Remarks on the Palsy of the Lower Limes,
i
i.
Observations on the Propriety of Amputation.
[PRICE ONE SHILLING AND SIX-PENCE.]
f
/
. '
W. , ■ ■' f • V
'
.
' r .., - .. ..
V,
«•
■
* 4 •• . ' > r :
A
I
\
♦
\
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.
Tf*
K ** ■ * ■
'& : ■
'
- '
■\:
fcr *. X. > •
v. fc.V ^
' V, :
.
f •
-j ’
; r‘
/
«V ' "*■:
■ • * • . : W '
* J$S --
* >Y V
• V ' •
■ ■
7 *'■••
r A
. T
i J
l '
/ . ;•.
'{■-
•
*r
V
j?
*
i'A
Tf
r r
• r'
v *
•’
v - .; ; ' T-i / .
V i
<
JL
■
■ ■. -
> >
*. >
' J;
n
t u
■ 7 . r .
< i. X / ?. ■' ■ a
;• t
wji
W
7 l.' -V^ ‘■'■'T <’ ■ i O’■* *: f /!H' ••*; ; :
- ^ v', sj .! ^ •/ J,
d
• .
^ / i.. jL
* r *\ A
* * J A
*' r t
• .%*". 1 .1 (4 *■ * .
■ •rrn'V :•• :t , t;:<\
l / 1
T
C I 1
■ V * * *« ** 3 il. 3 0 0 T
w 3 a U 0 •••' ■„ •• T .1
t <IV4 'A 3 ;ta no JEW c t 1
.1 £3. . A9D
\
; - tzu/I . » 8- '! OI 'f :> '" ■ 2 2 S C#>
*■ nr * ,\ -
^ ^ -j X •
> • 1 *
- - * * < I.
tf‘ - - -
» * • L . '
' A
r /-
H ■: y .>./
r j * *
• - ♦ . ;'\
4 L i i' t\ -* 1 j V i L i i i * * 1
- „
' r- ' •'>'»
** l ««w-*>#«.•
t ■’ I )
J ■>. ,J,, J
o/i ''I O i 1
• \I ’
■ ' f ’
I
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.
/
*
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
