Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE V.

REMOVAL OF THE HEAD OF THE FEMUR, ETC.

84. The removal of the head of the thigh-bone from its place in the hip-joint, after it has been separated in a measure from its attachments by disease of a scrofulous nature, is an operation which has been several times successfully performed, and life has been thereby preserved without much suffering or risk to the patient. In this case, the head of the bone is found lying outside the cavity, from which it has been drawn by the action of the muscles. A step further must be taken, and this operation must some day be done in cases of fracture of the head or neck of this bone caused by an external wound—cases which have hitherto been invariably fatal, or in which life has been preserved by amputation at the hip-joint.

The great advance which operative surgery has made within the last forty years, and the success which has followed the removal of the head of the humerus, the whole of the elbow, the ankle, and even the knee-joint, render it imperative on surgeons of ability to endeavor to save life without the performance of so formidable an operation as that of the removal of the whole limb, more particularly when the health is good and the parts sound, with the exception of those immediately injured.

The cases which seem more particularly favorable for this operation are those in which the head or neck of the bone is broken by a musket-ball. Picture to yourselves a man lying with a small hole either before or behind in the thigh, no bleeding, no pain, nothing but an inability to move the limb, to stand upon it, and think that he must inevitably die in a few weeks, worn out by the continued pain and suffering attendant on the repeated formation of matter burrowing in every direction, unless his thigh be amputated at the hip-joint, or he be relieved by the operation which, I insist upon it, ought first to be performed.

85. In order to do this operation with precision, the surgeon should make himself well acquainted with the anatomy of the parts; and as the war in the Russian Empire may offer opportunities for its performance, a recapitulation of the essential points to be noticed may be useful. Two limbs should be injected so as to show the great arteries distinctly, and one should be dissected so that every part may be brought into view at once. That being done, attention should be directed to two points, the great trochanter and the round head of the thigh-bone in its socket, which is directly below and a little internal to the anterior superior spinous process of the ilium.

When the thigh is bent in the dissected limb, the head of the bone will be seen rolling in the socket very distinctly, and, in order to lay it bare for removal, the muscles, etc. around it must be divided. The first, on the anterior and outer part, is the tensor vaginæ femoris; this should be divided; outside this the gluteus medius must be cut, going to be inserted into the upper and outer part of the top of the great trochanter; deeper, and between these two last, lies the gluteus minimus, winding forward to be inserted into the anterior portion of the same part. Now, let the great gluteus muscle be cut through backward in a curve, and the insertions of four muscles at one part—viz., the pit or fossa immediately behind the great trochanter—will be brought into view: these are the pyriformis, the gemelli, reckoned as one muscle, and the obturatores externus and internus. They should all be cut through within half an inch from their insertion. The square muscle lying or placed immediately below them, and running from the ischium to the inter-trochanteric line, is the quadratus femoris; it must be cut across. The head of the femur will now be seen to roll in the socket on the least motion being given to the knee. The surgeon should then open into the exposed joint with great care, when by a gentle rotation of the knee inward the head of the thigh-bone will be readily dislocated outward. The ligamentum teres, or the round ligament, as it is termed, although it is triangular at its origin, should now be divided, with as much of the capsular ligament as may be necessary, when everything will be ready for the application of the saw.

Pause a moment, and view the parts before the saw is applied. Two strong muscles are inserted into the small trochanter by a common tendon, the iliacus internus and psoas magnus. This insertion should remain untouched if the fracture should not extend below the little trochanter. It is not always necessary to injure them, and they will be of great use afterward, if the operation should prove successful. If the neck of the bone be broken through, rotating the thigh as directed may not assist much in dislocating its head. But then, the separation of the fractured parts may be readily completed, and the piece detached, when the remaining part of the head of the bone will be more easily removed. The sawing may be accomplished with the greatest ease by a small common saw, or by the improved chain saw, which will do good service. The arteries to be divided are all of small size. Filled with red injection, they are so small as scarcely to be seen; and they could not give any trouble; for the wound is so large as to give easy access to every part, and readily admit of any bleeding vessel being tied without difficulty. The round ligament should be cut off close to its origin in the acetabulum, and any portion of the capsular ligament and cartilaginous edge of the acetabulum which can be quickly removed with it, but no time should be unnecessarily lost in trying to remove the cartilaginous lining of the cavity itself, which will be gradually absorbed. The sawn end of the femur should now be brought up into the cavity, and kept there if possible by a supporting splint and bandage, with the hope that it may become rounded and adhere by a newly-formed ligamentous structure, in the same manner as the end of the humerus does to the glenoid cavity of the scapula, when similarly treated. The edges of the wound are then to be brought in apposition, and retained so by two or three sutures. The gluteus magnus slides over the trochanter major, having a bursa between them, and this part will not readily throw out granulations. The surgeon may therefore be less solicitous about the accuracy of the apposition of the edges at the under part, through which the discharge will more easily pass. The outside must, however, be supported by sticking-plaster and bandage compress, to prevent any bagging, and to keep all parts in contact. The saving the periosteum of as much of the femur to be taken away, as strongly recommended by MM. Flourens and Baudens in the excision of the head of the humerus, should be attempted, although not easy of execution. (Aph. 118.)

86. The surgeon should now do the operation on the undissected limb. The first cut through the skin, integuments, and fascia lata should be a curved one, beginning just over the inner edge of the tensor vaginæ femoris muscle, as shown on the other leg, curving downward and outward, so as to pass across the bone an inch at least below the trochanter major, when it should turn upward to the extent of three inches or more, as the size of the limb may require. This incision or flap should, when complete, divide, in addition to the integuments, the fascia lata, the tensor vaginæ femoris, and part of the gluteus maximus. The flap thus formed must be raised or turned up by an assistant, to enable the operator to get at and divide the parts below, in the order before named. It is not necessary to stop to tie any bleeding vessel until the operation is finished, for little or no blood will be lost.