Kitabı oku: «A dissertation on the inutility of the amputation of limbs», sayfa 2

SECT. VIII

Whenever a mortification attacks any part of the body, whether it be owing to an outward hurt, or proceeds from an internal cause, as often happens in persons afflicted with the scurvy, dropsy, a vitiated state of the blood, phagedenic sores, or very aged people, who begin, as it were, to die in the extremities: Whenever, I say, the mortification begins to appear, it requires immediate help. We must begin by making incisions on the part affected, in order to procure a discharge of the corrupted matter, and to assist the action of the medicines. I make long incisions, not only on the mortified parts, but on those adjacent, which would soon be so; I make several of them, as nearly as the large trunks of the blood vessels, and more considerable branches of nerves will allow, not above an inch distant from each other. We ought always to cut to the quick; and if the bone be affected, the periosteum must be cut through, and the bone laid bare. These incisions should follow the direction of the greater number of fibres of the muscles that happen to be thus cut upon; but when the gastrocnemii, the glutei or deltoid muscles have been wounded by a ball, they must be cut cross-ways, otherwise convulsions, particularly the spasmus cynicus, will probably ensue. Several aponeuroses, especially that of the biceps, ought likewise to be cut transversally: It is true, if the longitudinal incisions are sufficiently long and numerous, they take off the tension of these membranes so much as to render the transversal ones unnecessary.

Neither ought the tendons to be spared; they must be boldly cut through transversally.

If a wound, or any other ailment, happens near the articulations, I also, without fear, make large incisions through the ligaments.

It will easily be understood that these incisions must differ from each other in length and depth; they must be longer in those parts of the sore where the disease has spread the widest, and shorter in others. Both must be more superficial at their extremities, and deeper in the middle, in the place where the complaint began, and where the mortification reaches deepest.

The number of incisions, and their distance, must also vary, as they may be found necessary; so that a skilful surgeon may make three, four, six or eight, as the case may require.

It is obvious, that in an operation of this kind, a surgeon should not be too precipitate; and when he does not know the depth of the ailment, he should not go too deep with his incision: he may repeat it if he finds he has not reached the quick.

SECT. IX

After these incisions are made, we must carefully examine how far the part which is absolutely mortified, and which it is impossible to restore to life, may reach. This may be distinguished by the stench which exhales from it, by its change of colour, and want of feeling. These mortified parts ought immediately to be separated from the sound, and removed by means of a bistory in the same manner as one muscle is divided from another in an anatomical dissection. In order to do this, the dead flesh must be cut through cross-ways, which puts the patient to no kind of pain. But care must be taken in this operation, not to separate such parts as may be somewhat affected by the mortification, yet not totally corrupted, as it often happens, after the removal of what is entirely dead, that they recover, by proper assistance, their natural state.

In making these incisions, we should take all imaginable care, as I have already remarked, not to wound the larger blood vessels or more considerable nerves; for this purpose, the gangrened parts which lie near them, should be separated with great caution: It is even better to leave behind a small portion of the mortified flesh which may adhere to them, and to trust for its separation to the ensuing dressings, which they will not fail to accomplish. The reason for this rule is, that we often see the vessels remain sufficiently sound, while the other parts are very much corrupted. We find for example, in the arm, near the joint of the elbow, near the wrist, and even in the lower extremities, the vessels intire, although the mortification of the parts which surround them be so considerable, as to oblige us to make our incisions to the bone; and it is these vessels, after the extirpation of the dead parts, that must keep up life in those which remain: We ought to preserve the greatest number we can, not only of the larger vessels, but even of the smaller ones: It was with a view to this particular, that I recommended not to make our incisions rashly, but with a good deal of caution, both with respect to the place where they were made, their direction and their distance. In operating with this circumspection, we shall avoid incurring the censure of Platnerus, who remarks, that we ought not to separate the dead from the sound parts with violence, “Because,” says he, “incisions which cause an effusion of blood, often renew the inflammation.” Now in my method, there is neither any violence, nor incisions attended with blood.

SECT. X

When the incisions are made, if the neighbouring parts appear somewhat tainted, we must, by gentle compression, squeeze out the corrupted humour which may harbour there, and wipe it off with a bit of soft linnen rag. Afterwards, whether it may have been necessary to extract, either with the fingers, a scalpel, or with the instrument called a myrtle leaf⁷, 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.

SECT. XI

If the bone is not affected, or the periosteum laid bare, the balsam or thin liniment may be omitted. And the dressings may only consist of the layers of dry lint and vulnerary powder applied alternately.

SECT. XII

Besides the dressings I have mentioned (§ X. and § XI.) for these kinds of wounds, we must likewise make slight scarifications upon the neighbouring parts, and sprinkle them with the powder; after this treatment, embrocate all the sores with oil of turpentine, and then lightly bandage up the whole with plain linnen cloth, which must be kept moistened, night and day, with warm fomentations.

SECT. XIII

It is in following this method only, (§ X, XI, XII.) that these fomentations, so much recommended both by the antients and moderns, will be found truly serviceable and efficacious. Mr. Heister has collected a sufficient number of these forms, in treating of mortifications, in his excellent system of surgery, which is in every body's hands. It will be an easy matter for a surgeon, who understands the nature of the ailment and the quality of the medicines, to select such as will be most suitable to the case he happens to treat. Thus, for example, the fomentation consisting of a pint of lime water, three ounces of camphorated spirit of wine, and an ounce or half an ounce of sal ammoniac, is very useful in mortifications which are the consequences of high inflammation, as it relieves the inflamed parts that lie round those which are already mortified. The same effect may be obtained from the fomentation made with the balsam of life; namely, soap, salt of tartar, and oil of turpentine, mixed and dissolved in lime-water; and from the cataplasm, composed of the herbs called species pro cataplasmate, and venice soap and saffron added thereto⁸.

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 ball⁹ 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 drams¹⁰. 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 drams¹¹.

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.

SECT. XIV

The diligent use of these fomentations will alter, in the space of twelve hours, the condition of gangrened wounds for the better; at the end of which, the lint and vulnerary powder, with which they were filled, may be removed, and at the same time, all the detached pieces of mortified flesh may be extracted, and the same dressings (§ X, XI, XII.) applied, which must be renewed every twelve hours. The third or fourth dressing, the wound will discharge matter of a favourable aspect, so as to afford hopes of a cure: Then it will only be necessary to give the bark internally, and to dress the sore in the manner I shall mention by and bye. § XVI.

SECT. XV

The bark may be given by itself, in powder, or made into an electuary with rob of elder, or with the syrup of quinces, cinnamon, orange-peel, or any other cordial syrup; if it purges when taken in substance, it must be administered in the infusion or extract. If the fever be strong, the heat considerable, and the patient thirsty, the bark will be of no service¹²; 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.

SECT. XVI

I now return to the external treatment. When the dressings described, § X, XI, XII. have begun to procure a discharge of matter, the use of the vulnerary powder and oil of turpentine must be laid aside; but we must continue to assist and promote the suppuration for several days, sometimes even to the eighth; by dressing with the digestive, I shall hereafter mention, by keeping the parts constantly covered with emollient fomentations, and by avoiding to cleanse the wound too much, either by too strong compression, or by wiping it with too much exactness each time of dressing. We ought to be very much on our guard with respect to these two last points, till there be a sufficient suppuration; afterwards a somewhat stronger compression may be allowed, and the sore may be wiped with more exactness, but still, nevertheless, but very gently. For suppuration is the work of nature, an effort of the sound parts, by which they throw off whatever is vitiated and noxious; and it is the business of the surgeon to assist this salutary operation, by removing, with his instruments, such parts as are intirely corrupted; but this ought to be done, at least as much as possible, without causing any discharge of blood¹³. 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.