A dissertation on the inutility of the amputation of limbs. Johann Ulrich Bilguer
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;
See Dionis's surgery, page 18. 4th edition.