Part 4

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

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

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

I cured a patient who had been wounded by a bullet which entered the cavity of the os humeri; he would not consent to have it extracted, which did not however prevent his recovery, nor has he felt any further inconvenience from it than a small protuberance on the place where the ball is still lodged[24].

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

I fix the limb in its natural position, suspending the arm in a sling, or half-cylinder adapted for the purpose. For the leg, I use Mr. Petit's machine, or splints, made of wooden rods covered with straw, and wrapped up in linnen cloth; and in the dressings, my chief aim is to keep them sufficiently tight above and below the wound, to promote the consolidation of the larger pieces of bone, by keeping them firm in their places, and preventing the re-absorption of pus. The diet and medicines are the same as in § XXII. By this method a very great number of wounded men have been restored to health, in two, three or four months; and some not before the expiration of eight. My observations confirm those of Horstius, who remarks, that a man who has lost a great portion of the tibia and fibula, may nevertheless, after his cure, walk with ease, and halt but very little[25].

FOOTNOTES:

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

[25] HORSTII _observationes medicæ_, part ii. 1. 4. obs. 10. Mr. de Frengler, captain lieutenant in the regiment of Anhalt Bernbourg, is an instance of a most successful cure of a wound of the leg of this kind. In the sequel of this dissertation may be seen, several striking cases of an extraordinary loss of substance in the bones being again repaired.

SECT. XXV.

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

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

A moderate compression of the neighbouring parts, in this case, as in those I have already mentioned, contributes to prevent the reabsorption of the purulent matter. If the inflammation runs high, and the patient is young, it should be moderated by bleeding, and other medicines calculated to check and resolve the inflammatory denseness of the blood[26].

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

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

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

FOOTNOTES:

[26] 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.

SECT. XXVI.

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. Others, such as I have described § XXIV. 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[27], or to work at any trade; two hundred and thirteen remained incapable of any labour, civil or military, what they call grand invalides[28]; 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[29]: 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[30]. 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[31].

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[32], I hope it will be readily acknowledged, that my method of treating wounded limbs, by saving them, is highly preferable to that of amputation.

FOOTNOTES:

[27] _Halbe Invaliden._

[28] _Ganze Invaliden._

[29] _Schwerfracturirte._

[30] 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.

[31] 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.

[32] 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.

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[33]. 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[34].

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. 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. 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[35] 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. 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.

FOOTNOTES:

[33] 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.

[34] 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.

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

SECT. XXX.