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.
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.
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.
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].
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.
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.
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.
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.
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.
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.
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 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.
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.
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.
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.
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].
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.
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.
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.
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].
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].
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.
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.
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.
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.
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.
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.
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.
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].
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.
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.
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].
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.
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.
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].
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.
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.