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Pathology and Therapeutics, In Fifty Lectures

2003; Lippincott Williams & Wilkins; Volume: 408; Linguagem: Inglês

10.1097/00003086-200303000-00002

1528-1132

Theodor Billroth,

Medical History and Innovations

Theodor Billroth (1829–1894) (Fig 1) was born on an island in the Baltic sea off the coast of Pomerania where his father was the Lutheran pastor. When Billroth was 5 years old, his father died and the family moved to Griefswald where he received a solid education in the Gymnasium and where he later attended the university. Billroth wanted to be a musician but his mother insisted that he study medicine. He attended the medical school of the University of Gottingen, moving to Berlin for his senior year. After graduation, Billroth opened an office in Berlin as a general practitioner but, after 2 months in his office without one patient, he applied for a position in the clinic of Professor Langenbeck at the Charite in Berlin.Fig 1.: Dr. Theodor Billroth (Reprinted with permission from Mesiter der Chirurgie und die Chirurgischenschulen in Gesmate Deutschen Sprachraum. New York, George Thieme Verlag XXXVII: 56, 1951.)Billroth applied himself not only to the study of surgery, but also to pathology. In 1860 he accepted the chair of surgery in Zurich. In 1863, Billroth published his textbook, General Surgical Pathology and Therapy in Fifty Lectures. 1 In 1867, he moved to the University of Vienna where he presided over a surgical clinic of international importance. His clinic included animal laboratories where operations were perfected and residents were trained. In addition to being a great surgeon and teacher, Billroth was a scholar. In 1858, he published an important historic review of the treatment of gunshot wounds, “Historical Studies of the Nature and Treatment of Gunshot Wounds From the Fifteenth Century to the Present Time,” which was translated into English by Dr. C. P. Rhoades in 1931. 2 The classic article is from a chapter of Billroth’s textbook. 2 This chapter gives a good account of the treatment of gunshot wounds shortly after the introduction of anesthesia and shortly before the introduction of antiseptic and aseptic surgical techniques. Leonard F.Peltier MD, PhD In war many injuries occur that are to be classed among simple incised, cut, punctured, and contused wounds; gunshot-wounds themselves must be classed with contused wounds; but they have some peculiarities that entitle them to separate consideration, in doing which we must briefly come in contact with the domain of military surgery. Since fire-arms were first used in warfare (1338), gunshot-wounds have received special attention from surgical writers, so that the literature on this subject has become very extensive; of late, indeed, military surgery has been made almost a separate branch, which includes the care of soldiers in peace and war, and the special hygienic and dietetic rules which are so important in barracks, in stationary and field hospitals, also the clothing and food. Although the Romans, as was mentioned in the introduction, had surgeons appointed by the state with the army, in the middle ages it was more common for every leader of a troop to have a private doctor, who, with one or more assistants, very imperfectly took care of the soldiers after a battle, and then usually went on with the army, leaving the wounded to the care of compassionate people, without the commander or the army taking the responsibility. It was not till standing armies were formed that surgeons were detailed to certain battalions and companies, and certain (still very imperfect) rules and regulations were made for the care of the wounded. The position of military surgeon was, in those days, very ignoble, and such as we do not hear of now; for, even in the time of Frederick the Great, the army surgeon was publicly flogged if he permitted one of the long grenadiers to die. At that time, when the troops marched to meet the enemy at a parade-step, the movements of the army were very tedious and slow; the large armies had immense trains; for instance, in the Thirty Years’ War, the lancers carried along their wives and children in innumerable wagons; hence, in the medical arrangements pertaining to the train, there was no necessity for greater facilities of motion. The tactics started by Frederick the Great required greater mobility of the heavy trains, which, however, was only practically carried out in the French army under Napoleon. As long as a small province remained the seat of war during a whole campaign, a few large hospitals in neighboring cities might suffice; but, when armies moved about rapidly and had a fight now here now there, it became necessary to furnish more movable, so-called field hospitals, not far from the field of battle, and which could be readily moved from place to place. These ambulances, or flying hospitals, are the idea of one of the greatest of surgeons, Larrey, of whom we have already spoken. As I shall shortly tell you what is done with the wounded from the time they are injured till they enter the general hospital, I will here dismiss this subject, and only mention some of the many excellent works on military surgery. Especially interesting, not only medically but historically, are the somewhat lengthy “Memoirs of Larrey,” in which I especially recommend to you the Egyptian and Russian campaigns. These memoirs contain all Napoleon’s campaigns. Another excellent work we have in English literature, John Hennen’s “Principles of Military Surgery;” and in German, besides many other excellent works, we have “The Maxims of Military Surgery,” by Stromeyer, which is composed chiefly of experiences in the Schleswig-Holstein War; and, lastly, “Principles of General Military Surgery, from Reminiscences in the Crimea and Caucasus, and in the Hospital,” by Dr. Pirogoff. Wounds caused by large missiles, such as cannon-balls, grenades, bombs, shrapnel, etc., are partly of such a nature that they kill at once, in other cases tear off whole extremities, or so shatter them that amputation is the only remedy. The extensive tearing and crushing caused by these shot do not differ from other large crushed wounds caused by machinery, which unfortunately now so often occur in civil practice. Musket-balls used in modern warfare differ in some respects: while the small copper bullets with which the Circassians shoot are scarcely larger than our so-called buckshot, large, hollow, leaden bullets were used in the late Italian War; these were much larger than the old-fashioned ones, and were particularly dangerous, because they readily broke upon striking a bone or tense tendon. Besides these, the solid round and conical bullet are used, but their effects do not differ much. The Prussian long bullet, which is held in the cartridge of the needle-gun, is a solid bullet of the form and size of an acorn. You must not think that the projectile, as found in the wound, has the same shape as when put in the gun; but it is changed in form as it comes out of the rifles of the gun, and is also flattened in the wound, so that we often find it a shapeless mass of lead, which scarcely shows the form of the projectile. We shall now briefly consider the various injuries that may be caused by a bullet; in doing which, we shall naturally confine ourselves to the chief forms. In one set of cases the bullet makes no wound, but simply a contusion of the soft parts, accompanied by great suggillation and occasionally by subcutaneous fracture. According to recent authorities, simple subcutaneous fractures are not very uncommon in war. These injuries are caused by spent bullets, i.e., such as come from a long distance and have not force enough to penetrate the skin; such a bullet, striking over the liver, may push the skin before it and make a depression in or a rupture of the liver, and then fall back without producing an external wound. Like injuries are caused by bullets striking the skin at a very oblique angle. Firm bodies, such as watches, pocket-books, coins, leather straps on the uniform, etc., may also arrest the bullet. These contused wounds, which, especially when affecting the abdomen or thorax, may prove very dangerous, have always excited the attention of surgeons and soldiers; formerly they were always referred to the so-called “wind of the ball,” and it was thought that they were caused by the bullet passing very close to the body. The idea that injuries could be caused in this way was so firmly established, that even very well-informed persons worried themselves in trying to explain theoretically how they resulted from the wind of the ball. One said that the air in front of and near the bullet was so compressed that the injury was due to this pressure; another thought that, from the friction in the barrel of the gun, the bullet was charged with electricity, and could in some unknown manner cause contusion and burning at a certain distance. If the conclusion that the whole idea of the wind of balls was a fable had been arrived at sooner, these fantastic theories would not have arisen. Contusions from spent and oblique bullets are to be treated like other contusions. In the second case, the bullet does not enter the soft parts deeply, but carries away part of the skin from the surface of the body, leaving a gutter or furrow. This variety of gunshot-wound is one of the slightest, unless, as may happen in the head, the bone is grazed by the bullet, and portions of lead remain in the skull. The third case is where the bullet enters the skin without escaping again; the bullet enters and generally remains in the soft parts; it makes a tubular wound. Various other foreign bodies may be carried into these wounds, such as portions of uniform, cloth, leather, buttons, etc.; a bone may also be splintered, and the splinters driven into the wound and tear it. After perforating the skin and soft parts, the bullet might rebound from a bone and fall out of the same opening, so that you would not find it in the wound, in spite of there being only one opening. The wound that the bullet makes on entering the body is usually round, corresponding to the shape of the ball; its edges are contused, occasionally bluish-black, and somewhat inverted. These characteristics hold in the majority of cases, but are not absolute. The fourth and last case is where the bullet enters at one point and escapes at another. If the course of the wound is entirely through the soft parts, and the bullet has carried in no foreign body, the point of exit is usually smaller than the entrance, and is more like a tear. If the bullet has struck a bone and driven bone-splinters or other foreign body before it, the point of exit is occasionally much larger than the entrance; there may also be two or more points of exit from bursting of the bullet into several pieces or from several splinters of bone. Lastly, splinters of bone may make openings of exit like those from a bullet, while the latter, or part of it, remains in the wound. Too much value has been attached to the distinction of the openings of entrance and exit; this is only important in forensic cases, where it may be desirable to know from which side the bullet came, as this may give a clew to the author of the injury. The course of the bullet through the deep parts is occasionally very peculiar; its course is sometimes deviated by bones or tense tendons and fasciae, so that we should be greatly mistaken in supposing that the union of the points of entrance and exit by a straight line always represented the course of the bullet. In this respect, the encircling of the skull and thorax is most peculiar: for instance, a bullet strikes the sternum obliquely, but without sufficient force to perforate this bone; the bullet may run along a rib under the skin to the side of the thorax, or even to the spinal column, before escaping again; from the position of the points of entry and exit, we might suppose the bullet had passed directly through the chest, and be greatly astonished when such patients come, without any difficulty of breathing, to have their wound dressed. The complication of gunshot-wounds with burns by powder, such as results from shooting at close quarters, rarely occurs in war. It is not rare in cases of accidents from careless handling or bursting of fire-arms, or from blasting, and may cause the greatest variety of burn. The burnt particles of powder often enter the skin and heal there, giving it a bluish-black appearance for the rest of life. More of this in the chapter on burns. In gunshot injuries, there is said to be scarcely any pain; the rapidity of the injury is such that the patient only feels a blow on the side from which the bullet comes, and does not for some time perceive the bleeding wound and actual pain. There are numerous examples where combatants have received a shot, especially in the upper extremity, without knowing it till told by some one, or having their attention attracted by the flow of blood. In gunshot, as in contused wounds, the bleeding is usually less than in incised and punctured wounds; but it would be a great mistake to suppose that arteries which have been shot through do not bleed. On the contrary, many soldiers never leave the battle-field, having died from rapid hæmorrhage from large arteries. When one has seen a fully-divided carotid, subclavian, or femoral artery bleed, he will know that in a very short time the loss of blood will be so great that the only hope of safety lies in immediate aid; so that a hæmorrhage of two minutes’ duration from one of these arteries is certainly fatal. But arteries, even as large as the radial, often bleed but little. The first surgeons who gave us descriptions of gunshot-wounds called attention to this point. Before passing to the treatment of gunshot-wounds, I would briefly picture to you the transportation of and first aid offered to the wounded in battle. For the first aid there are usually established certain temporary places for dressing the wounded, in some sheltered place close behind the line of battle, usually in rear of the batteries; these are designated by white flags. The wounded are first brought to this spot, either by soldiers or by a trained ambulance corps. Of course, those wounded slightly or in the upper extremities walk to the spot. The ambulance corps has proved so efficient in late wars that it will certainly be more trusted to in future. It is composed of nurses trained to bring the wounded from the field, and, when necessary, to give them temporary aid, as in arresting bleeding from arteries and wounds, etc. They have been trained to carry a patient between two of them, either without other support, or on an improvised litter. For this latter purpose they usually carry a lance and a piece of cloth longer and broader than the body. The lances are passed through hems along the sides of the cloth, and a barrow is thus made; bayonets or swords may be used as provisional splints for supporting a limb that has been badly shot. The wounded are thus brought to the dressing-place, and the first dressings are applied; these remain on till the patient reaches the nearest field-hospital. At the same time hæmorrhage must be securely arrested, and injured limbs so arranged that transportation may do no harm; bullets, foreign bodies, and loose splinters of bone near the surface, should be removed, if it can be done quickly and readily. Limbs that have been entirely crushed by large shot should be at once amputated, if a dressing cannot be so applied as to render transportation possible. The chief object of this dressing-place is to render the wounded transportable; hence it is not proper to do many or tedious operations there. From the great pressure of the constantly-increasing throng from the front, only the most important cases can be attended to here, and Pirogoff is right, though it seems cruel, when he says the surgeons should not exhaust their strength on the mortally wounded and the dying. But, if possible, every patient, when carried to the field-hospital, should receive a short written account of what was found at the first examination; a card, containing a few words, thrust into one of his pockets is enough. The chief point is to tell whether the ball has been extracted, whether a wound of the breast or abdomen is perforating, etc., which will save time to the surgeon at the hospital and pain to the patient. Part of the ambulance corps has the further duty of placing the wounded properly in wagons for further transportation, under direction of the surgeon. For this purpose there are special ambulances, constructed most variously, which take some patients lying down, others sitting up. There are rarely enough of these, and it is often necessary to use common wagons, covered with hay, straw, etc. These wagons convey the wounded to the next field-hospital, which is established in a neighboring city or town; for it the largest attainable rooms should be taken. School-houses, churches, or barns, may be seized, although the latter are the best. In these places beds are prepared with straw, a few mattresses, and bedclothes. Surgeons and nurses await anxiously the arrival of the first load of patients, having been already notified of the commencement of the battle by the thunder of the artillery. Here begins the accurate examination of patients, who were only temporarily dressed on the field, and here operating goes on most actively. Amputations, resections, extractions of bullets, etc., are done by wholesale, and the surgeon who has been anxious for his first operation on a living patient may operate till he stops from exhaustion. This continues till far into the night; the fight lasts till late in the evening, and it is near morning before the last loads of wounded come in. With bad lights, on a temporary operating-table, and often with unskilful nurses for assistants, the surgeon must at once examine every patient, down to the last, and then operate and dress his wounds. In the field-hospitals the wounded have a period of rest, and, if possible, those who have been operated on or are seriously hurt should not be moved to another hospital till healthy suppuration begins and healing has at least commenced. This cannot always be done. Occasionally the place where the field-hospital has been established must be vacated. If one belongs to the vanquished party, and the enemy takes the place where the field-hospital was established, the surgeons are usually taken prisoners with their wounded; for, even when the enemy is most humane, after a great battle there is often such a demand for surgeons that those of the enemy cannot take the proper care of wounded prisoners. A few years since, in Geneva, a convention of European powers determined that surgeons and sanitary supplies should be considered neutral. Although there are some practical difficulties in carrying out this principle, it has done great good in the wars of late years, and is capable of still further development. At all events, the idea of considering a wounded enemy as an enemy no longer, but as a patient, is to be prized as a beautiful evidence of advancing humanity. When the wounded have all been brought under cover, bedded, and the necessary operations done, and the diet, etc., has been attended to, arrangements should be made for their proper disposition. Permanent collection of many wounded men in one place is injurious, and, when the seat of war is a poor country, with few railroad connections, the care of the wounded is particularly difficult. Hence, they should be sent off as soon as possible. This may be done, even with the severely wounded, when there is a railroad handy; when the transportation is less convenient, the more slightly wounded at least can be removed. This system of scattering, which of late has been conducted with excellent results, requires great circumspection and trouble from the superior medical and military authorities, but it has proved advantageous. If houses (barracks), or, in summer, tents, can be erected for those remaining—the severely wounded—that will be best. If this be not practicable, they may be distributed in private houses; it has proved unadvisable to leave the wounded in schoolhouses and churches. The war in North America, as well as that between Austria and Prussia in 1866, showed that there were still improvements to be made in military sanitary arrangements. A factor has been added that never before came as an aid, namely, extensive assistance from societies, Sisters of Charity, civil surgeons, and many other persons who, either personally or by money and stores, aided in the care of the wounded. When this private aid is properly organized, under proper management of the military officers, it may be very useful. Concerning the treatment of gunshot-wounds, views have greatly changed from time to time, according to the point of view from which they were regarded. The oldest surgeons whose opinions we have, considered them as poisoned, and thought, consequently, that they should be treated with the hot iron or boiling oil. The first to oppose this view successfully was Ambrose Paré, whom you already know to have introduced the ligature for arteries. He relates that in the campaign in Piedmont (1536) he ran short of oil for burning the wounds, and he expected the death of all the patients who could not be treated according to the rules of the time. But this did not happen; on the contrary, they did better than the chosen few on whom he used the remains of his oil. Thus a lucky accident tolerably soon freed medicine of this superstition. Later it was very correctly observed that the great difficulty in healing gunshot-wounds was due to the narrowness of the canal, and attempts were made to obviate this by plugging the wound with charpie or gentian-root. But sensible surgeons soon saw that this still more impeded the escape of pus from the deeper parts, and the correct view commenced to make some headway, that a gunshot-wound was a tubular contused wound. They sought to improve this in a peculiar way, by laying down the rule that every superficial gunshot-wound should be laid open, the opening of a canal leading into the deeper parts was to be enlarged by one or more incisions; various methods were proposed for changing the contused wound into a simple incised wound by these incisions, while, in fact, the only thing that was done was to add an incised wound to the gunshot-wound. The case was somewhat different when the rule was given to cut out the whole course of the canal, and close the resulting canal by sutures and compresses, so as to obtain healing by first intention; this proceeding cannot often be applied, and obtained little reputation. Of late, since the treatment of all wounds is so much simplified, the same thing has happened to gunshot-wounds which are treated on the same general principles as contused wounds. In these, as in other wounds, the first thing is to arrest any arterial hæmmorhage. This is to be done according to the rules already given, the bleeding artery being tied either in the wound itself, or the corresponding arterial trunk being ligated in its continuity; to accomplish the former, it is generally necessary to enlarge the opening of entrance or exit, otherwise we should not find the bleeding artery. If there be no hæmorrhage, we should examine the wound, especially any blind canal, or foreign bodies, particularly for the bullet. This may be done most certainly with the finger; should it not be long enough, or should the canal be too narrow, we may best use a silver female catheter, with which we may feel more certainly and safely than with a probe; if we feel the bullet, we try to remove it the shortest way, that is, either draw it out at the point of entrance, or, if it lies in a blind canal, close under the skin, we make an incision through the skin and extract it through this, thereby changing the blind canal into a complete one. The extraction of bullets through the opening of entrance may be made by aid of spoon or forceps-shaped instruments. Bullet-forceps with long, thin blades are often difficult to use, because they cannot be sufficiently opened in the narrow canal to seize the bullet, hence many military surgeons prefer the spoon-shaped instrument. Such a bullet scoop has lately been suggested by B. v. Langenbeck, and seems very practical; in it the spoon is movable so as to pass behind the bullet, and push it forward. Still better, it seems to me, is a recently-invented American forceps, whose peculiarity is that they can be opened even in a narrow canal, and they seize very securely. If the bullet be lodged in a bone, we may bore a long gimlet into it, and try to extract it in that way. If we do not succeed in removing the bullet or other foreign body by the opening of entrance, we proceed to enlarge it to gain more room so as to apply the instruments better. The experience that bullets may often remain in the body without injury should warn us against any violent operation that aims only at their extraction. Hence, hæmorrhage and difficult extraction of foreign bodies are the chief indications for primary dilatation of gunshot-wounds. Later other indications may arise to necessitate it; but, in the gunshot-wound, such enlargement is not necessary for a cure. This takes place by the throwing off of a small ring-shaped eschar, and the detachment of gangrenous shreds from the track of the wound, till healthy granulation and suppuration begin, and the canal gradually closes from within outward. In most cases the opening of exit cicatrizes before the entrance. Certain obstacles may stand in the way of this normal course; there may be deep progressive inflammations, rendering necessary new incisions and the employment of ice, as in other deep contused wounds. The first dressing of a gunshot-wound in the field is usually a moist compress, covered with a bit of oiled muslin or parchment-paper, held in place by a bandage or cloth. Frequently nothing further is required than simply keeping the wound moist and covered with charpie, lotions of lead-water, chlorine-water, etc. As yet there are no full observations of the treatment of gunshot-wounds without dressings. They occasionally, though rarely, heal by first intention; as a rule, they suppurate for a longer or shorter period. One of the chief causes of deep inflammation is the presence of foreign bodies, such as bits of clothing, leather, etc. The presence of the bullet, or a portion of it, is far less dangerous, for the cicatricial tissue may grow around and entirely encapsulate the lead, while the wound closes over it; the patient keeps the bullet in him. But these bullets do not always remain in the same spot; they partly sink, from their weight, partly are displaced, by muscular action, so that after years they are found at different (generally lower) points: for instance, a bullet may enter the thigh, and subsequently, after being almost forgotten, may be felt under the skin of the calf or heel, and may thence be readily extracted. I have told you the same thing about needles. But non-metallic bodies seem never able to remain thus without injury in the human body, and hence should always be extracted when discovered in a wound. In gunshot-wounds the fever generally depends on their size and extent, as well as on the accidental suppuration. In the excellentlydirected hospital of the Bavarian chief staff-surgeon Beck, which I visited at Tauberbischofsheim (1866), the thermometer was used for determining the amount of fever; the results as to fever generally correspond with those in other injuries. The special rules to be observed in perforating wounds of the skull, thorax, and abdomen, are given in special surgery; let us here make a few remarks on the fractures resulting from gunshot-wounds. We have already stated that simple subcutaneous fractures occur from spent or obliquely-falling bullets; but, in most cases, the fractures are accompanied by wounds of the soft parts. The soft, spongy bones and the epiphyses may be simply perforated by bullets without any splintering. This injury is comparatively favorable; if the adjacent joint be not opened, the bullet may remain in the bone, and, if it cannot be extracted, may heal there; the track of the wound in the bone suppurates, fills with granulations, which at least partly ossify, so that the firmness of the bone is not impaired. If the bullet strikes the diaphysis of a long bone, it generally splinters it. In these cases the splinters of bone, which are loose or but slightly attached to the soft parts, should be removed, and the injury then treated as a complicated fracture; the forcible removal of firmly-attached pieces of bone cannot be too much condemned. Gunshot-fractures do not differ from others of this class, unless by the sharpness of the fractures. This has induced some surgeons to saw off the sharp ends, or, as it is technically termed, to make a resection of the bone in its continuity. It was hoped that the wound would thus be simplified, and its course rendered more favorable; at the same time attempts were made to avoid a pseudarthrosis by detaching the periosteum from the fragments of bone, and preserving it in the wound. Experience has shown pretty decidedly that this procedure is not generally successful, although some favorable and peculiarly successful cases seem to favor it. If the injury has caused a complicated fracture in a joint, we cannot hope for much from an expectant treatment, according to present experience, which is based on statistics; the question rather seems to be, whether primary resection or amputation is preferable; this can only be decided by the peculiarities of each case. Lastly, we must mention that secondary hæmorrhages are particularly frequent in gunshot as in other contused wounds. I consider the treatment of gunshot-fractures, by fenestrated plaster-bandages, as the only proper method (excepting perhaps those in the upper part of the arm or thigh); the only thing against it is, that surgeons who have not already treated open fractures with plaster-dressings, and are not adept in the application, should not make their first experiments on gunshot-fractures, but should only apply dressings with which they are familiar. Secondary suppurative inflammations occur in gunshot-wounds even more frequently than in other contused wounds; the same causes that we have already learned for these dangerous accidents, unfortunately often act in gunshot-wounds also. We must satisfy ourselves with these few remarks on the subject of gunshot-wounds, glad as I should be to continue the subject. Those who feel special interest in the subject, I refer to the works already mentioned, and to a little book of my own, “Historical Studies on the Consideration and Treatment of Gunshot-Wounds,” in which you will find the old literature brought together.