weight may be laid on these experiments, this -consequence may at least be deduced from them, that we ought not -immediately to conclude that the bones and periosteum are affected, -because we prick, cut or tear the periosteum without giving pain; nor, -in like manner, from this symptom, ought we to neglect the medicines -indicated § VII. XVI. - -If the rottenness of the bone demonstrates that the limb cannot be -saved, which almost always happens, if the patient has been improperly -treated, we must amputate, if the strength of the patient be sufficient -to support this dreadful expedient, and amputate on the sound parts. -It is true, that amputation in this case is a doubtful remedy, but -nevertheless as there is no other, and as there is no symptom in the -patient that forbids its use, it is a remedy. If the patient be weak, -the case is desperate, as he is not able to support the operation -on the sound parts, and as nature is not in a condition to effect a -separation of the dead from the live flesh, if only the mortified part -be cut off. - -In so dangerous a case, the method I would take, would be, after -providing against any hemorrhage of the larger vessels by a proper -ligature, to lop off all the gangrened useless mass, not actually -through the quick itself, but very near it; afterwards I would -endeavour to stop the progress of the infection by internal medicines -and suitable dressings. I would support his strength by a proper -regimen; if it increases, we may be sure a separation of the soft parts -that are mortified will ensue naturally; after which, it will be easy -to saw off the little stump of dead bone that was left. The wound may -then be cicatrised, by means of epulotic applications, and such as we -have recommended for bones when laid bare, § X. - -This practice is not only conformable to sound reason, but what is -more, it is confirmed by repeated experience; since we find among the -collectors of observations, but few instances of amputation succeeding, -when it was performed while a mortification continued to gain ground, -or while the patient was feverish; but a much greater number of -successful cases, when amputation was performed late, and when the -disease had abated naturally: A variety of examples may be seen in the -work of Mr. Schaarschmid[19], which I have already quoted. - -It will, perhaps, be objected to me, that I am inconsistent with -myself, since I have just proposed one method, and actually follow -another; but this objection will vanish, if it be considered in the -first place, that if a person has been thus judiciously treated -from the beginning, and does not recover, a cure will almost never -be effected, after the cruel expedient of amputation. In the second -place, that all those who are under a necessity of submitting to this -dangerous operation, on account of their having neglected themselves, -or having been unskilfully treated, have no reason to complain of the -art, or of those who understand it, but of their own negligence, or of -the ignorance of those into whose hands they have had the misfortune -to fall. And in the third place, that in opposing amputation on the -sound parts, and in testifying my abhorrence against the needless pain -which accompanies it, I do not at all condemn the amputation of what is -absolutely mortified. - -I have however sufficiently expatiated on this point, which ought to -be considered before the others, as being more general. I now proceed -to examine the accidents that induce surgeons to amputate in order -to prevent a mortification. There are some who have carried their -precipitation, in this respect, to such a length, as to cut off limbs -upon the spot, that have been considerably bruised, before they tried -any other remedy: A piece of cruelty I cannot in any shape approve -of[20]. - -FOOTNOTES: - -[16] Mr. Sharp, to the best of my recollection, was the first who -solidly proved the impropriety of operating on the sound part, while -the mortification continued to gain ground. This excellent doctrine not -being as yet universally acknowledged, it is very much to be wished, -that the additional authority of so judicious a surgeon as Mr. Bilguer, -may contribute to give it fresh weight, in order to render it general. -TISSOT. - -[17] I shall transcribe Mr. Bilguer's own words. _Quo quidem loco -non possumus, quin observemus, signum illud corruptionis quod a -deffectu sensûs desumi solet, per illustris Halleri experimentis, -quodam modo incertum redditum esse, quibus quippe evictam periosteorum -insensibilitatem esse multi clarioque viri putant. Nostra de his rebus -experimenta fere cum Halleri doctrina congruunt, nisi Pericraneum -numquam non sensibilissimum deprehendimus_. - -[18] See, on this subject, the memoir of M. Haller, on the sensible and -irritable parts, T. 1. 4. - -[19] Sammlungen, &c. a performance which ought to be generally read. - -[20] This practice has also been condemned by others. See the -collection of pieces which put in for the prize conferred by the royal -academy of surgery. T. 3. p. 490. It is there observed that every -amputation performed immediately after the hurt, is generally dangerous -in its consequences. - -I know that a soldier, who had his arm cut off in the field of battle, -after the affair of Prague, died the third or fourth day after the -operation. - - -SECT. XX. - -I shall treat at present of large contusions of the limbs, especially -of those where the fleshy parts, as well as the bones, are extremely -bruised and shattered, as commonly happens, when the hand, the foot, -the elbow, the leg, arm or thigh, have been bruised by a large stone, -a beam of wood, a cart-wheel, a screw, a press, &c. In such cases, -shall the patient get sooner well by amputating or not amputating this -shattered limb? I answer, by not amputating; the worst consequences -that can be apprehended, is a mortification or an hemorrhage. With -regard to the mortification, unless every thing I have hitherto said -concerning it be intirely groundless, we ought not to be afraid of -it; and it is much easier to prevent than to cure it. With respect -to the hemorrhage, it is no doubt to be dreaded, but this dread can -be no reason for instantly taking off the limb: To be convinced of -this, we need only examine those wounded men who have had an arm or -leg carried off by a ball, and the stump so shattered, that the bone -has been shivered into several pieces, and the large blood vessels -most shockingly torn, who have, notwithstanding, been cured without -amputation, and with whom the bleeding has stopt, even without the -assistance of a surgeon. Nevertheless, every body knows that contusions -of this kind have been hitherto, by most surgeons, accounted a -sufficient cause for amputation; and that when the hand or foot have -been shattered, they have carried their inhumanity so far, as to take -off, not only the leg or fore-arm, but even sometimes above the knee or -joint of the elbow. - -Those who follow this method, amputate within a few days of the -accident, while the patient is vigorous, and without waiting for the -event of any other kind of treatment; for if the patient be weak, old -or very ill, even with the consequences of the wound, they do not -venture upon the operation. - -It would however, in my opinion, be much better not only not to take -off an arm, a thigh, or a leg, which are unhurt, but even to endeavour -to save the foot or hand which are shattered, in obviating, by medicine -and diet, as well as by external applications, the accidents that may -ensue; and thus prevent a person who has already suffered so severely, -from meeting with a treatment still more severe. - -It will be asked, if the thing be possible? The following observations -will furnish an answer. I publish them with so much the more -confidence, as they are known, not only by the patients themselves, but -by a great number of the physicians and surgeons of the army. They must -be decisive in favour of preserving contused and shattered limbs, in -opposition to amputation. - - -SECT. XXI. - -When a patient is brought to our military hospitals, who has had his -foot, leg, hand or arm shattered by a ball, or any other violent cause, -whether the parts are intirely carried off, or adhere by a little -flesh and skin, but in such a manner that there is not any hope of a -re-union; in this last case, we begin by cutting through these slender -attachments which keep the part suspended, and thus intirely separate -it from the body. In both cases, when pieces of the extremities of the -bones jut out, and may prove hurtful, they must be sawed off with a -convenient saw, whether they be moveable or still firmly adhere to the -limb: When they are moveable, they must be held by an assistant. I hope -no man in this treatment, will pretend to see any thing like what is -properly called amputation, which I condemn. - -After this first operation, I carefully examine if there be still any -small splinters left, and whether they are only held by the fleshy -parts, or still adhere to the bone; I remove all those, with the -fingers, or with instruments, that can be separated without violence -or a fresh effusion of blood. - -After removing as many splinters as I can, I slightly compress the limb -between my hands, gently stroking it lengthways, from above downwards, -endeavouring, at the same time, to restore, as much as possible, its -natural shape; I dress the sore with a digestive, to which I add a -little essence of myrrh, or solution of mastic: I cover the whole with -dry lint; applying the same bandage as after artificial amputation, -sufficiently tight, without, however, running the risque of causing -pain or increasing the inflammation: Afterwards I moisten the whole -with as much spirit of wine as may penetrate to the parts affected; -taking care to keep the limb extended in a right line, and laid soft. - -The first days, till the suppuration becomes plentiful, I only dress -it once every twenty-four hours, sometimes seldomer; but when the -suppuration is begun, I renew the dressings twice a day; and such of -them as immediately touch the bone, or fleshy parts of the wound, I -cover with lint dipt in solution of mastic, balsam of Fioraventi, or -some other balsamic essence, in order, by that means, to prevent too -large a suppuration. I likewise remove, each dressing, all the little -shivers of bone which do not reunite, and which, though they could not -be separated at the first dressing, may in the succeeding ones. - -With respect to the larger fragments, which must form the stump of the -bone, I not only take care not to loosen them, but even, as I already -remarked, endeavour to promote their coalition, by light compression -with the hands, and binding the bandage somewhat tighter than I would -otherwise do. If, at the expiration of a month, a fragment of this -kind is not coalesced, but on the contrary, is become more loose, -without however being intirely so; in that case, by shaking it gently, -moving it upwards and downwards, and loosening the fleshy parts that -hold it, I endeavour to bring it away intirely. If there are some of -them cracked as high as the articulation, I give myself no concern -about them, but leave them to nature[21]. But as to the small, short, -pointed shivers which do not re-unite with the bone, I take care, as -I have already observed, to remove them as soon as possible, commonly -in the first seven or eight dressings; and at each dressing, I gently -stroke down the muscular flesh towards the end of the stump; I keep -the whole firm, by giving a proper degree of tightness to the bandage; -moistening it, as long as the dressings are necessary, two or three -times a day with spirit of wine. By these means, such kind of patients, -at the end of four or five months, are as compleatly cured as the -nature of the accidents will admit of. - -FOOTNOTES: - -[21] Felix Wurz and G[oe]uey cured, as may be seen in Heister's Surgery, -t. 1. p. 183. the longitudinal fissures of the bone, by a suitable -dressing, which is mentioned in the same place. If it should happen, -what I have never yet had an opportunity of seeing, that the bone -was split longitudinally as far as the joint, and that it appeared -impossible to procure its coalition by means of proper dressings, I -would make, taking care to avoid the blood vessels, two incisions, from -the extremity of the stump to the joint, that should go as deep as the -bone, and whose distance must depend on the breadth of the splinter to -be extracted. I would raise up from the bone the flesh included between -the two incisions, with a scalpel or myrtle-leaf, avoiding to hurt the -blood vessels as much as possible; then, having detached the splinter, -by means of the scalpel, from its adhesion with the ligaments of the -joint, I would bring it away. - -If the hemorrhage were considerable, before I extracted the bone, I -would tie the vessels of the fleshy part which adhered to it; and after -having removed the bone, I would undo the ligatures, restore the flesh -to its place, take care of the small wounds made by the needles, and -would dress the whole part in the manner already mentioned in this -section. - - -SECT. XXII. - -Besides what I have already said, I must further add some other useful -remarks. - -If the patient, as is generally the case, be weakened by the discharge -of blood, his strength must be supported with broths, with herbs boiled -in them, and with wine and water. Further, I order him every four hours -half a dram of the bark, till the pulse is sufficiently raised, and a -laudable suppuration comes on; he may then be allowed some meat, herbs, -and food of different kinds of grain; water, acidulated with vinegar or -spirit of vitriol, may serve for drink. - -When the suppuration is too plentiful, and the wound appears disposed -to heal, I purge once or twice with Epsom salt, having previously for -a few days administered some absorbent powders. During the day I make -him drink a slight decoction of the bark, before and after meals a -little strengthening acid elixir; and in the evening, a small dose -of bark, mixed with a fourth part of an absorbent powder[22]. The -following is the composition of the strengthening elixir; _Half an -ounce of the extract of wormwood; of that of gentian, lesser centaury, -green oranges, and buckbean, of each a dram; rectified spirit of wine, -four ounces; and spirituous mint water, one ounce: Let the extracts be -dissolved in the spirits, over a gentle fire; strain them, then add to -the strained liquor, half an ounce of dulcified spirit of nitre, and -thirty drops of oil of vitriol_. - -FOOTNOTES: - -[22] I do not easily comprehend of what service absorbents can be to -wounded patients; but it appears obvious to me, that they must impair -the efficacy of the acids, which are clearly indicated with respect to -the fever, inflammation and gangrene: The only circumstance in which I -imagine they can be of use, is, when the stomach, by taking the acids -for several days, is a little disordered, which may happen when the -patient has been much reduced by the hemorrhage; then a few doses of -absorbents would remove this slight inconvenience. Otherwise, I am -convinced, by repeated experience, there is no occasion for them, when -the bark is joined with acids, as is judiciously done by Mr. Bilguer. -TISSOT. - - -SECT. XXIII. - -It sometimes happens that these patients, § XXII. are seized with a -fever, it begins with great cold, sometimes even with a chattering of -the teeth, which lasts half an hour, an hour, or sometimes longer, and -is succeeded by a gentle heat, which terminates in about three or four -hours, in a moderate sweat. The interval lasts two or three hours, at -the expiration of which the fit returns; sometimes it is accompanied -with a diarrh[oe]a. - -The most common causes of these fevers, are either in the first place, -a bad digestion when a person has taken too much food, or the food is -greasy, indigestible, and subject to putrefaction; or, secondly, a -reabsorption of purulent matter, which taints and inflames the blood; -or, thirdly, a bad air, such as is very often that of an hospital, -notwithstanding all the precautions that can be taken. - -It is of consequence immediately to stop this fever, lest it should -dissolve and corrupt the blood, and become a putrid fever: If it is -not accompanied with a diarrh[oe]a, a vomit of ipecacuan may be given, -joined with a few grains of rhubarb: If there is a looseness, the same -medicine may be repeated the following morning, and even sometimes the -third day. Through the day may be given a little of the strengthening -elixir described in the preceding section; and in the evening, when -the patient has had a vomit in the morning, half a dram or two scruples -of the following anodyne powder may be administered; _Virginian -snakeroot, zedoary, of an eleosaccharum made with the essential oil -of fennel, of each two scruples; calcined hartshorn, sixteen grains; -cynogloss pills, four and twenty grains_. Afterwards I gave every day -some of the strengthening elixir, a compounded powder of the bark, and -a strengthening decoction. The powder consists of _two drams of bark, -one dram of sal ammoniac, and a dram of an eleosaccharum, made with -the essential oil of fennel_. The ingredients for the strengthening -decoction are as follow: _The herbs of fluellin, baum and yarrow, of -each half an ounce; of that of mint, two drams; chamomile flowers, -an ounce; those of red poppy, half an ounce; orange peel, two drams; -shavings of sassafras, cassia lignea, carvy seed, of each a dram; bark, -four ounces; and Virginian snakeroot, one ounce_. These ingredients -must be properly cut small, bruised and mixed together. By the above -medicines the fever is commonly relieved[23]. - -FOOTNOTES: - -[23] Mr. Bilguer having seen the good effects of this composition, -inserts it according to the form he made use of; and without doubt, -it is a very efficacious medicine: But it might be rendered much -more simple without imparing its virtues; and simple medicines, in -my opinion, are preferable on every occasion, but particularly so in -hospitals. TISSOT. - - -SECT. XXIV. - -I have treated hitherto of limbs intirely divided; I shall now examine -what ought to be done, when a ball, or any piece of iron or lead, has -so greatly injured the bones of the hand, arm, foot or leg, that, -although they are not quite broke through, and the part suspended by -a small portion of flesh and skin, as in the former case, § XXI. are -nevertheless so much shattered that the part may be moved any way, -and seems to hang useless. In these circumstances, we must dilate -the aperture made by the ball, or by whatever body has inflicted the -wound, and separate the flesh from the bone; in a word, we must make -the wound sufficiently large, in order to lay the shattered bones bare, -especially where they are broken across, that they may be more easily -managed by the fingers; then as many splinters as possible must be -extracted, as well as the ball and other extraneous bodies. If there -be the apertures of two balls, they must both be treated in the same -manner: When it is expedient to make counter openings, they may be -made indifferently, whether there be one or two openings, and these -artificial wounds must be made sufficiently large, to admit of the -extracting of the splinters and other extraneous matters. In other -respects, the dressings must be the same as § XXI. Every time they -are renewed, the splinters must be extracted as they become loose and -can be easily separated; if there be some large fragments which must -be removed, we may begin by dividing them from the fleshy parts, then -sawing them through with a very small saw, whose blade is extremely -thin and narrow, crooked or straight, in order to push it from above -downwards, or from below upwards, or sideways, as may be convenient. -This method answered so well with me for the bones of the leg and arm, -that I have often, in this manner, separated pieces three or four -inches in length, and even longer. As for the smaller bones, such as -those of the hands or feet, I have divided and extracted them entire, -when they were broken and shattered, and sometimes even when they were -not. - -If a bullet has penetrated into the cavity of a bone, such bone must be -laid bare, either on the side by which the bullet has made its way, or -on the opposite one; afterwards it must be pierced with two or three -trepans, and the extraneous body, and the shivers of the bone extracted. - -If the bullet has made its way into one side of the joint of the elbow -or knee, and by that means shattered several bones at one stroke, I -treat it in the same manner, dilating the wound and extracting the -splinters as before, and the wounds get well like the others. - -I cured a patient who had been wounded by a bullet which entered the -cavity of the os humeri; he would not consent to have it extracted, -which did not however prevent his recovery, nor has he felt any further -inconvenience from it than a small protuberance on the place where the -ball is still lodged[24]. - -It will perhaps be asked, if it be possible that a ball should enter -the cavity of a bone without splitting or breaking it, as seems to have -happened in the case I have just mentioned? and where that circumstance -will appear still less feasible, when I affirm, that the bones of -this man were strong, hard and compact; and that on some occasions, -fissures and the other accidents of bones, I have been treating of, -are often the consequences of slight wounds, as of more considerable -ones. But be that as it may, I treat these kinds of wounds in this -manner: I dress the bone partly with dry lint, and partly with balsamic -essences, and sometimes I throw in injections: I apply a digestive to -the fleshy parts, and moisten all the dressings with spirit of wine, -as in § XXI. I check the suppuration a little, preserving, as much as -possible, the boney fragments which adhere together, so as to leave -room to hope for their coalition, sustaining them in their natural -position, and covering them again as much as possible with the flesh -and skin: If there be any pointed splinters, I endeavour to promote -their separation by proper applications, such as the balsamic essences, -and different powders, particularly that mentioned § X. - -I fix the limb in its natural position, suspending the arm in a sling, -or half-cylinder adapted for the purpose. For the leg, I use Mr. -Petit's machine, or splints, made of wooden rods covered with straw, -and wrapped up in linnen cloth; and in the dressings, my chief aim is -to keep them sufficiently tight above and below the wound, to promote -the consolidation of the larger pieces of bone, by keeping them firm -in their places, and preventing the re-absorption of pus. The diet and -medicines are the same as in § XXII. By this method a very great number -of wounded men have been restored to health, in two, three or four -months; and some not before the expiration of eight. My observations -confirm those of Horstius, who remarks, that a man who has lost a great -portion of the tibia and fibula, may nevertheless, after his cure, walk -with ease, and halt but very little[25]. - -FOOTNOTES: - -[24] He was a soldier in the guards, and is doing his duty in the field -at the very time I write this. - -[25] HORSTII _observationes medicæ_, part ii. 1. 4. obs. 10. Mr. de -Frengler, captain lieutenant in the regiment of Anhalt Bernbourg, is an -instance of a most successful cure of a wound of the leg of this kind. -In the sequel of this dissertation may be seen, several striking cases -of an extraordinary loss of substance in the bones being again repaired. - - -SECT. XXV. - -Such kind of wounds, however, are not without danger; the patient is -not only very liable to be seized with such a fever as I have spoken of -§ XXIII. but he also runs a risque from the wound itself. It is true, -that these two dangers, that attending the fever, and that from the -wound, which I shall mention by and bye, are connected, and generally -accompany each other. It sometimes happens of a sudden, and without -the patient, or the physicians and surgeons having any suspicion of -it, that the wounds dry up, become corrupted, and exhale an infectious -stench; the neighbouring parts are very much inflamed for some days, -after which the inflammation goes off, leaving a kind of [oe]dematous -tumour, which produces an abscess, with a laudable discharge, or -degenerates into a malignant sore, without any abscess. Sometimes these -sores are beset with swarms of maggots. - -The treatment of the fever is the same I have described § XXIII. that -of the wound, in this troublesome situation, ought to be to endeavour -intirely to remove the inflammation, which readily terminates in -suppuration, and forms large cavities full of matter, which must be -opened. - -A moderate compression of the neighbouring parts, in this case, as in -those I have already mentioned, contributes to prevent the reabsorption -of the purulent matter. If the inflammation runs high, and the patient -is young, it should be moderated by bleeding, and other medicines -calculated to check and resolve the inflammatory denseness of the -blood[26]. - -If the cause of the inflammation be obvious, it must be removed; thus -every pointed splinter of a bone must be separated with a knife or saw; -whatever occasions a compression must be taken away, and if there be -any fibrous part causing too great a stricture, it must be cut through, -dilating the wound by incisions of a convenient depth. - -The dryness and putrefaction of the wound, may be remedied by dressing -it with the powder composed of sal ammoniac and camphor, mentioned § -X. and by moistening it afterwards with oil of turpentine; or, I cause -the wounds, both the original ones, and those made by the surgeon, to -be dressed with pledgets, dipt in a balsam composed of _four ounces -spirit of wine, half an ounce spirit of turpentine, and three drams -spirit of sal ammoniac_: Afterwards, having first applied the dressings -very thin, the parts must be constantly fomented with some of the -compositions mentioned § XXI. - -The maggots may be destroyed, by frequently shifting the bandages, -linnen, cloaths, and coverings of the bed; by the application of the -balsams I have already spoken of, which destroy these insects and -prevent putrefaction; by constantly keeping on the bed-clothes, a -linnen cloth dipt in tincture of aloes or vitriol. But care must be -taken that the tincture of aloes does not touch the affected limb, -much less the sores themselves, lest part of it should be absorbed, -and occasion a diarrhæa; although in other respects aloes powerfully -resists putrefaction, and is sometimes a useful vulnerary. - -FOOTNOTES: - -[26] At present, since we know that pus is only a corruption of the -crassamentum of the blood, it is easier, perhaps, than formerly, to -explain why an inflammatory denseness of the blood terminates sometimes -in an abscess, and at other times in a compleat recovery without one. -Dr. Pringle, to whom we are indebted for so many useful discoveries, -which have thrown a new light on the theory and practice of physic, -was the first who pointed out the true manner in which pus was formed, -concerning which so many conjectures had been made; and Mr. Gaber -has demonstrated it very particularly by a number of very curious -experiments. TISSOT. - - -SECT. XXVI. - -I have had under my care, during the course of this late bloody war, a -great number of wounded limbs, torn and shattered by cannon and musket -balls, by the bursting of bomb-shells and grenades, by grape-shot, -&c. I cured them without ever performing amputation, by the method -described in the two preceding sections, although there were bones -broken and shattered, large blood vessels divided, the flesh miserably -lacerated, and limbs carried off in the manner I have described § XXI. -Others, such as I have described § XXIV. in which the bones were split -up as high as the articulation; all which circumstances might make us -reasonably apprehend a tedious and difficult cure, too plentiful a -suppuration, hemorrhages, violent inflammation, excessive corruption, -mortification and death. - -It will perhaps be asked me, Of those men so terribly wounded, whom -you attempted to cure without the means of amputation, did none die? I -shall return an answer by and bye. It will be further objected to me, -that I have not taken notice of the os humeri, or the thigh bone being -shattered; and it will be asked me, What must be done in cases where -either of these bones are fissured as far as their upper extremities, -in such a manner that we cannot hope to procure their coalition by -means of any bandage? And finally, it will be remarked, I have not -mentioned the wounding the brachial or crural arteries, or the large -branches of these which pass between the radius and ulna, or tibia and -fibula, called in both parts the inter-osseous arteries, whether these -wounds be accompanied with a fracture of the bones, or otherwise. I -shall reply to these two last objections, after having answered the -first question in the following section. - - -SECT. XXVII. - -I had at one time, during the war, in a military hospital, six -thousand six hundred and eighteen wounded patients, who were all -treated according to my direction, and part of whom I attended myself; -of these, five thousand five hundred and fifty-seven were perfectly -cured, and in a condition to support all the fatigues of the service; -a hundred and ninety-five were able to do duty in garrison, what they -call half-invalides[27], or to work at any trade; two hundred and -thirteen remained incapable of any labour, civil or military, what they -call grand invalides[28]; and six hundred and fifty-three died. - -These hundred and ninety-five half-invalides, and the two hundred -and thirteen grand invalides, in all, four hundred and eight, were -of the number of those who had their bones bruised, broken and -shattered; of those, in a word, whose wounds were called complicated -and dangerous[29]: For it is well known that with us, a man is not -put on the list of invalides for a wound of the head, or of the -fleshy parts; if, after wounds of this kind are healed up, there -remains any weakness, stiffness, or tension of the part, we employ -various medicines, both internal and external, ointments, liniments, -fomentations, warm baths, by means of which they are commonly -compleatly cured. - -Let us at present suppose, that of the six hundred and fifty-three -who died, no more than two hundred and forty-five died from the -consequences either of a violent concussion, from wounds of the head, -thorax, lower belly or spine; from a complicated fracture of the os -femoris, or from putrid fevers, fluxes and other inward diseases, which -often happen in military hospitals, even in cases of slight wounds, -from the bad air which is breathed there; there will remain four -hundred and eight, who may have died from the consequences of wounds -with shattered bones; and this number is equal to that of those who -were cured without amputation, although their wounds had been of the -same kind[30]. If, after making these calculations, we compare them -with the prodigious number of wounded men, who, at the beginning of -the war, had their limbs taken off on account of dangerous wounds, of -whom scarce one or two escaped with their lives; we may very safely -conclude, that much the greater part of those four hundred and eight -men cured and sent to the invalides, would have died if amputation had -been performed on them, and this mocking artificial wound added to -what they had already received. It would be trifling to pretend that -amputation would have saved a great many of those who died, had it been -timeously and properly performed[31]. - -Further, if it be considered, that many of those who died, might -have recovered, had they been taken care of any where else than in an -hospital, where the air is very bad; and if it be called to mind at -the same time, what some very eminent surgeons have observed, that two -thirds of those die who have their limbs cut off[32], I hope it will -be readily acknowledged, that my method of treating wounded limbs, by -saving them, is highly preferable to that of amputation. - -FOOTNOTES: - -[27] _Halbe Invaliden._ - -[28] _Ganze Invaliden._ - -[29] _Schwerfracturirte._ - -[30] It is obvious that Mr. Bilguer has not made his calculations in so -favourable a manner for himself, as he might have done; I am persuaded -that in 6618 wounded men, a much greater number than 245 must have -died from the consequences of concussion, large flesh wounds, fevers, -fluxes, and other diseases, owing to a bad habit, bad air, the season -of the year, &c. TISSOT. - -[31] Such a pretence would in effect be absurd: The reasoning would -amount to this; it is demonstrated that the danger arising from -amputation, joined to that attending wounds of themselves curable, has -killed a great many patients; therefore the danger arising from this -operation, joined to that attending wounds which have proved incurable, -would have saved a great many patients: Only the most blinded obstinacy -could reason in such a manner. TISSOT. - -[32] See the memoirs of the Academy of Surgery, t. 2. p. 256. where Mr. -Boucher, in speaking of gunshot wounds, with the bone shattered near -the articulation, shews that amputation commonly proves fatal, and that -of three patients on whom it is performed, generally two die; whereas -out of an hundred and sixty-five who had had the bones shattered, on -whom amputation had not been performed, not one died. A degree of -success which he ascribes, it must be owned, to the management of the -surgeon; who, instead of spirituous applications, only made use of -emollients, light digestives and anodynes. - - -SECT. XXVIII. - -Finally, I must add, that the greater number of those who died in our -hospitals, in consequence of wounded limbs, were of those who had the -os femoris shattered near its upper articulation; and as we are not -at present acquainted with any means of relieving that accident; and -as it has not as yet been attempted to amputate at that part, if we -deduct these cases from the number mentioned in the preceding section -who died, we shall see that the number of those whose lives were saved -without amputation, considerably exceeds that of those who died. Since -wounds near the superior part of the thigh bone, or shoulder, where the -bones are shattered, ought always to be looked on as desperate. - - -SECT. XXIX. - -With respect to the os femoris, I do not know that any person hitherto -has attempted to amputate it at its upper extremity with success: The -arm has been successfully taken off at the shoulder, though but very -rarely[33]. Every body knows that the most able surgeons only allow of -the amputation of the thigh at its lower part, a little above the knee; -but even supposing it could be safely taken off in the middle, when the -bone is neither shattered, nor fissured higher up, the operation will -prove useless when it is done, as has so often been the case with our -wounded men. - -The difficulty attending the amputation of the upper parts of the -thigh, is so considerable, that surgeons rather chuse to abandon -to their fate those wounded men where it appears necessary, than -to undertake it; and I own I am of the same opinion with them. If, -nevertheless, a case occured, wherein the death of the patient -appeared certain if amputation was not performed, and if the operation -could afford any hope, I would even prefer taking the limb off at -the articulation, rather than at any other place; for although it be -extremely difficult, it prevents, at least, the inconveniences and -accidents which a stump might occasion[34]. - -But as there can be no necessity for this operation, but in consequence -of the large arteries being wounded, by following the method I shall -point out § XXXV. it will be rendered unnecessary, and disputes -concerning it may be laid aside: For it is very certain, that the most -dangerous accidents even of this part, may be remedied, like those -in other parts, by joining to the method of treatment I have already -mentioned, the operation I shall describe § XXXV. providing it be -performed in time, before the patient be exhausted, and almost dying, -from the effects of the hurt being too long left to itself. But the -apprehension which patients have of the pain which deep incisions into -the fleshy parts would occasion, prevents extracting the pieces of -bone which compress or irritate the parts around; as also from cutting -through the membranes that are overstretched, and cause a constriction; -from giving a vent to impacted matter, and from conveying the medicines -to the parts where they ought to be applied. The consequence of all -this is, that the proper remedies are applied too late, and the -patient sinks under the pressure of the accident. - -But if nature were even able to get the better of these difficulties, -there are others to which our[35] wounded men are subject, lodged -together in too great number in military hospitals, where the state of -wounds is rendered worse by a concurrence of several causes, and the -cure of those of the most simple kind is retarded. The principal of -these causes are want of cleanliness, an improper regimen, inconvenient -beds, a continual noise, which hinders sleep, bad air, frequent -removals from one place to another, and conducted in an inconvenient -manner; these circumstances greatly contribute to make the instances -of people recovering who are severely wounded near the upper part of -the thigh, where the bone is shattered, so uncommon. But if any should -pretend to say that there are none cured by the method described -§ XXXV. I shall only, in answer, produce the invalide soldiers -themselves, who are at present, some in the country, others in the -hospitals, whose recovery demonstrates the contrary. I acknowledge that -this method is difficult and tedious, and that more die than recover; -these, however, are not sufficient reasons for declaiming against, or -intirely condemning it, as it is the only expedient left, amputation at -the shoulder, or upper part of the thigh, being an operation not only -difficult, but highly precarious. - -FOOTNOTES: - -[33] M. Morand, the father, was the first who took off the arm at -the joint of the shoulder. Mr. Le Dran performed it soon after in -the presence of the most eminent surgeons of Paris, Messieurs Petit, -Marechal, La Peyronie, Arnaud, &c. which number of witnesses, making -his operation more extensively known, that of Morand has, as it -were, been forgotten, and Mr. Le Dran has passed for having been the -inventor. Mr. Bromfield performed it successfully within these few -years at London; but notwithstanding a few cases whose event has -been favourable, it is a very dangerous operation, and has sometimes -miscarried. Dr. Home, an eminent physician at Edinburgh, equally a -promoter of agriculture, medicine, and the arts, relates, that in the -former war, he saw Mr. Mitchel perform the operation on two soldiers, -where the os humeri was fractured as high as the joint, and who both -died a few days after: It is true, he remarks that they were both in -a bad way when the amputation was performed; but he adds, that this -operation appears extremely dangerous, even when performed with every -favourable circumstance. _Medical facts and experiments, p. 114_. With -respect to the thigh, there is little room to hope that the struggle -that is made to determine, when and how it should be taken off at -the articulation, can be attended with the success which some people -seem to expect from it. If such an operation should take place, it -will perhaps very soon be asked, whether it ought not to be publicly -condemned? TISSOT. - -[34] I am of opinion, that if one had the misfortune of being reduced -to the necessity of chusing between amputating at the upper part of -the thigh, or at the articulation itself, one reason for prefering the -latter, would be the greater ease there is in stopping the hemorrhage -of the crural artery. - -A surgeon and anatomist, who has been in repute, observes, _That an -hemorrhage of the crural artery is what is chiefly to be dreaded, but -the operation requires too short a time, for such an hemorrhage to be -fatal_. It is surprizing to see him mention this operation as one that -is very familiar; I make this remark, because, as he is not the only -person who may allow himself to talk in this manner, a bold pretender -to the art, on reading such a passage, might undertake an operation as -easy and common, which has never yet been performed. TISSOT. - -[35] What Mr. Bilguer says with respect to the wounded Prussians, is -but too applicable to those of every army. - - -SECT. XXX. - -I ought now to say something concerning a contusion, or echymosis; I -shall confine my remarks particularly to that kind where there is a -great quantity of extravasated fluid diffused under the skin, such as -we often see, when a ball, without breaking the skin, injures it to -such a degree, that it looks like a mortified eschar, and at the same -time dislocates, fractures, or shatters the bones belonging to the -part. When a surgeon meets with a contusion of this kind, the treatment -is not greatly different from that recommended in a mortification; for -the skin must be treated exactly like a mortified slough, must be laid -open by several deep incisions, dressed with the powder mentioned § -X. covered with a digestive ointment mixed with a little essence of -myrrh, and the part affected, as well as all around it, kept constantly -bathed with emollient fomentations, without any ingredient, either -stimulating or astringent. With regard to the shattered bones, the -same method may be followed as in § XX. If any of them are luxated, -they must be reduced, without, however, confining them by the bandages -used in ordinary luxations, and which, in this case, would make the -necessary incisions uneasy, would prevent the gangrenous sloughs -from casting off, and hinder the formation of pus: It is therefore -sufficient, after having replaced the bone, to let it remain quite -undisturbed; and when the corrupted slough is come off, the sore may be -dressed like wounds of the fleshy parts. - - -SECT. XXXI. - -Some imagine that these violent contusions, accompanied with fractures, -require amputation, as the properest method of cure[36]. I shall -mention, what seems to me strongly against this opinion. In the first -place we must reflect, that the danger of dying, in these cases, does -not arise solely from the fluids extravasated in the contused part, -but from the violent concussion, which gives a shock, and occasions a -general compression of the vessels over all the body, especially the -internal ones[37]; and from the vessels being compressed, obstructed -or ruptured, proceed extravasation, inflammation and suppuration. - -This commotion of the whole body, depends on the external air, which -being compressed, condensed, and rapidly pushed on by a ball, moving -with vast velocity, acts on the body with greater force, and causes a -more violent contusion, than any other substance, even the heaviest -has ever done. From thence proceed contusions of the viscera, spitting -and vomiting of blood, oppression, cough, pains, inflammations and -suppurations internally, a fever, and other complaints which happen -after contusions, seemingly slight, and confined to some particular -part, but which are, in fact, the consequences of this general, and -what may be called invisible, contusion of the whole body[38]. - -The amputation of the limb does not remedy those accidents; on the -contrary, it increases them, by means of the dread the patient feels at -the thoughts of amputation, and by the excruciating pain which attends -it; thus accelerating that death it was meant to prevent. I therefore -boldly affirm, that amputation cannot be of service in those cases, -wherein the nature of the parts and the state they are in, forbid it; -that in many, it is hurtful, and hastens death; and that in others, -even where the patient recovers, it is likewise improper, if he could -be cured and the limb preserved; a surgeon is unpardonable who employs -it in such a case. - -FOOTNOTES: - -[36] Can it be called curing a limb to take it off altogether? - -[37] It has been known long since, that this concussion, or what may -be called a general contusion, is one of the principal causes of the -danger arising from gunshot wounds, and more or less from those of all -kinds of fire arms; but at present I do not recollect to have seen the -mechanism of this effect so well explained as in this performance. -The rapidity with which the air strikes, compensates what it wants in -density: Those who love to reduce every thing to calculation, will -be able exactly to determine this effect by the rule of proportion: -Supposing on one hand, a stream of air, which has acquired, by the -motion of the ball, a given velocity, and which acts upon a man with -this degree of velocity; supposing on the other hand, a man falling -upon a floor, likewise with a given degree of velocity, the effect -will be equal, if the velocity of air, is to the man who falls, as -the density of the board is to that of the air; or, more briefly, if -the contusing bodies be in an inverse ratio of their densities. I am -even induced to believe, that when the velocity is augmented to a -certain degree, its effect is augmented in a greater proportion than -its increase; or, to speak algebraically, that its effects ought to be -expressed by some quality of its degrees; thus the effect of a velocity -of 150 degrees, would be to the effect of a velocity of 125, not as -150 : 125 or as 6 : 5 but as the square, or perhaps some other quality -of 150, to the square or the correspondent quality of 125. - -There are physical reasons that induce us to believe that the case -is so, and there are several observations which seem to confirm it. -Those who have served in time of war, have all been witnesses of some -singular instance or other of the effects of the percussion of the -air; there are instances of people killed on the field, without being -touched by the ball. I was told by officers, men of veracity, that at -the battle of Fontanoy, a ball broke the thigh bone of a soldier in the -Dutch army, without touching him; another saw a man who was rendered -paralytic on one side, by a ball whizing past him. Curious observers -know, that nothing so greatly fatigues an army as a high wind, even -the centinels are tired, without marching; the reason is, that a high -wind occasions a kind of general contusion, which of course produces -weariness. I do not know but some of the effects of lightening may be -imputed to the same cause. I shall add nothing to what Mr. Bilguer says -concerning the effects of a contusion; he is sufficiently explicit on -this head; and as I have already treated the subject pretty largely in -my book termed _Advice to the People_, I shall only observe, that in -the wounds made by musket-ball, the effect of the general concussion -is not very considerable, but the danger, in such cases, proceeds from -the topical contusion accompanying the wound, the small quantity of -blood commonly discharged from it; and lastly, as Mr. Le Dran remarks, -because the instant a man receives a gunshot wound, he is struck with a -sudden dread he cannot possibly resist. There seems to me to be three -reasons for this dread, of which even the wounded person himself is not -altogether conscious; in the first place, the idea that gunshot wounds -are dangerous; secondly, because the degree of the hurt is not known; -thirdly, the instantaneous effect of the concussion, which renders -a man much more susceptible of fear. There is a point of time when -courage is useless. I shall beg leave, in this place, to insert a case -I had from the eye-witnesses, and which demonstrates the bad effect -of apprehension on wounded patients. Two officers, in the service of -France, were wounded in the last campaign but one; one of them very -dangerously, the other, who had been a prisoner a little time before, -and had been extremely ill used, but very slightly; they were carried -to the same place, and lodged in the same apartment; the first expected -to die, but nevertheless recovered in a short time; the second hoped -to be cured very quickly, and his wound, a superficial one in the leg, -did not discover the least sign of danger. The place they were in was -surprized, and they were informed they were made prisoners; the idea of -what he had suffered, made so strong an impression on the latter, that -he instantly found himself indisposed; the following dressing the wound -appeared mortified, every remedy proved useless, and he died in a few -days. TISSOT. - -[38] The troublesome symptoms which I have here enumerated, happen -seldomer when the limb is entirely carried off by the ball, although -the concussion caused by the compression of the air must be greater in -this case, than when the ball has only grazed; a circumstance which -might induce one to call in question the justness of my remarks in -this section. But these doubts will vanish, when we reflect, that -in a contusion there is no discharge of blood, whereas it is very -considerable in cases where the limb is intirely carried off; and thus, -the remedy is here a consequence of the accident itself, since this -hemorrhage effects what we would wish to effect by artificial bleeding; -in contusions, where there is no discharge of blood, it removes -obstructions, and disperses the extravasated humours, which are the -consequences of concussion. - - -SECT. XXXII. - -As I object to the amputation of contused limbs, it is reasonable I -should point out the method of treating such contusions: I prevent -the troublesome symptoms they produce, or disperse them if they have -already appeared, by frequent bleedings, and by the exhibition of -such medicines as attenuate the blood, resolve what is too gross, -remove what is obstructed, and render fit to be reabsorbed what is -extravasated. I join with them such as, by gently evacuating by stool, -unload the vessels; and I afterwards give such things as brace up the -fibres, and restore the natural crasis of the blood. - -I have found no medicine more effectual to attenuate the blood, and -resist the febrile disposition, than a powder, consisting of nitre, -Epsom salt, cream of tartar, and true Armenian bole[39]. - -FOOTNOTES: - -[39] I have not experienced a better medicine in such cases, than the -plentiful use of oxymel. TISSOT. - - -SECT. XXXIII. - -The external applications for a contused limb should vary, according -to circumstances, or according as the contusion has caused a mortified -slough, or has not. If it has not, but nevertheless the bone is -fractured, the applications should be of a very mild nature. In such -a case I make no incisions, but I endeavour to bring the two ends -of the bone together, to place them in their natural position, and -to keep them in it, by means of compresses and bandages, as in the -common simple fractures: I constantly stupe the whole dressings with -discutient and vulnerary fomentations[40], and exactly follow the plan -laid down § XIV. by which means I have almost always happily cured -contusions of this kind. - -If the contusion has caused a mortified slough, and has at the same -time shattered the bone, we must begin by separating the dead slough -from the sound parts, with a scalpel; we must make deep incisions, and -neglect no means proper for promoting the discussion or suppuration; -and the fracture of the bone must be treated agreeably to the method -recommended § XXIV. This case requires great vigilance in the care of -it, and we find ourselves amply recompensed for our labour, by the -pleasure of accomplishing the cure of these unfortunate patients, -either compleat, or at least as much so, as can possibly be obtained in -their situation. - -There is at present at the hospital at Torgau, a soldier who had been -grievously wounded; the shoulder and arm were very bad, from the -extravasation the contusion had occasioned; the scapula and clavicle -were entirely shattered; the head of the os humeri dislodged from the -glenoid cavity, and pushed downwards; the ligaments having been too -violently stretched, now hung loose; and the neighbouring parts, deeply -bruised, were covered with a black slough, like a mortification. The -contusion and double fracture of the shoulder blade and clavicle are -compleatly cured, the head of the os humeri never could be kept in its -articulation, on account of the relaxation of the ligaments; the other -symptoms are happily removed, but he has a cough, and almost constant -fever, with its concomitant symptoms; whence we may conclude that -matter is formed in some bowel, probably in the lungs, a consequence -resulting from the contusion of the internal parts. - -FOOTNOTES: - -[40] An infusion of water-germander, and yarrow in water, with the -addition of about a sixth or eighth of vinegar, is one of the most -proper fomentations in such cases. TISSOT. - - -SECT. XXXIV. - -Every one will easily conceive, that this method of curing limbs that -are wounded, fractured and shattered by gun-shot, such as I have been -hitherto describing, is accompanied with a great deal of pain, and -with murmurs and impatience on the part of the sick; that it requires -a very judicious surgeon, and gives him abundance of trouble, care and -anxiety; besides, I do not pretend that every patient was saved by it: -The following lines are applicable on the occasion: - - _Non est in medico semper relevetur ut æger, - Interdum docta plus valet arte malum._ - -But as they are oftener applicable with respect to amputation, the -expediency of the method I have recommended, stands nevertheless on a -solid foundation. To alleviate the pains and sooth the murmurs of the -sick, we must flatter them with hope; as for the wounds made by the -incisions, they are commonly necessary at a time when they do not -think of complaining or opposing them, and they are much less severe -than the horrible gash made by amputation. The objections arising -from the difficulty attending this method are happily removed in our -hospitals, by the care and humane vigilance which Frederick the Great -has exerted to provide his victorious armies with surgeons capable of -putting it in practice. - - -SECT. XXXV. - -I shall here add that with regard to those who have had the thigh or -arm carried off by a cannon ball, I do not recollect that any of the -first have been brought to our hospital; they doubtless died instantly -in the field of battle, in consequence of the hemorrhage. Several of -those who had the arm carried off were brought, but the camp surgeons -had previously stopt the bleeding, and applied the dressings commonly -used after amputation, and we cured them afterwards by the method -mentioned in § XXXI. The men wounded in this manner afford me an -opportunity of inserting in this place, what I had to say with respect -to the necessity of amputation in consequence of an hemorrhage; but -I shall be very brief, as in these times, when surgery makes such -progress, there is no artist but knows, and is familiarly acquainted -with the different methods of stopping a bleeding. Therefore, -although the interosseous, the brachial and crural arteries, near the -articulations of the elbow or knee, or any other branches of arteries -when divided, may give the surgeon a good deal of trouble, he is not -obliged on that account to take off the limb; for in whatever situation -we suppose the artery to be injured, the surgeon may always, by proper -dilations, come at the wound, and stop the bleeding by the application -of astringents, among which agaric and spirit of turpentine has, with -us, very often succeeded, or by compression or ligatures, or lastly by -all these means united; thus amputation ought never to be performed -on account of an hemorrhage. It is even astonishing to conceive -how surgeons should think of such an expedient, as frequently the -difficulty of stopping the bleeding after amputation is greater than on -any other occasion, especially if it be performed below the knee[41]. -I therefore persist in my opinion, whether the wound of the arteries -be only accompanied with one in the soft parts, or whether at the same -time the bone be fractured or shattered: In this last case, I should -join the treatment mentioned in this section to that of § XXIV. - -It will here perhaps be objected, that all these means would be to no -purpose, if the brachial or crural arteries are wounded at a certain -height, because, in such a case, the limb must waste away for want of -nourishment. I shall return an answer in a few words, with respect -to the crural artery at the upper part of the thigh, which is, that -whether my method can, or cannot be adopted in this case, there is no -alternative; no surgeon as far as I know having ventured to perform -amputation at this part, because every body would dread the patient's -expiring during the operation[42]: Neither would the wounds of the -brachial artery induce me to take off the arm at its upper part, -although it be practicable, because I think every expedient is to -be tried before we have recourse to this; and as from several cases -we learn, that after the operation for the aneurism the member has -recovered its heat, motion, and strength[43], even when the trunk of -the brachial artery has been cut through; I think when it is wounded, -we ought to tie it without fear, and afterwards provide for the -preservation of the limb, by aperient spirituous fomentations and -by gentle frictions, which contribute to open and enlarge the small -vessels, and by that means to restore heat and life to the parts[44]. -If we observe, the first or second day after the operation, a little -swelling or heat below the wound, we may conceive great hopes that the -whole limb will revive: If, on the contrary, whatever is below the -wound shrivels, grows cold and dry, then we may think of amputation, -without, however, being precipitate; as a mortification in this case is -always slow, and sometimes the limb recovers heat and motion very late. -But I am convinced this case will very rarely require amputation. In -conformity to the plan I have proposed, I should now mention the two -last circumstances wherein amputation is deemed necessary, a caries of -the bone, and a cancerous disposition of the part; but I imagine it -will be better first to relate some instances of cures effected without -amputation, wherein this operation to many surgeons would have appeared -indispensable. - -The first case I shall relate is very remarkable, of a soldier in -his royal highness prince Henry's regiment, whom my friend M. -Kretchmer, an able artist, and principal surgeon of the hospital, and -Mr. Sterneman one of the ordinary surgeons, had the care of under my -direction, and cured compleatly to the surprize of every body. The left -arm was terribly shattered by four different pieces of iron shot, the -os humeri was broke through the middle, and the arm pierced with eight -holes, and at the joint of the elbow there was a true aneurism, of the -bigness of a large fist. Mr. Kretchmer began by applying the tourniquet -at the armpit in order to stop the bleeding; then of the eight wounds -or apertures, he chose two nearest to the fracture, and dilated them -in such a manner as to lay the bone bare; he likewise dilated a -little the six others; after these dilatations he extracted several -large splinters, he then brought the two ends of the bone together, -placed them in their proper position, in which he made them be kept -by assistants, while he moistened all the wounds with equal parts of -spirit of wine and arquebusade water, and covered them with lint; he -wrapped up the whole arm in linnen cloth, and fastened the bandage -moderately tight: he next applied gradual compresses to the aneurism, -and bound it up with a roller by itself; after which he moistened -the whole with the same mixture of spirit of wine and arquebusade -water, and as much martial ball as he could dissolve in it, and -applied over the bandage for the aneurism the fomentation which I have -already mentioned, made with the species for the black decoction[45]. -He slackened the tourniquet every two hours, drawing it tight again -immediately; he removed it altogether at the end of a few days, -contenting himself with compressing the artery under the armpit with -bolsters and a bandage which did not hinder the dressing of the wounds. -He dressed them every day, but the bandage for the aneurism he renewed -only every other day, although two of the openings lay under it. In -this manner he persevered with great assiduity for a considerable time. -All this while he made the hand and fore arm be secured in a cylinder -of strong pasteboard, and suspended in a sling. He bled the patient -frequently, gave him vinegar and water for his drink, and made him take -from time to time the powders which I mentioned before, consisting -of nitre, Epsom salt, cream of tartar, and true Armenian bole[46]. -By these means only, he restored this arm, which was so bad that it -could not even be taken off, to such a state, that in the course of -three months, after having removed some splinters, the aneurism was -dispersed, and the fracture and wounds were perfectly cured. - -We cured another soldier belonging to the regiment of Brandenburgh -Bareith, whose elbow was miserably torn by five pieces of iron shot, -some of which stuck fast in the part, and where both bones of the fore -arm were shattered. - -After having dilated the wounds, we extracted some splinters, sawed off -a piece of the cubital bone about four inches long, and in dressing the -wounds endeavoured to avoid too large a suppuration. - -In the ordinary method amputation would certainly have been performed, -as the fore-arm was shattered, and the upper arm which was untouched -could admit of the operation, but we saved the arm and made a perfect -cure without having recourse to such an expedient, which are so many -evidences that give their testimony in favour of our method, which we -can produce to the partisans of amputation. - -M. de Sass, colonel commandant of a regiment belonging to the garrison -of Lattorf, and who is at present commandant at Brieg, received at the -battle fought near Czeslau, a musket shot in the leg, which shivered -the two bones into several fragments, of which some of four or five -inches in length were extracted. The surgeons thought amputation -necessary, and pressed him to submit to it; he refused however and -recovered; although the limb is bent outwards he can walk and go about -his business with ease. - -A soldier of the regiment of Cuirassiers of Gessler, called Lukrafka, -was wounded in the going through the exercise with the regiment, in -such a manner that the two bones were fractured in the middle, with -several fissures lengthways. After having laid the fissures of the -bone bare, I sawed through a piece of the tibia about five inches in -length, which I removed together with the marrow; I separated with a -pair of forceps the useless parts of the fibula which jutted out, then -I placed the bones in their natural position, and at the expiration of -four months the patient was cured. This limb was somewhat shorter than -the other, he could nevertheless walk and leap with ease. - -M. de Franckenberg, a captain in Hulsen's regiment of foot, was -terribly wounded by a musket ball at the battle of Loboschitz; all the -bones of the tarsus were broke and shattered in such a manner that it -seemed almost necessary to take away the whole number; which being -done, and the parts of the foot brought close together, it recovered -so far that this gallant officer, with the help of a double heel, can -walk conveniently, and is able to do duty along with his regiment in -garrison at Alt-Sydow. - -M. de Alvensleben, ensign in the guards, received at Torgau a wound -above the foot which shattered the tibia and fibula, and the splinters -forced by the violence of the shot formed three distinct layers; I -was obliged to make a great many deep incisions, and in a little time -he was so much better, that I could venture to entrust the remainder -of the cure to the surgeon of the regiment. A soldier of Sybourg's -regiment of foot, named Mieke, seventy years of age, received near -Miessen in 1759, a musket shot which shattered the shoulder bone two -fingers breadth below the articulation; a splinter was taken out five -inches long; he was nevertheless perfectly cured at the end of nine -months, and left Wittemberg to go to the hospital of Invalids at Berlin. - -M. de Stabenwol, captain lieutenant of Grabow's regiment of foot, at -the battle of Kunnersdorf, received a musket shot which shattered the -head of the os humeri close to its articulation with the scapula; he -was perfectly cured in the space of eight months, and went from Stettin -to Berlin[47]. - -M. de Rottkirk, commandant of the margrave Charles's regiment, and -M. de Krockow, captain in Schlabrendorf's regiment of Cuirassiers, -received each of them a wound through the joint of the shoulder, and -were both compleatly cured at the expiration of about ten months. - -M. de Britzke, commandant of Knobloch's regiment of foot, was wounded, -near Dresden, by a musket ball which pierced the articulation at the -elbow, and shattered the three bones which join at that place. Several -splinters were extracted; this officer nevertheless in about two years -was compleatly cured, and at present does his duty gloriously at the -head of his regiment. - -I shall finish the account of these cases with that of a prince -wounded at the battle of Kunnersdorf. A musket ball wounded him very -badly, passing through his foot at the articulation of the tarsus and -metatarsus in such a manner, that all the metatarsal bones excepting -one were shattered. Proper incisions and the other remedies already -mentioned effected his cure, and restored him to the nation and the -army to their great joy, although the wound was of that kind, for which -surgeons were accustomed to amputate not above fifty years ago[48]. - -FOOTNOTES: - -[41] Memoirs of the Academy of Sciences at Paris, for the year 1732. - -[42] I have not yet read the Dissertation on this subject, which -obtained the prize from the royal Academy of Surgery; but by persons -arrived from Paris, I have been informed, that the author carried a dog -with him to the Academy, whose thigh he had cut off at the articulation. - -_Note by Tissot._ There must be a mistake in this place, since the -writers of these pieces for the prize never make themselves known. Not -that I make any doubt of the possibility of taking off the thigh of a -dog, but I don't apprehend that such a fact can be at all conclusive -with respect to the same operation on the human species. - -[43] See Heister's Surgery, t. i. part i. ch. 13. Edinburgh Medical -Essays, vol. ii. art. 15. vol. v. art. 17. The Promptuar. Hamburg. and -the Collections of Breslau, in several places. - -[44] Anatomy, observations in surgery, and the opening of dead bodies, -concur to establish Mr. Bilguer's opinion. - -The anatomical proofs are drawn from the inspection of the arteries. I -am persuaded, that unless the crural artery is wounded almost at its -egress from the arch formed by the tendons of the abdominal muscles, -where it loses the name of iliac, its being destroyed will very seldom -occasion the loss of the limb; besides three small branches which -it sends off almost at its egress, and on which, I own, should have -no great reliance, for the nourishment of so large a limb, both on -account of their smallness and their distribution, at about two or -three inches distance from the artery, it sends off other branches much -more considerable, among others, two called the muscular arteries, -especially the external one, descends pretty large down the thigh, and -very evidently contributes to the nourishment of the muscular parts; -although their trunks have not been traced so far as the leg, I make -no doubt but it may be discovered that their branches reach that part, -and which, though scarcely visible in their natural state, would not -fail to become larger, when the blood was thrown into them in greater -abundance; besides, the anastomosis of any considerable branch with -the trunk of the crural artery, conveys so much blood to it, that it -may again become useful: Experience demonstrates that this happens in -the arm, and it is highly probable that the same thing may take place -in the thigh; the number of branches which spring from the brachial -artery, almost from its beginning, and their distribution being very -analogous to what we see in the crural artery. - -The surgical observations which demonstrate the recovery of heat in -the parts after the operation for the aneurism, although the brachial -artery has been tied very high, are common, and may be found among -other observators besides those quoted by Mr. Bilguer, and there are -doubtless few physicians or surgeons who have not had opportunities of -seeing such cases themselves. - -It is a sight extremely interesting, to observe the gradual return of -heat, strength and colour, to an arm on which the operation for the -aneurism has been performed. I do not know that this operation was ever -performed in the thigh, the artery being so guarded in this part, that -an aneurism rarely forms here. I have seen the operation succeed very -well in the inferior part of the leg, on the tibialis anterior, and the -foot suffered but very little for a few days; it is true it is supplied -with several other branches. - -Some curious dissections of dead bodies afford a third argument, as the -crural artery has been found quite obliterated in the upper part of the -thigh, in consequence of a morbid cause, without the leg having been -deprived of its nourishment, though supplied perhaps more imperfectly. - -Warm water baths, in these cases where the circulation is to be -promoted through the smaller vessels, and their diameters enlarged, are -among the most efficacious remedies. TISSOT. - -[45] See § XIII. - -[46] § XXXII. It is long since the bolar earths have had the reputation -of being useful in contusions, but this I am afraid is founded on a -mistake; I have never, in any case, experienced the least effect from -them that could induce me to think they possessed the virtues ascribed -to them. True bole armenic might prove somewhat astringent in the -first passages, but could not do any service in this way; or might -suffer perhaps a small portion of the vitriolic acid it contains, to -disengage itself; but four or five drops of the spirit of sulphur, -would be more useful in this respect than a dose of the bole: Thus I -am almost convinced it is of very little benefit in this composition, -and if of any, it must be by blunting the action of the neutral salts, -and preventing the uneasiness they sometimes occasion to persons of -delicate stomachs. TISSOT. - -[47] I have seen an officer, a captain in the French service, who -received a musket shot, with the muzzle of the piece close to the -part; the ball shattered the humeral bone near its head, close to -the articulation: had the wound been somewhat lower, that is less -dangerous, his arm would have been taken off; the impossibility, or -the difficulty of the operation prevented it; he suffered all the -inconveniencies that a wound can occasion, for a considerable time -several splinters were extracted, at length at the end of five months -he was cured. This case appears to me of consequence, because here we -see a very bad wound of that kind for which amputation is performed -every day, and the danger aggravated by the nature of the part where -it is inflicted, where they do not amputate, because it cannot be -done, yet it was cured. If this officer had been so fortunate as to be -wounded a few inches lower, he would have had the misfortune of having -his arm taken off. TISSOT. - -[48] _Fifty years_, a compliment which Mr. Bilguer pays surgeons of a -more modern date. - -M. le Conte de B... a general officer in the Austrian service, received -a wound much of the same kind, at Hochirken, and had the good fortune -to be compleatly cured by M. Brunet, without amputation, which appeared -indispensably necessary. He only continued a little weak, which in a -man of his age and constitution generally goes off of itself: He was -advised to go to the baths at Baden in Austria, and on his return was -seized with an inflammatory fever, which proved mortal. TISSOT. - - -SECT. XXXVII. - -I might enumerate the cases of a great number of wounded men cured in -this way, but the instances I have mentioned may suffice to make it -known; I shall only add, that even while I am writing, there are a -great many patients in the hospitals at Torgau, whose bones were so -broken and shattered, that hitherto surgeons would not have conceived -that it was possible to cure them without amputation, and who are all -nevertheless in the way of recovery, by the method I have recommended. -There are very few surgeons of the army, who have not seen instances -in our hospitals of patients whose limbs were to have been cut off, -where to their great dread, every thing was ready, and they placed in -order to undergo the operation, when, either from their fainting or -their resistance, it has been put off, and recourse has been had to -the method I have just pointed out, by which, contrary to the general -opinion, they have been cured, have saved their limb, and used it -afterwards with convenience. If we compare this with what has been -said, § XXVII. it will readily appear, that for the most part it is -extremely wrong to amputate the limbs. - - -SECT. XXXVIII. - -I have treated hitherto of accidents which quickly carry off the -patients; I come now to consider those where the danger is not so -pressing, and which terminate in death by slow degrees, a caries of the -bone, and a cancerous state of the parts; for it is well known, that in -these circumstances amputation is often deemed necessary. - -A caries of the bone is either superficial or deep seated, recent -or inveterate, occasioned by a vicious state of the fluids, or the -consequence of some external hurt. - -When it is recent and inconsiderable, whatever be the cause, there is -no room to think of amputation at all, but the bone must be laid bare -according to the extent of the caries, and scraped with a scalpel, or -perforated in sundry places with the spike of a trepan; when the caries -has gained the opposite part of the bone, we must then use the crown -of the trepan, in order to take out the entire piece. I do not however -propose entering into a detail of the manner of performing these -operations. - -With respect to the medicines proper in a caries of the bone, without -the application of instruments, or which finish what the instruments -have begun, we are furnished with a great many, of which it would be -too tedious to give a list: I must only give a caution not to employ -the mineral acids, even the anodyne mineral liquor of Hoffman, so much -boasted of by some practitioners in diseases of the bones; for they -all do hurt. It is well known that when these acids are used for the -teeth, they whiten them, but at the same time destroy their substance, -rendering them crumbly and friable like limestone; now the other bones -being less solid and hard than the teeth, there is so much the more -reason to apprehend the same effect, by their penetrating from the -affected part of the bone, where they are applied, to that which is -sound. In consequence of this, the bones which appear mended after the -use of these liquors, are, in a short time, worse than before[49]. - -The real method of doing service to bones consumed by a caries, is like -what happens to boards joined together with nails, if you make them -excessively dry, the nails fall out of themselves; and doubtless it is -this notion that has given rise to the practice of employing hot irons, -and acid liquors, as driers, to promote the exfoliation of bones. But -both these methods are attended with the inconvenience I have already -mentioned, with respect to acids, of acting with so much violence on -the diseased parts, that they extend their action in a dangerous -manner, to those that are sound. We may nevertheless employ hot irons -with success in constitutions abounding with moisture, or when it -is of consequence immediately to stop the progress of the disease. -The following medicines act efficaciously, but with less violence, -frankincense, mastich, myrrh, balsam of Peru, and essential oil of -cloves; but this oil should be used with moderation, since when it is -employed for carious teeth, they become friable, and crumble away by -degrees in a short time[50]. - -When the caries is removed, in order to compleat the cure, we ought to -prescribe a nourishing diet, but not too oily; broth, in which viper -flesh is boiled, is very useful[51]. The dressing should then only -consist of dry lint, taking all imaginable care to hinder the contact -of the external air. When the caries is accompanied with a vitiated -state of the blood, the external treatment is the same, and succeeds -equally, provided internal medicines, suitable to the nature of the -ailment, be joined with it; with this precaution, a caries from a -venereal cause, may be cured like any other. - -FOOTNOTES: - -[49] I saw two patients who had each of them a troublesome caries, the -one on the tibia, the other on the external protuberance of the fibula; -their complaints, they told me, were of long standing, and that they -were cured by a travelling quack, the one in six weeks, the other in a -somewhat longer time. What I learned of the colour of the medicine, its -properties, and of its effects on the ailment, induced me to think it -was an acid spirit. This incident confirms what I was told by others, -and what Mr. Bilguer now remarks. TISSOT. - -[50] I have seen several times, as well as Mr. Bilguer, the teeth -crumble away by degrees, after using the oil of cloves; I have seen the -same thing happen without the use either of it or of acids; I have, at -other times, employed it without any such effect, and although I am -convinced that it does hurt sometimes, it is only, I imagine, when the -caries is very considerable, and the tooth much wasted: This is not, -however, sufficient reason to give up, entirely, a medicine often very -serviceable in many cases of carious teeth. TISSOT. - -[51] The indiscriminate use of viper broth is not proper at all times, -or in all cases of carious bones. - - -SECT. XXXIX. - -It will certainly be asked, What must be done when the best -applications fail, and must we not amputate when the caries is very -extensive? I answer, that amputation is to no purpose if the caries be -attended with a bad habit of body, and while the morbid cause remains; -when this is removed, we ought not to despair of a cure, although -the greater part of the bone be carious, as the cases I have already -related plainly demonstrate[52]. We ought therefore to try other means, -and trepan the bone in several places, till whatever is rotten be -taken away. There are many bones, whereon amputation, even if it were -of use, is not practicable; if, for instance, the caries has attacked -the upper parts of the humeral, or thigh-bone, the jaw-bone, &c. The -method of treating the diseases of the bones, may be learned from the -cases of so many soldiers wounded at the articulations of the elbow, -knee, &c. and who, by the care bestowed on them in our hospitals, had -their limbs saved, notwithstanding they lost very large pieces of bone; -some of which were separated by nature, and some by the help of the -surgeon: And as no person will deny that the wounds made by a surgeon, -with an exceeding sharp instrument, and with much circumspection, in -order to remove the pieces of corrupted bone, are more easily cured -than wounds that are lacerated and contused, by means of a ball, -grape-shot, or splinters, &c. If the habit of body allows of any hope -of curing the caries, the method I have pointed out § XX. may also be -practiced in this case. It is true, the limb often remains deformed -after it, but this does not always happen; and frequently the callus -fills up the whole vacuity left by the part of the bone which is taken -out, however considerable it may have been. We read of successful -cures, where even the loss of the entire bone has been supplied by -means of a callus[53]; besides, the deformity of the limb does not -take away the total use of it[54]. - -FOOTNOTES: - -[52] The observations of M. Muzel, p. 83. confirm my opinion, where he -says, that all those on whom amputation was performed on account of -carious bones, died in consequence of it. - -[53] Such is that mentioned by Scultetus, _Armentar. Chirurgicum_, -_obs._ 81. in which we see a callus supply the place, not only of -the tibia, but also of a part of the fibula, which he had extracted, -and at the close of the cure, the patient walked without the help -of a staff.----See also the Medical Essays of Edinburgh, vol. i. p. -312.----_Ubersatzt durch D. Carl. Cristian Krausen_, _p. 51_. And the -same Essays, vol. v. p. 371. mention one much more surprizing, "for -the whole tibia of one leg came out, and the tibia of the other leg -separated in small pieces. Nevertheless the patient, who was a boy -of 10 or 11 years of age, in four months was able to walk without -crutches, with his legs straight, and continued well afterwards, and -fit for country work." These cases are so much the more decisive in -favour of the method I employ, as the callus much more easily repairs -the fragments of bone taken away by the surgeon after an external hurt, -and where there is no morbid cause, which was very considerable in the -case I have cited. - -[54] See § XXXVI. - - -SECT. XL. - -It now remains, that I should say something concerning cancers; on -which subject I shall be brief, as it has been treated of by very able -hands[55]. If the complaint be recent, the constitution good, if -internal medicines and outward applications have produced no effect, -the vitiated part must be extirpated before the disease takes root, and -communicates the infection farther. But the greater number of those -who have the misfortune to be attacked with this disease, putting off -the amputation from time to time, it happens when they do resolve on -it, either that it accelerates their death, or the humour falls upon -another part: For this reason, the operation for extirpating it, should -be performed much more seldom than it is[56]; and it were greatly to -be wished, that physicians would endeavour to find out some remedy for -this horrid disease, without having recourse to amputation; but it is -not my intention to dwell on this topic. - -FOOTNOTES: - -[55] See the Dissertation of M. Kattschmied, on this subject. - -[56] When the cancer is evidently the consequence of an external -accident, neglected or injudiciously treated, amputation performed in -time, may effect a cure; but when the disease has come on gradually, -without being able to assign any external cause for it, I have almost -constantly observed, although it be performed in time, it accelerates -the patient's death; and sometimes after having been made undergo a -degree of torture more painful than that of the cancer itself. It -is hoped, that the virtues of hemlock will make the frequency of -amputation in these cases be discontinued: It appears, however, by the -conclusion of the section, that Mr. Bilguer had not seen Dr. Stork's -pamphlet. - - -SECT. XLI. - -I have now finished what I had most material to say, against the -practice which still prevails, of too precipitately taking off the -limbs when they are contused or shattered. - -Are my reasons well-founded, or does the method I propose deserve to -be adopted? This I leave to be determined by the judicious reader; for -my own part, I shall never experience any sensation more agreeable, -than the recollection of having saved the lives and preserved the limbs -of so many unfortunate men in our hospitals, whose wounds were of the -kind for which practitioners hitherto have had recourse to amputation; -and it were to be wished, that so many cures happily effected, might -repress that kind of folly, by which, in some countries, surgeons are -excited, and even encouraged by public rewards, to perform frequent -amputations. Another advantage will accrue from this publication, which -is, that all those who judged unfavourably of the surgeons of our -hospitals, on hearing they never employed amputation, will, I hope, lay -aside their prejudices on this score, and may even derive benefit from -our example. - - FINIS. - - - - -Transcriber's Note - - -Original spellings, punctuation, inconsistencies and all apparent -printers' errors are retained, with two exceptions: - - In section 6, "hat" has been changed to "that" - ("...that there is room to dread..."). - In section 24, "endeavovour" has been changed to "endeavour" - ("If there be any pointed splinters, I endeavour to..."). - -The heading for Section 36 is missing from this translation. In -Tissot's translation the missing Section 36 heading is at the top -of page 83, before the sentence: "In conformity to the plan I have -proposed...". - - - - - -End of the Project Gutenberg EBook of A dissertation on the inutility of the -amputation of limbs, by Johann Ulrich Bilguer - -*** END OF THIS PROJECT GUTENBERG EBOOK A DISSERTATION *** - -***** This file should be named 44089-8.txt or 44089-8.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/4/4/0/8/44089/ - -Produced by Fay Dunn and the Online Distributed Proofreading -Team at http://www.pgdp.net (This file was produced from -images generously made available by The Internet Archive) - - -Updated editions will replace the previous one--the old editions -will be renamed. - -Creating the works from public domain print editions means that no -one owns a United States copyright in these works, so the Foundation -(and you!) can copy and distribute it in the United States without -permission and without paying copyright royalties. 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