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Remarks on the Palsy of the Lower Limes, 

i 

i. 

Observations on the Propriety of Amputation. 


[PRICE ONE SHILLING AND SIX-PENCE.] 





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REMARKS 

K ’ . \ 

ON THAT KIND OF 

PALSY 

OF THE 

LOWER LIMBS, 

WHICH IS FREQUENTLY FOUND TO ACCOMPANY 

A CURVATURE of the SPINE, 

AND IS SUPPOSED TO BE CAUSED BY IT. 
TOGETHER WITH 

ITS METHOD OF CURE. 

TO WHICH ARE ADDED, 

OBSERVATIONS on the Necessity and 
« Propriety of AMPUTATION, - 

In certain CASES, 

* 

And under certain CIRCUMSTANCES. 


By PERCIVALL POTT, F. R. S. 

And Surgeon to St. Bartholomew’s Hospital. 

Verumque eft ad ipfam curandi rationem nihil plus conferre 
guam experientiam. Celsus. 


LONDON: 

Printed for J. Johnson, No. 72, St. Paul’s Church-Yard, 

M,DCC,LXXIX. 






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T O 


Dr. JOHN LEWIS PETIT, 

One of the PHYSICIANS to St. 
Bartholomew’s Hospital, 

i 

THE FOLLOWING 

T R . A C T S 

ARE INSCRIBED, 

AS A SMALL MARK OF THE GREAT ESTEEM 

AND REGARD OF 


The AUTHOR. 




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* 



E R R A T J. 

Page 49. line 15, for Jenfe, read opinion. 

t 52. line 16, after the word late, put a Colon. 
62. line 9, for That is, in, read This is. 

12, after the word Bone, put a Colon, 
and then read. Let the caufe of the 
mortification be what it may. 

68. line 2, for thefe , read there . 



REMARKS, 2fV. 


A MONG the various objefts of Phyfick 
and Surgery, there are unfortunately 
fome in which all the efforts of both, have 
hitherto been found ■ abfolutely ineffectual, 
^ and which therefore have always made a 
very difagreeable, and melancholy part of 
practice. . 

• V 

To remove, or even to relieve any of the 
miferies, to which mankind are liable, is a 
very fatisfadtory employment; but to attend 
on a diftemper from its beginning, through 
a long and painful courfe, to its laft, fatal 
period, without even the hope of being 
able to do any thing which fhall be 
really ferviceable, is, of all talks, the moft 
unpleafant. 


B 


In 




( 6 ) • 

In fuch cafes, any attempts, however 
hazardous, provided they were rational, 
would be juftifiable ; certainly then, what¬ 
ever is not in itfelf dangerous, and affords 
the fmalleft ray of hope, ought to be em® 
braced. 

t » * 

Some little time ago I gave to the publick 

an account of the fuccefs which I had feen 

* 

attend the free ufe of opium in mortifications 
of the toes and feet; particularly in thofe 
which began,or were attended with great pain. 

In that publication I merely related the 
faft, as it had happened under my own 
eye; I entered into no reafoning about it; 
nor did I give to the medicine any greater 
degree of credit than it appeared to me to 
deferve; I did not propofe it as a certain 
fpecific, or as a remedy whofe fuccefs was 
always and infallibly, or indeed even ge¬ 
nerally to be depended upon; I acknow¬ 
ledged, that I had feveral times feen it fail; 
but as I had alfo feveral times feen it fuc- 
ceed, as I was very fure that no hazard 
could poffibly attend the experiment, and, 

■ y as 


I 


('7 ) 

as the beft and mo ft experienced prafti- 
tioners were obliged to allow, that they 
were not yet acquainted with any means 
whereby they were enabled to prevent the 
fatal effects of this moft horrid diftemper, 
or even to retard its daily and painful ra¬ 
vages, I thought it my duty to make known 
as' early as I could, what I had feen, that 
others might make the fame trial, and 
thereby propagate the benefit. Had any 
other means of relief been known to the 
faculty, and this had therefore appeared to 
me only in the light of another, or a pre¬ 
ferable one, I fhould certainly have with¬ 
held my obfervations, until more time had 
verified and confirmed them, and thereby 
have proved the fuperior utility of what I 
had to propofe: but as the fa£t was directly 
the contrary, as opium was the only me¬ 
dicine which I had ever feen prove really, 
and eflentially lerviceable; as it had fuc- 
ceeded fo often, and to fuch a degree, as to 
fatisfy me that much good might be ex¬ 
pedited from it; and as I was perfectly fare 
that not the leaft degree of hazard could 
attend the trial, I thought that fuch pub- 

B 2 licatiQn, 


( 8 ) 

lication, though early, could not be re¬ 
garded in any other light than its true one ; 

I mean that of a requeft to the profefiion in 
general to repeat the experiment ; and that 
therefore it could not be juftly deemed pre¬ 
mature. If upon repeated trial the fuccefs 
fhould not be found equal to what I thought 
I had good reafon to expeft, no harm could 
accrue to the patient ; if it fhould anfwer 
my expectation, it would ferve the moft 

valuable of all purpofes. 

' ’ • v 

Since that time I have had the fatisfaCtion 
of having my opinion confirmed, not only 
by my own experience, but by the con¬ 
current teflimony of feveral practitioners of 
eminence in different parts of the kingdom, 
who have done me the favour to commu¬ 
nicate to me the remit of their experiments; 
the fuccefs of thefe, as I expeCted, from 
what I had feen, have not been con flan t, 
but it has been fo frequent, as to make me 
very well pleafed at having furnifhed the 
hint. I fincerely with that the good effeCt 
was more general and more certain, but the 
prefervation of even a few, from a malady, 

found 

T. , ' \ 

* / 


( 9 ) 

/ ♦ *» • 

found hitherto to have been inevitably de- 

ftrudlive to all, is a matter of fome im- ' 

* 

portance, and furnifhes no unpleafing re¬ 
flection. 

I now do the fame thing, ‘ relative to 
another diforder, which I then did with 
regard to the mortification. I publifh an 
account of the good fuccefs which has at¬ 
tended a particular method of treating a 
difeafe, which has hitherto foiled all the 
efforts of art; and as I do it now from the 
fame principle which I did then, viz. that 
of inducing others, by making the fame 
experiment, to propagate the benefit, I 
make no apology for another early pub¬ 
lication. 

The difeafe of which I mean to fpeak, 
is generally called a palfy, as it confifts in 
a total or partial abolition of the power of 
ufing, and fometimes of even moving the 
lower limbs, in confequence, as is generally 
fuppofed, of a curvature of fome part of the 
fpine. 

B 3 


To 


( IO ) 

To this diftemper both fexes, and all 
ages, are equally liable. If the patient be 
an infant, it becomes an object of conftant, 
though unavailing diftrefs to its parents; 
if an adult, he is rendered perfectly help- 

lefs to himfelf, and ufelefs to all others, 

’» 

which, of all poflible ftates, is furely the 

very worth 

* , 

When this difeafe attacks an infant of 

, . % ..*•* * ( \ - • c 

only a year or two old, or under, the true 
caufe of" it is feldom difcovered until fome 

•• A v i. * . . x 

time after the efFedt has taken place, at leafb 
not by parents and nurfes, who know not 

where to look for it. The child is faid to 

. • ... - * 

be uncommonly backward in the ufe of his 
legs, or it is thought to have received fome 
hurt in its birth. 

When it affedis a child who is old enough 
to have already walked, and who has been 
able to walk, the lofs of the ufe of his legs 
is gradual, though in general not very flow, 
tie at firft complains of being very foon 
tired, is languid, lifllefs, and unwilling 
to move much, or at all brifldy; in no 

great 


( II ) 

great length of time after this he may be 
obferved frequently to trip, and ftumble ? 
although there be no impediment in his 
wav; and whenever he attempts to move 
brifkly, he finds that his legs involuntarily 
crofs each other, by which he is frequently 
thrown down, and that without Hum¬ 
bling ; upon endeavouring to ftand ftill and 
eredb, without fupport, even for a few mi¬ 
nutes, his knees give way and bend for¬ 
ward. When the diftemper is a little 
farther advanced, it will be found that he 
cannot, without much difficulty and de¬ 
liberation, diredt either of his feet precifely 
to any exadi point , and very foon after this, 
both thighs and legs lofe a good deal of 
their natural fenfibility, and become per- 
fedtly ufelefs for all the purpofes of loco-* 
motion. When an adult is the-patient* 
the progrefs of the diftemper is much the 
fame, but rather quicker. 

Untill the curvature of the fpinehas been 
difcovered, it generally paffes for a nervous 
complaint ; but when the ftate of the back 
bone has been adverted to, recourfe is almoft 

B 4 always 


( 12 ) 

always had to fome previous violence to 
account for it; fome pulling, lifting, car¬ 
rying, or drawing a heavy body, which is 
fuppofed to have hurt the back. In fome 
few inftances, this exertion may have been 
fuch, as might be allowed to have been 
equal to the effedt, but, in by much the 
majority, this is fo far from being the cafe, 
that if it be admitted to have had any fhare 
at all in it, fome predifpofing caufe, at 
leaft, mull be looked for, in which, (in my 
opinion) confifts the very elfence of the 
difeafe. r 1 'l' 

I have, in compliance with cuftom, called 
the difeafe a pally ; but it Ihould be ob- 
ferved, that notwithftanding the lower 
limbs be rendered almoft, or totally ufelefs, 
yet there are fome effential circumftances 
in which this affedtion differs from a com¬ 
mon nervous palfy : the legs and thighs 

i 

are, I have juft faid, rendered unfit for all 
the purpofes of loco-motion, and do allb 
lofe much of their natural fenfibility, but 
notwithftanding this, they have neither the 
flabby feel, which a truly paralytick limb 

has. 


( i3 ) ' 

has, nor have they that Teeming loofenefs 
at the joints, nor that total incapacity of 
refinance, which allows the latter to be 
twilled in almoft all diredlions : on the 

i ■ - . ‘ * : * * s + 

' \ . .... . ..... j t » ' ^ . * . . 

contrary the joints have frequently a cop- 
fiderable degree of ftiffnefs, particularly 
the ancles, by which ftiffnefs the feet of 
children are generally pointed downward, 
and they are prevented from fetting them 
flat upon the ground. 

The curvature of the fpine, which is fup- 
pofed to be the caufe of this complaint, 
varies in fituation, extent and degree, being 
either in the neck or back, and fometimes 

„ t • e , ^ > . 4 , ‘ * . x. * •. * * #“■ 

(though very feldom) in the upper part of 
the loins ; fometimes comprehending two 
vertebrae only, fometimes three, or more, 
by which the extent of the curve becomes 
neceffarily more or lefs; but whatever may 
be the number of vertebrae concerned, or 
whatever may be the degree or extent of 
the curvature, the lower limbs only feel 
the effedt—at leaft I have* never once feen 
the arms affedted by it. 


This 





N 


( 14 ) 

This effect is alfo different in different 
fubjedts: fome are rendered totally and ab- 
folutely incapable of walking in any manner, 
or with any help, and that very early in the 
courfe of the diftemper; others, can make 
a fhift to move about with the help of 
crutches, or by grafping their own thighs 
with their hands; fome can fit in an eredt 
pofture, or in a chair, without much trouble 
' or fatigue, which others are incapable of, at 

lead: for any length of time; fome have 

‘ 

fuch a degree of motion in their legs and 
thighs, as -to enable them to turn and move 
for their own convenience in bed, others 
have not that benefit, and are obliged to lie 
till moved by another. 

When a naturally weak infant is the fub- 
jecl, and the curvature is in the vertebra of 
the back, it is not infrequently productive 
of additional deformity, by gradually ren¬ 
dering the whole back what is commonly 
called humped; and by alterations which all 
the bones of the thorax fometimes undergo, 
in confequence of the flexure and weaknefs 
of the fpine, by which fuch perfons are 


( *5 ).' 

juftly faid to be fhortened in their ftature; 
but in all cafes where this effe£t has been 
gradually produced, to whatever degree the 
deformity may extend, or however the al¬ 
teration made in the difpofition of the ribs 
and fternum may contribute to fnch de¬ 
formity, yet I think that it will always be 
found, that the curvature of the fpine ap¬ 
peared fir ft, and, if I may fo fay, fingly, 
and that all the reft was confequentiah 

_ . r ' - - ■ 1 * ■ - 


While the curvature of the fpine remains 
pndifcovered or unattended to, the cafe is 
generally fuppofed to be nervous, and me¬ 
dicines fo called are moft frequently pre¬ 
ferred, together with warm liniments, em¬ 
brocations, and blifters, to the parts affedted; 
and when the true caufe is known, recourfe 


is always had to fteel ftays, the fwing, the 
fcrew chair, and other pieces of machinery, 
in order to reftore the fpine to its true and 
natural figure ; but all, as far as I have ob~ 
ferved, to no real or permanent good pur. 
pofe; the patient becomes unhealthy, and 
languifhing for fome time under a variety 
of complaints, dies in an exhaufted, ema¬ 
ciated 


( i6- ) 

dated ftate 5 or, which is ftill worfe/draes 

o 

on a miferable exiftence, confined to a great 
chair, or bed, totally deprived of the power 
of loco-motion, and ufelefs both tohimfelf 
and others. 

This in an infant is moft melancholy to 
fee, in an adult moft miferable to endure. 

• The general health of the patient does 
not feem at firft, to be materially, if at all, 
affedted, but when the difeafe has been 
fome time, and the curvature thereby in- 
creafed, many inconveniences and com¬ 
plaints come on, fuch as difficulty in jre- 
fpiration, indigeftion, pain, and what they 
all call tightnefs at the ftomach, obftinate 
conftipations, purgings, involuntary flux of 
urine and faeces, &c. with the addition of 
what are called nervous complaints; fome 
of which are caufed by the alterations made 
in the form of the cavity of the thorax, 
others feem to arife from impreffions made 
on the abdominal vifcera. Thefe are dif- 
f ferent both in kind, and in degree, in dif¬ 
ferent fubjedts, but feem to depend very 

much 

T i . .. j 

l « 


' ( *7 ) 

much on the confequences of the curvature 
—that is, in naturally infirm children, al¬ 
though the curvature of the dorfal vertebras 
is always the firft mark of the diftemper, by 
preceding every other, yet it is frequently 
foon followed by fuch a degree of deformity 
of the bones of the trunk, as to be, in con¬ 
junction with the necefiary inactivity and 
confinement of the patient, productive of 
all the ills above-mentioned. , 

An affecting inftance of this diftemper in 
the perfon of a very promifing youth of 
fourteen years old, with whofe family I 
was nearly connected, induced me to think 
more of it than perhaps I otherwife fhould 
have done ; and the reftoration of the ufe 
of his limbs, immediately after a feemingly 
accidental abfcefs near the part, engaged my 
attention ftill more, and became a matter of 
frequent, though not very fatisfaClory con¬ 
templation ; I fay unfatisfaClory, becaufe it 
ferved only to increafe my doubts, without 
leading me toward a folution of them. The 
more I thought upon the fubjeCt, the more 
I was inclined to fufpedl that we had been 

A 

milled 


i 


( *8 ) 

milled by appearances, and that a diflem- 
pered ftate of the parts forming, or in the 
neighbourhood of curvature, preceded, or 

accompanied it: in fhort, that there was 
fomething predifpoiing, and that we had 
moft probably miftaken an effed for a 
caufe. 

For thefe fufpicions, I had the following 
realons, which appeared to' me to have 
fome weight: 

1. That I had never feen this paraly- 
tick effed on the legs from a mal-for¬ 
mation of the fpine, however crooked fuch 
mal-formation might have rendered it, or 
whether fuch crookednefs had been from 
time of birth, or had come on at any time 
afterwards during infancy. 

2. That none of thofe ftrange twifts and 
deviations, which the majority of European 
women get in their fhapes, from the very 
abfurd cufcom of dreffing them in flays 
during their infancy, and which put them 
into all directions but the right, ever caufed 
any thing of this kind, however great the 
deformity might be. 


3. That 


( *9 ) 

36 That the curvature of the fpine, 
which is accompanied by this affedtion of 
the limbs, whatever may be its degree, or 
extent, is at firft almoft always the fame, 
that is, it is always from within, outward, 
and feldom or never to either fide. 

4. That fince I had been particularly 
attentive to the diforder, I had remarked, 
that neither the degree nor the extent of 
the curve, made any alteration in the nature 
or degree of the fymptoms at firft, nor for 
fome time after the appearance; or, in other 
words, that the fmalleft curvature, in which 
only two or three of the vertebras were 
concerned, was always, at firft, attended 
by the fame fymptoms as the largeft. 

5. That although it fometimes happened 
that a fmart blow, or a violent ftrain had 
immediately preceded the appearance of the 
curve, and might be fuppofed to have given 
rife to it, yet in many more adults it hap¬ 
pened that no fuch caufe was fairly af- 
fignable, and that they began to ftoop, and 
to faulter in their walking, before they 

thought 


' ( 20 } . 

thought at all of their back, or of any 
violence offered to it. 

6. That exadly the fame fymptoms are 
found in infants, and in young children* 
who have not exerted themfelves, nor have 
been injured by others, as in the adult, 
who has ftrained himfelf, or received a 
blow* and that the cafe was ftill the fame 
in thofe grown people, who have neither 
done, nor fuffered any ad: of violence. 

7. That although it mu ft be allowed* 
that a diflocation of any of the vertebras, 
would moft probably be attended with the 
fame kind of fymptoms from the preffure 
it muft make on the fpinal marrow/ yet 
it is alfo moft probable that fuch fymptoms 
would be immediate, and attended with 
great pain in the part ; neither of which 
is in general the cafe here. 

Thefe confiderations appeared to me to 
have much force ; but what confirmed me 
in my opinion was the ftate of the parts 
forming the curvature, and which I had 
feveral fair opportunities of examining 

after 


( 21 ) 

after death. By thefe examinations I found 

1 • . * V ■* J 

in infants, in young children, and in thofe 
who had been affii&ed with the diforder 
but a fmall lpace of time, that the ligaments 
connecting the vertebrae, which formed the 
curve, wdre in fome degree altered from a 
natural ftate, by being fome what thickened 
and relaxed, and that what are called the 
bodies of thofe bones, were palpably fpread 
and enlarged in their texture, juft as the 
bones forming the articulations are in chil¬ 
dren who are called ricketty. That in thofe 
who had long laboured under the diftemper, 
and in whom the fymptoms were aggra¬ 
vated, whatever might be their age, the 
ligaments were ftill more thickened, re¬ 
laxed, and altered, the bodies of the bones 
fno're fpread, more enlarged, and more in¬ 
clining to becorpe carious, and the carti¬ 
lages between thi bodies of the vertebrae 
much comprefted and lefiened in fize; and 
that in all thofe: who had fo long laboured 
under the difeafe, as to have been deftroyed 
by it, or by its confequences, the corpora 
vertebrarum were compleatly carious, the 
intervening cartilages totally deftroyed, and 

C a quantity 


( 22 ) 

a quantity of fanies lodged between the 
rotten bones, and the membrane inverting 
the fpinal marrow*. 

All thefe circumftances put together, in¬ 
duced me, as I have already faid, to fufpedt, 
that when we attribute the whole of this 
mifchief to the mere accidental curvature of 
the fpine, in confequence of violence, we 
miftake an effedt for a caufe, and that pre¬ 
vious both to the paralytic ftate of the legs* 
and to the alteration of the figure of the 
back bone, there is a pre-difpofing caufe 
of both, confirting in a diftempered ftate of 
the ligaments and bones, where the curve 
foon after makes its appearance. 

While the fubjedt was frefh in my mind, 
I happened to be at Worcefter, and in a 
eonverfation on it with the late Dodtor 
Cameron of that place, I mentioned to him 
my opinion, and my doubts ; the Dodtor 

# In the body of a man who died not long fince, of this 
diforder, in its lait and word; date, the bodies of three of the 
vertebra were not only quite carious, but compleatly fepa- 
rated from all connections with the other parts of the fame 
vertebras. 


concurred 


( 23 ) 

concurred with me, and at the fame time 
mentioned a circumftance, which made a 
ftrong impreffion on me. He faid, that he 
remembered fome years ago, to have noted 
a paffage in Hippocrates, in which he fpeaks 
of a paralyfis of the lower limbs being cured 
by an abfcefs in the back or loins, and that 
taking the hint from this, he, Dr. Ca- 
meron, had, in a cafe of a palfy of the 
legs and thighs, attended by a curvature of 
the back bone, endeavoured to imitate this 
a£t of nature, by exciting a difcharge near 
the part, and that it had proved very advan¬ 
tageous. He alfo referred me to Mr. Jeffrys, 
a furgeon of eminence at Worcefter, for a 
farther account of the fame kind of attempt; 
this gentleman confirmed what Dr. Cameron 
had told me, and allured me that he had 
found the method equally fuccefsful. 

It may eaiily be fuppofed, that thefe ac¬ 
counts from gentlemen of veracity, and of 
reputation in their profeffion, ftill added to 
my defire of knowing more on this fubjecft, 
and determined me to lofe no opportunity 
of getting information. 

C a 


The 


( 24 ) 

' The fir ft that offered was in an infant, 
whofe curvature was in the middle of the 
neck, and who had loft the ufe of its legs 
for about two or three months. I made an 
iffue by incifion on one fide of the pro¬ 
jection, and gave ftriCt charge to the mother 
to take care that the pea was kept in; the 
woman, who had no faith in the remedy, 
did not take the proper care, and confe- 
quently the difcharge was not equal to what 
it fhould, and might have been j but not- 
withftanding this negledt, at the end of 
about three weeks or a month the child was 
manifeftly better, and began to make ufe of 
its legs 5 it was then feized with the fmall-pox 
and died. The bodies of the vertebrae con¬ 
cerned in the curve, were larger than they 
fhould be, and than thofe above and below 
were, and their texture much more open 
and fpongy, which difference appeared im¬ 
mediately, before the parts covering them 
were diffeCted off. 

« 

Some time paffed before I had another 
opportunity. My next patient was a tall 
thin man, about thirty-five years old, who 
thought that he had hurt himfelf by lifting 

r a heavy 


C 25 ) 

a heavy weight: his legs and thighs were 
cold, and what he called nummy, but not 
abfolutely ufelefs : he could with difficulty 
go about the room with the help of a pair 
of crutches, but he could neither rife from 
his chair, nor get on his crutches without 
the affiftance of another perfon, nor could 
he without them walk, at all. 

I made a fetomon each fide of the curve, 
which was in his back, about the middle, 

and having given his wife directions how to 

» > 

drefs them, I called on him once in three 
or four days. At the end of fix weeks he 
had recovered the due degree of fenfation in 
his limbs, and found much lefs necefiity 

0 • 

for the ufe of his crutches ; he could rife 
from his bed, and from his chair without 
alfiftance, and by means of one crutch, and 
an underhand ftick, could walk for an 
hour, or more, without refting, and with¬ 
out fatigue. The fetons had now, from 
not having been properly managed, worp 
their way out, and I would have converted 
each of them into an ififue, but as neither 
the patient nor his wife had ever believed 
that the difcharge had had any fhare in his 

C 3 amendment. 


( 26 ) 

amendment, but on the contrary that he 
would have been better without it, he 
would not fubmit to what I propofed, and 
I left him. At the diftance of about three 
weeks from the time of my leaving him, I 
met him in the ftreet walking very ftoutly, 
with a common cane, of which he made 

little or no ufe. I afked him what he had 

* 

done : he told me that the fores had con* 
tinued to difcharge till within a few days, 
but that he had drank a great deal of com* 
frey-root tea, with ifinglafs, apd he fup- 
pofed that had cured him. 

I believe that the cure of this man will, 
by all who know any thing of medicine, 
be thought to be fo unlikely to have been 
affe&ed by the comfrey and ifinglafs* that 
jny inference in favour of the feton will 
not be thought unreafonable, and that my 
determination to profecute the method, 
from what I had heard and feen, was well 
founded. 

V ; 

Within the courfe of the Jaft ten or 
twelve months, I have had feveral fair op- 
tunities of doing this, both in St. Bar¬ 
tholomew’s 


( 27 - ) 

tholomew’s hofpital, and out pf it, and am 
very happy to be able to fay, that it has 
not only always anfwered, but in fome in- 
ftances greatly exceeded my moft fanguine 
expectations, by reftoring feveral moft mi- 
ferable and totally helplefs people to the ufe 
of their limbs, and to a capacity of en¬ 
joying life themfelves, as well as of being 
ufeful to others, 

» p i 

I have now in the hofpital a boy about 
twelve years old, whofe cafe was fo truly 
deplorable, that 1 made the experiment 
merely to avoid the appearance of inhu¬ 
manity, by difcharging him as incurable, 
without trying fomething. The curvature 
was in his back, and confifted of three or 
four vertebras, but by means of the weak- 
nefs thereby induced, the whole fet of 
dorfal ones had fo univerfally and gradually 
given way, that he was exceedingly de¬ 
formed both behind and before : he was fa 
abfolutely incapable of motion, that he could 
neither turn himfelf, nor fit up in his bed: 
his feet were pointed downwards, and his an¬ 
cles fo ftiff, that when he was held up under 
the arms, the extremities of his great toes 

C 4 touched 


( 2 8 ) 

#•«'«< J» p 

touched the floor, nor could his feet bq 

. ■ ■ ‘ ; • ' • * 

brought flat to the ground by any means, 
or force whatever. In fhort, he was as 
perfedtly and as totally helplefs as can be 
fuppofed, and at the fame time in an ex¬ 
ceeding general bad ftate of health, from 
diforders of the thoracic and abdominal 
vifcera. In this ftate he had been more 
than a year : it is now about three months 
fince the cauftics were applied ; he is 
become healthy, and free from moft of his 
general complaints, has the molt perfedt 
ufe of his legs while he is in bed, can walk 
without the afliftance of any body, or any 
thing to hold by ; and from his manner of 
executing this, will, I make no doubt, in 
a very fhort fpace, recover perfectly the ufe 
of his legs—To this I ought to add/ that 
notwithftanding a confrderable degree of de¬ 
formity does, and I fuppofe will, remain, 
yet the lpine in general is fo much 
llrengthened, that he is fome inches taller 
ihan he was four months ago. 

' O 

The remedy for this molt dreadful difeafe 
confifts merely in procuring a large dis¬ 
charge of matter, bv fuppuration from un¬ 
derneath 


( 2 9 ) 

► . , 

derneath the membrana adipofa on each fide 
of the curvature, and in maintaining fuch 
difcharge until the patient fhal 1 have perfectly 
recovered the ufe of his legs. To accomplifh 
this purpofe, I nave made ufe of different 

means, fuch as fetons, iflues made by in- 

1 ' * 

cifion, and iffues made by cauftic ; and al¬ 
though there be no very material difference, 
I do upon the whole prefer the laft. A 
feton is a painful and a nafty thing, befide 
which it frequently wears through the fkin 
before the end for which it was made can 

. < t • 

be accomplifhed : iflues made by incifion, 
if they be large enough for the intended 
purpofe, are apt to become inflamed, and 
to be very troublefome before they come 
to fuppuration; but openings made by 
cauftic are not in general liable to any of 
thefe inconveniences, at leaft, not fo fre¬ 
quently, nor in the fame degree : they are 
neither fo troublefome to make or to main- 

• - j. ? 

tain. I make the efchars about 

this fize and / V fhape on each 
fide the curve, / \ taking care to 

le’ave a fufhcient 1 J portion of fkin 

between them A / in a few days, 

when 

4 





( 3 ° ) 

when the efchar begins to loofen and fepa- 
rate, I cut out all the middle, and put into 
each a large kidney-bean: when the bottoms 
of the fores are become clean by jfuppuration, 
I fprinkle every third or fourth day, a fmall 
quantity of finely powdered cantharides on 
them, by which the fores are prevented 
from, eon trading, the difcharge increafed, 
and poffibly other benefit obtained. The 
iflues I keep open until the cure is com- 
pleat, that is, until the patient recovers 
perfectly the ufe of his legs, or even for 
fome time longer, and I fhould think that 
it would be more prudent to heal only one 
of them firft, keeping the other open for 
fome time, that is, not only until the pa¬ 
tient can walk, but until he can walk 

• V # • * e 

firmly, brifkly, and without the affiftance 
of a flick ; until he can ftand quite upright, 
and has recovered all the height, which the 
habit, or rather theneceffity of flopping occa- 
fioned by the diftenaper, had made him lofe. 

I have faid that the difcharge by means 
of the iflue, is all that is requifite for a 
cure, which is true, as I have experimentally 
proved by not ufing any other, in cafes 

which 


{ 3 1 ) 

which have fucceeded perfedtly ; but this 
fadt being eftablifhed, there is no reafon 
why every affiftant means fhould not be 
applied at the fame time, in order to 
expedite : fuch as bark, cold - bathing, 
fridtions, &c. 

That the patient becomes more upright 
as his legs become flronger, is certain, and 
therefore appears taller, as well as flraighter 
in proportion, as the whole fpineftrengthens; 
but whether the curvature will always and 
totally djfappear, I am not yet able to fay 
with certainty. In two late inftances, both 
adults, it has, but the deformity, which in 
weak infants and children, is often the con- 
fequence of the curvature, and of the ftate 
of the fpine at that place, mull in fome 
degree, I fear, be expedted to remain; but of 
this I am not yet able to fpeak with abfolute 
certainty. There are a few'other circum- 
ftances, of no great moment perhaps, but 
which will require more time to afeertain 
than I thought fhould be fufFered to pafs, 
before mankind were made acquainted with 
the great means of relief, in fo diftreffing, 

' " ‘ ^ f Q 


( 3 ? ) 

fo melancholy, and fo dreadful a malady : 
for the reader will be pleafed to remember 
what I told him at the beginning of this 
trad:, which was, that my motive for pnb- 
lifhing this account fooner than might ap¬ 
pear in general to be right, or indeed than 
I otherwife fhould have done, was a defire 
that as little time as poflible might be loft, 
in conveying to the profeflion in particular, 
and to mankind in general, the means of 
relief under an aftlidion, which, till thefe 
were known, has not admitted of any : and 
this I was ftill more incited to do, becaufe 
the remedy is as harmlefs, and as void of 
hazard, as it is eflicaceous, 

«►' * , i - . • i ■ • 



IN the preceding trad I have related the 
appearances which the parts conftituting the 
feat of the diftemper make upon examination 
after death; or to fpeak more properly, the 
different ftates of thefe parts in different 
perfons, and at different periods of this 

difeafe* 



( 33 ) 

difeafe. Thefe, though neceflarily fubjeCt 
to confiderable variety, may, I think, be 
reduced to three general ones. 

v 

1. A fmall degree of an increafe of fize 
in the bodies of the vertebrae, forming the 
curve, with an apparent laxity in their 
texture, and a relaxed ftate of the con¬ 
necting ligaments, by which they feem to 
have loft part of their power of holding 
the bones together. 

2. A more confiderable, and more ap¬ 
parent enlargement of the fame parts of the 
vertebrae, whofe fpongy texture becomes 
more vifibly fpread through their whole 
fubftance, and tending towards a caries, 
with an apparently diftempered ftate, both 
of the ligaments, and of the intervening 
cartilages. 

3. A truly carious ftate of the bodies of 
the bones, a diffolutionj or deftrudtion of 
the cartilaginous fubftance between them, 
and a lodgement of fanies on the furface 
of the membrane envelloping the fpinal 
marrow. 


Thefe 


( 3 + ) 

Thele are I think the moft particularly 
different flates or ftages of the diforder, and 
are fuch as, in my opinion, decilively mark 
the true nature of it. 

Between thefe in different perfons, and 
tinder different circumftances, there muft 

be a confiderable variety, but the material 
difference will be only in degree. 

From the whole, the few following 
practical inferences feem fairly deducible. 

1. That the difeafe does not originally 
eonfift in a difplacement of the vertebrae, 
made by violence, the bones and ligaments 
being previoufly in a found and uninjured 
flate ; but in fuch a morbid alteration of 
the texture of both, as will, if not timely 
prevented, produce curvature and caries, 
with all their confequences. 

2. That the proper remedies for this 
difeafe cannot be applied too foon, 

3. That the refloration of the fpine to 
its natural figure, depends much on the 
early adminiftration of the help propofed. 

4.^ That 


( 35 ) 

4* That although the diftemper may be 
fo far cured, that the patient may perfedtly 
recover the ufe of his legs, yet fuch an 
alteration may have taken place in the 
bodies of the vertebra?, as to render it im- 
poflible for the fpine to become ftraight 
again, 

5. That when three or four, or more 
vertebra?, are concerned in the curve, the 
trunk of the body will have fo little 
fupport from that part of the fpine which 
is not diftempered, that no degree of de¬ 
formity can be wondered at ; nor can it 
be expedted that fuch deformity fhould be 
removed, whatever other benefit fuch pa¬ 
tient may receive. 

6. That if from inattention, from length 
of time, or from any other circumftances, 
it happens that the bodies of the vertebra? 
become compleatly carious, and the inter¬ 
vening cartilages are deftroyed, no affiftance 
is to be expedted from the propofed re¬ 
medy. 

To thefe I will take the liberty of 
adding, that it appears to me well worth 

while. 


( 36 ) 

v * . .* 

while, to try what a large and free dif- 
charge, made for a length of time from the 
vicinitv of the diftempered part, might be 
capable of doing in the very beginning 
of what are commonly called fcrophulous 
joints i which when arrived to a certain 
point, baffle all our art, and render a pain¬ 
ful and hazardous operation abfolutely 
neceflary. 

£ • t jf 

Within thefe laft iix or eight months, 
feveral cafes of curved fpine have been 
received into St. Bartholomew’s hofpital^ 
where they have been feen by great numbers 
of the profeffion. The novelty of the treat¬ 
ment, and the fuccefs which has hitherto 
conflantly attended it, has neceffarily en¬ 
gaged the attention of many, and occafioned 
fornc converfations on the fubjeCt. In fome 
of thefe it has been faid, that as it appears 
to be undeniably a difeafe of the bony 
texture of the bodies of the vertebra, it 
may be apprehended, that the relief ex¬ 
pected from the cauftics, 'may, in fome 
cafes, fail, and in others may not prove 
permanent ; and, that the fame kind of 

eonflitution 


% • ( 37 3 

^onftitution remaining, a return of the 
malady may not unreafonably be feared* 

To this I can only anfwer, that although 
I have called this an early publication, yet 
I have waited a fufficient length of time, 
and have treated a fufficient number of fub- 
jeCts, to be clear in the truth of what I 
have afferted as far as fuch time, and fuch 
individuals go. That the patients whom 
I have attended in the early part of the 
diftemper of whatever age, have all got 
well: that is have all not only regained the 
ufe of their legs, but have become healthy, 
and fit for any exercife or labour, as num¬ 
bers can teftify, who have feen them daily. 
Moft of them have become much ftraiter, 
fome quite ftrait, and all of them per¬ 
fectly free from all kind of inconvenience 
arifing from the Curve, 

- * *. * i. 

That in all the infants whom I have 
feen, the general health of the patient has 
always been reftored in proportion to the 
reftoration of the ufe of the limbs. 


D 


That 


*f 38 ) 

That I mu ft fuppofe all this to have 
been done . by the difcharge from the 
cauftics, becaufe in many of them no 
other means of any kind have been made 
«fe of. 

That as far as my experience goes I have 
not the leaft doubt, that if the means pro- 
pofed, be made ufe of before the bones are 
become really carious and rotten, that they 
will always be fuccefsful. When indeed a 
truly rotten ftate of the bones takes place 
no good is to be expeCted from this or from 
any thing elfe: but it fhould be obferved 
at the fame time, that this never happens 
but when the diftemper is of very old date, 
and that when this is the cafe, the whole 
machine is fo difordered, and the patient 
fo truly and fo generally diftempered, that 
there can be no reafonable expectation of 
fuccefs from any thing. 

To this I mult take the liberty of ad- 

* 

ding, that what I have affirmed, is what 
I have feen and proved, and that the ob¬ 
jection 


£ „ 


( 39 ) 

jedti©ns are merely fpeculative and theore¬ 
tical. However, fuppofing them to be not 
quite unreafonable, the moil ufeful infe¬ 
rence to be drawn from them is, that the 
fame remedy by which fo great and fo 
evident relief is obtained ought to be con¬ 
tinued, while there may be any fear of 
return of the mifchief, and that every other 
means for the reftoration of health and 
ftrength ihould at the fame time be made 
life of; both which coincide abfolutely with 

my own opinion and advice. 

« 


f 


REMARKS 






\ 



REMARKS 

ON THE 

Necessity, and Propriety of the Operation 

" OF 

AMPUTATION, 

■ i v % 

In certain Cases, and under certain Circumstances, 







C 





* Y 


TVT O man however flightly acquainted 
JL with the hiftory of Surgery, can have 
the fmalleft doubt of the fuperiority which 
its prefent ftate juftly claims over that 
of our predeceflors, efpecially over that of 
our more remote ones. 

The furgery of the laft century, and 
even of fome part of this, was coarfe and 
cruel in its operative part, painful and te¬ 
dious in what is generally called the cura-* 
tive. A multiplicity of heavy unmanage-* 
able inftruments chara&erifed the former, 
and a variety of irritating applications the 
latter. By means of the one, many ope¬ 
rations were rendered much more terrible 
to bear, as well as more hazardous in the 
event than they ought to have been; while 
long fufferance, and tedious confinement, 
became the necefiary confequences of the 
ufe of the other. 

D 4 

/ 


T© 





( 44 ) 

To Amplify the art has been the aim 
of all the heft practitioners of later times, 
and to this they owe both their fuccefs, 
and their reputation; by this they have re¬ 
duced our inftruments to a fmall number, 
and have rendered thofe which are now 
ufed much more manageable; upon the 

fame plan, they have difcharged a farrago 

> / 

of external applications, the majority of 
which were either ufelefs, or mifchievous i 
a profecution of the fatpe method will, I 
make no doubt, produce greater improve¬ 
ments, but ftill operations will for ever re¬ 
main unavoidable in particular circum- 

ftances, and fome difeafes will ftill fome- 

« , * 

times require applications which muft pro¬ 
duce uneafinefs : to render thefe as feldom 
neceffary, and as little painful as poflible, 
fhould be the buftnefs of every pra&itioner, 
and this is all that art can do, or that 
fhould be expeded from it. The boaft of 
univerfal fpecifics, of remedies infallibly pre¬ 
ventative of difeafes, and of means whereby 
ehirurgical operations may be rendered to¬ 
tally 


f 


/ 


r 


( 45 ) 

tally unnecefiary, is the language of quack¬ 
ery, and not of fcience. 

The amputation of a limb is an opera¬ 
tion terrible to bear, horrid to fee, and 
muft leave the perfon on whom it has been, 
performed in a mutilated imperfect ftate . 

but ftill it is one of thofe which becomes, 

\ 

in certain circumftances, abfolutely and im* 
penfably neceflary, 

j v . ' \ - ' x , 

To thofe who are w’ell acquainted with 
furgery, it muft appear needlefs to have 
faid this; they w*ell know the truth of it i 
but as they w 7 ho have not had fufficient op¬ 
portunity of obtaining practical information, 
may be milled by a contrary dodtrine when 
boldly advanced; and as they who are 
really well informed may, under certain cir¬ 
cumftances, be deterred from adting up to 
their knowledge, I have thought that I 
ftiould not abfolutely mifpend my time, 
nor do mankind a dilfervice, if I took this 
opportunity of giving the fubjedt a little 
confideration. 


I 


( 46 ), 

1 am the more inclined to do this for 
three reafons: 

\ ■ ■ - 4 ■ V : ■ • - * 

I ft. Becaufe I am fatisfied that the pro¬ 
priety of amputations in certain cafes, ftands 
i upon as fixed and as rational principles 
any part of furgery. 

2d. Becaufe a contrary doCtrine has 
within a few years been boldly, and induf- 
trioufly propagated, not without fome very 
indecent, as well as untrue reflections, on 
the profeflion in general, and on thofe who 
Jiave the care of hofpitals in particular: and 

jdly. Becaufe I am convinced that 
fuch dodtrine has been employed to the 
prejudice of mankind, by covering Igno¬ 
rance, and Timidity, and alfo for ferving 
the bafe purpofe of malevolence. 

<s Ne occidifle nifi fervaflet,” is under 
certain limitations a very juft and prudent 
maxim, but taken at large may be pro¬ 
ductive of much mifchief. Mankind are 
rather too apt to form their opinion from 
events only; fuccefs with many confti- 
tutes propriety, and the failure of it is 

often 

• . *. • . 1 


often very unjuftly fet to the account of 
mifconduCt, or of want of knowledge. A 
young practitioner at a diftance from affift- 
ance, and thereby deprived of that fupport, 
may be afraid to put his character to 
hazard, by aCting in fuch manner as al¬ 
though it might juftly entitle him to fuc- 
cefs, yet cannot command it. He may 
underftand his art, but art is not infallible. 
He may be a very excellent furgeon, and 
yet be afraid to encounter the prejudices of 
fome, or the malevolence of others. 

A few years ago a book was publifhed 
profefledly to oppofe, and condemn the 
practice of amputation in all cafes what¬ 
ever, and almoft without exception. The 
book was written by a Mr. Bilguer, a fur¬ 
geon in the Pruffian fervice; Mr. Tiflot 
wrote fome Annotations on it, and a Pre¬ 
face, announcing its great and wonderful 
merit and utility ; and the whole was tranf- 
lated into Englifh, and dedicated to Sir 
John Pringle. Both the Book and the 
Annotations, contain fome very extraor¬ 
dinary 


( 4 ? ) 

dinary dodtrines and afiertions, neither of 
which it is my intention to criticife in this 
place. They who read the work, and un- 
derftand the fubjedt, will I verily believe 
have but one opinion. The writer as well 
as the annotator may have meant well, but 
certain I am if their opinions were gene¬ 
rally followed, mankind would be great 
fufferers. The particular cafes in which 
the operation of amputation is totally and 
abfolutely urmeceflary, and therefore wrong, 
are, in his own words, or at lead: in thofc 
of his tranflator, as follows: 

* e i ft. A mortification which fpreads 
<< until it reaches the bone, 

iC 2dly. Any limb fo greatly hurt, 
<c whether by fradture or dilaceration, that 
there is room to dread the moll fatal 
< c confequences. 

€( 3<ily. A violent contufion of the foft 
« parts, which has at the fame time fhat- 
tered the bones. 


4 thly q 


( 49 ) 

“ 4thly. Wounds of the larger veffels, 

“ which convey blood into the limb, either 
“ as the only way of flopping the H^morr- 
“ hage, or through apprehenfion it fliould 
“ perifh for want of nourifhment. 

“ 5thly. An incurable caries of the 
“ bone.’' 

. * 

In the firft of thefe the art of furgery 

i 

has very little to do, except the mere 
fawing the bones through; nature, if the 
patient lives, will in general do all the reft, 
and will remove the limb whether the fur- 
geon may choofe it or not. In the 2d, 3d, 
and 4th, what the writer has afferted is fo 
repugnant to the univerfal fenfe of all the 
ableft and beft practitioners, to common 
fenfe, and to conftant experience, and his 
dodtrine would, if followed, be productive 
of fo much mifchief to mankind, that I 
cannot help bearing my teftimony againft 
it. But as fiat contradictions have no more 
authority than pofitive affertions, I take 
this opportunity of giving my reafons, for 
a different opinion, at large. 


The 





V • 


/ 

( 5 ° > ' 

,, i j ( . ► /' * I * 1 

The cafes, in which, under certain cir- 
cumjiances , amputation may become necef- 
fary for the prefervation of the patient's 
life, are feveral, but I will confine myfelf 
to four, 

r 

} ' : \ ’» • 4 

Thefe are : Find—A compound fradture. 

2. Some kind of fcrophulous joints, 

3. Some kind of aneurifms. 

4. A caries of the whole fubftance of the , 
bone or bones compofing a limb. 

In all, and each of which, it may, and 
does fometimes fo happen that the patient's 
life can be only preferved by the lofs of his 
limb. This doftrine is very oppofite to 
that of the book juft cited, but if it be con- 
fonant to truth and experience, it matters 
not from whom it may differ. 

In compound fraftures, there are three 
points of time, in which the operation of 
amputation may become neceffary. The 
firft of thefe is immediately, or as foon as 

may 


( 5 1 ) 

may be after the receipt of the injury. The 
fecond is, when the bones continue for a 
great length of time without any difpofition 
to unite, and the difcharge from the wound 
has been fo long, and is fo large, that the 
patient’s ftrength fails, and general fymp- 
toms foreboding diffolution come on ; and 
the third is, when a mortification fhall have 
taken fuch compleat pofleflion of the foft 
parts of the inferior part of the limb, quite 
down to the bone, that upon feparation of 
fuch parts, the bone or bones fhall be left 
bare in the inter-fpace. 

The firfi: and fecond of thefe are matters 
of very ferious confiderations. The third 
hardly requires any. 

When a compound fradlure is caufed by 
the pafiage of a very heavy body over a 
limb, fuch, for inftance, as the broad wheel 
of a waggon, or a loaded cart, or by the 
fall of a very ponderous body on it, or by 
a cannon-fhot, or by any other means fo 
violent as to break the bones into many 

frag- ^ 


I 


( 5 2 5 

fragments, and fo to tear, bruife and wound 
the foft parts, that there fhall be good 
reafon to fear that there will not be vefiels 
fufficient to carry on the circulation with 
the parts below the fradture, it becomes a 
matter of the moft ferious confideration, 
whether an attempt to fave fuch perfon’s 
limb, will not be the occafion of the lofs 
of his life : this confideration muft be before 
any degree of inflammation has feized the 

part, and therefore muft be immediately 
after the accident. 

'y jV \ •’ ' Js r y '' i ■ ' * - * * 

, %> ■ •. . .. * - - y , - - r 

When inflammation, irritation and tenfion 
have taken place, and when the air admitted 
freely into the tela cellulofa has begun to 
exert its pernicious influence, it is too late 
an operation then, inftead of being bene¬ 
ficial, would prove deftrudtive. 

The neceffity of immediate, or very early 
decifion in this cafe, arifing from the cir- 
cumftances already mentioned, make this a 
very delicate part of practice : for however 
prefling the cafe may feem to the furgeon 

to 



( 53 ). 

to be, it will not in general appear in the 
fame light to the patient, to the relations, 
or to bye-ftanders; they will be inclined to 
regard the proportion as arifing from ig¬ 
norance how to treat the cafe properly, or 
from an inclination to fave trouble, or per¬ 
haps from a flill worfe motive, a defire to 
operate ; and it will often require more 
firmnefs on the part of the practitioner, and 
more refignation and confidence on the 
part of the patient, than is generally met 
with, to fuhmit to fuch a fevere operation, 
in fuch a feeming hurry, and upon fo little 
apparent deliberation ; and yet it often hap¬ 
pens, that the fuffering this point of time 
to pafs, decides the patient’s fate. I mufl 
repeat, that this necefilty of early decilion, 
arifes from the very juft dread of the ill 
effeCts of a greatly obftruCted circulation^ 
owing to a large deftruCtion of veffels ; 
thefe added to thofe arifing from pain, ir¬ 
ritation, and the admifiion of air, often 
produce a high fever, and intenfe inflam¬ 
mation, ending, and that very fhortly, in 

* . 

E gangrene. 


f 


( 54 ) 


gangrene, mortification and death. That 
this is no exaggeration, melancholy and 
frequent experience evinces, even in thofe 
vvhofe conftitutions previous to the accident 
were in good order ; but much more in 
thofe, who had been heated by violent 
exercife, or labour, or liquor, who have 
led very debauched and intemperate lives, 
or who have habits naturally inflammable, 
and irritable. 


This may be, and often is the cafe, when 
the fradture happens to the middle part of 
the bones, at the greatefl: poflible diftance 
from the extremities, but is much more 
likely to happen, and indeed much more 
frequently is the cafe, when any of the 
large joints are concerned ; the circum- 
fiances of broken bones in thefe parts, and 
of torn, bruifed, and wounded ligaments, 
to fay nothing of the admiffion of air into 
joints, are dreadful additions to the hazard, 
and demand a fpeedy decifion, as they are 

productive 


\ 


( 55 ) 

productive of the word: confequences in the 
fhorteft fpace of time ; and, therefore, that 
in many of thefe cafes, a determination for 
* or againft amputation, is really a deter¬ 
mination for or againft the patient's ex- 
iftence, is a truth of which I am as well 
fatisfied, as I am, or can be, of any truth 
whatever* 

That it would have been impoffible to 
have faved fome limbs which have been cut 
off, no man will pretend to fay, no man 
that knows any thing of the matter can 
fay it: but this does not at all alter the 
confideration, or render the practice inju¬ 
dicious or blameable, the queftion really 
{landing thus : Do not the majority of thofe 
whofe misfortune it is to get into the juft 
mentioned hazardous circumftances, and on 
whom the operation of amputation is not 
performed, perifh, and that by means of 
their wounds ? or, to put the fame queftion 
into other words, have not many lives been 
preferved by means of amputation, which 

E z from 

. , - I . 

v 


( 56 ) 

from the fame circ urn fiances would other- 
wife moil probably have been loft ?—It is 
not for me, efpecially after what I have 
faid, to determine it : it is not indeed for 
any one man to do it; I therefore appeal to 
all the beft practitioners, to thofe who have 
feen the moft of thefe accidents, for the 
truth of the affertion. 

When a judicious man fays that ?. limb 
ought to be removed, it is not to be fup- 
pofed that he means to fay, that it is 
abfolutely impoflible, at all events, that 

fuch limb can be faved, nor, that fuch 

« 

patient moft infallibly die, if the operation 
be not performed j no, he only means, that 
from repeated experience of himfelf, and 
others, in all times, it has been found, that 
the circumftances above-mentioned, put the 
patient’s life much more to hazard in an 
attempt to fave the limb, than the operation 
does in removing it; and therefore that hu¬ 
manity as well as judgement determine for 
the latter. On the other hand it muft be 
allowed, that from fome of the worft of 
thefe cafes, fome have had the good fortune 

to 


( 57 ) 

to efcape; but efcapes they fo truly are, 
that I make no fcruple to affirm, that in 
certain cafes and circumftances a deter¬ 
mination not to amputate, is a determination 
much more unfavourable and hazardous to 
the patient, than that for amputation can 
be. 

4 « 

It is, I think, impoffible for any perfon 
who has either fenfe or candour, fo to mif- 
conftrue what I have faid, as to imagine 
that I would recommend the amputation of 
the majority of limbs which have fuffered 
a compound frafture ; fuch condudt would 
- be as injudicious as it would be cruel:— 
My meaning is, that the operations ffiould 
be limited and confined to certain cafes and 
circumftances, already mentioned, and that 
under them it is not only proper, but ne- 
cefiary. 

Preffing and urgent as the ft ate of a com¬ 
pound fra&ure may be at this firft point of 
time, ftill it will be a matter of choice 
whether the limb, fhall be removed or not, 

/ E 3 very 


( 58 ) 

very ferious deliberation may be required, 
added to all the judgement and experience 
of the moft able praditioner, to determine 
what may be moft for the patient’s fafety: 
but at the fecond period which I have men¬ 
tioned, the operation ceafes to be a matter 
of choice, it muft be fubmitted to, or the 
patient muft die. 

»i • * xJ S'' ^ v* r 

The moft unpromifing appearances at hr ft 
do not neceflarily or conftantly end unfor¬ 
tunately. Every body converfant with bufi- 
nefs of this kind, knows, that fometimes, 
after the moft threatening firft Symptoms, 
after confiderable length of time, great dis¬ 
charges of matter, and large exfoliation of 
bone, it happens, that notwithftanding all 
thefe difficulties and difcouragements, fuc- 
cefs fliall ultimately be obtained, and the 
patient (hall recover his health and the ufe 
of his limb. 

But it is alfo as well known, that after 
the moft judicious treatment through every 
ftage of the difeafe ; after the united efforts 

: of 


( 59 ) 

of phyfick and furgery, it fometimes happens 
that the fore inftead of granulating kindly, 
and contracting daily to a fmaller fize, fhall 
remain as large as at firft, with a tawny, 
fpongy furface, difcharging a large quantity 
.of thin fanies, inftead of a ftnall one of good 
matter : that the fractured ends of the bones, 
inftead of tending to exfoliate, or to unite, 
will remain as perfectly loofe and difunited 
as at firft,' while the patient fhall lofe his 
fleep, his appetite, and his ftrength, a fymp- 
tomatic fever of the heftical kind, with a 
quick, fmall, hard pulfe, profufe fweats, 
and colliquative purgings, contributing at 
the fame time to bring him to the brink of 
the grave, notwithftanding every kind of 
affiftance. In thefe circumftances, which 
are by no means uncommon, if amputation 
be not performed, I fhould be glad to be 
informed, what elfe can refcue the patient 
from deftrudtion ? 

Let it not, by way of anfwcr, be laid, that 
a more generous plan of diet fhould be pre¬ 
ferred : that bark, cordials, anodynes, 

E 4 aftringents, 


( 6 ° ) 

aflnngents, &c. fhould be. taken, becaufe 
I fliould be very forry to have it fuppofed 
that I was either fo unknowing or fo brutal 
as to think of amputation, before every 
thing of this kind had been fairly and fully 
tried, and found ineffectual. I eonfefs that 

4. - - 

I know of nothing but the operation which 
can be attempted, and when, inftead of this, 
I hear people talk of fpecific balfams, par¬ 
ticular fomentations, &c. I can only be 
forry to find that they are fo weak, or fo 
wicked. 

* - "N T * 7 ’ ? „ 

I might in this place mention a cafe 
which I have twice feen, which is, that in 
a compound fradlure, which has got well 
through the firft or inflammatory ftate, the 
bones-, inftead on the one hand of exfo¬ 
liating, or uniting, or on the other, of re¬ 
maining intirely difunited, fhall (in parti¬ 
cular conftitutions) become thoroughly di~ 
ftempered and enlarged through their whole 
fubftance, forming fuch a kind of caries, 
as nothing but amputation can cure. 

The 




( 6i ) 

The third and lafl: period which I men¬ 
tioned regarding compound fractures, and 
requiring amputation, is indeed a matter 
which does not require much confideratiom 

Every practitioner knows that fometimes, 

too often indeed, it happens that the in- 

* •» 

flammation confequent upon the injury, in- 
flead of producing abfcefs and fuppuration, 
tends to gangrene and mortification ; the 
progrefs of which is often fo rapid, as to de- 
ftroy the patient in a very fhort fpace of time, 
conftituting that very fort of cafe in which 
amputation fhould have been immediately 
performed. But it alfo fometimes happens, 
that even this dreadful and very threatening 
malady, is, by the help of art, put a flop 
to, but not until it has totally deflroyed all 
the furrounding j mufcles, tendons, and 
membranes, quite down to the bone, which 
upon the feparation of the mortified parts, 
is left quite bare, and all circulation between 
the parts above and thofe below, is, by 
this, totally cut off*. If it fhould be faid, 
that merely fawing the bare bones cannot 




( 62 ) 

be called amputating, I will not difpute 
about the propriety of the phrafe, but only 
beg leave to obferve, that call the operation 
by what name you pleafe, the patient lofes 
his limb. 

The cafe is exaftly the fame, when a 
mortification, from whatever caufe, has 
feized the lower part of a limb, and pro¬ 
duced the fame effedt—That is, in the very 
cafe which Mr. Bilguer has mentioned, of 
mortification feizing all the parts down to 
the bone, let the caufe be what it may, if 
the effefl: be the deftruftion of all the foft 
parts down to the bone or bones, either the 
furgeon muff faw them, or they mu ft be 
left to feparate; in either cafe the patient 
lofes his limb. 

Scrophulous joints, with enlarged ca-* 
rious bones, and diftempered ligaments, 
make a fecond kind of cafe, in which I have 
faid that amputation may become abfolutely 

neceffary. 

There is one circumftance attending this 
kind of complaint, which often renders it 

particularly 


>4 


( 63 ) 

particularly unpleafant, which is, that the 
fubjefts are moft frequently young children* 
pr at leaft are at fo early an age as to be 
incapable of determining for themfelves, 
which inflidls a very diftreffing talk on their 
neareft relations* 


The common people call thefe, white 
fwellings, a term not very unapt, becaufe 
it conveys an idea of one mark of the 
diftemper, which is, that notwithstanding 
the inereafe of fize in the joint, the Ikin is 
not inflamed but retains its natural colour. 

An hiflory of this kind of difeafe is a 
thing very much wanted, and I much with 
that fome man who has leifure and capacity, 
and who has feen bufinefs, would undertake 
it. If I was poiTefled of the requifite know¬ 
ledge, it would carry me too far from my 
prefent purpofe, which is only to prove that 
when it affects the joints in a certain man¬ 
ner, and to a certain degree, that then the 
mifchief which it caufes, is fuch, that 
nothing but the removal of the joint can 
remedy. 

y - • »• 

t * 


Whoever 


( H ) 

Whoever has had opportunity of feeing 
much of this difeafe, mufc know, that all 
the efforts of phyfick and furgery, by inter¬ 
nal as well as external means, do often prove 
ahfolutely ineffectual not only to cure, but 
even to retard the progrefs of this moft 
terrible malady. 

I fhould be forry to be mifunderftood : I 
do not mean to fay that this is always, or 
even moft commonly the cafe, nor that fero- 
phulous joints are not fometimes relieved, 
and even cured by means of art; I fincerely 
wifti that they were more frequently, and 
that we were poffeffed of more effectual re¬ 
medies for this purpofe than we are, or at 
leaft than I am acquainted with ; but to 
the great misfortune of fcrophulous people, 
every man converfant with buftnefs, knows, 
that the difeafe often begins in the very 
inmoft receffes of the cellular texture of the 
heads of the bones forming the larger arti¬ 
culations, fuch as the hip, knee, ancle, and 
elbow 5 that the bones fo affeCled fpread 

gradually, 

O X. J 


( 65 ) 

gradually, and become inlarged to a very 
confiderable degree, and carious throughout, 

• fometimes with great pain and fymptomatic 
fever, fometimes with very little of either, 
at lead in the beginning: that the carti¬ 
lages covering the ends of thefe bones, and 
defigned for the mobility of the joints, are 
totally dedroyed : that the epiphyfes in > 
many young fubjedts, are either partially or 
totally feparated from the faid bones: that 
the ligaments of the joints are fo thickened 
and fpoiled by the didemper, as to lofe all 
natural appearance, and become quite unfit 
for all the purpofes for which they were 
intended : that the parts appointed for the 
fecretion of the fynovia, become didem- 
pered in like manner; that all thefe to¬ 
gether furnifh a large quantity of dinking 
famous matter, which is difcharged either 
through artificial openings made for the 
purpofe, or by fmall ones made by erofions, 
and that thefe openings commonly lead to 
bones which are rotten through their whole 
texture ; that bad as this is, it is not all, nor 
the word-: for when the difeafe is got into 

this 


( 66 ) 

this ftate, the conftant pain, the irritation, 
and the abforption of poifon from all thefe 
diftempered parts, bring on a fever of the 
truly hedtical kind, attended with the mo ft 
deftrudtive general fymptoms, fuch as total 
lofs of appetite, reft, and ftrengthj profufe 
night fweats, and as profufe purgings, which 
foil all the efforts of medicine, and bring 
the patient to the brink of deftrudtion. 

That this is no exaggeration is known to 
every body. 

Now, fuppofing that the art of furgery, 
or, what is by many fuppofed to be more 
capable, the art of quackery, could exfoliate 
all the bones of a large joint, and reftore 
the internal and medullary parts of it to a 
found ftate ; fuppofing either of them ca¬ 
pable of giving the ligamentous parts a new 
and healthy ftrudiure, and of re-uniting the 
loofened epiphyfes ; I fay, fuppofing, again ft 
all fenfe and experience all this to be prac¬ 
ticable, yet it mart require a length of time 


i 


( 6 7 ) 

to accomplifh, which fuch patients ftate 
will not admit. 

The ftate which I have defcribed is no 
uncommon one, neither are the circum- 
ftances at all exaggerated, but it is the ftate 
of a perfon haftening rapidly to deftrudtion, 
who has no time to lofe, and whofe life 
can be preferved by the removal of the limb 
only. 

• \ 

That unlefs the operation be performed, 
fuch patient will perifh, is an inconteftible 
truth ; and it is as inconteftibly true, that 
numbers in the fame circumftances, have, 
by fubmitting to the operation, recovered 
firm and vigorous health, which they have 
enjoyed for many years, or even during a 
long life ; and therefore bad as this ftate of 
things is, and terrible as it muft be to lofe a 
limb, yet if it be thought preferable to 
parting with life, it is a confolation to have 
the malady fall on a part where amputation 

can be performed, fuch as the knee, ancle, 

* \ 

or wrift, rather than on the hip, where it 

cannot 


( 68 ) 

cannot, or on the parts about the lumbal, 
vertebrae, thefe cauftng thofe moli dreadful 
and moft deftru&ive diftempers, known * by 
the names of the Lumbal and Pfdas Abfcefs. 

The 

j * v 

* M. Bilguer, and M. Tiffot, are the only people whom 
1 have met with, or heard of, in the profeffion, who fpeak 
of an amputation in the joint of the hip as an advifeable 
thing, or as being preferable to the fame operation in the- 
thigh : the doftrine is fo new, and fo uncommon, that I muft 
beg leave to cite the whole paffage in their own words, left 
my reader Ihould not give me credit. 

tc The difficulty attending amputation in the upper parts 
“ of the thigh is fo confiderable, that furgeons rather chufe 
re to abandon to their fate thofe wounded men where it ap- 
“ pears neceffary, than to undertake it; and I own I am of 
“ the fame opinion with them : If, neverthelefs, a cafe oc- 
C( curred, wherein the death of the patient was certain, if 
<s amputation was not performed, I would even prefer taking 
tf off the limb at the articulation rather than at any other 
tc place” 

* ... 

The reafori which M. Bilguer gives for this is as extraor¬ 
dinary : <{r for although it be extremely difficult, yet it pre- 
“ vents the inconveniences and accidents which a ftump 
“ might occafton.” 

M. Bilguer’s annotator feems determined not to be behind 
hand with his author, part of his note on the preceding 

paffage being as follows-- <f I am of opinion that if any 

<( one had the misfortune of being reduced to the neceffity of 

chcofmg 


\ 


( 6 9 ) 

The third kind of diforder which I men¬ 
tioned as fometimes producing the neceffity 
of amputation, was the aneurifm. 

“ choofing between amputation at the upper part of the thigh, 
(i or at the articulation itfelf, one reafon for preferring the 
“ latter would be, the greater eafe there is in Hopping the 
“ hoemorrhage of the crural artery.”—Very extraordinary 
dodtrine this! 

That amputation in the joint of the hip is not an imprac¬ 
ticable operation (although it be a dreadful one) I very well 
know: I cannot fay that I have ever done it, but I have feen 
it done, and am now very fure I (hall never do it unlefs it be 
on a dead body.—The parallel which is drawn between this 
operation, and that in the joint of the Ihoulder, will not hold 
—In the latter it fometimes happens, that the caries is con¬ 
fined to the head of the os humeri, and that the fcapula is 
perfectly found and unaffe&ed. In the cafe of a carious hip- 
joint, this never is the fadl; the acetabulum ifchii, and parts 
about, are always more cr lefs in the fame Hate, or at leaft 
in a diftempered one, and fo indeed moil frequently are the 
parts within the pelvis—A circumftance this of the- greateft 
confequence ; for the power of performing the operation 
beyond the feat of the difeafe, and confequently of totally 
removing all the diftempered parts, is the very decifive cir- 
cumftance in favour of amputation every where but in the 
hips, where (to fay nothing of the horridnefs of the operation 
itfelf) the haemorrhage from a multiplicity of veffels, fome of 
which are of confiderable fize, and the immenfe difcharge 
which a fore of fuch dimenfions muft furnilh, the diftempered 
ftate of the parts, which cannot by the operation be removed, 
will render it ineffectual, bold and bloody as it muft be. 

jj '3 0 • ' ,F * ' That 




( 7 ° ) 

That kind of dilatation of the arterial 
tube which is called a true aneurifm, is 
fometimes found in the middle, fometimes 
in the upper part of the thigh, and fome¬ 
times in the ham. 

The general charadteriftic marks of this 
difternper, are a circumfcribed tumor, fmall 
at its firft appearance, but gradually in- 
creafing, and for fome length of time 
having a pulfatory motion and feel exactly 
correfpondent with the patient’s pulfe at the 
wrift; this pulfation arifing from the mo¬ 
tion of the blood from the heart through 
the artery, is very eafily feen and felt for 
fome length of time, but as the tumor be¬ 
comes gradually larger, the pulfation in it 
becomes more and more obfcure to the- 
touch, and in length of time, when either 
the artery is dilated to a very confiderable 
lize, or has burh, and has (lied part of its 
contents, the motion becomes in fome cafes 
fo obfcure as hardly to be felt at all, or at 
lead; not without very diligent attention. 
When it has got into this ftate, whether it 
be femoral or poplitean, the lower part of 

the 


( 7* ) 

m 

the limb becomes, by the preflure of thq 
extravafated blood, and by the obftrudtiofi 
to the circulation through the dilated af- 

i j 

tery, confiderably loaded, and fwollei^, unfit 
for ufe or motion, and generally very 
painful. 

This is the ftate, or very nearly the ftate, 
in which we moft frequently fee it, efpe- 
cially among the labouring poor, who ge¬ 
nerally negledt it until it renders them lame 
and incapable of following their employ¬ 
ment ; and when it is got into this ftate, it 
requires immediate attention. 

N, N 

In what manner is this difeafe, when got 
to this point, to be treated ? or how is the 
cure of it to be attempted ? for if fome- 
thing be not done, the limb will become 
mortified, and the patient will peri£h. 

If a man was to anfwer from theory, he 
would fay, that the fkin is to be divided, the 
extravafated blood to be cleared away, and the 
artery to be tied above and below the dila¬ 
tation—in fhort, that what is called the ope¬ 
ration for the aneurifm, is to be performed. 

F 2 Sorry 


( 52 ) 

Sorry I am to find myfelf obliged to fay, 
that as far as my obfervation and experience 
go, fuch operation, however judicioufly 
performed, will not be fuccefsful, that is, 
will not fave the patient’s life. 

In both thefe aneurifms, the femoral and 
the poplitean, it mofi frequently happens, 
that the artery is not only dilated and burft, 
but it is alfo diftempered fome w r ay above 
the dilatation, particularly in the poplitean. 
This may very probably be one reafon why 
the ligature is in general lo unfuccefsful. 
The want of collateral branches of fufficient 
fize to carry on the circulation, is another 
very powerful impediment. Whether thefe 
may be allowed fufficient to fruftrate the 
attempt, by the operation, I will not take 
upon me to fay; but certain I am, that it 
does not fucceed : I have tried it myfelf 
more than once or twice; I have feen it 
tried by others, but the event has always 
been fatal ; exceffive pain, a high degree of 
Symptomatic fever, great tenfion of the 
whole limb, rapidly tending to gangrene, 
and ending in mortification both upwards 

and 


I 


( 73 5 ' 

and downwards, have deftroyed all thofe 
whom I have feen on whom the operation 
of tying the artery has been pradtifed. 

Noi\have I ever feen any other operation 
than that of amputation, which has pre- 
ferved the life of the patient. 

To this an objedtion has been made by 
fome, which, if it was founded in fadt, 
would be a very valid one. It has been 
faid, that the aneurifm in the thigh, or ham, 
is very feldom the only one which the patient 
labours under, and that he moft frequently 
has the fame kind of dilatation either of 
the aorta, or of fome of the larger veflels 
within the body. This is urged as a reafon 
againft amputation in this aifeafe ; they 
who maintain this opinion, very juftly ob- 
ferving, that it cannot be of any ufe to cut 
off a patient’s leg for a femoral, or a pop- 
litean aneurifm, who will, in all proba¬ 
bility, be deftroyed very foon by the fame 
kind of difeafe in another part of him. 

If the datum was true, the inference 

would be juft, but it is not. When I fay 

F 3 that 


( 74 ) 

that it is not true, I mean that it is not 
conftantly or neceflarily, or even generally 

i v - • : * ■ ■ • 

fo, as I can from repeated experience 
affirm, having feveral times performed the 
operation of amputation for both the/e, on 
people who have lived feveral years after, 
without any fymptoms of the fame kind of 
difeafe in any other part of them. Indeed, 

,j f - ■ • t 4 * • 

the determination for an operation when a 
poplitean aneurifm is arrived to the ftate 

t 4 V v > 

which I have juft defcribed, is hardly to be 
called a matter of choice : it isdndeed a 
matter of abfolute neceffity. When the 
fwelling from the extravafated blood is 

» • * < v . ■ * 

become fo large, that the pulfatory feel of 
the artery is rendered very obfcure, the 
whole limb below is exceedingly loaded and 
fwollen, the return of the fluids, both by 

the veins and by the lymphatics, fo very 

^ * 

difficultly executed, that the patient gets 
little or no reft from the conftant pain, and 
if fome relief be not obtained, and that 
fpeedily, from the art of furgery, gangrene 
and mortification are the inevitable confe- 


quences, 


The 


' '( 75 ) 

The means of relief are two—and two 
only; the operation of amputation, and that 
of tying the artery above and below the 
difeafed part. 

The operator undoubtedly may make his 
choice between them, and follow the dic¬ 
tates of his own judgment, and his own 
experience; but it muft be worth his while 
to obferve, that for the fuccefs of the latter, 
a free circulation through all the inferior 
part of the limb, feems to be a very ne- 
ceffary circumftance, and that when the 
load, and prelfure, and obftrudtion are be¬ 
come fo great as even to threaten gangrene 
and mortification, which is frequently the 
cafe, fuch free circulation is not much to 
be expedted ; but, on the contrary, all the 
evils arifing from a very obftrudted one, and 
that through diftempered parts. 

There’is another kind of complaint affedt- 
ing the leg, removable (as far as my expe- 
riencegoes) by amputation only, whichisone 
reafon why I mention it in this place, and to 
which I might add another reafon, which i§ 

F 4 that 


('. 76 ) 

that it either derives its origin from a 
burden artery, or at lead is always accom¬ 
panied by it. 

I know no name to give it, or under 

what clafs to range it, but will defcribe it 

> 

in the bed manner I can. 

It has its feat in the middle of the calf 
of the leg, or rather more toward its upper 
part, under the gadroenemius and foleus 
mufcles : it begins by a fmall, hard, deep- 
feated fwelling, fometimes very painful, 
fometimes but little fo, and only hindering 
the patient's exercifes; it does not alter the 
natural colour of the fkin, at lead until it 
has attained a confiderable flze j it en¬ 
larges gradually, does not foften as it en¬ 
larges, but continues through the greated 
part of it incompreffibly hard, and when it 
is got to a large fize, it feems to contain a 
fluid which may be felt towards the bottom, 
or reding, as it were, on the back part of 
the bones. If an opening be made tor the 
difcharge of this fluid, it mud be made 
very deep, and through a Arangely didem- 


( 77 ) 

pered mafs. This fluid is generally fmall 
in quantity, and confifts of a fanies mixed 
with grumous blood : the difcharge of it 
produces very little diminution of the tumor, 
and in the few cafes which I have feen very 
high fymptoms of irritation and inflam¬ 
mation come on, and advancing with great 
rapidity, and mofl: exquifite pain, very foon 
deflroy the patient, either by the fever, 
which is high and unremitting, or by a 
mortification of the whole leg. 

If amputation has not been performed, 
and the patient dies, after the tumor has 
been freely opened, the mortified and putrid 
ftate of the parts, prevents all fatisfactory 
examination ; but if the limb was removed 
without any previous operation (and which, 
as far as my experience goes, is the only 
way of preferving the patient's life), the 
arteria tibialis poftiea will be found to be 
inlarged, diftempered, and burfi: j the muf- 
cles of the calf of the leg to have been con¬ 
verted into a ftrangely morbid mafs, and 
the pofterior part of both the tibia and the 
fibula more or lefs carious. 


The 


( 7 § ) 

The fourth kind of diftemper which I 

\ 

mentioned, * as being fometimes productive 
of the neceffity of amputation, is a caries of 
the whole bone or bones forming a limb. 
By this I would be underftood to mean a 
caries poffeffing not only the furface of fuch 
bones, but the whole internal fubftance, 
and that from end to end. This I take to 
be the very individual cafe, in which both 
M. Bilguer, and M. Tiffot, have repro¬ 
bated amputation, and which the former 
has mentioned in his fifth article, under 
the title of Incurable Caries, 

The terms in which M. Bilguer has 
chofen to exprefs himfelf, are rather unfor¬ 
tunate, 

S • - ; -*v „ 

After having mentioned three or four 
different diftempers, in which, in certain 
cafes, and under certain circumftances, am¬ 
putation has in general been thought ne- 
ceffary and right, and in which he is of a 
totally different opinion, he adds—An in¬ 
curable caries of the bones, which incurable 

o 

^caries, 


( 79 ) 

caries, he fays, ought not to be amputated* 
becaufe there is a method of curing it. 

If this was merely a blunder in language, 
and went no farther, it would be a matter 
of little importance, but it is aferious piece 
of advice, delivered authoritatively, and by a 
writer who profeffes to correct the errors 
both of his predecelfors and cotemporaries, 
therefore it fhould not be merely laughed 
at; and as it is an advice which is not 
built on faCt, and which is fraught with 
mifchief to mankind, it ought to be con¬ 
tradicted. 

K . - «• 

That bones become carious from a variety 
of caufes, fuch as the ftruma, the lues ve¬ 
nerea, deep-feated impofthumation, pref- 
fure, &c. is well known tp eyery body; 
and that fuch carious bones properly treated 
will exfoliate, and caft off their rotten parts, 
is as well-known; but, when in fome par¬ 
ticular habits, whether fcrophulous, fcor- 
butic, or cancerous, the whole fubftance of 
the bone becomes difeafed, not only on its 
furface, but through its whole internal me- 


( 3q: ) 

( ft V I 

dullary texture, and that from end to end, 
the fame means, be they what they may, 
will not avail. The ufe of the fcalper, the 
rafpatory, and the rugine, for the removal 
of the difeafed furface of bones ; of the 
trephine, for perforating into the internal 
texture of carious ones, and of what are 
called exfoliating applications, are as well 
known, I prefume, to every practitioner, as 
to M. Bilguer ; but giving to thefe all their 
teal or their fuppofed merit, ftiil I affirm, 
and that from repeated experience, that 
there are cafes of caries, in which none of 
thefe will fucceed, though ever fo judi- 
ciouflyufed; that neither by thefe, nor by 
any other means, can an exfoliation be ob¬ 
tained ; and that, unlefs the whole bone be 
removed by amputation, the patient will 
• 

The metaphor, or fimile, by which M. 
Bilguer endeavours to illuftrate his meaning, 
is fomewhat fingular : he fays, The real 
“ method of doing fervice to bones con- 
t( fumed by caries, is like what happens to 

“ boards 



( 8i ) 

(t boards joined together by nails : if you 
“ make them exceflively dry, the nails fall 
“ out of themfelves, See.” 


Now admitting what I think will not be 
admitted, that this limile conveys a juft 
and true idea of the manner in which the 
rotten parts of bones are feparated from the 
found, yet it neceffaril)* implies, that in 
thefe very bones there are fome found part 
or parts, from which the rotten are to be 
dried off, in order to loofen the nails, and 
that the exiftence of fuch found parts is 
the fine qua non of the cure. 

It may, perhaps, in anfwer to this be 
faid, that proper treatment, external and 
internal, may fo alter and corredl even the 
carious part of a bone, as to render it ca¬ 
pable of parting with the reft, and thereby 
of becoming found. I fay, admitting this, 
which is not in general admifiible, yet it 
fometimes happens, that there is not time 
for fuch experiment, and that even in very 
young fubjedis, the whole habit is by the 

rotten 


»»«■ 


) 


i 




.. ( 8a ) ' 

rotteri bone, fo poifoned and fpoiled, that 5 
a hediic fever of the putrid kind, with all 
its horrid train of horrid fymptoms, will, 
in fpite of all the efforts of phyfick and 
furgery, in fpite of bark and every other 
fpecific, in fpite of drying, burning, rafp- 
ing, and boring, come on, and in a very 

fhort fpace of time deftroy the patient, unlefs 

t * 

refcued by amputation, which alone can 
remove a whole bone* 

* i \ ; * * 1 -4 

I have as high an opinion of, and as juft 
a reverence for, both branches of the me¬ 
dical art as any man, but I alfo know, that 
they are both in many inftances exceedingly 
unequal to our expectations, and very much 
limited. 

This is a difagreeable and an unfortunate 
truth, but Itill it is a truth, and fo much 
fo, that whoever profeffes a contrary opinion, 
is either much deceived himfelf, or inclined 
to deceive others. 


POST- 


d 


( S 3 ) 


POSTSCRIPT. 

In the firft of the preceding trads (that 
on the curved fpine) I have omitted a few 
circumftances which I ought to have men¬ 
tioned, and which are : that the palfy, or 
debility, or incapacity of motion, or by 
whatever name it may be thought proper to 
call the effed produced on the legs and 
thighs, not only never affeds the arms, but 
always affeds both the lower limbs, and 
both of them equally. 


That the firft fenfation of alteration in 
thofe who are capable of attending to, and 
of defcribing it, is always faid by them 
to* begin in the thighs, by producing aa 
unufual degree of fenfibility, and frequent 
irregular twitchings in the mufcles. 


That, although in many cafes it is, and 
muft be a long time before the patient walks 
firmly and well, yet he ultimately does fo; 
and in all the time preceding this period, 
although fuch patient walks weakly and 
unfteadily, yet it is a very different kind of 

weaknefs 


■ (C .84 ) 

weaknefs and unfteadinefs from that which 
is feen in people who have had what is 
called a paralytic ftroke, and very diftin- 
guifhable from it; and, that practitioners 
muft expeft to meet with a confiderable 
degree of variety in different perfons, with 
regard to their recovery of the ufe of their 
legs at all, fome being fo happy as to attain 
it in a few weeks, while others are obliged 
to wait many months. 

' j 




i 


1