SECT.XI.

FOOTNOTES:[8]See Dionis's surgery, page 18. 4th edition.

[8]See Dionis's surgery, page 18. 4th edition.

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.

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.

It is in following this method only, (§ X,XI,XII.) that these fomentations, so much recommended both by the antientsand 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 apint 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 thebalsam of life; namely,soap, salt of tartar, and oil of turpentine, mixed and dissolved in lime-water; and from thecataplasm, composed of the herbs calledspecies pro cataplasmate, andvenice soap and saffronadded 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.

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.

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: Thespecies pro cataplasmatic, consists ofyarrow, 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 bysextarius; 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 calledspecies 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.

[9]These two last applications are not in Heister: Thespecies pro cataplasmatic, consists ofyarrow, 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.

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 bysextarius; 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.

I do not exactly know what quantity Mr. Bilguer means bysextarius; 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 calledspecies 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.

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.

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.

[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.

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 effortof 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 drylint, 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 poundand 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.

[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.

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.

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[15].

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]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.

[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.

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 healthiestman. 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 ofthe 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]. Whateverweight 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 uselessmass, 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 ofM.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.

[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 ofM.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.

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.

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, whilethe 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.

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, allthe 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, pointedshivers 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.

[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.

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.

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 ofan 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.

[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.

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 theevening, 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 oftwo 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].

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