Part 6

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[47].

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[48].

FOOTNOTES:

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

[42] 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.

[43] 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.

[44] 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.

[45] See § XIII.

[46] § XXXII. 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.

[47] 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.

[48] _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. 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.

A caries of the bone is either superficial or deep seated, recent or inveterate, occasioned by a vicious state of the fluids, or the consequence of some external hurt.

When it is recent and inconsiderable, whatever be the cause, there is no room to think of amputation at all, but the bone must be laid bare according to the extent of the caries, and scraped with a scalpel, or perforated in sundry places with the spike of a trepan; when the caries has gained the opposite part of the bone, we must then use the crown of the trepan, in order to take out the entire piece. I do not however propose entering into a detail of the manner of performing these operations.

With respect to the medicines proper in a caries of the bone, without the application of instruments, or which finish what the instruments have begun, we are furnished with a great many, of which it would be too tedious to give a list: I must only give a caution not to employ the mineral acids, even the anodyne mineral liquor of Hoffman, so much boasted of by some practitioners in diseases of the bones; for they all do hurt. It is well known that when these acids are used for the teeth, they whiten them, but at the same time destroy their substance, rendering them crumbly and friable like limestone; now the other bones being less solid and hard than the teeth, there is so much the more reason to apprehend the same effect, by their penetrating from the affected part of the bone, where they are applied, to that which is sound. In consequence of this, the bones which appear mended after the use of these liquors, are, in a short time, worse than before[49].

The real method of doing service to bones consumed by a caries, is like what happens to boards joined together with nails, if you make them excessively dry, the nails fall out of themselves; and doubtless it is this notion that has given rise to the practice of employing hot irons, and acid liquors, as driers, to promote the exfoliation of bones. But both these methods are attended with the inconvenience I have already mentioned, with respect to acids, of acting with so much violence on the diseased parts, that they extend their action in a dangerous manner, to those that are sound. We may nevertheless employ hot irons with success in constitutions abounding with moisture, or when it is of consequence immediately to stop the progress of the disease. The following medicines act efficaciously, but with less violence, frankincense, mastich, myrrh, balsam of Peru, and essential oil of cloves; but this oil should be used with moderation, since when it is employed for carious teeth, they become friable, and crumble away by degrees in a short time[50].

When the caries is removed, in order to compleat the cure, we ought to prescribe a nourishing diet, but not too oily; broth, in which viper flesh is boiled, is very useful[51]. The dressing should then only consist of dry lint, taking all imaginable care to hinder the contact of the external air. When the caries is accompanied with a vitiated state of the blood, the external treatment is the same, and succeeds equally, provided internal medicines, suitable to the nature of the ailment, be joined with it; with this precaution, a caries from a venereal cause, may be cured like any other.

FOOTNOTES:

[49] I saw two patients who had each of them a troublesome caries, the one on the tibia, the other on the external protuberance of the fibula; their complaints, they told me, were of long standing, and that they were cured by a travelling quack, the one in six weeks, the other in a somewhat longer time. What I learned of the colour of the medicine, its properties, and of its effects on the ailment, induced me to think it was an acid spirit. This incident confirms what I was told by others, and what Mr. Bilguer now remarks. TISSOT.

[50] I have seen several times, as well as Mr. Bilguer, the teeth crumble away by degrees, after using the oil of cloves; I have seen the same thing happen without the use either of it or of acids; I have, at other times, employed it without any such effect, and although I am convinced that it does hurt sometimes, it is only, I imagine, when the caries is very considerable, and the tooth much wasted: This is not, however, sufficient reason to give up, entirely, a medicine often very serviceable in many cases of carious teeth. TISSOT.

[51] The indiscriminate use of viper broth is not proper at all times, or in all cases of carious bones.

SECT. XXXIX.

It will certainly be asked, What must be done when the best applications fail, and must we not amputate when the caries is very extensive? I answer, that amputation is to no purpose if the caries be attended with a bad habit of body, and while the morbid cause remains; when this is removed, we ought not to despair of a cure, although the greater part of the bone be carious, as the cases I have already related plainly demonstrate[52]. We ought therefore to try other means, and trepan the bone in several places, till whatever is rotten be taken away. There are many bones, whereon amputation, even if it were of use, is not practicable; if, for instance, the caries has attacked the upper parts of the humeral, or thigh-bone, the jaw-bone, &c. The method of treating the diseases of the bones, may be learned from the cases of so many soldiers wounded at the articulations of the elbow, knee, &c. and who, by the care bestowed on them in our hospitals, had their limbs saved, notwithstanding they lost very large pieces of bone; some of which were separated by nature, and some by the help of the surgeon: And as no person will deny that the wounds made by a surgeon, with an exceeding sharp instrument, and with much circumspection, in order to remove the pieces of corrupted bone, are more easily cured than wounds that are lacerated and contused, by means of a ball, grape-shot, or splinters, &c. If the habit of body allows of any hope of curing the caries, the method I have pointed out § XX. may also be practiced in this case. It is true, the limb often remains deformed after it, but this does not always happen; and frequently the callus fills up the whole vacuity left by the part of the bone which is taken out, however considerable it may have been. We read of successful cures, where even the loss of the entire bone has been supplied by means of a callus[53]; besides, the deformity of the limb does not take away the total use of it[54].

FOOTNOTES:

[52] The observations of M. Muzel, p. 83. confirm my opinion, where he says, that all those on whom amputation was performed on account of carious bones, died in consequence of it.

[53] Such is that mentioned by Scultetus, _Armentar. Chirurgicum_, _obs._ 81. in which we see a callus supply the place, not only of the tibia, but also of a part of the fibula, which he had extracted, and at the close of the cure, the patient walked without the help of a staff.----See also the Medical Essays of Edinburgh, vol. i. p. 312.----_Ubersatzt durch D. Carl. Cristian Krausen_, _p. 51_. And the same Essays, vol. v. p. 371. mention one much more surprizing, “for the whole tibia of one leg came out, and the tibia of the other leg separated in small pieces. Nevertheless the patient, who was a boy of 10 or 11 years of age, in four months was able to walk without crutches, with his legs straight, and continued well afterwards, and fit for country work.” These cases are so much the more decisive in favour of the method I employ, as the callus much more easily repairs the fragments of bone taken away by the surgeon after an external hurt, and where there is no morbid cause, which was very considerable in the case I have cited.

[54] See § XXXVI.

SECT. XL.

It now remains, that I should say something concerning cancers; on which subject I shall be brief, as it has been treated of by very able hands[55]. If the complaint be recent, the constitution good, if internal medicines and outward applications have produced no effect, the vitiated part must be extirpated before the disease takes root, and communicates the infection farther. But the greater number of those who have the misfortune to be attacked with this disease, putting off the amputation from time to time, it happens when they do resolve on it, either that it accelerates their death, or the humour falls upon another part: For this reason, the operation for extirpating it, should be performed much more seldom than it is[56]; and it were greatly to be wished, that physicians would endeavour to find out some remedy for this horrid disease, without having recourse to amputation; but it is not my intention to dwell on this topic.

FOOTNOTES:

[55] See the Dissertation of M. Kattschmied, on this subject.

[56] When the cancer is evidently the consequence of an external accident, neglected or injudiciously treated, amputation performed in time, may effect a cure; but when the disease has come on gradually, without being able to assign any external cause for it, I have almost constantly observed, although it be performed in time, it accelerates the patient's death; and sometimes after having been made undergo a degree of torture more painful than that of the cancer itself. It is hoped, that the virtues of hemlock will make the frequency of amputation in these cases be discontinued: It appears, however, by the conclusion of the section, that Mr. Bilguer had not seen Dr. Stork's pamphlet.

SECT. XLI.

I have now finished what I had most material to say, against the practice which still prevails, of too precipitately taking off the limbs when they are contused or shattered.

Are my reasons well-founded, or does the method I propose deserve to be adopted? This I leave to be determined by the judicious reader; for my own part, I shall never experience any sensation more agreeable, than the recollection of having saved the lives and preserved the limbs of so many unfortunate men in our hospitals, whose wounds were of the kind for which practitioners hitherto have had recourse to amputation; and it were to be wished, that so many cures happily effected, might repress that kind of folly, by which, in some countries, surgeons are excited, and even encouraged by public rewards, to perform frequent amputations. Another advantage will accrue from this publication, which is, that all those who judged unfavourably of the surgeons of our hospitals, on hearing they never employed amputation, will, I hope, lay aside their prejudices on this score, and may even derive benefit from our example.

FINIS.

Transcriber's Note

Original spellings, punctuation, inconsistencies and all apparent printers' errors are retained, with two exceptions:

In section 6, “hat” has been changed to “that” (“...that there is room to dread...”). In section 24, “endeavovour” has been changed to “endeavour” (“If there be any pointed splinters, I endeavour to...”).

The heading for Section 36 is missing from this translation. In Tissot's translation the missing Section 36 heading is at the top of page 83, before the sentence: “In conformity to the plan I have proposed...”.