Pause again. The surgeon has just done nearly the outer half of the operation as to cutting, for removing the whole limb at the joint; and if he should now find that the bone is so much shattered in the shaft that he cannot hope to save the limb, there is no difficulty in removing it. To do this, place your long knife inside the bone, with the middle of its edge resting against the outer edge of the iliacus and psoas muscles, and at one firm cut of a strong hand let it cut its way inward, forming an inner flap, your assistant steadily compressing the femoral artery against the bone above. This artery and the great profunda will both be divided; seize them with the finger and thumb of the left hand, and place a ligature, or assist in placing one, on each branch with the right; or, if the trunk of the profunda should have been cut very short, tie the main trunk of the femoral. Let the ligature be a single thread of strong dentists’ silk, with which I have successfully tied the common iliac, and no fear need be entertained of its not holding fast if you tie it reasonably tight. The idea usually entertained that a great artery cannot be closed by the ordinary process of nature under a ligature, if a branch be given off near it, is erroneous. I never placed reliance on this opinion unless in the accidental circumstance of the outside of the orifice of the branch being in contact with the ligature, the irritation caused by which outside may not be sufficient to close the orifice within, and the common iliac artery of one of the two cases in which I tied it successfully (the patient dying a year afterward) may be seen in the Museum of the College of Surgeons. It is tied about an inch from the aorta, and was pervious on each side of the ligature, which has closed the vessel to no greater extent than its own width, proving all the facts I have mentioned so frequently on this subject. As to the smaller vessels, they will give no trouble, being easily commanded, each by the point of a finger. I have not done this operation of removing the head and neck of the femur on a healthy living man after an accident, but it must be done, and I am satisfied it will in the end succeed. It was done in the 3d Division of the army in the Crimea after the engagement of the 18th of June. The continuity of the head with the shaft was not altogether destroyed, the fracture being principally confined to the great trochanter and the trochanteric ridge. It was at first thought the operation might be dispensed with, but as great irritation ensued, with every prospect of considerable mischief, the head, neck, and both trochanters were excised. On the 6th of July the man was doing well, but unfortunately he was attacked by cholera three days afterward, and died. This operation has since been done by Mr. Blenkin, of the Grenadier Guards; the result will be stated hereafter.
Amputation at the hip-joint should not be performed, unless the head and neck of the thigh-bone be injured; and it ought not to be done if they be, unless the shaft of the thigh-bone be extensively broken also. The operation I have recommended should be its substitute, and I hope yet to see a man walking with ease and comfort on whom it has been performed. The recommendation thus given is the result of the experience of former times, of the whole of the war in the Peninsula and at Waterloo, matured by that of the last forty years in London hospitals, and by a due consideration of the state of surgery throughout all civilized Europe and America. Surgery is never stationary, and surgeons of the present day must continue to show that it is as much a science as an art.
87. Wounds of the knee-joint from musket-balls, with fracture of the bones composing it, require immediate amputation; for although a limb may be sometimes saved, it cannot be called a recovery, or a successful result, where the limb is useless, and is a constant source of irritation and distress after several mouths of acute suffering have been endured, to obtain even this partial relief from impending death. For one limb thus saved, ten lives will be lost; and the sufferer is often glad, after months and years have elapsed, to lose the limb thus saved, more particularly when the ball has lodged in the articulating surface of either of the bones. Amputation at a secondary period, in these cases, does not afford half the chance of success, for many will not survive the inflammation and the fever which will ensue. The amputation should therefore be immediate, unless excision can be substituted for it, and it is a point to be hereafter decided whether excision may not almost always be so substituted when the wound is made by a musket-ball, and the popliteal artery and nerve are not injured.
88. Compound fractures of the patella, without injury to the other bones, admit of delay, provided the bone be not much splintered. If the ball should have pierced the center of the patella, and passed out nearly in an opposite direction behind, the limb will not be saved. If the ball have struck the patella on its edge, and gone through it transversely, opening into the joint, it will very rarely be saved; but if it be merely fractured, there is hope under the most rigorous antiphlogistic treatment, and delay is proper. A ball will occasionally penetrate the capsular ligament, and lodge in the knee-joint, with little injury to the bones. If it cannot be extracted without opening extensively into the cavity of the joint, and the extraction of the ball is absolutely necessary, amputation or excision had better be performed at first, for it will be ultimately necessary. The condyles of the femur and the lower part of the bone being spongy, a ball may pass through them or between them, and fall into the knee-joint, or it may make a prominence on the side of the patella, without passing out, or immediately interrupting the motion of the leg, for the soldier may walk some distance afterward. The popliteal artery may also be divided in addition, and either of these cases will render amputation necessary, for the ball must be taken out on the fore part, and the general inflammation of the joint will either destroy the patient in a short time, or, after much distress and hazard, leave him no alternative but amputation. If a ball lodge in the condyles of the femur within the capsular ligament, and cannot be easily extracted, excision or amputation is advisable; for the limb, if preserved, will not be a useful one. If the ball, on the other hand, lodge without the capsular ligament, and cannot readily be extracted, the wound should be healed as soon as possible; and, although it may cause some little inconvenience to the knee-joint, the limb and life of the patient may be saved, as I have seen in many instances, when a continuance of persevering efforts to extract the ball would have exposed both to great danger. Many cases of wounds in the knee-joint, in which the capsular ligament has been wounded, and the articulation opened into without injury to the bones, do well, such as simple incised wounds made with a clean cutting instrument. The success attending all wounds of the knee-joint depends entirely upon absolute rest, upon the antiphlogistic mode of treatment being rigidly enforced, on the healthy state of the atmosphere, and on the locality being free from endemic disease. The limb is to be placed in the straight position, a splint to be put beneath it, in order to prevent any motion, and cold or iced water to be applied, especially in summer, to diminish the increasing heat. General bleeding may be had recourse to in sufficient quantity to keep all general inflammatory action in due bounds; but it is on local blood-letting that the surgeon must principally rely for the prevention of inflammation. Cupping can sometimes be performed with marked effect; but leeches are more serviceable when they can be procured in sufficient numbers; from twenty to forty, or more, may be applied at a time; whenever the sensation of heat is felt, and is accompanied by pain, they should be repeated until these symptoms subside. The necessity for the local abstraction of blood is so great that it should never be lost sight of for a moment; for if suppuration take place throughout the cavity of the joint, it is followed, in most instances, by ulceration of the cartilages and caries of the bones. By local and general bleeding, the application of cold, rigid abstinence, and the straight position, a recovery may sometimes be effected; but wounds of the knee-joint, however simple, should always be considered as of a very dangerous nature, infinitely more so than those of the shoulder, the elbow, or the ankle. When a poultice is applied to a gunshot wound of this kind, I consider it the precursor of amputation. Col. Donnellan, of the 48th Regiment, was wounded, at the battle of Talavera, in the knee-joint, by a musket-ball, which gave him so little uneasiness that he could scarcely be persuaded to proceed to the rear. At a little distance from the fire of the enemy, we talked over the affairs of the moment, when, tossing his leg about on his saddle, he declared he felt no inconvenience from the wound, and would go back, as he saw his corps was very much exposed. After he had stayed with me a couple of hours, I persuaded him to go into the town. This injury, although at first to all appearance so trifling, proceeded so rapidly as to prevent any relief at last being obtained from amputation, and caused his death in a few days.
89. Excision of the knee-joint is an operation formerly attended with so little success that it has been but rarely performed until lately. The result will, in all probability, be more favorable in cases of injury from musket-balls, in which the femur and tibia have both been much injured, without so much mischief being inflicted on the soft parts as would have rendered amputation necessary. In such cases, provided every accommodation, and particularly absolute rest and good air, can be obtained for the sufferer, excision should be attempted, in preference to the amputation recommended in 84 and 85. Some cases of success have lately been published by Mr. Jones, of the island of Jersey; some by Mr. Syme, Mr. Mackenzie, Dr. Gurdon Buck, Mr. Fergusson, and others. Mr. Jones’s method of operating is here transcribed, as sent to me by himself:—
“In my first case, the incisions were in this form H, two lateral, one along each side of the joint, and a transverse one immediately over the middle of the patella. The flaps were then dissected upward and downward, the patella removed—and I do not see that any advantage can be gained by keeping it, even if not diseased—the crucial and lateral ligaments were then divided, and the joint completely opened. The leg was afterward bent backward on the thigh, and the diseased portion of the femur was cleared, and removed with an ordinary amputating saw. The same method was followed with the tibia: the bones were then placed in juxtaposition, the flaps brought together by means of a few stitches, and the limb placed in a species of fracture-box. Water-dressing was applied. In the second case, I followed very nearly the same plan, with the exception of my first incisions, which were made something in a horseshoe shape. In the third case, I removed a considerable portion of integument, and, I conceive, with marked advantage. In the two former cases, I think the cure was protracted by preserving all the diseased external parts.”
Dr. Gurdon Buck, of the United States of America, in a case of anchylosis, with deformity, after a gunshot wound, removed the knee-joint by a transverse incision from one condyle to the other across the lower margin of the patella. A longitudinal incision intersected this, extending four inches above and below it. The flaps being dissected up, the joint was opened into by an incision across the ligamentum patellæ at the inferior edge of the bone, and also across the lateral ligaments. The adhesions of the articular surfaces were broken up by forced flexion very gradually applied. A slice was then removed with the common amputating saw from the surface of the condyles of the femur, including the pulley-like surface, care being taken to make this section on a plane parallel with the surfaces of support upon which the condyles rest, when the body is erect. The articular surface of the tibia was next removed on a level with the upper extremity of the fibula, after the insertions of the capsular ligament had been dissected up from the posterior half of the circumference of the head of the bone. The broad, fresh-cut bony surfaces, which were very vascular and healthy, admitted of accurate coaptation without stretching the tendons and other parts in the ham. To secure them in close contact, and prevent displacement, a flexible iron wire was passed through both bones on either side, and the two ends twisted and left out between the flaps of skin. The patella, being disorganized and softened, was removed, except the superior margin, which affords insertion to the quadriceps muscle. The flaps of integument having been trimmed, were brought together by sutures and adhesive plaster, and the limb placed in a fracture-box. The constitutional fever was moderate, and disappeared in a fortnight. Suppuration never exceeded half an ounce daily. At the end of five weeks and a half the wires became loose, and were removed. No exfoliation followed. At the end of nine weeks the wound had entirely healed, and the limb could be raised bodily from the bed. There is no mobility between the bones; the difference in the length of the limb, as compared with the other, is one inch and a half, which permits the foot to clear the surface of the ground, which cannot be done when the limb is of the same length as the other.
Mr. Jones, since the publication of his original cases, has in a subsequent one not only preserved the patella, but even the ligamentum patellæ, which he considers to be a great improvement when it can be effected; he operated in the following manner: A longitudinal incision down to the bone, four inches in extent, was made on each side of the knee-joint, midway between the vasti and the flexors of the leg. These two cuts were then connected by a transverse one just over the prominence of the tubercle of the tibia, care being taken not to cut the ligamentum patellæ. The flap was turned upward; the patella and its ligament were freed, drawn over the internal condyle, and kept there by means of a broad, flat, and turned-up spatula. The joint was thus exposed, the synovial capsule was divided as far as could be seen, when the leg was forcibly bent, the crucial ligaments, almost breaking in the act, only required a slight touch of the knife to divide them completely. The articular surfaces of the bones were now completely brought into view, when the diseased portions were removed by suitable saws, the soft parts being kept aside by assistants; the external condyle had been hollowed out by a large abscess, so that it was necessary to saw off (obliquely) another portion of the carious bone, and to gouge out the remainder, until the healthy cancellous structure was reached. The articular surface of the patella had also to be gouged until sound bone was attained. The bones were brought into apposition, and the patella and its ligament replaced, as nearly as possible; at the end of seven weeks the patient, twelve years old, was able to turn the limb from side to side, and ultimately recovered.
This little boy I saw walking firmly on his leg, an admirable instance of conservative surgery. It is, nevertheless, an operation which ought not to be done on the field of battle, unless perfect quiescence and every desired accommodation can be obtained, and no endemic disease prevail.
90. Amputation of the leg is performed in two ways—by the circular incision and by two flaps, the circular incision being only applicable to the calf. In either way the stump should, if possible, be seven inches long, for the more convenient application of an artificial leg, which is now made with a socket to fit the stump, instead of resting against the bent knee, unless the stump be too short for its proper adaptation otherwise.