Kitabı oku: «A dissertation on the inutility of the amputation of limbs», sayfa 3

SECT. XVII

It was probably by some such application, that S** G**** cured a man whose arm was mortified, and whom the physicians and surgeons had given up; a cure which appears to me much less wonderful than what is imagined. The physicians and surgeons despaired of his recovery, and quitted him, because he would not submit to amputation, at the very time when, doubtless, the separation of the sound and mortified parts began to take place, owing either to the force of nature or the medicines they had administered, and when granulations of new flesh began to shoot. It was easy for S** G****, called in at this instant, to effect a cure, by means of his quieting powders and balsam. What is most astonishing in this case, and deserves at the same time to excite our indignation, is the obstinacy and the cruelty of the physicians; but they were sufficiently punished for it.

SECT. XVIII

This is not the only instance of patients in whose cases physicians and surgeons have pronounced amputation to be unavoidable, and who, upon their refusing to submit to it, have afterwards been cured by very simple treatment. This ought to be a lesson for us never to be too precipitate in having recourse to this operation¹⁴.

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.

SECT. XIX

When a mortification in a healthy constitution is the consequence of an external accident, the point is not so easily determined; I will venture, nevertheless, to remove the difficulty.

It must first be inquired into, if the ailment has been properly treated at the begining, and if sufficient care has been taken with respect to the cause. If there appears any default in these points, we must first endeavour to repair it, before we think of amputation. If, on the contrary, the treatment has been judicious, we must examine if the mortification continues to spread, or if it be stopt, and its edges begin to discover themselves.

If it continues to spread, it is improper to amputate, for several reasons. In the first place, because the whole habit is in a bad state, and there must be a fever and general inflammation, which would be greatly increased by an operation which, of itself, is sufficient to bring on the death of the healthiest man. In the second place, amputation cannot be performed on the sound part, in the manner as is generally imagined, as the infection is very often more deeply seated than it appears to be: We may judge of this by observing what happens very frequently in whitlows of a bad kind, where the matter quickly insinuates itself along the arm, and is pent up there, inflaming sometimes even the axillary glands; as an inflammation of the toes, in a short time, brings on that of the glands in the groin: Thus the disease having taken root in the place where the operation is performed, would of course be increased by the ligatures, which are indispensably necessary in this operation, unless we would suffer the patient to perish by an hemorrhage. In such a case then, amputation is not a dubious remedy, but it is no remedy at all¹⁵; 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 hopes¹⁶ 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 sensible¹⁷. 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. Schaarschmid¹⁸, 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 of¹⁹.

SECT. XX

I shall treat at present of large contusions of the limbs, especially of those where the fleshy parts, as well as the bones, are extremely bruised and shattered, as commonly happens, when the hand, the foot, the elbow, the leg, arm or thigh, have been bruised by a large stone, a beam of wood, a cart-wheel, a screw, a press, &c. In such cases, shall the patient get sooner well by amputating or not amputating this shattered limb? I answer, by not amputating; the worst consequences that can be apprehended, is a mortification or an hemorrhage. With regard to the mortification, unless every thing I have hitherto said concerning it be intirely groundless, we ought not to be afraid of it; and it is much easier to prevent than to cure it. With respect to the hemorrhage, it is no doubt to be dreaded, but this dread can be no reason for instantly taking off the limb: To be convinced of this, we need only examine those wounded men who have had an arm or leg carried off by a ball, and the stump so shattered, that the bone has been shivered into several pieces, and the large blood vessels most shockingly torn, who have, notwithstanding, been cured without amputation, and with whom the bleeding has stopt, even without the assistance of a surgeon. Nevertheless, every body knows that contusions of this kind have been hitherto, by most surgeons, accounted a sufficient cause for amputation; and that when the hand or foot have been shattered, they have carried their inhumanity so far, as to take off, not only the leg or fore-arm, but even sometimes above the knee or joint of the elbow.

Those who follow this method, amputate within a few days of the accident, while the patient is vigorous, and without waiting for the event of any other kind of treatment; for if the patient be weak, old or very ill, even with the consequences of the wound, they do not venture upon the operation.

It would however, in my opinion, be much better not only not to take off an arm, a thigh, or a leg, which are unhurt, but even to endeavour to save the foot or hand which are shattered, in obviating, by medicine and diet, as well as by external applications, the accidents that may ensue; and thus prevent a person who has already suffered so severely, from meeting with a treatment still more severe.

It will be asked, if the thing be possible? The following observations will furnish an answer. I publish them with so much the more confidence, as they are known, not only by the patients themselves, but by a great number of the physicians and surgeons of the army. They must be decisive in favour of preserving contused and shattered limbs, in opposition to amputation.

SECT. XXI

When a patient is brought to our military hospitals, who has had his foot, leg, hand or arm shattered by a ball, or any other violent cause, whether the parts are intirely carried off, or adhere by a little flesh and skin, but in such a manner that there is not any hope of a re-union; in this last case, we begin by cutting through these slender attachments which keep the part suspended, and thus intirely separate it from the body. In both cases, when pieces of the extremities of the bones jut out, and may prove hurtful, they must be sawed off with a convenient saw, whether they be moveable or still firmly adhere to the limb: When they are moveable, they must be held by an assistant. I hope no man in this treatment, will pretend to see any thing like what is properly called amputation, which I condemn.

After this first operation, I carefully examine if there be still any small splinters left, and whether they are only held by the fleshy parts, or still adhere to the bone; I remove all those, with the fingers, or with instruments, that can be separated without violence or a fresh effusion of blood.

After removing as many splinters as I can, I slightly compress the limb between my hands, gently stroking it lengthways, from above downwards, endeavouring, at the same time, to restore, as much as possible, its natural shape; I dress the sore with a digestive, to which I add a little essence of myrrh, or solution of mastic: I cover the whole with dry lint; applying the same bandage as after artificial amputation, sufficiently tight, without, however, running the risque of causing pain or increasing the inflammation: Afterwards I moisten the whole with as much spirit of wine as may penetrate to the parts affected; taking care to keep the limb extended in a right line, and laid soft.

The first days, till the suppuration becomes plentiful, I only dress it once every twenty-four hours, sometimes seldomer; but when the suppuration is begun, I renew the dressings twice a day; and such of them as immediately touch the bone, or fleshy parts of the wound, I cover with lint dipt in solution of mastic, balsam of Fioraventi, or some other balsamic essence, in order, by that means, to prevent too large a suppuration. I likewise remove, each dressing, all the little shivers of bone which do not reunite, and which, though they could not be separated at the first dressing, may in the succeeding ones.

With respect to the larger fragments, which must form the stump of the bone, I not only take care not to loosen them, but even, as I already remarked, endeavour to promote their coalition, by light compression with the hands, and binding the bandage somewhat tighter than I would otherwise do. If, at the expiration of a month, a fragment of this kind is not coalesced, but on the contrary, is become more loose, without however being intirely so; in that case, by shaking it gently, moving it upwards and downwards, and loosening the fleshy parts that hold it, I endeavour to bring it away intirely. If there are some of them cracked as high as the articulation, I give myself no concern about them, but leave them to nature²⁰. 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.