65. Amputation of a limb is the last resource and the opprobrium
of surgery, as death is of the practice of physic; it being,
notwithstanding, impossible to do impossibilities, and save a limb or
a life which can no longer be preserved. Art and science at that point
cease to be useful.
66. At the commencement of the war in the Peninsula, all surgeons
believed it to be impossible to compress in an effective manner the
artery of the thigh against the bone, as it passes over the edge of the
pubes, and that the loss of blood on its division must be so formidable
as to be murderous. This was merely a surgical delusion, which
maintained its ground in London until the end of 1815, when the French
soldier, whose thigh I had successfully taken off at the hip-joint,
after the battle of Waterloo, without first tying the femoral artery,
was shown to all disbelievers. It was the great point in advance in
English and European surgery, and one great result of the practice of
that war.
67. This great, indeed most important fact, having been established,
the surgery of amputation was deprived of nearly all its terrors.
Confidence, and with it coolness, were obtained; and many young
surgeons diligently sought for an operation on the hip-joint as the
_ne plus ultra_ of operative boldness and dexterity, much after the
fashion of the young lady _pianistes_, who do not consider themselves
in any way advanced on the road to perfection until they can play at
least the overture to _Guillaume Tell_, if not the _Galop Chromatique_
of Listz, nearly as well as the composer himself.
68. As a tourniquet cannot be applied in this amputation, nor even at
that of the shoulder-joint, without doing harm, its inutility in the
greatest operations is proved; and recourse should not be had to it in
the smaller or less dangerous ones, provided sufficient assistance can
be obtained. When the surgeon has only one assistant, he should apply
a tourniquet, or even if he should have several bad ones on whom he
cannot depend.
69. There is always more blood lost, and particularly in secondary
amputations, when a tourniquet is used than when the principal artery
is compressed by one assistant, and two others are ready to press on
the outside of the flaps, or upon the divided vessels, with the ends
of their fingers; the force necessary to prevent the passage of blood
through the common femoral, or the axillary artery, being merely that
of the finger and thumb, applied in a very gentle manner, or even of
the end of the forefinger of a competent person. I have rarely applied
a tourniquet since 1812, and few persons have done more formidable
operations under more difficult circumstances. The ancient illusion
with regard to the necessity for tourniquets in amputation must be
given up, except by incompetent persons, or by those who are fearful
and superstitious, and do not like to depart from the ways of their
forefathers.
70. A tourniquet is useful when loosely applied after an operation,
and the attendant should be taught how to turn it, so as to suppress
any serious bleeding which may take place until the surgeon can be
procured. It may be, although it rarely is, necessary on the field of
battle. The surgeon need not, therefore, load himself or his assistant,
as formerly, with a sackful, for a thoroughly useful tourniquet can be
made in a moment with a pebble and a pocket-handkerchief, or a roller.
The great point is to know where and how to apply it. When gentlemen
called surgeons by warrant are sent to an army, as many were to that in
Spain and France, with only the knowledge of a druggist, having been
refused a commission on account of their ignorance, it is necessary
this instruction should be especially given to them; and this horrible
fact is recorded with the hope it may be useful in preventing any such
atrocious proceedings in future. Peace or humane societies, if they
cannot prevent a war, may interfere with advantage on this point, to
divest it of some of its horrors. At the battle of Inkerman, a young
officer, the son of a friend of mine, was wounded in the leg by a
musket-ball, which caused much loss of blood. A tourniquet was applied,
instead of the required operation being performed, and he was sent on
board a transport from Balaklava. The leg mortified, as a matter of
course, and was amputated. He died, an eternal disgrace to British
surgery, or rather to the nation which will not pay sufficiently able
men, and therefore employs ignorant ones--the best they can get for the
money.
71. When circular operations were performed in the olden time,
particularly on the thigh, the skin, when divided, was dissected, and
turned up like the cuff of a coat--a painful proceeding, as unnecessary
as it was barbarous. Forty years have elapsed since I demonstrated
its absurdity, and showed that the first incision in the thigh should
include the fascia lata, any deep attachments it might have should
follow, when the parts thus divided ought to be retracted as a whole,
to form a proper covering for the stump.
It was at the same time shown that, in whatever way, and however
clumsily and tediously, the muscles might be divided, it did not
prevent the successful result of the operation, provided the bone was
cut short, so as to form a cone, with an elongated or depressed point.
72. The nicking of the periosteum, and pushing it upward and downward,
so as to leave a space for the saw, was at the same time forbidden, as
leading to necrosis of the part of the bone thus denuded, if unremoved
by the saw. The saw was also directed to be held perpendicularly to,
and not across, the bone, nor even diagonally to it--an apparently
trivial, but yet great improvement. The last part divided is an outer
and thin layer of hard bone, which does not so readily splinter on the
side as on the under part, by the weight of the leg.
73. The limb to be amputated is not to be held by the assistant in the
manner described and usually shown in books: one hand ought not to be
above the knee, but below and by the side of it, the other grasping
the calf, so that the limb may be duly supported, and drawn inward or
outward, in the opposite direction to the saw, as it divides the last
layers of the bone.
74. The common integuments of the stump should be drawn together,
in primary amputations, by sutures formed of flexible leaden wires;
by threads of silk, if leaden wires be not attainable. The vessels
which bleed should be carefully secured by single yet fine threads
of dentists’ or other strong silk, one end to be cut off in primary
amputations. In secondary amputations, when the parts are not always
sound, both ends of the ligature should be cut off, and in such cases
the edges of the wound should be brought in contact only, with a layer
of fine linen between them, without the expectation of, or the desire
for, union taking place.
75. The removal of a limb should not occupy two minutes, but the
securing the blood-vessels should be done without reference to time;
when carefully effected, there is little fear of secondary bleeding,
and the stump should be closed at once. It has been lately recommended
not to close the stump for four, six, or eight hours after the
operation; but this is not advisable, unless the depressed state of the
patient, or other causes, should have rendered it impossible to secure,
in a proper manner, all the vessels which are likely to bleed. It will
be less painful and dangerous to delay, in such cases, than to have to
reopen the stump.
76. When the edges of the incision have been brought together by the
hands of the assistants, and by the sutures indicated, strips of
some kind of agglutinative plaster without resin should be applied
between them, and a little wet lint over the incision, retained by two
cross-pieces of rollers, the ends of which are maintained in their
situation by another roller applied round the body and over the upper
part of the thigh, including the extremities of the two cross-pieces;
but this roller is not to be applied over the end of the stump. When
the war came well in, stump-caps, as they were called, went out, being
worse than useless. The stump should be supported on a soft pillow, so
as to be as comfortable as possible, and protected by a cradle from
accidental injury.
If inflammation, accompanied by pain, should take place, cold or iced
water should be applied, particularly in primary amputations. In
secondary ones, warm fomentations or light warm poultices will be more
advantageous, all constriction by sutures or plasters being removed,
the parts being simply approximated to each other. Attention should be
paid to the directions in aphorism 61.