77. This amputation essentially owes its existence to the wars of the
French Revolution. M. Bourgery says Blandin performed it three times
in 1794; once successfully. Baron Larrey did it seven times during his
different campaigns, and he says one or two persons who had survived
were seen during their cure by an officer in Russian Poland, but they
never reached France. Nevertheless, I always assume that one at least
did recover, whether he was really seen or not, being a compliment and
a reward justly due to the zeal and ability of my old friend the Baron,
to whom the surgery of France is so much indebted. This operation was
first done in Spain by the late Mr. Brownrigg, at Elvas, in 1811, and
by myself after the siege of Ciudad Rodrigo, but none of our patients
ultimately recovered. I operated on a French soldier at Brussels soon
after the receipt of the injury at Waterloo; he survived; and he was
the first and the _only man_ seen for a long time afterward in either
London or Paris. The biographer of Baron Larrey says he was present
at, and advised the operation to be done; but that is an error, as the
Baron did not visit Brussels until after I had left it for Antwerp;
neither had I any knowledge of the Baron’s writings in 1811 or 1812,
when my first operation was done in Portugal. Eighteen or twenty ways
have been suggested for doing this operation, and twenty persons are
believed to have survived its performance, several of whom may be
living at the present time.
A very extensive destruction of the soft parts, the femur remaining
entire, does not authorize the removal of the limb in the first
instance, unless the main artery be also injured. Captain Flack, of the
88th Regiment, was struck by a large cannon-shot at Ciudad Rodrigo,
on the outside and anterior part of the left thigh, which tore up and
carried away nearly all the soft parts from the groin, or bend of the
thigh, below Poupart’s ligament, to within a hand’s-breadth of the
knee. It was an awful affair. He was supposed to be dying, was returned
dead, and his commission was given to another. Left to die in the field
hospital after the town was stormed, and finding himself thus deserted
by his own friends, he claimed my aid as a stranger. I took him five
leagues to my hospital at Aldea del Obispo. The femoral artery lay bare
for the space of nearly four inches, in a channel at the bottom of the
wound; the whole, however, gradually closed in, and he recovered.
If the injury is on the back part, a flap should be made in amputation
from the fore part. If the wound should be on the outside, the flap
is to be made from the inside, and _vice versa_, the object being to
make the stump as long as possible. A wound of the artery, accompanied
by a fracture of the femur, requires amputation, for although many
would survive either injury alone, none would, it may be apprehended,
surmount both united.
If after a fracture in course of treatment, the principal artery should
be wounded by some accidental motion of the bone, amputation should in
general be resorted to. A ligature on the artery higher up would fail,
and the operation of seeking for both ends of the injured vessel would
cause so much mischief in an unsound part that the consequences would
in all probability be fatal.
78. When the femur is suffering from a malignant disease, commencing
in the periosteum, or in its cancellated internal structure, I am
reluctantly obliged to say, from experience, that the removal of the
whole bone at the hip-joint offers the best, perhaps the only chance
of success. In such cases, the operator has in general the power of
selecting his mode of proceeding.
It may be laid down as a principle in all cases of accident, whether
from shot, shell, or railway carriages, that no man should suffer
amputation at the hip-joint when the thigh-bone is entire. It should
never be done in cases of injury when the bone can be sawn through
immediately below the trochanter major, and sufficient flaps can be
preserved to close the wound thus made. An injury warranting this
operation should extend to the neck, or head of the bone, and it may
be possible, as I have proposed, even then to avoid it by removing the
broken parts.
79. The principle being established, as a general rule in all cases of
recent injury, that the femur must be broken at least as high as the
trochanter to constitute an imperative case for this operation, the
next point of importance relates to the manner of forming the first
incisions. The instructions and recommendations to be found in books
for the performance of this operation are frequently inapplicable, and
are not to be depended upon; the errors occurring from the operation
having been considered and performed on the dead body and not on the
living; on the normal and not on the injured state of parts. Thus,
for instance, it is recommended that an assistant should rotate the
knee outward or inward, to show the head of the femur; to which
recommendation there is the insuperable objection, that no person
should suffer this operation who has a knee, or half a thigh, or even
a third of one, to move by the rotary process. Pure theorists in
surgery have decided upon having a large flap made on the fore part of
the thigh, and a smaller one behind, regardless of the fact that this
cannot be done in many cases requiring a primary operation from the
nature of the injury; although it may be done in many secondary cases,
in which this severe operation would not have been required if the limb
had been amputated in the first instance. It is the mode recommended by
Mr. Brownrigg, who in his operations, which were secondary ones, had a
choice of integument, and it is, perhaps, under these circumstances,
the best.
Baron Larrey tied the femoral artery in the first instance, and then
made two lateral flaps; but this operation, dependent on the fear of
hemorrhage, was never performed in the British army.
80. My first successful operation, performed in 1815, was done from
without inward, the flaps being anterior and posterior, the artery
being compressed against the pubis.
The patient is to be laid on a low table, or other convenient thing,
in a horizontal position; an assistant, standing behind and leaning
over, compresses the external iliac artery becoming femoral, as it
passes over the edge of the pubis. The surgeon, standing on the inside,
commences his first incision some three or four inches directly below
the anterior spinous process of the ilium, carries it across the
thigh through the integuments, inward and backward, in an oblique
direction, at an equal distance from the tuberosity of the ischium
to nearly opposite the spot where the incision commenced; the end of
this incision is then to be carried upward with a gentle curve behind
the trochanter, until it meets with the commencement of the first;
the second incision being rather less than one-third the length of
the first. The integuments, including the fascia, being retracted,
the three gluteal muscles are to be cut through to the bone. The
knife being then placed close to the retracted integuments, should be
made to cut through everything on the anterior part and inside of the
thigh. The femoral or other large artery should then be drawn out by
a tenaculum or spring forceps, and tied. The capsular ligament being
well opened, and the ligamentum teres divided, the knife should be
passed behind the head of the bone thus dislocated, and made to cut its
way out, care being taken not to have too large a quantity of muscle
on the under part, or the integuments will not cover the wound, under
which circumstance a sufficient portion of muscular fiber must be cut
away. The obturatrix, gluteal, and ischiatic arteries are not to be
feared, being each readily compressed by a finger until they can be
duly secured. The capsular ligament, and as much of the ligamentous
edge of the acetabulum as can be readily cut off, should be removed.
The nerves, if long, are to be cut short. The wound is then to be
carefully cleansed, and brought together by three or more soft leaden
sutures in a line from the spine of the ilium toward the tuberosity of
the ischium. The ligatures are to be brought out between the sutures,
and some adhesive strips of plaster applied to support them. A little
wet lint is to be placed over the wound, and some well-adapted compress
under the lower flap; the whole to be retained by a soft bandage. In my
successful case there was a shot-hole in the under flap, which did good
service; and from having seen its use, I have no objection to a small
perpendicular slit being made in the lower flap, and a strip of linen
introduced to prevent adhesion. The immediate union of the flaps cannot
be expected, nor is it often to be desired.
This mode of proceeding is more certain of making good flaps where
integuments are scarce. Where the integuments will admit of the
anterior flap being made by the sharp-pointed puncturing knife dividing
the parts after it has been passed across from without inward, there
is no objection to this proceeding, and some prefer it. I have had two
such knives added to each of the cases of instruments supplied to the
army for the purpose.
Professor Langenbeck, when lately in London, informed me he had
performed amputation at the hip-joint several times in the Holstein
war, and he believed more than once successfully; making the anterior
flap by the pointed knife, cutting from within outward, but the
posterior one by cutting through the integuments from without inward,
as I have recommended in high amputation below the joint, in order to
make the flap of a more equal and proper thickness. One point to be
attended to is to leave as little as possible of the internal tendinous
structure of the great gluteus muscle, as it does not readily unite
with other parts; a second, not to leave too much muscle on the under
part; and a third, to remove as much as possible of the ligamentous
structure about the joint. The after-treatment will be the same as in
other formidable cases. The shock, however, of the injury, and of the
amputation, will render blood-letting unnecessary. Cordials, in small
quantities, with opiates and a good but light nourishing diet, should
be given. The wound should be wetted with cold water, and the patient
constantly watched, so that hemorrhage may be arrested if it should
take place. In an otherwise successful operation performed by Mr. C. G.
Guthrie, at the Westminster Hospital, the patient was lost on the third
day from this cause.
Mr. Brownrigg’s operation is to be done in the following manner: The
patient is to be placed on a low table and properly secured, with
the nates projecting over its edge, the artery being compressed. The
surgeon enters the pointed knife between the spine of the ilium and
the trochanter major, and carries it across the thigh, as near as may
be to the head and neck of the femur, until the point appears on the
inside, near the scrotum, which should have been previously drawn away.
The knife is to cut slowly downward, to make a flap, under which, and
behind the knife, an assistant inserts his four fingers, in order to be
able to grasp the flap and aid in compressing the principal artery, as
the operator completes the flap, which it is intended should be a large
one, as shown in the diagram, fig. 1.
[Illustration: Fig. 1.
_Amputation of the Hip-joint as performed by_ Mr. Brownrigg.
(Upper figure.)
_a_ _a_ _a_, anterior flap in dotted lines;
_c_, thumb compressing the artery on the pubis;
_d_, fingers introduced under the flap;
_e_, the straight knife, entrance and exit of.
(Lower figure.)
_Flap Amputation as performed by_ Mr. Luke, _on the lower half of
the thigh_.
_A_, middle of the outside of the thigh and point of entrance of knife;
_B_, under part;
_C_, upper part;
_A_ to _E_, the under flap;
_G_ to _F_, dotted line of upper flap, beginning short of commencement
of under flap.]
The assistant holding up the flap, the surgeon cuts the attachment of
the gluteus medius muscle, from the upper edge of the trochanter, if it
has not been already done, opens the capsular ligament of the joint,
and divides the ligamentum teres. The head of the bone can then be
readily withdrawn from the acetabulum. The knife being placed behind
the head of the bone and the trochanter, should be carried obliquely
downward and backward, so as to form a shorter flap behind than was
made before. The amputations of the hip-joint, performed in the Crimea,
have not, I understand, been as successful as the ability with which
they were performed might have led the operators to expect.
[Illustration: Fig. 2.