Stump made as in [Fig. 713]. (Chalot.)
Amputation of the Thigh above the Knee.
—For removal of the thigh it is well to preserve as much of its length as possible, and yet not at the expense of all other considerations. A thigh stump too short is likely to be pulled awkwardly upward by the psoas muscle, and upon such a stump it is difficult to secure an artificial limb tolerable of control against such action of this muscle. On this account, then, thigh stumps should be long. So far as the method is concerned the circular, or some modification thereof, gives the best results in the majority of instances. It may easily be modified into one of the oblique methods, or liberating incisions may be used whenever they will be of service. If it be absolutely necessary to make the amputation high hemostasis can be secured by the same methods that are used in hip-joint amputations. The dense and strong fascia lata, which lies beneath the superficial fascia, should be divided at the same level with the skin, since it serves admirably, when secured by a separate set of sutures, to make a good covering for the ends of the muscles, after these have been themselves carefully united by buried sutures. The sciatic nerve should be especially sought, thoroughly stretched, and divided high up. The vessels often evince a tendency to retract within Hunter’s canal; it is not, however, difficult to separate the vastus internus from the adductor longus, between which they lie, and in this way gain access to them. Even for high work on the thigh one may, if necessary, do as some have done at the hip, make a preliminary ligation of the femoral artery. This may be especially serviceable as an emergency measure, or in special cases of tumors which have attained large size, are placed high up and call for somewhat atypical methods.
The Hip-joint.
—Amputation here is essentially a disarticulation and constitutes one of the usually formidable and serious operations of major surgery. Although the joint itself is generally easily reached there are many things to be considered in the performance of this operation, of which the mere arthrotomy is by no means the most important.
Preparations being all made, the first consideration is the control of hemorrhage, for which several methods have been suggested, but of which but two or three are in general use. Such procedures as compression of the abdominal aorta, either with the hand or by tourniquet, or of the common aorta through the rectum, with a lever, as suggested by Davey, or with the hand, as suggested by Woodbury, or the exposure of the common iliac, either within the peritoneum as practised by McBurney, or externally, or exposing the common femoral above Poupart’s ligament, are now adopted by very few surgeons. Langenbeck used to be fond of preliminary ligation of the femoral where it is most accessible in the groin, and this is probably the best of all of these methods. But they have been all practically discarded since Wyeth introduced the simple method of transfixing the limb with his pins (i. e., long mattress needles or skewers made for the purpose), these serving to hold in place an elastic cord or tourniquet ([Fig. 715]). This has been found to be a great improvement on the suggestion of Senn, who excised the femoral head and then compressed each half of the limb with a separate elastic band.
Fig. 715
Wyeth’s bloodless method: pins inserted and tube applied.
The directions for the use of Wyeth’s pins are simple. Here, as in other cases, it may not be practicable to use the elastic bandage from the lower end of the limb, but one may at least elevate the limb and thus coax the blood out of it by gravity or by gentle manipulation. While it is still in this position one of the long pins is introduced just below the anterosuperior spine and a trifle to its inner side, and made to emerge on a level with and about three inches from the point of its entrance. The other needle is inserted just to the inner side of the saphenous opening, and below the level of the crotch, and brought out about one inch below the tuberosity of the ischium. Corks should then be placed upon them so as to protect the needle points. Next a piece of elastic tubing or band is placed around the limb above these pins and tightened, each turn being made a little tighter, so as to absolutely control the circulation. The effect of this is felt upon practically every vessel in that part of the body, and if the method be properly practised it affords absolute security.