FOOTNOTES:
[15] I hardly ever knew any old officers who have not been witnesses of some examples of this kind; and I have seen several people who have themselves been in such a situation.
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 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.