A dissertation on the inutility of the amputation of limbs

by Johann Ulrich Bilguer

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.