A dissertation on the inutility of the amputation of limbs

FINIS

1

Le Manuel du Chirurgien d'Armée; or, The Art of methodically curing Gunshot Wounds, &c. By L. L. M. C. Printed for Houry, at Paris. My edition is the second, published 1693.

2

I would not chuse to lay much stress on this argument; for if one weighs the circumstances of pain, the amount of what the patient suffers from the treatment necessary for saving the limb, will often be equal to that arising from amputation. But the two strongest reasons for prefering Mr. Bilguer's method is, the saving the limb as well as the life of the patient; the loss of which is often occasioned by amputation, but never by the pain of an incision. It is also true, that pain when slighter, though longer continued, is more easily supported by the patient. Tissot.

3

To these instances may be added, that of the son of Thomas Koulichan, a captain in the Austrian service, who, being wounded in the leg, and the bones shattered, in one of the latter battles of the war, held a candle with one hand and extracted the splinters with the other. He exhibited many other proofs, not only of courage in the field, but also of that fortitude in bearing pain which is very different from the other, and much more seldom met with. Tissot.

4

Celsus de re medica, l. 7. præf. Nevertheless Mr. Dionis, in his course of operations, (Demonstr. 2, Art. 9.) acknowleges, that even the most intrepid surgeons tremble at the instant they are going to perform this operation. Of all the operations, says he, that which occasions the greatest horror, is the amputation of a thigh, a leg or an arm. When a surgeon is about to take off a limb, and reflects on the cruel means he must employ, he cannot help feeling a tremour, and pitying the misfortune of the poor patient, who is under a fatal necessity of being deprived, for life, of a part of his body. And in another place he says, This operation ought rather to be performed by a butcher than by a surgeon.

5

Memoirs of the Royal Academy of Sciences, 1732. Art. 7.

6

Mr. Ranby, however, who was one of the surgeons of the British troops at the time of the battle of Dettingen, lays great stress upon the bark: It is true, that in one of his cases, having ordered it to an officer of seventy years of age, whose leg had been amputated, on account of his ancle, with the neighbouring parts, having been terribly shattered by a cannon ball, it did not keep the sore from growing worse, or prevent the patient's death. But that we may form a just estimate of the merit of the bark, and the effects of amputation at the same time, it will be necessary to compare this case with the one which precedes it. This comparison will, I imagine, be of use. – I shall quote the author's own words. “An Austrian officer, who had his hand miserably shattered by a cannon ball, was, by some accident, left in a wood near the field of battle, destitute of any manner of help, from Thursday till the Sunday following, when he was brought to Hanau. The next morning I was carried to see him, and to assist in taking off his arm. On viewing it, I found it mortified almost to the elbow, with a great swelling and inflammation quite up to the shoulder. As it was by no means adviseable to attempt an amputation in such circumstances, I proposed giving him the bark; which being no ways objected to, he entered upon immediately. The next day he was rather better: But, on the third, was evidently so. The inflammation was less, the swelling began to subside, and the edges of the mortification were separating. The arm was fomented and wrapped up in the oatmeal and stale beer poultice, with theriaca: And the dreadful symptoms which forbad the operation, were now so much abated, that his surgeons did not at all hesitate to take it off. But this was done to very little purpose; for three or four days after the amputation, being attacked with convulsions, he expired.”

I shall here subjoin five questions.

Would Mr. Bilguer have amputated in these two instances?

Would not his method have saved both these patients, especially the last?

Does not amputation seem to have contributed to their death?

Does it not evidently appear, that in the latter of these two cases, amputation destroyed the good effects of the bark, which seemed to conduct the patient to a speedy cure; and that in the former case, the bark had not power sufficient to repair the mischief occasioned by the amputation?

Does it not follow from these two observations, that however salutary the effects of the bark may be, those of amputation are hurtful in a greater degree? Tissot.

7

See Dionis's surgery, page 18. 4th edition.

8

These two last applications are not in Heister: The species pro cataplasmatic, consists of yarrow, wormwood, water germander, southernwood, chamomile, sage, hysop, rue, elder, St. John's wort, and red roses.

It is quite unnecessary to make use of all these ingredients at one time. Tissot.

9

As the composition of the martial ball may not be generally known, I shall describe it in this place: Take of filings of iron one part; white tartar two parts: Let them be reduced to a fine powder, and put into a matrass with as much French brandy as will swim about an inch above the powder; exhale to dryness, either in the heat of the sun or in that of a water bath. Pour fresh brandy upon the remainder, and evaporate them in this manner several times successively, till the mass appears resinous; then form it into balls nearly of the bigness of an egg.

I do not exactly know what quantity Mr. Bilguer means by sextarius; that measure, among the ancients, contained twenty four ounces, but here I believe it denotes somewhat less. If we suppose it to be about a pint, the medicine will be extremely good.

10

This composition is commonly called species pro decocto nigro, or the species for the black decoction.

11

In using the external vulnerary medicines, in which aloes is an ingredient, it must be remembered, what Mr. Bilguer remarks in another place, that they often prove purgative.

12

Mr. Bilguer might have even said hurtful; the only true temperants are, repeated bleedings and the acids, which are preferable to nitre, which is not very proper wherever there is reason to apprehend a mortification. Absorbents, which in some parts of the country where Mr. Bilguer writes, are still ranked in the class of temperants, are very hurtful in the present case, and never afford any relief to wounded patients.

13

This precept, of which the very reverse is but too frequently practised, is of very great consequence: It is founded upon this, that a discharge of blood proves that an incision has reached the quick; now every such incision produces an inflammation, which retards the suppuration already begun, and hence we interrupt this operation of nature which we meant to promote, and, as it is the means of preventing a mortification, whatever interrupts it contributes to the disease: It cannot, therefore, be too often repeated, that in general, incisions which cause a discharge of blood, ought never to be practised after a suppuration is begun. Tissot.

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.

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.

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.

17

See, on this subject, the memoir of M. Haller, on the sensible and irritable parts, T. 1. 4.

18

Sammlungen, &c. a performance which ought to be generally read.

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.

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.

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.

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.

23

He was a soldier in the guards, and is doing his duty in the field at the very time I write this.

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.

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.

26

Halbe Invaliden.

27

Ganze Invaliden.

28

Schwerfracturirte.

29

It is obvious that Mr. Bilguer has not made his calculations in so favourable a manner for himself, as he might have done; I am persuaded that in 6618 wounded men, a much greater number than 245 must have died from the consequences of concussion, large flesh wounds, fevers, fluxes, and other diseases, owing to a bad habit, bad air, the season of the year, &c. Tissot.

30

Such a pretence would in effect be absurd: The reasoning would amount to this; it is demonstrated that the danger arising from amputation, joined to that attending wounds of themselves curable, has killed a great many patients; therefore the danger arising from this operation, joined to that attending wounds which have proved incurable, would have saved a great many patients: Only the most blinded obstinacy could reason in such a manner. Tissot.

31

See the memoirs of the Academy of Surgery, t. 2. p. 256. where Mr. Boucher, in speaking of gunshot wounds, with the bone shattered near the articulation, shews that amputation commonly proves fatal, and that of three patients on whom it is performed, generally two die; whereas out of an hundred and sixty-five who had had the bones shattered, on whom amputation had not been performed, not one died. A degree of success which he ascribes, it must be owned, to the management of the surgeon; who, instead of spirituous applications, only made use of emollients, light digestives and anodynes.

32

M. Morand, the father, was the first who took off the arm at the joint of the shoulder. Mr. Le Dran performed it soon after in the presence of the most eminent surgeons of Paris, Messieurs Petit, Marechal, La Peyronie, Arnaud, &c. which number of witnesses, making his operation more extensively known, that of Morand has, as it were, been forgotten, and Mr. Le Dran has passed for having been the inventor. Mr. Bromfield performed it successfully within these few years at London; but notwithstanding a few cases whose event has been favourable, it is a very dangerous operation, and has sometimes miscarried. Dr. Home, an eminent physician at Edinburgh, equally a promoter of agriculture, medicine, and the arts, relates, that in the former war, he saw Mr. Mitchel perform the operation on two soldiers, where the os humeri was fractured as high as the joint, and who both died a few days after: It is true, he remarks that they were both in a bad way when the amputation was performed; but he adds, that this operation appears extremely dangerous, even when performed with every favourable circumstance. Medical facts and experiments, p. 114. With respect to the thigh, there is little room to hope that the struggle that is made to determine, when and how it should be taken off at the articulation, can be attended with the success which some people seem to expect from it. If such an operation should take place, it will perhaps very soon be asked, whether it ought not to be publicly condemned? Tissot.

33

I am of opinion, that if one had the misfortune of being reduced to the necessity of chusing between amputating at the upper part of the thigh, or at the articulation itself, one reason for prefering the latter, would be the greater ease there is in stopping the hemorrhage of the crural artery.

A surgeon and anatomist, who has been in repute, observes, That an hemorrhage of the crural artery is what is chiefly to be dreaded, but the operation requires too short a time, for such an hemorrhage to be fatal. It is surprizing to see him mention this operation as one that is very familiar; I make this remark, because, as he is not the only person who may allow himself to talk in this manner, a bold pretender to the art, on reading such a passage, might undertake an operation as easy and common, which has never yet been performed. Tissot.

34

What Mr. Bilguer says with respect to the wounded Prussians, is but too applicable to those of every army.

35

Can it be called curing a limb to take it off altogether?

36

It has been known long since, that this concussion, or what may be called a general contusion, is one of the principal causes of the danger arising from gunshot wounds, and more or less from those of all kinds of fire arms; but at present I do not recollect to have seen the mechanism of this effect so well explained as in this performance. The rapidity with which the air strikes, compensates what it wants in density: Those who love to reduce every thing to calculation, will be able exactly to determine this effect by the rule of proportion: Supposing on one hand, a stream of air, which has acquired, by the motion of the ball, a given velocity, and which acts upon a man with this degree of velocity; supposing on the other hand, a man falling upon a floor, likewise with a given degree of velocity, the effect will be equal, if the velocity of air, is to the man who falls, as the density of the board is to that of the air; or, more briefly, if the contusing bodies be in an inverse ratio of their densities. I am even induced to believe, that when the velocity is augmented to a certain degree, its effect is augmented in a greater proportion than its increase; or, to speak algebraically, that its effects ought to be expressed by some quality of its degrees; thus the effect of a velocity of 150 degrees, would be to the effect of a velocity of 125, not as 150: 125 or as 6: 5 but as the square, or perhaps some other quality of 150, to the square or the correspondent quality of 125.

There are physical reasons that induce us to believe that the case is so, and there are several observations which seem to confirm it. Those who have served in time of war, have all been witnesses of some singular instance or other of the effects of the percussion of the air; there are instances of people killed on the field, without being touched by the ball. I was told by officers, men of veracity, that at the battle of Fontanoy, a ball broke the thigh bone of a soldier in the Dutch army, without touching him; another saw a man who was rendered paralytic on one side, by a ball whizing past him. Curious observers know, that nothing so greatly fatigues an army as a high wind, even the centinels are tired, without marching; the reason is, that a high wind occasions a kind of general contusion, which of course produces weariness. I do not know but some of the effects of lightening may be imputed to the same cause. I shall add nothing to what Mr. Bilguer says concerning the effects of a contusion; he is sufficiently explicit on this head; and as I have already treated the subject pretty largely in my book termed Advice to the People, I shall only observe, that in the wounds made by musket-ball, the effect of the general concussion is not very considerable, but the danger, in such cases, proceeds from the topical contusion accompanying the wound, the small quantity of blood commonly discharged from it; and lastly, as Mr. Le Dran remarks, because the instant a man receives a gunshot wound, he is struck with a sudden dread he cannot possibly resist. There seems to me to be three reasons for this dread, of which even the wounded person himself is not altogether conscious; in the first place, the idea that gunshot wounds are dangerous; secondly, because the degree of the hurt is not known; thirdly, the instantaneous effect of the concussion, which renders a man much more susceptible of fear. There is a point of time when courage is useless. I shall beg leave, in this place, to insert a case I had from the eye-witnesses, and which demonstrates the bad effect of apprehension on wounded patients. Two officers, in the service of France, were wounded in the last campaign but one; one of them very dangerously, the other, who had been a prisoner a little time before, and had been extremely ill used, but very slightly; they were carried to the same place, and lodged in the same apartment; the first expected to die, but nevertheless recovered in a short time; the second hoped to be cured very quickly, and his wound, a superficial one in the leg, did not discover the least sign of danger. The place they were in was surprized, and they were informed they were made prisoners; the idea of what he had suffered, made so strong an impression on the latter, that he instantly found himself indisposed; the following dressing the wound appeared mortified, every remedy proved useless, and he died in a few days. Tissot.

37

The troublesome symptoms which I have here enumerated, happen seldomer when the limb is entirely carried off by the ball, although the concussion caused by the compression of the air must be greater in this case, than when the ball has only grazed; a circumstance which might induce one to call in question the justness of my remarks in this section. But these doubts will vanish, when we reflect, that in a contusion there is no discharge of blood, whereas it is very considerable in cases where the limb is intirely carried off; and thus, the remedy is here a consequence of the accident itself, since this hemorrhage effects what we would wish to effect by artificial bleeding; in contusions, where there is no discharge of blood, it removes obstructions, and disperses the extravasated humours, which are the consequences of concussion.

38

I have not experienced a better medicine in such cases, than the plentiful use of oxymel. Tissot.

39

An infusion of water-germander, and yarrow in water, with the addition of about a sixth or eighth of vinegar, is one of the most proper fomentations in such cases. Tissot.

40

Memoirs of the Academy of Sciences at Paris, for the year 1732.

41

I have not yet read the Dissertation on this subject, which obtained the prize from the royal Academy of Surgery; but by persons arrived from Paris, I have been informed, that the author carried a dog with him to the Academy, whose thigh he had cut off at the articulation.

Note by Tissot. There must be a mistake in this place, since the writers of these pieces for the prize never make themselves known. Not that I make any doubt of the possibility of taking off the thigh of a dog, but I don't apprehend that such a fact can be at all conclusive with respect to the same operation on the human species.

42

See Heister's Surgery, t. i. part i. ch. 13. Edinburgh Medical Essays, vol. ii. art. 15. vol. v. art. 17. The Promptuar. Hamburg. and the Collections of Breslau, in several places.

43

Anatomy, observations in surgery, and the opening of dead bodies, concur to establish Mr. Bilguer's opinion.

The anatomical proofs are drawn from the inspection of the arteries. I am persuaded, that unless the crural artery is wounded almost at its egress from the arch formed by the tendons of the abdominal muscles, where it loses the name of iliac, its being destroyed will very seldom occasion the loss of the limb; besides three small branches which it sends off almost at its egress, and on which, I own, should have no great reliance, for the nourishment of so large a limb, both on account of their smallness and their distribution, at about two or three inches distance from the artery, it sends off other branches much more considerable, among others, two called the muscular arteries, especially the external one, descends pretty large down the thigh, and very evidently contributes to the nourishment of the muscular parts; although their trunks have not been traced so far as the leg, I make no doubt but it may be discovered that their branches reach that part, and which, though scarcely visible in their natural state, would not fail to become larger, when the blood was thrown into them in greater abundance; besides, the anastomosis of any considerable branch with the trunk of the crural artery, conveys so much blood to it, that it may again become useful: Experience demonstrates that this happens in the arm, and it is highly probable that the same thing may take place in the thigh; the number of branches which spring from the brachial artery, almost from its beginning, and their distribution being very analogous to what we see in the crural artery.