A dissertation on the inutility of the amputation of limbs

I have had under my care, during the course of this late bloody war, a great number of wounded limbs, torn and shattered by cannon and musket balls, by the bursting of bomb-shells and grenades, by grape-shot, &c. I cured them without ever performing amputation, by the method described in the two preceding sections, although there were bones broken and shattered, large blood vessels divided, the flesh miserably lacerated, and limbs carried off in the manner I have described § XXI. (#pgepubid00075) Others, such as I have described § XXIV. (#pgepubid00086) in which the bones were split up as high as the articulation; all which circumstances might make us reasonably apprehend a tedious and difficult cure, too plentiful a suppuration, hemorrhages, violent inflammation, excessive corruption, mortification and death.

It will perhaps be asked me, Of those men so terribly wounded, whom you attempted to cure without the means of amputation, did none die? I shall return an answer by and bye. It will be further objected to me, that I have not taken notice of the os humeri, or the thigh bone being shattered; and it will be asked me, What must be done in cases where either of these bones are fissured as far as their upper extremities, in such a manner that we cannot hope to procure their coalition by means of any bandage? And finally, it will be remarked, I have not mentioned the wounding the brachial or crural arteries, or the large branches of these which pass between the radius and ulna, or tibia and fibula, called in both parts the inter-osseous arteries, whether these wounds be accompanied with a fracture of the bones, or otherwise. I shall reply to these two last objections, after having answered the first question in the following section.

SECT. XXVII

I had at one time, during the war, in a military hospital, six thousand six hundred and eighteen wounded patients, who were all treated according to my direction, and part of whom I attended myself; of these, five thousand five hundred and fifty-seven were perfectly cured, and in a condition to support all the fatigues of the service; a hundred and ninety-five were able to do duty in garrison, what they call half-invalides[26 - Halbe Invaliden.], or to work at any trade; two hundred and thirteen remained incapable of any labour, civil or military, what they call grand invalides[27 - Ganze Invaliden.]; and six hundred and fifty-three died.

These hundred and ninety-five half-invalides, and the two hundred and thirteen grand invalides, in all, four hundred and eight, were of the number of those who had their bones bruised, broken and shattered; of those, in a word, whose wounds were called complicated and dangerous[28 - Schwerfracturirte.]: For it is well known that with us, a man is not put on the list of invalides for a wound of the head, or of the fleshy parts; if, after wounds of this kind are healed up, there remains any weakness, stiffness, or tension of the part, we employ various medicines, both internal and external, ointments, liniments, fomentations, warm baths, by means of which they are commonly compleatly cured.

Let us at present suppose, that of the six hundred and fifty-three who died, no more than two hundred and forty-five died from the consequences either of a violent concussion, from wounds of the head, thorax, lower belly or spine; from a complicated fracture of the os femoris, or from putrid fevers, fluxes and other inward diseases, which often happen in military hospitals, even in cases of slight wounds, from the bad air which is breathed there; there will remain four hundred and eight, who may have died from the consequences of wounds with shattered bones; and this number is equal to that of those who were cured without amputation, although their wounds had been of the same kind[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.]. If, after making these calculations, we compare them with the prodigious number of wounded men, who, at the beginning of the war, had their limbs taken off on account of dangerous wounds, of whom scarce one or two escaped with their lives; we may very safely conclude, that much the greater part of those four hundred and eight men cured and sent to the invalides, would have died if amputation had been performed on them, and this mocking artificial wound added to what they had already received. It would be trifling to pretend that amputation would have saved a great many of those who died, had it been timeously and properly performed[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.].

Further, if it be considered, that many of those who died, might have recovered, had they been taken care of any where else than in an hospital, where the air is very bad; and if it be called to mind at the same time, what some very eminent surgeons have observed, that two thirds of those die who have their limbs cut off[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.], I hope it will be readily acknowledged, that my method of treating wounded limbs, by saving them, is highly preferable to that of amputation.

SECT. XXVIII

Finally, I must add, that the greater number of those who died in our hospitals, in consequence of wounded limbs, were of those who had the os femoris shattered near its upper articulation; and as we are not at present acquainted with any means of relieving that accident; and as it has not as yet been attempted to amputate at that part, if we deduct these cases from the number mentioned in the preceding section who died, we shall see that the number of those whose lives were saved without amputation, considerably exceeds that of those who died. Since wounds near the superior part of the thigh bone, or shoulder, where the bones are shattered, ought always to be looked on as desperate.

SECT. XXIX

With respect to the os femoris, I do not know that any person hitherto has attempted to amputate it at its upper extremity with success: The arm has been successfully taken off at the shoulder, though but very rarely[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.]. Every body knows that the most able surgeons only allow of the amputation of the thigh at its lower part, a little above the knee; but even supposing it could be safely taken off in the middle, when the bone is neither shattered, nor fissured higher up, the operation will prove useless when it is done, as has so often been the case with our wounded men.

The difficulty attending the amputation of the upper parts of the thigh, is so considerable, that surgeons rather chuse to abandon to their fate those wounded men where it appears necessary, than to undertake it; and I own I am of the same opinion with them. If, nevertheless, a case occured, wherein the death of the patient appeared certain if amputation was not performed, and if the operation could afford any hope, I would even prefer taking the limb off at the articulation, rather than at any other place; for although it be extremely difficult, it prevents, at least, the inconveniences and accidents which a stump might occasion[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.].

But as there can be no necessity for this operation, but in consequence of the large arteries being wounded, by following the method I shall point out § XXXV. (#pgepubid00124) it will be rendered unnecessary, and disputes concerning it may be laid aside: For it is very certain, that the most dangerous accidents even of this part, may be remedied, like those in other parts, by joining to the method of treatment I have already mentioned, the operation I shall describe § XXXV. (#pgepubid00124) providing it be performed in time, before the patient be exhausted, and almost dying, from the effects of the hurt being too long left to itself. But the apprehension which patients have of the pain which deep incisions into the fleshy parts would occasion, prevents extracting the pieces of bone which compress or irritate the parts around; as also from cutting through the membranes that are overstretched, and cause a constriction; from giving a vent to impacted matter, and from conveying the medicines to the parts where they ought to be applied. The consequence of all this is, that the proper remedies are applied too late, and the patient sinks under the pressure of the accident.

But if nature were even able to get the better of these difficulties, there are others to which our[34 - What Mr. Bilguer says with respect to the wounded Prussians, is but too applicable to those of every army.] wounded men are subject, lodged together in too great number in military hospitals, where the state of wounds is rendered worse by a concurrence of several causes, and the cure of those of the most simple kind is retarded. The principal of these causes are want of cleanliness, an improper regimen, inconvenient beds, a continual noise, which hinders sleep, bad air, frequent removals from one place to another, and conducted in an inconvenient manner; these circumstances greatly contribute to make the instances of people recovering who are severely wounded near the upper part of the thigh, where the bone is shattered, so uncommon. But if any should pretend to say that there are none cured by the method described § XXXV. (#pgepubid00124) I shall only, in answer, produce the invalide soldiers themselves, who are at present, some in the country, others in the hospitals, whose recovery demonstrates the contrary. I acknowledge that this method is difficult and tedious, and that more die than recover; these, however, are not sufficient reasons for declaiming against, or intirely condemning it, as it is the only expedient left, amputation at the shoulder, or upper part of the thigh, being an operation not only difficult, but highly precarious.

SECT. XXX

I ought now to say something concerning a contusion, or echymosis; I shall confine my remarks particularly to that kind where there is a great quantity of extravasated fluid diffused under the skin, such as we often see, when a ball, without breaking the skin, injures it to such a degree, that it looks like a mortified eschar, and at the same time dislocates, fractures, or shatters the bones belonging to the part. When a surgeon meets with a contusion of this kind, the treatment is not greatly different from that recommended in a mortification; for the skin must be treated exactly like a mortified slough, must be laid open by several deep incisions, dressed with the powder mentioned § X. (#pgepubid00039) covered with a digestive ointment mixed with a little essence of myrrh, and the part affected, as well as all around it, kept constantly bathed with emollient fomentations, without any ingredient, either stimulating or astringent. With regard to the shattered bones, the same method may be followed as in § XX. (#pgepubid00071) If any of them are luxated, they must be reduced, without, however, confining them by the bandages used in ordinary luxations, and which, in this case, would make the necessary incisions uneasy, would prevent the gangrenous sloughs from casting off, and hinder the formation of pus: It is therefore sufficient, after having replaced the bone, to let it remain quite undisturbed; and when the corrupted slough is come off, the sore may be dressed like wounds of the fleshy parts.

SECT. XXXI

Some imagine that these violent contusions, accompanied with fractures, require amputation, as the properest method of cure[35 - Can it be called curing a limb to take it off altogether?]. I shall mention, what seems to me strongly against this opinion. In the first place we must reflect, that the danger of dying, in these cases, does not arise solely from the fluids extravasated in the contused part, but from the violent concussion, which gives a shock, and occasions a general compression of the vessels over all the body, especially the internal ones[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.]; and from the vessels being compressed, obstructed or ruptured, proceed extravasation, inflammation and suppuration.

This commotion of the whole body, depends on the external air, which being compressed, condensed, and rapidly pushed on by a ball, moving with vast velocity, acts on the body with greater force, and causes a more violent contusion, than any other substance, even the heaviest has ever done. From thence proceed contusions of the viscera, spitting and vomiting of blood, oppression, cough, pains, inflammations and suppurations internally, a fever, and other complaints which happen after contusions, seemingly slight, and confined to some particular part, but which are, in fact, the consequences of this general, and what may be called invisible, contusion of the whole body[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.].

The amputation of the limb does not remedy those accidents; on the contrary, it increases them, by means of the dread the patient feels at the thoughts of amputation, and by the excruciating pain which attends it; thus accelerating that death it was meant to prevent. I therefore boldly affirm, that amputation cannot be of service in those cases, wherein the nature of the parts and the state they are in, forbid it; that in many, it is hurtful, and hastens death; and that in others, even where the patient recovers, it is likewise improper, if he could be cured and the limb preserved; a surgeon is unpardonable who employs it in such a case.

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 bole[38 - I have not experienced a better medicine in such cases, than the plentiful use of oxymel. Tissot.].

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 fomentations[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.], and exactly follow the plan laid down § XIV. (#pgepubid00051) 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. (#pgepubid00086) 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. (#pgepubid00111) 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 knee[40 - Memoirs of the Academy of Sciences at Paris, for the year 1732.]. 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. (#pgepubid00086)

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 operation[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.]: 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 strength[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.], 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 parts[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.The surgical observations which demonstrate the recovery of heat in the parts after the operation for the aneurism, although the brachial artery has been tied very high, are common, and may be found among other observators besides those quoted by Mr. Bilguer, and there are doubtless few physicians or surgeons who have not had opportunities of seeing such cases themselves.It is a sight extremely interesting, to observe the gradual return of heat, strength and colour, to an arm on which the operation for the aneurism has been performed. I do not know that this operation was ever performed in the thigh, the artery being so guarded in this part, that an aneurism rarely forms here. I have seen the operation succeed very well in the inferior part of the leg, on the tibialis anterior, and the foot suffered but very little for a few days; it is true it is supplied with several other branches.Some curious dissections of dead bodies afford a third argument, as the crural artery has been found quite obliterated in the upper part of the thigh, in consequence of a morbid cause, without the leg having been deprived of its nourishment, though supplied perhaps more imperfectly.Warm water baths, in these cases where the circulation is to be promoted through the smaller vessels, and their diameters enlarged, are among the most efficacious remedies. Tissot.]. 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 decoction[44 - See § XIII. (#pgepubid00044)]. 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 bole[45 - § XXXII. (#pgepubid00117) It is long since the bolar earths have had the reputation of being useful in contusions, but this I am afraid is founded on a mistake; I have never, in any case, experienced the least effect from them that could induce me to think they possessed the virtues ascribed to them. True bole armenic might prove somewhat astringent in the first passages, but could not do any service in this way; or might suffer perhaps a small portion of the vitriolic acid it contains, to disengage itself; but four or five drops of the spirit of sulphur, would be more useful in this respect than a dose of the bole: Thus I am almost convinced it is of very little benefit in this composition, and if of any, it must be by blunting the action of the neutral salts, and preventing the uneasiness they sometimes occasion to persons of delicate stomachs. Tissot.]. 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 Berlin[46 - I have seen an officer, a captain in the French service, who received a musket shot, with the muzzle of the piece close to the part; the ball shattered the humeral bone near its head, close to the articulation: had the wound been somewhat lower, that is less dangerous, his arm would have been taken off; the impossibility, or the difficulty of the operation prevented it; he suffered all the inconveniencies that a wound can occasion, for a considerable time several splinters were extracted, at length at the end of five months he was cured. This case appears to me of consequence, because here we see a very bad wound of that kind for which amputation is performed every day, and the danger aggravated by the nature of the part where it is inflicted, where they do not amputate, because it cannot be done, yet it was cured. If this officer had been so fortunate as to be wounded a few inches lower, he would have had the misfortune of having his arm taken off. Tissot.].

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 ago[47 - Fifty years, a compliment which Mr. Bilguer pays surgeons of a more modern date.M. le Conte de B… a general officer in the Austrian service, received a wound much of the same kind, at Hochirken, and had the good fortune to be compleatly cured by M. Brunet, without amputation, which appeared indispensably necessary. He only continued a little weak, which in a man of his age and constitution generally goes off of itself: He was advised to go to the baths at Baden in Austria, and on his return was seized with an inflammatory fever, which proved mortal. Tissot.].

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. (#pgepubid00097) 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.