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].