A dissertation on the inutility of the amputation of limbs

by Johann Ulrich Bilguer

I shall treat at present of large contusions of the limbs, especially of those where the fleshy parts, as well as the bones, are extremely bruised and shattered, as commonly happens, when the hand, the foot, the elbow, the leg, arm or thigh, have been bruised by a large stone, a beam of wood, a cart-wheel, a screw, a press, &c. In such cases, shall the patient get sooner well by amputating or not amputating this shattered limb? I answer, by not amputating; the worst consequences that can be apprehended, is a mortification or an hemorrhage. With regard to the mortification, unless every thing I have hitherto said concerning it be intirely groundless, we ought not to be afraid of it; and it is much easier to prevent than to cure it. With respect to the hemorrhage, it is no doubt to be dreaded, but this dread can be no reason for instantly taking off the limb: To be convinced of this, we need only examine those wounded men who have had an arm or leg carried off by a ball, and the stump so shattered, that the bone has been shivered into several pieces, and the large blood vessels most shockingly torn, who have, notwithstanding, been cured without amputation, and with whom the bleeding has stopt, even without the assistance of a surgeon. Nevertheless, every body knows that contusions of this kind have been hitherto, by most surgeons, accounted a sufficient cause for amputation; and that when the hand or foot have been shattered, they have carried their inhumanity so far, as to take off, not only the leg or fore-arm, but even sometimes above the knee or joint of the elbow.

Those who follow this method, amputate within a few days of the accident, while the patient is vigorous, and without waiting for the event of any other kind of treatment; for if the patient be weak, old or very ill, even with the consequences of the wound, they do not venture upon the operation.

It would however, in my opinion, be much better not only not to take off an arm, a thigh, or a leg, which are unhurt, but even to endeavour to save the foot or hand which are shattered, in obviating, by medicine and diet, as well as by external applications, the accidents that may ensue; and thus prevent a person who has already suffered so severely, from meeting with a treatment still more severe.

It will be asked, if the thing be possible? The following observations will furnish an answer. I publish them with so much the more confidence, as they are known, not only by the patients themselves, but by a great number of the physicians and surgeons of the army. They must be decisive in favour of preserving contused and shattered limbs, in opposition to amputation.

SECT. [XXI].

When a patient is brought to our military hospitals, who has had his foot, leg, hand or arm shattered by a ball, or any other violent cause, whether the parts are intirely carried off, or adhere by a little flesh and skin, but in such a manner that there is not any hope of a re-union; in this last case, we begin by cutting through these slender attachments which keep the part suspended, and thus intirely separate it from the body. In both cases, when pieces of the extremities of the bones jut out, and may prove hurtful, they must be sawed off with a convenient saw, whether they be moveable or still firmly adhere to the limb: When they are moveable, they must be held by an assistant. I hope no man in this treatment, will pretend to see any thing like what is properly called amputation, which I condemn.

After this first operation, I carefully examine if there be still any small splinters left, and whether they are only held by the fleshy parts, or still adhere to the bone; I remove all those, with the fingers, or with instruments, that can be separated without violence or a fresh effusion of blood.

After removing as many splinters as I can, I slightly compress the limb between my hands, gently stroking it lengthways, from above downwards, endeavouring, at the same time, to restore, as much as possible, its natural shape; I dress the sore with a digestive, to which I add a little essence of myrrh, or solution of mastic: I cover the whole with dry lint; applying the same bandage as after artificial amputation, sufficiently tight, without, however, running the risque of causing pain or increasing the inflammation: Afterwards I moisten the whole with as much spirit of wine as may penetrate to the parts affected; taking care to keep the limb extended in a right line, and laid soft.

The first days, till the suppuration becomes plentiful, I only dress it once every twenty-four hours, sometimes seldomer; but when the suppuration is begun, I renew the dressings twice a day; and such of them as immediately touch the bone, or fleshy parts of the wound, I cover with lint dipt in solution of mastic, balsam of Fioraventi, or some other balsamic essence, in order, by that means, to prevent too large a suppuration. I likewise remove, each dressing, all the little shivers of bone which do not reunite, and which, though they could not be separated at the first dressing, may in the succeeding ones.

With respect to the larger fragments, which must form the stump of the bone, I not only take care not to loosen them, but even, as I already remarked, endeavour to promote their coalition, by light compression with the hands, and binding the bandage somewhat tighter than I would otherwise do. If, at the expiration of a month, a fragment of this kind is not coalesced, but on the contrary, is become more loose, without however being intirely so; in that case, by shaking it gently, moving it upwards and downwards, and loosening the fleshy parts that hold it, I endeavour to bring it away intirely. If there are some of them cracked as high as the articulation, I give myself no concern about them, but leave them to nature[21]. But as to the small, short, pointed shivers which do not re-unite with the bone, I take care, as I have already observed, to remove them as soon as possible, commonly in the first seven or eight dressings; and at each dressing, I gently stroke down the muscular flesh towards the end of the stump; I keep the whole firm, by giving a proper degree of tightness to the bandage; moistening it, as long as the dressings are necessary, two or three times a day with spirit of wine. By these means, such kind of patients, at the end of four or five months, are as compleatly cured as the nature of the accidents will admit of.