A dissertation on the inutility of the amputation of limbs

SECT. XVII

It was probably by some such application, that S** G**** cured a man whose arm was mortified, and whom the physicians and surgeons had given up; a cure which appears to me much less wonderful than what is imagined. The physicians and surgeons despaired of his recovery, and quitted him, because he would not submit to amputation, at the very time when, doubtless, the separation of the sound and mortified parts began to take place, owing either to the force of nature or the medicines they had administered, and when granulations of new flesh began to shoot. It was easy for S** G****, called in at this instant, to effect a cure, by means of his quieting powders and balsam. What is most astonishing in this case, and deserves at the same time to excite our indignation, is the obstinacy and the cruelty of the physicians; but they were sufficiently punished for it.

SECT. XVIII

This is not the only instance of patients in whose cases physicians and surgeons have pronounced amputation to be unavoidable, and who, upon their refusing to submit to it, have afterwards been cured by very simple treatment. This ought to be a lesson for us never to be too precipitate in having recourse to this operation[14 - I hardly ever knew any old officers who have not been witnesses of some examples of this kind; and I have seen several people who have themselves been in such a situation.].

But what must be done, they will say, when every medicine has failed? Is it not better, in such a situation, to try a doubtful remedy, as Celsus expresses it, than to do nothing?

As what is called a doubtful remedy, is for the most part no remedy at all, I look upon such an argument as very fallacious; I shall explain, what I think on this point. Every mortification is the consequence either of some internal morbid cause, or an external accident. In the first case, amputation can be of no service while the morbid cause remains; and who can hope, in so short a time, to remove a consumption, the scurvy, a decay from old age, a dropsy, or cachexy? And if these cannot be removed before amputation, it is to very little purpose to operate on the sound part, as it would only be killing the patient. Is there a physician or surgeon but would conclude he occasioned the death of a dropsical person, were he to cut his mortified leg off above the knee? What is true in a dropsical case, is equally so with respect to others: To amputate, is only to give needless pain, and to accelerate the patient's death. It may be further asked, Must we then in such a situation intirely abandon the patient? I answer, No; but we ought to direct our efforts against the morbid cause, and at the same time, employ the most effectual applications externally, lopping off whatever is absolutely mortified, without cutting to the quick, lest the pain, and other accidents which are the consequence of such incisions, should hasten death. After this treatment, the remainder may be left to nature, assisted with the most efficacious medicines, internal as well as external; and if the patient dies, we may rest satisfied that the disease was beyond the resources of art.

SECT. XIX

When a mortification in a healthy constitution is the consequence of an external accident, the point is not so easily determined; I will venture, nevertheless, to remove the difficulty.

It must first be inquired into, if the ailment has been properly treated at the begining, and if sufficient care has been taken with respect to the cause. If there appears any default in these points, we must first endeavour to repair it, before we think of amputation. If, on the contrary, the treatment has been judicious, we must examine if the mortification continues to spread, or if it be stopt, and its edges begin to discover themselves.

If it continues to spread, it is improper to amputate, for several reasons. In the first place, because the whole habit is in a bad state, and there must be a fever and general inflammation, which would be greatly increased by an operation which, of itself, is sufficient to bring on the death of the healthiest man. In the second place, amputation cannot be performed on the sound part, in the manner as is generally imagined, as the infection is very often more deeply seated than it appears to be: We may judge of this by observing what happens very frequently in whitlows of a bad kind, where the matter quickly insinuates itself along the arm, and is pent up there, inflaming sometimes even the axillary glands; as an inflammation of the toes, in a short time, brings on that of the glands in the groin: Thus the disease having taken root in the place where the operation is performed, would of course be increased by the ligatures, which are indispensably necessary in this operation, unless we would suffer the patient to perish by an hemorrhage. In such a case then, amputation is not a dubious remedy, but it is no remedy at all[15 - Mr. Sharp, to the best of my recollection, was the first who solidly proved the impropriety of operating on the sound part, while the mortification continued to gain ground. This excellent doctrine not being as yet universally acknowledged, it is very much to be wished, that the additional authority of so judicious a surgeon as Mr. Bilguer, may contribute to give it fresh weight, in order to render it general. Tissot.]; and if the patient sometimes does escape, it must be acknowledged that nature has effected the cure; that she has got the better both of the disease and of the bad treatment, and has thus overcome a double enemy.

It is evident, from what I have said, that while the mortification gains ground, the method I have proposed, § VII. (#pgepubid00030)XVI (#pgepubid00055). should be followed. When its progress is stopt, it must be considered whether the limb can be preserved or not. We may entertain hopes[16 - I shall transcribe Mr. Bilguer's own words. Quo quidem loco non possumus, quin observemus, signum illud corruptionis quod a deffectu sensûs desumi solet, per illustris Halleri experimentis, quodam modo incertum redditum esse, quibus quippe evictam periosteorum insensibilitatem esse multi clarioque viri putant. Nostra de his rebus experimenta fere cum Halleri doctrina congruunt, nisi Pericraneum numquam non sensibilissimum deprehendimus.] of its preservation, if all the corrupted parts cast off, and the sound parts, and even the bones, begin to produce granulations of new flesh. I cannot here omit remarking, that Mr. Haller's late experiments, which prove to the satisfaction of many eminent anatomists, the insensibility of the periosteum, render the sign of a mortification derived from such insensibility very doubtful. My experiments on this subject agree with his, excepting in this, that I always found the pericranium extremely sensible[17 - See, on this subject, the memoir of M. Haller, on the sensible and irritable parts, T. 1. 4.]. Whatever weight may be laid on these experiments, this consequence may at least be deduced from them, that we ought not immediately to conclude that the bones and periosteum are affected, because we prick, cut or tear the periosteum without giving pain; nor, in like manner, from this symptom, ought we to neglect the medicines indicated § VII. (#pgepubid00030)XVI (#pgepubid00055).

If the rottenness of the bone demonstrates that the limb cannot be saved, which almost always happens, if the patient has been improperly treated, we must amputate, if the strength of the patient be sufficient to support this dreadful expedient, and amputate on the sound parts. It is true, that amputation in this case is a doubtful remedy, but nevertheless as there is no other, and as there is no symptom in the patient that forbids its use, it is a remedy. If the patient be weak, the case is desperate, as he is not able to support the operation on the sound parts, and as nature is not in a condition to effect a separation of the dead from the live flesh, if only the mortified part be cut off.

In so dangerous a case, the method I would take, would be, after providing against any hemorrhage of the larger vessels by a proper ligature, to lop off all the gangrened useless mass, not actually through the quick itself, but very near it; afterwards I would endeavour to stop the progress of the infection by internal medicines and suitable dressings. I would support his strength by a proper regimen; if it increases, we may be sure a separation of the soft parts that are mortified will ensue naturally; after which, it will be easy to saw off the little stump of dead bone that was left. The wound may then be cicatrised, by means of epulotic applications, and such as we have recommended for bones when laid bare, § X. (#pgepubid00039)

This practice is not only conformable to sound reason, but what is more, it is confirmed by repeated experience; since we find among the collectors of observations, but few instances of amputation succeeding, when it was performed while a mortification continued to gain ground, or while the patient was feverish; but a much greater number of successful cases, when amputation was performed late, and when the disease had abated naturally: A variety of examples may be seen in the work of Mr. Schaarschmid[18 - Sammlungen, &c. a performance which ought to be generally read.], which I have already quoted.

It will, perhaps, be objected to me, that I am inconsistent with myself, since I have just proposed one method, and actually follow another; but this objection will vanish, if it be considered in the first place, that if a person has been thus judiciously treated from the beginning, and does not recover, a cure will almost never be effected, after the cruel expedient of amputation. In the second place, that all those who are under a necessity of submitting to this dangerous operation, on account of their having neglected themselves, or having been unskilfully treated, have no reason to complain of the art, or of those who understand it, but of their own negligence, or of the ignorance of those into whose hands they have had the misfortune to fall. And in the third place, that in opposing amputation on the sound parts, and in testifying my abhorrence against the needless pain which accompanies it, I do not at all condemn the amputation of what is absolutely mortified.

I have however sufficiently expatiated on this point, which ought to be considered before the others, as being more general. I now proceed to examine the accidents that induce surgeons to amputate in order to prevent a mortification. There are some who have carried their precipitation, in this respect, to such a length, as to cut off limbs upon the spot, that have been considerably bruised, before they tried any other remedy: A piece of cruelty I cannot in any shape approve of[19 - This practice has also been condemned by others. See the collection of pieces which put in for the prize conferred by the royal academy of surgery. T. 3. p. 490. It is there observed that every amputation performed immediately after the hurt, is generally dangerous in its consequences.I know that a soldier, who had his arm cut off in the field of battle, after the affair of Prague, died the third or fourth day after the operation.].

SECT. XX

I shall treat at present of large contusions of the limbs, especially of those where the fleshy parts, as well as the bones, are extremely bruised and shattered, as commonly happens, when the hand, the foot, the elbow, the leg, arm or thigh, have been bruised by a large stone, a beam of wood, a cart-wheel, a screw, a press, &c. In such cases, shall the patient get sooner well by amputating or not amputating this shattered limb? I answer, by not amputating; the worst consequences that can be apprehended, is a mortification or an hemorrhage. With regard to the mortification, unless every thing I have hitherto said concerning it be intirely groundless, we ought not to be afraid of it; and it is much easier to prevent than to cure it. With respect to the hemorrhage, it is no doubt to be dreaded, but this dread can be no reason for instantly taking off the limb: To be convinced of this, we need only examine those wounded men who have had an arm or leg carried off by a ball, and the stump so shattered, that the bone has been shivered into several pieces, and the large blood vessels most shockingly torn, who have, notwithstanding, been cured without amputation, and with whom the bleeding has stopt, even without the assistance of a surgeon. Nevertheless, every body knows that contusions of this kind have been hitherto, by most surgeons, accounted a sufficient cause for amputation; and that when the hand or foot have been shattered, they have carried their inhumanity so far, as to take off, not only the leg or fore-arm, but even sometimes above the knee or joint of the elbow.

Those who follow this method, amputate within a few days of the accident, while the patient is vigorous, and without waiting for the event of any other kind of treatment; for if the patient be weak, old or very ill, even with the consequences of the wound, they do not venture upon the operation.

It would however, in my opinion, be much better not only not to take off an arm, a thigh, or a leg, which are unhurt, but even to endeavour to save the foot or hand which are shattered, in obviating, by medicine and diet, as well as by external applications, the accidents that may ensue; and thus prevent a person who has already suffered so severely, from meeting with a treatment still more severe.

It will be asked, if the thing be possible? The following observations will furnish an answer. I publish them with so much the more confidence, as they are known, not only by the patients themselves, but by a great number of the physicians and surgeons of the army. They must be decisive in favour of preserving contused and shattered limbs, in opposition to amputation.

SECT. XXI

When a patient is brought to our military hospitals, who has had his foot, leg, hand or arm shattered by a ball, or any other violent cause, whether the parts are intirely carried off, or adhere by a little flesh and skin, but in such a manner that there is not any hope of a re-union; in this last case, we begin by cutting through these slender attachments which keep the part suspended, and thus intirely separate it from the body. In both cases, when pieces of the extremities of the bones jut out, and may prove hurtful, they must be sawed off with a convenient saw, whether they be moveable or still firmly adhere to the limb: When they are moveable, they must be held by an assistant. I hope no man in this treatment, will pretend to see any thing like what is properly called amputation, which I condemn.

After this first operation, I carefully examine if there be still any small splinters left, and whether they are only held by the fleshy parts, or still adhere to the bone; I remove all those, with the fingers, or with instruments, that can be separated without violence or a fresh effusion of blood.

After removing as many splinters as I can, I slightly compress the limb between my hands, gently stroking it lengthways, from above downwards, endeavouring, at the same time, to restore, as much as possible, its natural shape; I dress the sore with a digestive, to which I add a little essence of myrrh, or solution of mastic: I cover the whole with dry lint; applying the same bandage as after artificial amputation, sufficiently tight, without, however, running the risque of causing pain or increasing the inflammation: Afterwards I moisten the whole with as much spirit of wine as may penetrate to the parts affected; taking care to keep the limb extended in a right line, and laid soft.

The first days, till the suppuration becomes plentiful, I only dress it once every twenty-four hours, sometimes seldomer; but when the suppuration is begun, I renew the dressings twice a day; and such of them as immediately touch the bone, or fleshy parts of the wound, I cover with lint dipt in solution of mastic, balsam of Fioraventi, or some other balsamic essence, in order, by that means, to prevent too large a suppuration. I likewise remove, each dressing, all the little shivers of bone which do not reunite, and which, though they could not be separated at the first dressing, may in the succeeding ones.

With respect to the larger fragments, which must form the stump of the bone, I not only take care not to loosen them, but even, as I already remarked, endeavour to promote their coalition, by light compression with the hands, and binding the bandage somewhat tighter than I would otherwise do. If, at the expiration of a month, a fragment of this kind is not coalesced, but on the contrary, is become more loose, without however being intirely so; in that case, by shaking it gently, moving it upwards and downwards, and loosening the fleshy parts that hold it, I endeavour to bring it away intirely. If there are some of them cracked as high as the articulation, I give myself no concern about them, but leave them to nature[20 - Felix Wurz and Gœuey cured, as may be seen in Heister's Surgery, t. 1. p. 183. the longitudinal fissures of the bone, by a suitable dressing, which is mentioned in the same place. If it should happen, what I have never yet had an opportunity of seeing, that the bone was split longitudinally as far as the joint, and that it appeared impossible to procure its coalition by means of proper dressings, I would make, taking care to avoid the blood vessels, two incisions, from the extremity of the stump to the joint, that should go as deep as the bone, and whose distance must depend on the breadth of the splinter to be extracted. I would raise up from the bone the flesh included between the two incisions, with a scalpel or myrtle-leaf, avoiding to hurt the blood vessels as much as possible; then, having detached the splinter, by means of the scalpel, from its adhesion with the ligaments of the joint, I would bring it away.If the hemorrhage were considerable, before I extracted the bone, I would tie the vessels of the fleshy part which adhered to it; and after having removed the bone, I would undo the ligatures, restore the flesh to its place, take care of the small wounds made by the needles, and would dress the whole part in the manner already mentioned in this section.]. But as to the small, short, pointed shivers which do not re-unite with the bone, I take care, as I have already observed, to remove them as soon as possible, commonly in the first seven or eight dressings; and at each dressing, I gently stroke down the muscular flesh towards the end of the stump; I keep the whole firm, by giving a proper degree of tightness to the bandage; moistening it, as long as the dressings are necessary, two or three times a day with spirit of wine. By these means, such kind of patients, at the end of four or five months, are as compleatly cured as the nature of the accidents will admit of.

SECT. XXII

Besides what I have already said, I must further add some other useful remarks.

If the patient, as is generally the case, be weakened by the discharge of blood, his strength must be supported with broths, with herbs boiled in them, and with wine and water. Further, I order him every four hours half a dram of the bark, till the pulse is sufficiently raised, and a laudable suppuration comes on; he may then be allowed some meat, herbs, and food of different kinds of grain; water, acidulated with vinegar or spirit of vitriol, may serve for drink.

When the suppuration is too plentiful, and the wound appears disposed to heal, I purge once or twice with Epsom salt, having previously for a few days administered some absorbent powders. During the day I make him drink a slight decoction of the bark, before and after meals a little strengthening acid elixir; and in the evening, a small dose of bark, mixed with a fourth part of an absorbent powder[21 - I do not easily comprehend of what service absorbents can be to wounded patients; but it appears obvious to me, that they must impair the efficacy of the acids, which are clearly indicated with respect to the fever, inflammation and gangrene: The only circumstance in which I imagine they can be of use, is, when the stomach, by taking the acids for several days, is a little disordered, which may happen when the patient has been much reduced by the hemorrhage; then a few doses of absorbents would remove this slight inconvenience. Otherwise, I am convinced, by repeated experience, there is no occasion for them, when the bark is joined with acids, as is judiciously done by Mr. Bilguer. Tissot.]. The following is the composition of the strengthening elixir; Half an ounce of the extract of wormwood; of that of gentian, lesser centaury, green oranges, and buckbean, of each a dram; rectified spirit of wine, four ounces; and spirituous mint water, one ounce: Let the extracts be dissolved in the spirits, over a gentle fire; strain them, then add to the strained liquor, half an ounce of dulcified spirit of nitre, and thirty drops of oil of vitriol.

SECT. XXIII

It sometimes happens that these patients, § XXII. (#pgepubid00080) are seized with a fever, it begins with great cold, sometimes even with a chattering of the teeth, which lasts half an hour, an hour, or sometimes longer, and is succeeded by a gentle heat, which terminates in about three or four hours, in a moderate sweat. The interval lasts two or three hours, at the expiration of which the fit returns; sometimes it is accompanied with a diarrhœa.

The most common causes of these fevers, are either in the first place, a bad digestion when a person has taken too much food, or the food is greasy, indigestible, and subject to putrefaction; or, secondly, a reabsorption of purulent matter, which taints and inflames the blood; or, thirdly, a bad air, such as is very often that of an hospital, notwithstanding all the precautions that can be taken.

It is of consequence immediately to stop this fever, lest it should dissolve and corrupt the blood, and become a putrid fever: If it is not accompanied with a diarrhœa, a vomit of ipecacuan may be given, joined with a few grains of rhubarb: If there is a looseness, the same medicine may be repeated the following morning, and even sometimes the third day. Through the day may be given a little of the strengthening elixir described in the preceding section; and in the evening, when the patient has had a vomit in the morning, half a dram or two scruples of the following anodyne powder may be administered; Virginian snakeroot, zedoary, of an eleosaccharum made with the essential oil of fennel, of each two scruples; calcined hartshorn, sixteen grains; cynogloss pills, four and twenty grains. Afterwards I gave every day some of the strengthening elixir, a compounded powder of the bark, and a strengthening decoction. The powder consists of two drams of bark, one dram of sal ammoniac, and a dram of an eleosaccharum, made with the essential oil of fennel. The ingredients for the strengthening decoction are as follow: The herbs of fluellin, baum and yarrow, of each half an ounce; of that of mint, two drams; chamomile flowers, an ounce; those of red poppy, half an ounce; orange peel, two drams; shavings of sassafras, cassia lignea, carvy seed, of each a dram; bark, four ounces; and Virginian snakeroot, one ounce. These ingredients must be properly cut small, bruised and mixed together. By the above medicines the fever is commonly relieved[22 - Mr. Bilguer having seen the good effects of this composition, inserts it according to the form he made use of; and without doubt, it is a very efficacious medicine: But it might be rendered much more simple without imparing its virtues; and simple medicines, in my opinion, are preferable on every occasion, but particularly so in hospitals. Tissot.].

SECT. XXIV

I have treated hitherto of limbs intirely divided; I shall now examine what ought to be done, when a ball, or any piece of iron or lead, has so greatly injured the bones of the hand, arm, foot or leg, that, although they are not quite broke through, and the part suspended by a small portion of flesh and skin, as in the former case, § XXI. (#pgepubid00075) are nevertheless so much shattered that the part may be moved any way, and seems to hang useless. In these circumstances, we must dilate the aperture made by the ball, or by whatever body has inflicted the wound, and separate the flesh from the bone; in a word, we must make the wound sufficiently large, in order to lay the shattered bones bare, especially where they are broken across, that they may be more easily managed by the fingers; then as many splinters as possible must be extracted, as well as the ball and other extraneous bodies. If there be the apertures of two balls, they must both be treated in the same manner: When it is expedient to make counter openings, they may be made indifferently, whether there be one or two openings, and these artificial wounds must be made sufficiently large, to admit of the extracting of the splinters and other extraneous matters. In other respects, the dressings must be the same as § XXI. (#pgepubid00075) Every time they are renewed, the splinters must be extracted as they become loose and can be easily separated; if there be some large fragments which must be removed, we may begin by dividing them from the fleshy parts, then sawing them through with a very small saw, whose blade is extremely thin and narrow, crooked or straight, in order to push it from above downwards, or from below upwards, or sideways, as may be convenient. This method answered so well with me for the bones of the leg and arm, that I have often, in this manner, separated pieces three or four inches in length, and even longer. As for the smaller bones, such as those of the hands or feet, I have divided and extracted them entire, when they were broken and shattered, and sometimes even when they were not.

If a bullet has penetrated into the cavity of a bone, such bone must be laid bare, either on the side by which the bullet has made its way, or on the opposite one; afterwards it must be pierced with two or three trepans, and the extraneous body, and the shivers of the bone extracted.

If the bullet has made its way into one side of the joint of the elbow or knee, and by that means shattered several bones at one stroke, I treat it in the same manner, dilating the wound and extracting the splinters as before, and the wounds get well like the others.

I cured a patient who had been wounded by a bullet which entered the cavity of the os humeri; he would not consent to have it extracted, which did not however prevent his recovery, nor has he felt any further inconvenience from it than a small protuberance on the place where the ball is still lodged[23 - He was a soldier in the guards, and is doing his duty in the field at the very time I write this.].

It will perhaps be asked, if it be possible that a ball should enter the cavity of a bone without splitting or breaking it, as seems to have happened in the case I have just mentioned? and where that circumstance will appear still less feasible, when I affirm, that the bones of this man were strong, hard and compact; and that on some occasions, fissures and the other accidents of bones, I have been treating of, are often the consequences of slight wounds, as of more considerable ones. But be that as it may, I treat these kinds of wounds in this manner: I dress the bone partly with dry lint, and partly with balsamic essences, and sometimes I throw in injections: I apply a digestive to the fleshy parts, and moisten all the dressings with spirit of wine, as in § XXI (#pgepubid00075). I check the suppuration a little, preserving, as much as possible, the boney fragments which adhere together, so as to leave room to hope for their coalition, sustaining them in their natural position, and covering them again as much as possible with the flesh and skin: If there be any pointed splinters, I endeavour to promote their separation by proper applications, such as the balsamic essences, and different powders, particularly that mentioned § X. (#pgepubid00039)

I fix the limb in its natural position, suspending the arm in a sling, or half-cylinder adapted for the purpose. For the leg, I use Mr. Petit's machine, or splints, made of wooden rods covered with straw, and wrapped up in linnen cloth; and in the dressings, my chief aim is to keep them sufficiently tight above and below the wound, to promote the consolidation of the larger pieces of bone, by keeping them firm in their places, and preventing the re-absorption of pus. The diet and medicines are the same as in § XXII. (#pgepubid00080) By this method a very great number of wounded men have been restored to health, in two, three or four months; and some not before the expiration of eight. My observations confirm those of Horstius, who remarks, that a man who has lost a great portion of the tibia and fibula, may nevertheless, after his cure, walk with ease, and halt but very little[24 - Horstii observationes medicæ, part ii. 1. 4. obs. 10. Mr. de Frengler, captain lieutenant in the regiment of Anhalt Bernbourg, is an instance of a most successful cure of a wound of the leg of this kind. In the sequel of this dissertation may be seen, several striking cases of an extraordinary loss of substance in the bones being again repaired.].

SECT. XXV

Such kind of wounds, however, are not without danger; the patient is not only very liable to be seized with such a fever as I have spoken of § XXIII. (#pgepubid00082) but he also runs a risque from the wound itself. It is true, that these two dangers, that attending the fever, and that from the wound, which I shall mention by and bye, are connected, and generally accompany each other. It sometimes happens of a sudden, and without the patient, or the physicians and surgeons having any suspicion of it, that the wounds dry up, become corrupted, and exhale an infectious stench; the neighbouring parts are very much inflamed for some days, after which the inflammation goes off, leaving a kind of œdematous tumour, which produces an abscess, with a laudable discharge, or degenerates into a malignant sore, without any abscess. Sometimes these sores are beset with swarms of maggots.

The treatment of the fever is the same I have described § XXIII. (#pgepubid00082) that of the wound, in this troublesome situation, ought to be to endeavour intirely to remove the inflammation, which readily terminates in suppuration, and forms large cavities full of matter, which must be opened.

A moderate compression of the neighbouring parts, in this case, as in those I have already mentioned, contributes to prevent the reabsorption of the purulent matter. If the inflammation runs high, and the patient is young, it should be moderated by bleeding, and other medicines calculated to check and resolve the inflammatory denseness of the blood[25 - At present, since we know that pus is only a corruption of the crassamentum of the blood, it is easier, perhaps, than formerly, to explain why an inflammatory denseness of the blood terminates sometimes in an abscess, and at other times in a compleat recovery without one. Dr. Pringle, to whom we are indebted for so many useful discoveries, which have thrown a new light on the theory and practice of physic, was the first who pointed out the true manner in which pus was formed, concerning which so many conjectures had been made; and Mr. Gaber has demonstrated it very particularly by a number of very curious experiments. Tissot.].

If the cause of the inflammation be obvious, it must be removed; thus every pointed splinter of a bone must be separated with a knife or saw; whatever occasions a compression must be taken away, and if there be any fibrous part causing too great a stricture, it must be cut through, dilating the wound by incisions of a convenient depth.

The dryness and putrefaction of the wound, may be remedied by dressing it with the powder composed of sal ammoniac and camphor, mentioned § X. (#pgepubid00039) and by moistening it afterwards with oil of turpentine; or, I cause the wounds, both the original ones, and those made by the surgeon, to be dressed with pledgets, dipt in a balsam composed of four ounces spirit of wine, half an ounce spirit of turpentine, and three drams spirit of sal ammoniac: Afterwards, having first applied the dressings very thin, the parts must be constantly fomented with some of the compositions mentioned § XXI. (#pgepubid00075)

The maggots may be destroyed, by frequently shifting the bandages, linnen, cloaths, and coverings of the bed; by the application of the balsams I have already spoken of, which destroy these insects and prevent putrefaction; by constantly keeping on the bed-clothes, a linnen cloth dipt in tincture of aloes or vitriol. But care must be taken that the tincture of aloes does not touch the affected limb, much less the sores themselves, lest part of it should be absorbed, and occasion a diarrhæa; although in other respects aloes powerfully resists putrefaction, and is sometimes a useful vulnerary.

SECT. XXVI