Elements of Surgery

by Robert Liston

In all cases, and in all situations and circumstances, hemorrhage can be restrained during completion of the incisions, and during the employment of means to close the cut ends of the vessels, by means of very slight but exact pressure on the trunk of the principal vessel. The point at which this is to be applied should be at as short a distance as possible above the place of incision, and at the same time above the origin of any branches which must be cut. Not the slightest pressure should be made until the instant when the incisions are about to be commenced, so that no venous congestion may take place in the limb. All the blood in the limb, below the incisions, must necessarily be lost. The veins are more easily compressed than the arteries, and pressure, made a short time before the operation, may arrest the return of the blood, whilst it may not completely stop its influx; thus engorgement of the lower part of the limb is produced, and the quantity of blood that must be lost is increased. For a similar reason, pressure, sufficiently firm to stop arterial hemorrhage, is to be continued till the principal branches are tied, and then entirely removed; for the continuance of even slight pressure will increase the flow from the surface of the stump—blood, flowing in, and being arrested in its venous return, trickles out through the open ends of the veins. If a circular band be used for the compression, such as the screw tourniquet, it should be put on quickly, and screwed up at once, and then the incisions should not be delayed one instant after; there should be no relaxation of the pressure at any part of the operation; and as soon as the principal vessels have been secured, the apparatus should be altogether removed—otherwise, as already stated, rapid oozing will continue from the face of the stump. It is my confirmed opinion, that much more blood is lost from the use of a tourniquet than without it. I would rather trust to a no very efficient assistant, than put on a tourniquet. It is evident that compression on the whole circumference of a limb must completely interrupt venous return, and cause the increase of hemorrhage already mentioned; whereas pressure on only two points of the same circumference, as is effected by the hand of an assistant, is not liable to this objection. Besides, the latter mode is more quickly applied, and more readily removed, causes infinitely less pain to the patient, and is equally effectual in arresting the flow in the main arterial trunk. Neither does it interfere with the due contraction and retraction of the divided tissues. The incisions should always be made rapidly; and after their completion, the surgeon, if distrustful of his assistant, or if his hand has become cramped and tired, may himself grasp the limb and compress the vessel, giving the forceps or ligatures to another.

The first step in the operation is to arrange the measures for temporary arrestment of the bleeding. The patient is placed in a favourable position, either sitting or lying, as may be most convenient for the particular amputation, and is firmly secured by one or more assistants; all the apparatus must be in good order and conveniently placed, and an assistant should be stationed to attend to them, and hand those required. The compressor and the operator are each at their post, and ready to act in concert. The incisions may be made either from without inwards, or from within outwards, after transfixion of the limb. The latter mode is to be preferred when practicable, as requiring less pressure; the parts are more stretched than in the former method, are therefore more easily and rapidly cut, and consequently less pain is inflicted. To the inexperienced transfixion may appear cruel, it may appal them, but in reality it is almost unattended with pain; it is rapidly executed, and renders the operator capable of completing his work with great quickness and little suffering, and at the same time with neatness and precision. The knife should be of a size and length proportioned to the incisions, straight-backed, and with a good point; of a form to pass through readily, yet strong, and not too broad. With one sweep of this, the incisions are made at once, through the muscles, through the cellular and fatty tissues, and through the integument—or vice versâ if the mode from without inwards be preferred. By these parts being cut rapidly and at once, their connexions with each other are not separated, the cut surface is smooth, and the parts are in the most favourable state for becoming agglutinated and consolidated; the bone is more deeply covered, and the stump of a handsomer and more useful shape, than when the parts are cut successively and with detachment.

The operator places himself so that he may grasp the part to be removed, during the sawing of the bone, without change of position. The incisions are made with the left hand free; but as soon as the saw is in the right, the left should take firm hold of the limb below the wound. During the operation, the limb is supported by an assistant, either sitting or kneeling before the patient; but the regulating of the position of the limb, during sawing, is not to be intrusted to him alone. He may, from anxiety to facilitate the action of the saw, snap the bone and splinter it when it has been little more than half divided; or, from dread of this, he may lock the instrument, and so delay completion of the operation. The management of the lower part of the limb should always be by the person using the saw. This instrument should have its teeth well set, and be provided with a workmanlike handle. It is worked steadily and not hurriedly, with very slight pressure, and that pressure employed only when pushing forwards. Before its application, all the soft parts must necessarily be divided completely; and this is done by carrying the knife, after formation of the flaps, round the bone, with its edge rasping on it, and as high up as possible. The instrument is then placed accurately on the point thus exposed, close to the soft parts, and during the sawing the flaps are well retracted by the hands of an assistant. The saw may be worked either horizontally or vertically; the latter direction is to be preferred, for thus, when the section is nearly completed, the uncut part of bone is deep, and less likely to snap on the weight of the limb being allowed to operate, or when undue pressure is made downwards. If splintering of the bone have occurred, whether from neglect of the foregoing precautions, or by other accident, the sharp projecting parts should be taken away, and the cut surface made quite smooth by means of the bone pliers; and with this instrument also, the sharp edge of the bone may be rounded off, in cases where subsequent pressure might cause ulceration or sloughing of part of the integument of the stump.

The arteries are tied close to their connexions. Their cut ends are laid hold of with the dissecting forceps, or by those represented at page 170, and pulled out; a small firm thread, either of linen or silk, is then applied tightly, and one end immediately cut away close to the reef-knot. Separation of the ligatures generally takes place from the sixth to the tenth or twelfth day; they produce little discharge or irritation during their presence, and no source of irritation connected with them is left behind. But when both ends are cut away close to the knot, separation is often long of taking place, and though the parts may heal over them kindly enough, the stump never can be considered sound till all are discharged. Probably several of these knots remain deeply imbedded after cicatrisation of the integument, and when the patient considers himself cured, and is moving about the room or ward, actively and cheerfully, painful hardness forms deeply, part of the stump reddens and swells, matter forms, and at length the insignificant origin of the mischief is discharged; and this may occur more than once. Generally such suppurations are limited, and soon cease; but occasionally the abscess formed round the knot is extensive, deep and free incision is required, the filling up of the cavity is necessarily slow, the cure is long protracted, and both practitioner and patient are disappointed and annoyed. Besides, the suppurations thus occasioned, though slight in extent, may, when in the neighbourhood of a principal arterial branch, cause ulceration of the coats of the vessel, producing troublesome hemorrhage at a late period. All these untoward consequences of cutting off both ends I have experienced in a series of cases, and from the results of a faithful comparative trial of both methods, I am now fully determined always to leave one end of the ligature hanging from the lips of the wound.

No one now, it is presumed, dreams of the absorption of ligatures, whether composed of animal substance or not; therefore the catgut ligature, at one time much recommended, has no superiority over the linen or silk thread,—besides it is not so convenient of application.

Twisting or bruising the cut ends of arteries has been long known as effectual in arresting bleeding. Vessels of a large size can be so treated with sufficient facility, and they may not bleed after; but well-tied ones are much more secure. The smaller cannot be pulled out and twisted, ligatures must be used for them; and the application of one or two more ligatures, namely, to the large arteries as well as the small, will add to the patient’s safety, and to the operator’s comfort and peace of mind, and can have little effect in increasing irritation. I have made trial of the method of torsion after amputation, and for the above reasons, and because the manipulations are more tedious, I disapprove of the plan, and decidedly prefer the ligatures. I am not aware that the proposal of leaving the vessels both untwisted and without ligature has been tried in this country; one would think that it must always be troublesome, and not unfrequently hazardous.

In some cases, as when the incisions are made in the neighbourhood of diseased bone, the soft parts are so condensed that the vessels cannot be pulled out by means of the forceps; they are to be transfixed by a sharp hook or tenaculum, and a ligature is then applied round the parts which the instrument holds; or the vessels may be encircled by a thread passed round by means of a curved needle; in both methods more or less of the surrounding tissues must necessarily be included in the noose, though always as little as possible. Sometimes an artery of the bone, whether sound or inflamed, bleeds sharply; in such circumstances the application of ligature is impossible, and I have occasionally been obliged to insert a wooden peg into the opening; to this a chord is attached by which it can be removed after a few days.

When bleeding has been satisfactorily arrested, the surface of the wound is to be cleaned of coagula, either with the fingers or with a warm and soft sponge, the ligatures are brought to the margin at convenient points, and the edges of the integument are then put together by interrupted sutures—two, three, or more, according to the extent of the wound. They need not be numerous, for they are only temporary, effecting partial approximation, and showing the line in which the parts are to be brought together by the after dressing. The stump is then covered with lint soaked in cold water, and this application is renewed frequently so long as any trickling of blood continues. Farther dressing is delayed for six or eight hours, when the oozing has entirely ceased, and the visible cut surface become glazed. Under this management, there is less chance of bleeding breaking out afresh than when the limb is encompassed by bandages and pledgets of lint, perhaps compressed so as to interfere with the return of the blood, and heated by superfluous dressings. If bleeding to any extent should occur, as there is always a risk of, after the patient has become warm and comfortable in bed, and reaction has been established, there is but little pain or annoyance in reaching the bleeding point, and taking measures to stop the flow; the few stitches are soon clipped away, and then the surface of the wound is completely exposed, and ligatures can be applied to those vessels which require them. Then, after removing all coagula, sutures are placed in the same perforations, and the stump is in as favourable a state as previously. I now generally leave the wound quite open, until all risk of hemorrhage has ceased, and, if one or two stitches are required, these are put in at the time of applying the plaster.

After six or eight hours, as already stated, any clots that have formed are to be taken away gently, and the glazed edges of the wound are then brought accurately and neatly together by the adhesive composition already recommended,—with the difference of its being spread upon slips of oiled silk, which I have found to be more pliable, and altogether preferable to the glazed riband. Interstices are left for the sutures and the ends of the ligatures, and the latter may now be abridged slightly. This mode of keeping the edges in contact I can confidently recommend from experience. The plasters are much more adhesive than those in common use, do not irritate, and are not loosened by discharge. After twelve or twenty-four hours, often much earlier, the sutures are clipped through and removed. No other dressing is required till the end of the cure, provided this proceed favourably. The part is kept cool, and the slight discharge which occurs in a day or two is wiped up from time to time, if it be in such abundance as to reach the oiled cloth over the pillow on which the stump is laid. No disturbance of the parts is necessary as when ointments, bandages, and compresses are employed, or straps that require frequent removal and reapplication. The patient suffers comparatively nothing; and the surgeon is saved much troublesome and dirty work,—for union by the first intention seldom fails.

Bleeding within a few hours after the operation, before excited action of the vessels has commenced, is easily arrested by exposure of the surface, removal of all clots, for by these hemorrhage is encouraged, and by including the open vessels in ligatures. For the accomplishment of this, the period and mode of dressing, above recommended, afford great facility, as has been already observed. Hemorrhage at a later period is not common. It happens occasionally in consequence of the stump having acquired an unhealthy condition, from sloughing,—or from abscess, as when this occurs round ligatures which have been retained, along with the slough of the vessel and cellular tissue, both ends having been cut away. The matter formed during separation of the ligature in the usual way, escapes readily along the protruding end, but when there is merely a knot, the integuments have most probably closed over, there is no direct outlet; the matter is confined, and causes ulceration of the coats of the vessel as well as of the surrounding tissues. In this kind of hemorrhage, it is needless to attempt finding the bleeding point by tearing open the stump, separating any adhesions that may have formed, causing much pain and retardation of cure. And even though the bleeding vessel or vessels could be found, they are not in a state to hold a ligature. The artery is surrounded by sloughing cellular substance, its coats are tender, and in no condition to assume a healthy action necessary for permanent closure after deligation. If ligature is applied, the included part quickly separates, and then the vessel is as open as before. Astringents, and even the cautery, are useless. Ligature of the main arterial trunk, above the origin of branches supplying the stump, so as to weaken for a time the circulation, is found to be effectual. I have had recourse to this in many cases, and uniformly with success. Some years ago, several occurred in the Royal Infirmary, within a very short time of one another; it was during rather an unhealthy season, and at the time I was making trial of cutting off both ends of the ligatures. They were all after removal of the lower limb; one patient died—the amputation was high, through the trochanter minor, and the vessel tied secondarily was the common iliac; this had the effect of completely arresting the hemorrhage, but the previous loss of blood proved too much for the system to recover from; transfusion was had recourse to, and produced temporary benefit. The others, cases of amputation below the knee, made most favourable recoveries after ligature of the superficial femoral, and in more than one the stump healed very rapidly after its readjustment. Indeed, it is not unfrequently found that when the flaps are separated, from whatever cause, and replaced when the granulations have appeared, there follows a rapid union and cure.