Kitabı oku: «A dissertation on the inutility of the amputation of limbs», sayfa 4
SECT. XXII
Besides what I have already said, I must further add some other useful remarks.
If the patient, as is generally the case, be weakened by the discharge of blood, his strength must be supported with broths, with herbs boiled in them, and with wine and water. Further, I order him every four hours half a dram of the bark, till the pulse is sufficiently raised, and a laudable suppuration comes on; he may then be allowed some meat, herbs, and food of different kinds of grain; water, acidulated with vinegar or spirit of vitriol, may serve for drink.
When the suppuration is too plentiful, and the wound appears disposed to heal, I purge once or twice with Epsom salt, having previously for a few days administered some absorbent powders. During the day I make him drink a slight decoction of the bark, before and after meals a little strengthening acid elixir; and in the evening, a small dose of bark, mixed with a fourth part of an absorbent powder21. 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.
SECT. XXIII
It sometimes happens that these patients, § XXII. are seized with a fever, it begins with great cold, sometimes even with a chattering of the teeth, which lasts half an hour, an hour, or sometimes longer, and is succeeded by a gentle heat, which terminates in about three or four hours, in a moderate sweat. The interval lasts two or three hours, at the expiration of which the fit returns; sometimes it is accompanied with a diarrhœa.
The most common causes of these fevers, are either in the first place, a bad digestion when a person has taken too much food, or the food is greasy, indigestible, and subject to putrefaction; or, secondly, a reabsorption of purulent matter, which taints and inflames the blood; or, thirdly, a bad air, such as is very often that of an hospital, notwithstanding all the precautions that can be taken.
It is of consequence immediately to stop this fever, lest it should dissolve and corrupt the blood, and become a putrid fever: If it is not accompanied with a diarrhœa, a vomit of ipecacuan may be given, joined with a few grains of rhubarb: If there is a looseness, the same medicine may be repeated the following morning, and even sometimes the third day. Through the day may be given a little of the strengthening elixir described in the preceding section; and in the evening, when the patient has had a vomit in the morning, half a dram or two scruples of the following anodyne powder may be administered; Virginian snakeroot, zedoary, of an eleosaccharum made with the essential oil of fennel, of each two scruples; calcined hartshorn, sixteen grains; cynogloss pills, four and twenty grains. Afterwards I gave every day some of the strengthening elixir, a compounded powder of the bark, and a strengthening decoction. The powder consists of two drams of bark, one dram of sal ammoniac, and a dram of an eleosaccharum, made with the essential oil of fennel. The ingredients for the strengthening decoction are as follow: The herbs of fluellin, baum and yarrow, of each half an ounce; of that of mint, two drams; chamomile flowers, an ounce; those of red poppy, half an ounce; orange peel, two drams; shavings of sassafras, cassia lignea, carvy seed, of each a dram; bark, four ounces; and Virginian snakeroot, one ounce. These ingredients must be properly cut small, bruised and mixed together. By the above medicines the fever is commonly relieved22.
SECT. XXIV
I have treated hitherto of limbs intirely divided; I shall now examine what ought to be done, when a ball, or any piece of iron or lead, has so greatly injured the bones of the hand, arm, foot or leg, that, although they are not quite broke through, and the part suspended by a small portion of flesh and skin, as in the former case, § XXI. are nevertheless so much shattered that the part may be moved any way, and seems to hang useless. In these circumstances, we must dilate the aperture made by the ball, or by whatever body has inflicted the wound, and separate the flesh from the bone; in a word, we must make the wound sufficiently large, in order to lay the shattered bones bare, especially where they are broken across, that they may be more easily managed by the fingers; then as many splinters as possible must be extracted, as well as the ball and other extraneous bodies. If there be the apertures of two balls, they must both be treated in the same manner: When it is expedient to make counter openings, they may be made indifferently, whether there be one or two openings, and these artificial wounds must be made sufficiently large, to admit of the extracting of the splinters and other extraneous matters. In other respects, the dressings must be the same as § XXI. Every time they are renewed, the splinters must be extracted as they become loose and can be easily separated; if there be some large fragments which must be removed, we may begin by dividing them from the fleshy parts, then sawing them through with a very small saw, whose blade is extremely thin and narrow, crooked or straight, in order to push it from above downwards, or from below upwards, or sideways, as may be convenient. This method answered so well with me for the bones of the leg and arm, that I have often, in this manner, separated pieces three or four inches in length, and even longer. As for the smaller bones, such as those of the hands or feet, I have divided and extracted them entire, when they were broken and shattered, and sometimes even when they were not.
If a bullet has penetrated into the cavity of a bone, such bone must be laid bare, either on the side by which the bullet has made its way, or on the opposite one; afterwards it must be pierced with two or three trepans, and the extraneous body, and the shivers of the bone extracted.
If the bullet has made its way into one side of the joint of the elbow or knee, and by that means shattered several bones at one stroke, I treat it in the same manner, dilating the wound and extracting the splinters as before, and the wounds get well like the others.
I cured a patient who had been wounded by a bullet which entered the cavity of the os humeri; he would not consent to have it extracted, which did not however prevent his recovery, nor has he felt any further inconvenience from it than a small protuberance on the place where the ball is still lodged23.
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 little24.
SECT. XXV
Such kind of wounds, however, are not without danger; the patient is not only very liable to be seized with such a fever as I have spoken of § XXIII. but he also runs a risque from the wound itself. It is true, that these two dangers, that attending the fever, and that from the wound, which I shall mention by and bye, are connected, and generally accompany each other. It sometimes happens of a sudden, and without the patient, or the physicians and surgeons having any suspicion of it, that the wounds dry up, become corrupted, and exhale an infectious stench; the neighbouring parts are very much inflamed for some days, after which the inflammation goes off, leaving a kind of œdematous tumour, which produces an abscess, with a laudable discharge, or degenerates into a malignant sore, without any abscess. Sometimes these sores are beset with swarms of maggots.
The treatment of the fever is the same I have described § XXIII. that of the wound, in this troublesome situation, ought to be to endeavour intirely to remove the inflammation, which readily terminates in suppuration, and forms large cavities full of matter, which must be opened.
A moderate compression of the neighbouring parts, in this case, as in those I have already mentioned, contributes to prevent the reabsorption of the purulent matter. If the inflammation runs high, and the patient is young, it should be moderated by bleeding, and other medicines calculated to check and resolve the inflammatory denseness of the blood25.
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.
SECT. XXVI
I have had under my care, during the course of this late bloody war, a great number of wounded limbs, torn and shattered by cannon and musket balls, by the bursting of bomb-shells and grenades, by grape-shot, &c. I cured them without ever performing amputation, by the method described in the two preceding sections, although there were bones broken and shattered, large blood vessels divided, the flesh miserably lacerated, and limbs carried off in the manner I have described § XXI. Others, such as I have described § XXIV. in which the bones were split up as high as the articulation; all which circumstances might make us reasonably apprehend a tedious and difficult cure, too plentiful a suppuration, hemorrhages, violent inflammation, excessive corruption, mortification and death.
It will perhaps be asked me, Of those men so terribly wounded, whom you attempted to cure without the means of amputation, did none die? I shall return an answer by and bye. It will be further objected to me, that I have not taken notice of the os humeri, or the thigh bone being shattered; and it will be asked me, What must be done in cases where either of these bones are fissured as far as their upper extremities, in such a manner that we cannot hope to procure their coalition by means of any bandage? And finally, it will be remarked, I have not mentioned the wounding the brachial or crural arteries, or the large branches of these which pass between the radius and ulna, or tibia and fibula, called in both parts the inter-osseous arteries, whether these wounds be accompanied with a fracture of the bones, or otherwise. I shall reply to these two last objections, after having answered the first question in the following section.
SECT. XXVII
I had at one time, during the war, in a military hospital, six thousand six hundred and eighteen wounded patients, who were all treated according to my direction, and part of whom I attended myself; of these, five thousand five hundred and fifty-seven were perfectly cured, and in a condition to support all the fatigues of the service; a hundred and ninety-five were able to do duty in garrison, what they call half-invalides26, or to work at any trade; two hundred and thirteen remained incapable of any labour, civil or military, what they call grand invalides27; 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 dangerous28: 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 kind29. 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 performed30.
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 off31, I hope it will be readily acknowledged, that my method of treating wounded limbs, by saving them, is highly preferable to that of amputation.
