Kitabı oku: «A dissertation on the inutility of the amputation of limbs», sayfa 5

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 rarely³². 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 occasion³³.

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 our³⁴ 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.

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. 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 cure³⁵. 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 ones³⁶; 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 body³⁷.

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 bole³⁸.

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 fomentations³⁹, 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.

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 knee⁴⁰. 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 operation⁴¹: 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 strength⁴², 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 parts⁴³. 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 decoction⁴⁴. 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 bole⁴⁵. 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 Berlin⁴⁶.

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 ago⁴⁷.