A dissertation on the inutility of the amputation of limbs

SECT. XXXII

As I object to the amputation of contused limbs, it is reasonable I should point out the method of treating such contusions: I prevent the troublesome symptoms they produce, or disperse them if they have already appeared, by frequent bleedings, and by the exhibition of such medicines as attenuate the blood, resolve what is too gross, remove what is obstructed, and render fit to be reabsorbed what is extravasated. I join with them such as, by gently evacuating by stool, unload the vessels; and I afterwards give such things as brace up the fibres, and restore the natural crasis of the blood.

I have found no medicine more effectual to attenuate the blood, and resist the febrile disposition, than a powder, consisting of nitre, Epsom salt, cream of tartar, and true Armenian bole38.

SECT. XXXIII

The external applications for a contused limb should vary, according to circumstances, or according as the contusion has caused a mortified slough, or has not. If it has not, but nevertheless the bone is fractured, the applications should be of a very mild nature. In such a case I make no incisions, but I endeavour to bring the two ends of the bone together, to place them in their natural position, and to keep them in it, by means of compresses and bandages, as in the common simple fractures: I constantly stupe the whole dressings with discutient and vulnerary fomentations39, and exactly follow the plan laid down § XIV. by which means I have almost always happily cured contusions of this kind.

If the contusion has caused a mortified slough, and has at the same time shattered the bone, we must begin by separating the dead slough from the sound parts, with a scalpel; we must make deep incisions, and neglect no means proper for promoting the discussion or suppuration; and the fracture of the bone must be treated agreeably to the method recommended § XXIV. This case requires great vigilance in the care of it, and we find ourselves amply recompensed for our labour, by the pleasure of accomplishing the cure of these unfortunate patients, either compleat, or at least as much so, as can possibly be obtained in their situation.

There is at present at the hospital at Torgau, a soldier who had been grievously wounded; the shoulder and arm were very bad, from the extravasation the contusion had occasioned; the scapula and clavicle were entirely shattered; the head of the os humeri dislodged from the glenoid cavity, and pushed downwards; the ligaments having been too violently stretched, now hung loose; and the neighbouring parts, deeply bruised, were covered with a black slough, like a mortification. The contusion and double fracture of the shoulder blade and clavicle are compleatly cured, the head of the os humeri never could be kept in its articulation, on account of the relaxation of the ligaments; the other symptoms are happily removed, but he has a cough, and almost constant fever, with its concomitant symptoms; whence we may conclude that matter is formed in some bowel, probably in the lungs, a consequence resulting from the contusion of the internal parts.

SECT. XXXIV

Every one will easily conceive, that this method of curing limbs that are wounded, fractured and shattered by gun-shot, such as I have been hitherto describing, is accompanied with a great deal of pain, and with murmurs and impatience on the part of the sick; that it requires a very judicious surgeon, and gives him abundance of trouble, care and anxiety; besides, I do not pretend that every patient was saved by it: The following lines are applicable on the occasion:

Non est in medico semper relevetur ut æger,Interdum docta plus valet arte malum.

But as they are oftener applicable with respect to amputation, the expediency of the method I have recommended, stands nevertheless on a solid foundation. To alleviate the pains and sooth the murmurs of the sick, we must flatter them with hope; as for the wounds made by the incisions, they are commonly necessary at a time when they do not think of complaining or opposing them, and they are much less severe than the horrible gash made by amputation. The objections arising from the difficulty attending this method are happily removed in our hospitals, by the care and humane vigilance which Frederick the Great has exerted to provide his victorious armies with surgeons capable of putting it in practice.

SECT. XXXV

I shall here add that with regard to those who have had the thigh or arm carried off by a cannon ball, I do not recollect that any of the first have been brought to our hospital; they doubtless died instantly in the field of battle, in consequence of the hemorrhage. Several of those who had the arm carried off were brought, but the camp surgeons had previously stopt the bleeding, and applied the dressings commonly used after amputation, and we cured them afterwards by the method mentioned in § XXXI. The men wounded in this manner afford me an opportunity of inserting in this place, what I had to say with respect to the necessity of amputation in consequence of an hemorrhage; but I shall be very brief, as in these times, when surgery makes such progress, there is no artist but knows, and is familiarly acquainted with the different methods of stopping a bleeding. Therefore, although the interosseous, the brachial and crural arteries, near the articulations of the elbow or knee, or any other branches of arteries when divided, may give the surgeon a good deal of trouble, he is not obliged on that account to take off the limb; for in whatever situation we suppose the artery to be injured, the surgeon may always, by proper dilations, come at the wound, and stop the bleeding by the application of astringents, among which agaric and spirit of turpentine has, with us, very often succeeded, or by compression or ligatures, or lastly by all these means united; thus amputation ought never to be performed on account of an hemorrhage. It is even astonishing to conceive how surgeons should think of such an expedient, as frequently the difficulty of stopping the bleeding after amputation is greater than on any other occasion, especially if it be performed below the knee40. I therefore persist in my opinion, whether the wound of the arteries be only accompanied with one in the soft parts, or whether at the same time the bone be fractured or shattered: In this last case, I should join the treatment mentioned in this section to that of § XXIV.

It will here perhaps be objected, that all these means would be to no purpose, if the brachial or crural arteries are wounded at a certain height, because, in such a case, the limb must waste away for want of nourishment. I shall return an answer in a few words, with respect to the crural artery at the upper part of the thigh, which is, that whether my method can, or cannot be adopted in this case, there is no alternative; no surgeon as far as I know having ventured to perform amputation at this part, because every body would dread the patient's expiring during the operation41: Neither would the wounds of the brachial artery induce me to take off the arm at its upper part, although it be practicable, because I think every expedient is to be tried before we have recourse to this; and as from several cases we learn, that after the operation for the aneurism the member has recovered its heat, motion, and strength42, even when the trunk of the brachial artery has been cut through; I think when it is wounded, we ought to tie it without fear, and afterwards provide for the preservation of the limb, by aperient spirituous fomentations and by gentle frictions, which contribute to open and enlarge the small vessels, and by that means to restore heat and life to the parts43. If we observe, the first or second day after the operation, a little swelling or heat below the wound, we may conceive great hopes that the whole limb will revive: If, on the contrary, whatever is below the wound shrivels, grows cold and dry, then we may think of amputation, without, however, being precipitate; as a mortification in this case is always slow, and sometimes the limb recovers heat and motion very late. But I am convinced this case will very rarely require amputation. In conformity to the plan I have proposed, I should now mention the two last circumstances wherein amputation is deemed necessary, a caries of the bone, and a cancerous disposition of the part; but I imagine it will be better first to relate some instances of cures effected without amputation, wherein this operation to many surgeons would have appeared indispensable.

The first case I shall relate is very remarkable, of a soldier in his royal highness prince Henry's regiment, whom my friend M. Kretchmer, an able artist, and principal surgeon of the hospital, and Mr. Sterneman one of the ordinary surgeons, had the care of under my direction, and cured compleatly to the surprize of every body. The left arm was terribly shattered by four different pieces of iron shot, the os humeri was broke through the middle, and the arm pierced with eight holes, and at the joint of the elbow there was a true aneurism, of the bigness of a large fist. Mr. Kretchmer began by applying the tourniquet at the armpit in order to stop the bleeding; then of the eight wounds or apertures, he chose two nearest to the fracture, and dilated them in such a manner as to lay the bone bare; he likewise dilated a little the six others; after these dilatations he extracted several large splinters, he then brought the two ends of the bone together, placed them in their proper position, in which he made them be kept by assistants, while he moistened all the wounds with equal parts of spirit of wine and arquebusade water, and covered them with lint; he wrapped up the whole arm in linnen cloth, and fastened the bandage moderately tight: he next applied gradual compresses to the aneurism, and bound it up with a roller by itself; after which he moistened the whole with the same mixture of spirit of wine and arquebusade water, and as much martial ball as he could dissolve in it, and applied over the bandage for the aneurism the fomentation which I have already mentioned, made with the species for the black decoction44. He slackened the tourniquet every two hours, drawing it tight again immediately; he removed it altogether at the end of a few days, contenting himself with compressing the artery under the armpit with bolsters and a bandage which did not hinder the dressing of the wounds. He dressed them every day, but the bandage for the aneurism he renewed only every other day, although two of the openings lay under it. In this manner he persevered with great assiduity for a considerable time. All this while he made the hand and fore arm be secured in a cylinder of strong pasteboard, and suspended in a sling. He bled the patient frequently, gave him vinegar and water for his drink, and made him take from time to time the powders which I mentioned before, consisting of nitre, Epsom salt, cream of tartar, and true Armenian bole45. By these means only, he restored this arm, which was so bad that it could not even be taken off, to such a state, that in the course of three months, after having removed some splinters, the aneurism was dispersed, and the fracture and wounds were perfectly cured.

We cured another soldier belonging to the regiment of Brandenburgh Bareith, whose elbow was miserably torn by five pieces of iron shot, some of which stuck fast in the part, and where both bones of the fore arm were shattered.

After having dilated the wounds, we extracted some splinters, sawed off a piece of the cubital bone about four inches long, and in dressing the wounds endeavoured to avoid too large a suppuration.

In the ordinary method amputation would certainly have been performed, as the fore-arm was shattered, and the upper arm which was untouched could admit of the operation, but we saved the arm and made a perfect cure without having recourse to such an expedient, which are so many evidences that give their testimony in favour of our method, which we can produce to the partisans of amputation.

M. de Sass, colonel commandant of a regiment belonging to the garrison of Lattorf, and who is at present commandant at Brieg, received at the battle fought near Czeslau, a musket shot in the leg, which shivered the two bones into several fragments, of which some of four or five inches in length were extracted. The surgeons thought amputation necessary, and pressed him to submit to it; he refused however and recovered; although the limb is bent outwards he can walk and go about his business with ease.

A soldier of the regiment of Cuirassiers of Gessler, called Lukrafka, was wounded in the going through the exercise with the regiment, in such a manner that the two bones were fractured in the middle, with several fissures lengthways. After having laid the fissures of the bone bare, I sawed through a piece of the tibia about five inches in length, which I removed together with the marrow; I separated with a pair of forceps the useless parts of the fibula which jutted out, then I placed the bones in their natural position, and at the expiration of four months the patient was cured. This limb was somewhat shorter than the other, he could nevertheless walk and leap with ease.

M. de Franckenberg, a captain in Hulsen's regiment of foot, was terribly wounded by a musket ball at the battle of Loboschitz; all the bones of the tarsus were broke and shattered in such a manner that it seemed almost necessary to take away the whole number; which being done, and the parts of the foot brought close together, it recovered so far that this gallant officer, with the help of a double heel, can walk conveniently, and is able to do duty along with his regiment in garrison at Alt-Sydow.

M. de Alvensleben, ensign in the guards, received at Torgau a wound above the foot which shattered the tibia and fibula, and the splinters forced by the violence of the shot formed three distinct layers; I was obliged to make a great many deep incisions, and in a little time he was so much better, that I could venture to entrust the remainder of the cure to the surgeon of the regiment. A soldier of Sybourg's regiment of foot, named Mieke, seventy years of age, received near Miessen in 1759, a musket shot which shattered the shoulder bone two fingers breadth below the articulation; a splinter was taken out five inches long; he was nevertheless perfectly cured at the end of nine months, and left Wittemberg to go to the hospital of Invalids at Berlin.

M. de Stabenwol, captain lieutenant of Grabow's regiment of foot, at the battle of Kunnersdorf, received a musket shot which shattered the head of the os humeri close to its articulation with the scapula; he was perfectly cured in the space of eight months, and went from Stettin to Berlin46.

M. de Rottkirk, commandant of the margrave Charles's regiment, and M. de Krockow, captain in Schlabrendorf's regiment of Cuirassiers, received each of them a wound through the joint of the shoulder, and were both compleatly cured at the expiration of about ten months.

M. de Britzke, commandant of Knobloch's regiment of foot, was wounded, near Dresden, by a musket ball which pierced the articulation at the elbow, and shattered the three bones which join at that place. Several splinters were extracted; this officer nevertheless in about two years was compleatly cured, and at present does his duty gloriously at the head of his regiment.

I shall finish the account of these cases with that of a prince wounded at the battle of Kunnersdorf. A musket ball wounded him very badly, passing through his foot at the articulation of the tarsus and metatarsus in such a manner, that all the metatarsal bones excepting one were shattered. Proper incisions and the other remedies already mentioned effected his cure, and restored him to the nation and the army to their great joy, although the wound was of that kind, for which surgeons were accustomed to amputate not above fifty years ago47.

SECT. XXXVII

I might enumerate the cases of a great number of wounded men cured in this way, but the instances I have mentioned may suffice to make it known; I shall only add, that even while I am writing, there are a great many patients in the hospitals at Torgau, whose bones were so broken and shattered, that hitherto surgeons would not have conceived that it was possible to cure them without amputation, and who are all nevertheless in the way of recovery, by the method I have recommended. There are very few surgeons of the army, who have not seen instances in our hospitals of patients whose limbs were to have been cut off, where to their great dread, every thing was ready, and they placed in order to undergo the operation, when, either from their fainting or their resistance, it has been put off, and recourse has been had to the method I have just pointed out, by which, contrary to the general opinion, they have been cured, have saved their limb, and used it afterwards with convenience. If we compare this with what has been said, § XXVII. it will readily appear, that for the most part it is extremely wrong to amputate the limbs.

SECT. XXXVIII

I have treated hitherto of accidents which quickly carry off the patients; I come now to consider those where the danger is not so pressing, and which terminate in death by slow degrees, a caries of the bone, and a cancerous state of the parts; for it is well known, that in these circumstances amputation is often deemed necessary.

A caries of the bone is either superficial or deep seated, recent or inveterate, occasioned by a vicious state of the fluids, or the consequence of some external hurt.

When it is recent and inconsiderable, whatever be the cause, there is no room to think of amputation at all, but the bone must be laid bare according to the extent of the caries, and scraped with a scalpel, or perforated in sundry places with the spike of a trepan; when the caries has gained the opposite part of the bone, we must then use the crown of the trepan, in order to take out the entire piece. I do not however propose entering into a detail of the manner of performing these operations.

With respect to the medicines proper in a caries of the bone, without the application of instruments, or which finish what the instruments have begun, we are furnished with a great many, of which it would be too tedious to give a list: I must only give a caution not to employ the mineral acids, even the anodyne mineral liquor of Hoffman, so much boasted of by some practitioners in diseases of the bones; for they all do hurt. It is well known that when these acids are used for the teeth, they whiten them, but at the same time destroy their substance, rendering them crumbly and friable like limestone; now the other bones being less solid and hard than the teeth, there is so much the more reason to apprehend the same effect, by their penetrating from the affected part of the bone, where they are applied, to that which is sound. In consequence of this, the bones which appear mended after the use of these liquors, are, in a short time, worse than before48.

The real method of doing service to bones consumed by a caries, is like what happens to boards joined together with nails, if you make them excessively dry, the nails fall out of themselves; and doubtless it is this notion that has given rise to the practice of employing hot irons, and acid liquors, as driers, to promote the exfoliation of bones. But both these methods are attended with the inconvenience I have already mentioned, with respect to acids, of acting with so much violence on the diseased parts, that they extend their action in a dangerous manner, to those that are sound. We may nevertheless employ hot irons with success in constitutions abounding with moisture, or when it is of consequence immediately to stop the progress of the disease. The following medicines act efficaciously, but with less violence, frankincense, mastich, myrrh, balsam of Peru, and essential oil of cloves; but this oil should be used with moderation, since when it is employed for carious teeth, they become friable, and crumble away by degrees in a short time49.

When the caries is removed, in order to compleat the cure, we ought to prescribe a nourishing diet, but not too oily; broth, in which viper flesh is boiled, is very useful50. The dressing should then only consist of dry lint, taking all imaginable care to hinder the contact of the external air. When the caries is accompanied with a vitiated state of the blood, the external treatment is the same, and succeeds equally, provided internal medicines, suitable to the nature of the ailment, be joined with it; with this precaution, a caries from a venereal cause, may be cured like any other.

SECT. XXXIX

It will certainly be asked, What must be done when the best applications fail, and must we not amputate when the caries is very extensive? I answer, that amputation is to no purpose if the caries be attended with a bad habit of body, and while the morbid cause remains; when this is removed, we ought not to despair of a cure, although the greater part of the bone be carious, as the cases I have already related plainly demonstrate51. We ought therefore to try other means, and trepan the bone in several places, till whatever is rotten be taken away. There are many bones, whereon amputation, even if it were of use, is not practicable; if, for instance, the caries has attacked the upper parts of the humeral, or thigh-bone, the jaw-bone, &c. The method of treating the diseases of the bones, may be learned from the cases of so many soldiers wounded at the articulations of the elbow, knee, &c. and who, by the care bestowed on them in our hospitals, had their limbs saved, notwithstanding they lost very large pieces of bone; some of which were separated by nature, and some by the help of the surgeon: And as no person will deny that the wounds made by a surgeon, with an exceeding sharp instrument, and with much circumspection, in order to remove the pieces of corrupted bone, are more easily cured than wounds that are lacerated and contused, by means of a ball, grape-shot, or splinters, &c. If the habit of body allows of any hope of curing the caries, the method I have pointed out § XX. may also be practiced in this case. It is true, the limb often remains deformed after it, but this does not always happen; and frequently the callus fills up the whole vacuity left by the part of the bone which is taken out, however considerable it may have been. We read of successful cures, where even the loss of the entire bone has been supplied by means of a callus52; besides, the deformity of the limb does not take away the total use of it53.

SECT. XL

It now remains, that I should say something concerning cancers; on which subject I shall be brief, as it has been treated of by very able hands54. If the complaint be recent, the constitution good, if internal medicines and outward applications have produced no effect, the vitiated part must be extirpated before the disease takes root, and communicates the infection farther. But the greater number of those who have the misfortune to be attacked with this disease, putting off the amputation from time to time, it happens when they do resolve on it, either that it accelerates their death, or the humour falls upon another part: For this reason, the operation for extirpating it, should be performed much more seldom than it is55; and it were greatly to be wished, that physicians would endeavour to find out some remedy for this horrid disease, without having recourse to amputation; but it is not my intention to dwell on this topic.

SECT. XLI

I have now finished what I had most material to say, against the practice which still prevails, of too precipitately taking off the limbs when they are contused or shattered.

Are my reasons well-founded, or does the method I propose deserve to be adopted? This I leave to be determined by the judicious reader; for my own part, I shall never experience any sensation more agreeable, than the recollection of having saved the lives and preserved the limbs of so many unfortunate men in our hospitals, whose wounds were of the kind for which practitioners hitherto have had recourse to amputation; and it were to be wished, that so many cures happily effected, might repress that kind of folly, by which, in some countries, surgeons are excited, and even encouraged by public rewards, to perform frequent amputations. Another advantage will accrue from this publication, which is, that all those who judged unfavourably of the surgeons of our hospitals, on hearing they never employed amputation, will, I hope, lay aside their prejudices on this score, and may even derive benefit from our example.