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Title: A dissertation on the inutility of the amputation of limbs
Author: Bilguer, Johann Ulrich, 1720-1796
Language: English
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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.

Original spellings, punctuation, inconsistencies and 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-rhœtus _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 œdematous 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 Gœuey 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 diarrhœa.

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 diarrhœa, 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 œdematous
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...”.





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