A dissertation on the inutility of the amputation of limbs

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.