Part 8
68. As a tourniquet cannot be applied in this amputation, nor even at that of the shoulder-joint, without doing harm, its inutility in the greatest operations is proved; and recourse should not be had to it in the smaller or less dangerous ones, provided sufficient assistance can be obtained. When the surgeon has only one assistant, he should apply a tourniquet, or even if he should have several bad ones on whom he cannot depend.
69. There is always more blood lost, and particularly in secondary amputations, when a tourniquet is used than when the principal artery is compressed by one assistant, and two others are ready to press on the outside of the flaps, or upon the divided vessels, with the ends of their fingers; the force necessary to prevent the passage of blood through the common femoral, or the axillary artery, being merely that of the finger and thumb, applied in a very gentle manner, or even of the end of the forefinger of a competent person. I have rarely applied a tourniquet since 1812, and few persons have done more formidable operations under more difficult circumstances. The ancient illusion with regard to the necessity for tourniquets in amputation must be given up, except by incompetent persons, or by those who are fearful and superstitious, and do not like to depart from the ways of their forefathers.
70. A tourniquet is useful when loosely applied after an operation, and the attendant should be taught how to turn it, so as to suppress any serious bleeding which may take place until the surgeon can be procured. It may be, although it rarely is, necessary on the field of battle. The surgeon need not, therefore, load himself or his assistant, as formerly, with a sackful, for a thoroughly useful tourniquet can be made in a moment with a pebble and a pocket-handkerchief, or a roller. The great point is to know where and how to apply it. When gentlemen called surgeons by warrant are sent to an army, as many were to that in Spain and France, with only the knowledge of a druggist, having been refused a commission on account of their ignorance, it is necessary this instruction should be especially given to them; and this horrible fact is recorded with the hope it may be useful in preventing any such atrocious proceedings in future. Peace or humane societies, if they cannot prevent a war, may interfere with advantage on this point, to divest it of some of its horrors. At the battle of Inkerman, a young officer, the son of a friend of mine, was wounded in the leg by a musket-ball, which caused much loss of blood. A tourniquet was applied, instead of the required operation being performed, and he was sent on board a transport from Balaklava. The leg mortified, as a matter of course, and was amputated. He died, an eternal disgrace to British surgery, or rather to the nation which will not pay sufficiently able men, and therefore employs ignorant ones--the best they can get for the money.
71. When circular operations were performed in the olden time, particularly on the thigh, the skin, when divided, was dissected, and turned up like the cuff of a coat--a painful proceeding, as unnecessary as it was barbarous. Forty years have elapsed since I demonstrated its absurdity, and showed that the first incision in the thigh should include the fascia lata, any deep attachments it might have should follow, when the parts thus divided ought to be retracted as a whole, to form a proper covering for the stump.
It was at the same time shown that, in whatever way, and however clumsily and tediously, the muscles might be divided, it did not prevent the successful result of the operation, provided the bone was cut short, so as to form a cone, with an elongated or depressed point.
72. The nicking of the periosteum, and pushing it upward and downward, so as to leave a space for the saw, was at the same time forbidden, as leading to necrosis of the part of the bone thus denuded, if unremoved by the saw. The saw was also directed to be held perpendicularly to, and not across, the bone, nor even diagonally to it--an apparently trivial, but yet great improvement. The last part divided is an outer and thin layer of hard bone, which does not so readily splinter on the side as on the under part, by the weight of the leg.
73. The limb to be amputated is not to be held by the assistant in the manner described and usually shown in books: one hand ought not to be above the knee, but below and by the side of it, the other grasping the calf, so that the limb may be duly supported, and drawn inward or outward, in the opposite direction to the saw, as it divides the last layers of the bone.
74. The common integuments of the stump should be drawn together, in primary amputations, by sutures formed of flexible leaden wires; by threads of silk, if leaden wires be not attainable. The vessels which bleed should be carefully secured by single yet fine threads of dentists’ or other strong silk, one end to be cut off in primary amputations. In secondary amputations, when the parts are not always sound, both ends of the ligature should be cut off, and in such cases the edges of the wound should be brought in contact only, with a layer of fine linen between them, without the expectation of, or the desire for, union taking place.
75. The removal of a limb should not occupy two minutes, but the securing the blood-vessels should be done without reference to time; when carefully effected, there is little fear of secondary bleeding, and the stump should be closed at once. It has been lately recommended not to close the stump for four, six, or eight hours after the operation; but this is not advisable, unless the depressed state of the patient, or other causes, should have rendered it impossible to secure, in a proper manner, all the vessels which are likely to bleed. It will be less painful and dangerous to delay, in such cases, than to have to reopen the stump.
76. When the edges of the incision have been brought together by the hands of the assistants, and by the sutures indicated, strips of some kind of agglutinative plaster without resin should be applied between them, and a little wet lint over the incision, retained by two cross-pieces of rollers, the ends of which are maintained in their situation by another roller applied round the body and over the upper part of the thigh, including the extremities of the two cross-pieces; but this roller is not to be applied over the end of the stump. When the war came well in, stump-caps, as they were called, went out, being worse than useless. The stump should be supported on a soft pillow, so as to be as comfortable as possible, and protected by a cradle from accidental injury.
If inflammation, accompanied by pain, should take place, cold or iced water should be applied, particularly in primary amputations. In secondary ones, warm fomentations or light warm poultices will be more advantageous, all constriction by sutures or plasters being removed, the parts being simply approximated to each other. Attention should be paid to the directions in aphorism 61.
AMPUTATION AT THE HIP-JOINT.
77. This amputation essentially owes its existence to the wars of the French Revolution. M. Bourgery says Blandin performed it three times in 1794; once successfully. Baron Larrey did it seven times during his different campaigns, and he says one or two persons who had survived were seen during their cure by an officer in Russian Poland, but they never reached France. Nevertheless, I always assume that one at least did recover, whether he was really seen or not, being a compliment and a reward justly due to the zeal and ability of my old friend the Baron, to whom the surgery of France is so much indebted. This operation was first done in Spain by the late Mr. Brownrigg, at Elvas, in 1811, and by myself after the siege of Ciudad Rodrigo, but none of our patients ultimately recovered. I operated on a French soldier at Brussels soon after the receipt of the injury at Waterloo; he survived; and he was the first and the _only man_ seen for a long time afterward in either London or Paris. The biographer of Baron Larrey says he was present at, and advised the operation to be done; but that is an error, as the Baron did not visit Brussels until after I had left it for Antwerp; neither had I any knowledge of the Baron’s writings in 1811 or 1812, when my first operation was done in Portugal. Eighteen or twenty ways have been suggested for doing this operation, and twenty persons are believed to have survived its performance, several of whom may be living at the present time.
A very extensive destruction of the soft parts, the femur remaining entire, does not authorize the removal of the limb in the first instance, unless the main artery be also injured. Captain Flack, of the 88th Regiment, was struck by a large cannon-shot at Ciudad Rodrigo, on the outside and anterior part of the left thigh, which tore up and carried away nearly all the soft parts from the groin, or bend of the thigh, below Poupart’s ligament, to within a hand’s-breadth of the knee. It was an awful affair. He was supposed to be dying, was returned dead, and his commission was given to another. Left to die in the field hospital after the town was stormed, and finding himself thus deserted by his own friends, he claimed my aid as a stranger. I took him five leagues to my hospital at Aldea del Obispo. The femoral artery lay bare for the space of nearly four inches, in a channel at the bottom of the wound; the whole, however, gradually closed in, and he recovered.
If the injury is on the back part, a flap should be made in amputation from the fore part. If the wound should be on the outside, the flap is to be made from the inside, and _vice versa_, the object being to make the stump as long as possible. A wound of the artery, accompanied by a fracture of the femur, requires amputation, for although many would survive either injury alone, none would, it may be apprehended, surmount both united.
If after a fracture in course of treatment, the principal artery should be wounded by some accidental motion of the bone, amputation should in general be resorted to. A ligature on the artery higher up would fail, and the operation of seeking for both ends of the injured vessel would cause so much mischief in an unsound part that the consequences would in all probability be fatal.
78. When the femur is suffering from a malignant disease, commencing in the periosteum, or in its cancellated internal structure, I am reluctantly obliged to say, from experience, that the removal of the whole bone at the hip-joint offers the best, perhaps the only chance of success. In such cases, the operator has in general the power of selecting his mode of proceeding.
It may be laid down as a principle in all cases of accident, whether from shot, shell, or railway carriages, that no man should suffer amputation at the hip-joint when the thigh-bone is entire. It should never be done in cases of injury when the bone can be sawn through immediately below the trochanter major, and sufficient flaps can be preserved to close the wound thus made. An injury warranting this operation should extend to the neck, or head of the bone, and it may be possible, as I have proposed, even then to avoid it by removing the broken parts.
79. The principle being established, as a general rule in all cases of recent injury, that the femur must be broken at least as high as the trochanter to constitute an imperative case for this operation, the next point of importance relates to the manner of forming the first incisions. The instructions and recommendations to be found in books for the performance of this operation are frequently inapplicable, and are not to be depended upon; the errors occurring from the operation having been considered and performed on the dead body and not on the living; on the normal and not on the injured state of parts. Thus, for instance, it is recommended that an assistant should rotate the knee outward or inward, to show the head of the femur; to which recommendation there is the insuperable objection, that no person should suffer this operation who has a knee, or half a thigh, or even a third of one, to move by the rotary process. Pure theorists in surgery have decided upon having a large flap made on the fore part of the thigh, and a smaller one behind, regardless of the fact that this cannot be done in many cases requiring a primary operation from the nature of the injury; although it may be done in many secondary cases, in which this severe operation would not have been required if the limb had been amputated in the first instance. It is the mode recommended by Mr. Brownrigg, who in his operations, which were secondary ones, had a choice of integument, and it is, perhaps, under these circumstances, the best.
Baron Larrey tied the femoral artery in the first instance, and then made two lateral flaps; but this operation, dependent on the fear of hemorrhage, was never performed in the British army.
80. My first successful operation, performed in 1815, was done from without inward, the flaps being anterior and posterior, the artery being compressed against the pubis.
The patient is to be laid on a low table, or other convenient thing, in a horizontal position; an assistant, standing behind and leaning over, compresses the external iliac artery becoming femoral, as it passes over the edge of the pubis. The surgeon, standing on the inside, commences his first incision some three or four inches directly below the anterior spinous process of the ilium, carries it across the thigh through the integuments, inward and backward, in an oblique direction, at an equal distance from the tuberosity of the ischium to nearly opposite the spot where the incision commenced; the end of this incision is then to be carried upward with a gentle curve behind the trochanter, until it meets with the commencement of the first; the second incision being rather less than one-third the length of the first. The integuments, including the fascia, being retracted, the three gluteal muscles are to be cut through to the bone. The knife being then placed close to the retracted integuments, should be made to cut through everything on the anterior part and inside of the thigh. The femoral or other large artery should then be drawn out by a tenaculum or spring forceps, and tied. The capsular ligament being well opened, and the ligamentum teres divided, the knife should be passed behind the head of the bone thus dislocated, and made to cut its way out, care being taken not to have too large a quantity of muscle on the under part, or the integuments will not cover the wound, under which circumstance a sufficient portion of muscular fiber must be cut away. The obturatrix, gluteal, and ischiatic arteries are not to be feared, being each readily compressed by a finger until they can be duly secured. The capsular ligament, and as much of the ligamentous edge of the acetabulum as can be readily cut off, should be removed. The nerves, if long, are to be cut short. The wound is then to be carefully cleansed, and brought together by three or more soft leaden sutures in a line from the spine of the ilium toward the tuberosity of the ischium. The ligatures are to be brought out between the sutures, and some adhesive strips of plaster applied to support them. A little wet lint is to be placed over the wound, and some well-adapted compress under the lower flap; the whole to be retained by a soft bandage. In my successful case there was a shot-hole in the under flap, which did good service; and from having seen its use, I have no objection to a small perpendicular slit being made in the lower flap, and a strip of linen introduced to prevent adhesion. The immediate union of the flaps cannot be expected, nor is it often to be desired.
This mode of proceeding is more certain of making good flaps where integuments are scarce. Where the integuments will admit of the anterior flap being made by the sharp-pointed puncturing knife dividing the parts after it has been passed across from without inward, there is no objection to this proceeding, and some prefer it. I have had two such knives added to each of the cases of instruments supplied to the army for the purpose.
Professor Langenbeck, when lately in London, informed me he had performed amputation at the hip-joint several times in the Holstein war, and he believed more than once successfully; making the anterior flap by the pointed knife, cutting from within outward, but the posterior one by cutting through the integuments from without inward, as I have recommended in high amputation below the joint, in order to make the flap of a more equal and proper thickness. One point to be attended to is to leave as little as possible of the internal tendinous structure of the great gluteus muscle, as it does not readily unite with other parts; a second, not to leave too much muscle on the under part; and a third, to remove as much as possible of the ligamentous structure about the joint. The after-treatment will be the same as in other formidable cases. The shock, however, of the injury, and of the amputation, will render blood-letting unnecessary. Cordials, in small quantities, with opiates and a good but light nourishing diet, should be given. The wound should be wetted with cold water, and the patient constantly watched, so that hemorrhage may be arrested if it should take place. In an otherwise successful operation performed by Mr. C. G. Guthrie, at the Westminster Hospital, the patient was lost on the third day from this cause.
Mr. Brownrigg’s operation is to be done in the following manner: The patient is to be placed on a low table and properly secured, with the nates projecting over its edge, the artery being compressed. The surgeon enters the pointed knife between the spine of the ilium and the trochanter major, and carries it across the thigh, as near as may be to the head and neck of the femur, until the point appears on the inside, near the scrotum, which should have been previously drawn away. The knife is to cut slowly downward, to make a flap, under which, and behind the knife, an assistant inserts his four fingers, in order to be able to grasp the flap and aid in compressing the principal artery, as the operator completes the flap, which it is intended should be a large one, as shown in the diagram, fig. 1.
The assistant holding up the flap, the surgeon cuts the attachment of the gluteus medius muscle, from the upper edge of the trochanter, if it has not been already done, opens the capsular ligament of the joint, and divides the ligamentum teres. The head of the bone can then be readily withdrawn from the acetabulum. The knife being placed behind the head of the bone and the trochanter, should be carried obliquely downward and backward, so as to form a shorter flap behind than was made before. The amputations of the hip-joint, performed in the Crimea, have not, I understand, been as successful as the ability with which they were performed might have led the operators to expect.