(Second figure.)
b c, line of incision marked by three sutures.
81. Amputation by the circular incision is to be done in the following manner: When a tourniquet is used, which it should not be, if the surgeon can depend on his assistants, the pad should be firm and narrow, and carefully held directly over the artery, while the ends of the bandage in which it is contained are pinned together. The strap of the tourniquet is then to be put round the limb, the instrument itself being directly over the pad, with the screw entirely free; the strap is then to be drawn tight and buckled on the outside, so as to prevent its slipping, and yet not to interfere with the screw. Should the screw require to be turned more than half its number of turns, the strap is not sufficiently tight, or the pad has not been well applied. The patient being placed on a table at a convenient height, the assistants are carefully to retract the integuments upward, and put them on the stretch downward, by which means their division is more easily and regularly accomplished. The surgeon, standing on the outside, passes his hand under the thigh and round above quite to the outside, and there he begins his incision with the heel of the knife, and with a quick, steady movement, carries it round the thigh until the circular division of the skin, cellular membrane, and fascia has been completed. The skin cannot be sufficiently retracted unless the fascia be divided, and as the division of the skin is certainly the most painful part of the operation, it ought never to be done by two incisions, when the largest thigh can most readily and speedily be encircled by one. If the fascia should not be completely divided by the first circular incision, it is to be cut with the point of the knife, together with any attachment to the bone or muscles beneath. The amputating knife is then to be applied close to the retracted fascia and integuments, and the outermost muscles are to be divided by a circular incision, with any portion of the fascia that may not have equally retracted. This incision completed, the knife is immediately to be placed close to the edge of the muscular fibers which have retracted, and the remainder of the soft parts divided to the bone in the same manner. In making these two incisions, care should be taken to cut at least half an inch on each side of the great artery by one incision, which should be either the first or second, as may be most convenient. The muscles attached to the bone are then to be separated with a scalpel for about three inches in large thighs, by which means the bone will be fairly imbedded when sawed off. The common linen retractor is next to be placed on the limb, and the muscles steadily kept back while the bone is sawed through. The periosteum may or may not be divided by one circular cut of the scalpel after the retractor has been put on. The heel of the saw is then to be applied and drawn toward the surgeon, so as to mark the bone, in which furrow he will continue to cut with long and steady strokes, the point of the saw slanting downward in a perpendicular direction until the bone be nearly divided, when the saw is to be more lightly pressed upon, to avoid splintering it, which this manner of sawing will also tend to prevent. During this operation the thigh should be held steadily above, and in such a manner below that the part to be cut off does not weigh or drag on the bone above; at the same time it must not be pressed inward or upward, or it will prevent the motion of the saw or splinter the bone. The retractor is then to be removed, the great artery to be pulled out by a tenaculum passed through its sides, separated a little from its attachments, and firmly tied with a two-threaded, strong ligature, provided dentists’ silk be not used, and the tenaculum is not to be withdrawn until this has been accomplished; any other vessels that show themselves may be secured, and compression should for an instant be taken off the main artery, when others will start. If used, the tourniquet should now be removed, and the small remaining vessels will be discovered. If the great vein continue to bleed after some pressure has been made upon it, a single-threaded ligature should be put over it; but this should not be done if it can be avoided, and only when the loss of a little blood might be dangerous. If the cancellated part of the bone bleed freely, the thumb of the left hand pressed steadily upon it, while the vessels are tying, will in a short time suppress the hemorrhage. Any inequality of bone should be removed by forceps. The ligatures should now be shortened, one end of each thread being cut off; the stump is to be sponged with cold water and dried, the bandage rolled steadily down the thigh; the muscles and integuments brought forward and placed in apposition, horizontally across the face of the stump, and retained by leaden sutures and adhesive plasters carefully applied, from below upward, and from above downward; the ligatures being brought out nearly as straight as possible, in two or three places between the slips of plaster, unless both ends have been cut short. A compress of lint is to be placed over and under the wound, supported by two slips of bandage, in the form of a Maltese cross, vertically and horizontally, and the whole secured by a few more turns of the bandage. No stump-cap is to be applied; the stump is to be raised a little on a proper pillow from the bed, in which the patient lies on his back; and if the bone appear to press too much against the upper flap, the body may be a little raised, which will relieve it.
In secondary amputation of the thigh, the integuments may not be sound, and will not retract, in which case they must be dissected back to an equal distance all round. If the muscles are much diminished in size, or flabby, they should be left even longer than may appear necessary for the formation of a good stump; and this is to be done more especially on the under part, for the bone will frequently protrude under these circumstances, when enough has been supposed to have been preserved. In all these cases the bone should be shorter than usual, and the skin should, if possible, retain its attachments to the parts beneath. No inconvenience can ever arise from too much muscle and skin in a circular stump; but it does sometimes from too much skin alone.
In primary operations there will be from three to seven vessels to be tied; in secondary ones, from ten to sixteen, and even then there may be an oozing from the stump. In this case a little delay in searching for the vessels is necessary; the tourniquet and all tight bandages should be removed, and the stump well sponged with cold water before it is dressed. A certain degree of oozing is to be expected from all stumps, although it does not always occur: but when there is really any hemorrhage, so that blood distills freely through the dressings, the stump should be opened, when the bleeding vessel will generally be discovered readily, though not visible before. A stump under these circumstances should not be closed in the first instance; the parts should be merely approximated until all bleeding has ceased.
When the operation is performed near the knee, the gradual thickening of the thigh prevents the retraction of the integuments, and has an effect upon the vessels of the stump; both of which evils are avoided after the circular incision has been completed, by making a cut, an inch and a half in length, in the integuments through the fascia on each side, in the horizontal direction in which they are recommended to be placed, after the operation is finished; but this will very rarely be necessary.
82. Amputation of the thigh, by the flap operation, is best accomplished by the method adopted by Mr. Luke, of the London Hospital, which is as follows: The patient being placed so that the thigh projects beyond the table, the surgeon stands with his left hand toward the body, or on the outside when amputating the right, and on the inside when amputating the left thigh. The knife to be used ought to be narrow, pointed, and longer by two or three inches than the diameter of the thigh at the place of amputation. The point of the knife should be entered mid-distance between the anterior and posterior surfaces of the thigh, which may be effected with accuracy, if the eye is brought to a level with the thigh, when the middle point is easily determined. The posterior flap is to be formed first, by carrying the knife transversely through the thigh, so that its point shall come out on the opposite side, exactly midway between the anterior and posterior surfaces. In traversing the thigh, the knife should pass behind the bone, and will be more or less remote from it in different individuals, according to the greater or less development of the posterior muscles, when, by cutting obliquely downward, to the extent of from four to six inches, according to the thickness of the thigh, a posterior flap is formed. The anterior flap is effected, not by making a flap, but by commencing an incision through the integuments and muscles on the side of the thigh opposite to the surgeon, at a little distance anterior to the extremity of the posterior flap. This incision is made from without inward, through the integuments, so as to form an even curve, and without angular irregularity, over the thigh, to near the base of the posterior flap on the side on which the surgeon stands. The length of this flap is determined by that of the posterior. It will therefore vary from four to six inches, as before stated; and for its completion will require a second, or perhaps a third, application of the knife. In the two flaps thus made, the division of almost all the soft structures is included, a few only immediately surrounding the bone remaining uncut. These are to be divided by a circular sweep of the knife, at the part where it is intended to saw the bone; in this way it is sufficiently denuded for the application of the saw. The flaps being held back by an assistant, the bone is to be sawn through in the usual way. In amputations of the lower part of the thigh it usually happens that the ischiatic nerve lies upon the surface of the posterior flap, and should be removed. It occasionally occurs, although not frequently, that the popliteal artery is cut obliquely at its commencement; but in amputations above the passage of the arterial trunk through the tendon of the triceps, this does not take place, the division of the artery being usually included in the circular sweep made after the formation of the flaps. The divided arteries having been carefully secured, the flaps are to be brought together and retained by three sutures passed through the integuments at equal distances from each other, and from the extremity or base of the flaps. It appears to be a matter of considerable importance not only that their edges should be kept in apposition, but that their whole surfaces should be kept in accurate contact. For this purpose, the following method of dressing is adopted: The edges, in the intervals between the sutures, are to be held together by strips of adhesive plaster about one inch in breadth. A compress of lint is then to be fitted over each flap, that upon the posterior being the larger. The compresses are to cover the flaps only, and not to extend over the extremity of the bone, where their pressure would probably be ill endured. The posterior compress is made large, that it may serve as a cushion on which the thigh rests when the patient is placed in bed. The compresses are to be retained in position by one or two strips of plaster, and supported by a bandage applied carefully round the stump. If this be properly accomplished, the whole surfaces of the flaps will be kept accurately in contact with each other, and complete union may be reasonably expected. By securing the perfect apposition and support of the entire surfaces in accurate contact, the disposition to the issue of blood from small vessels is also obviated to a great extent, and it is even probable that vessels of a larger diameter than the smallest, which would bleed if not restrained, are, by the pressure of the opposing surface, prevented from doing so, and the probability of secondary hemorrhage is diminished. Experience has demonstrated the fact that primary union of the flaps is most effectually procured in the great majority of amputations thus treated. Indeed, non-union of the flaps is the exception; union, the rule. In the subsequent treatment of the stump, care must be taken to prevent an accumulation of discharge in the tracks of the ligatures; and the dressings must be renewed according to circumstances having reference to the quantity of discharge, and the uneasiness of the patient. The line of division of the integuments of the two flaps is situated, at first, in the center of the face of the stump; but when the flaps have united, a gradual change takes place in the position of the cicatrix: it recedes, by degrees, to the posterior aspect of the thigh, and the bone abuts upon the anterior flap, by which alone it is eventually covered, and the cicatrix is thus removed from its pressure.
83. A protrusion of bone is a disagreeable occurrence after amputation; it will sometimes happen after sloughing of the stump, without any fault of the operator. If, on completing the operation, it is evident the bone cannot be well covered, a sufficient portion should be at once sawn off, and the error remedied.
When the bone protrudes at a subsequent period to the extent of an inch or more, it should be removed by operation, an incision being made on, and down to, the bone, and the saw applied where it is sound. The chain saw, when at hand, answers well, and some should be supplied for the use of the principal hospitals with every army. The protruded end of bone should be held steadily by pincers, or it may be introduced into a hollow tube, which fixes it firmly.
When the bone has been badly sawn through, or split in the act of dividing the last layer, or the periosteum is unduly separated, the end will often exfoliate with the split, which may extend up for several inches, giving rise to the formation of abscesses, causing much suffering, and occupying a great length of time before the ring of bone and the split portion exfoliate, and the stump becomes quite sound. A splinter of this kind may even require to be removed at a late or at a distant period, from the nervous irritation and suffering it may occasion. This irritation has been often attributed to the extremity of the principal nerve, which always enlarges, assumes a bulbous form, and is painful on pressure, when made for the purpose, although not so under ordinary circumstances. This enlargement never requires removal, unless it should adhere to the cicatrix, or be the subject of disease incidentally occasioned in it. The great sciatic nerve became early thus enlarged in the thigh of the late Marquess of Anglesea, and was mistaken for disease, for which he was advised to have it removed, it being painful on pressure, and therefore the supposed cause of the tic douloureux under which he labored. Consulted on the propriety of this operation, his leg-maker, Mr. Pott, being present, who had also lost a leg above the knee, I requested his lordship to squeeze Mr. Pott’s bulbous nerve, in the same manner as the doctor had squeezed his lordship. He did so, and Mr. Pott roared and sprang from the floor in a manner which quite satisfied Lord Anglesea.