Part 5

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. 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. 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[36]. 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[37]; 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[38].

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.

FOOTNOTES:

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

[37] 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.

[38] 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.

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[39].

FOOTNOTES:

[39] 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[40], and exactly follow the plan laid down § XIV. by which means I have almost always happily cured contusions of this kind.

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

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

FOOTNOTES:

[40] 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.

SECT. XXXIV.

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

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

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

SECT. XXXV.

I shall here add that with regard to those who have had the thigh or arm carried off by a cannon ball, I do not recollect that any of the first have been brought to our hospital; they doubtless died instantly in the field of battle, in consequence of the hemorrhage. Several of those who had the arm carried off were brought, but the camp surgeons had previously stopt the bleeding, and applied the dressings commonly used after amputation, and we cured them afterwards by the method mentioned in § XXXI. The men wounded in this manner afford me an opportunity of inserting in this place, what I had to say with respect to the necessity of amputation in consequence of an hemorrhage; but I shall be very brief, as in these times, when surgery makes such progress, there is no artist but knows, and is familiarly acquainted with the different methods of stopping a bleeding. Therefore, although the interosseous, the brachial and crural arteries, near the articulations of the elbow or knee, or any other branches of arteries when divided, may give the surgeon a good deal of trouble, he is not obliged on that account to take off the limb; for in whatever situation we suppose the artery to be injured, the surgeon may always, by proper dilations, come at the wound, and stop the bleeding by the application of astringents, among which agaric and spirit of turpentine has, with us, very often succeeded, or by compression or ligatures, or lastly by all these means united; thus amputation ought never to be performed on account of an hemorrhage. It is even astonishing to conceive how surgeons should think of such an expedient, as frequently the difficulty of stopping the bleeding after amputation is greater than on any other occasion, especially if it be performed below the knee[41]. I therefore persist in my opinion, whether the wound of the arteries be only accompanied with one in the soft parts, or whether at the same time the bone be fractured or shattered: In this last case, I should join the treatment mentioned in this section to that of § XXIV.

It will here perhaps be objected, that all these means would be to no purpose, if the brachial or crural arteries are wounded at a certain height, because, in such a case, the limb must waste away for want of nourishment. I shall return an answer in a few words, with respect to the crural artery at the upper part of the thigh, which is, that whether my method can, or cannot be adopted in this case, there is no alternative; no surgeon as far as I know having ventured to perform amputation at this part, because every body would dread the patient's expiring during the operation[42]: 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[43], 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[44]. 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[45]. 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[46]. 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.