_a_, anterior superior spine of ilium;
_b_, commencement of anterior incision, continued by the black line;
_c_, the posterior incision joining the anterior one.
(Second figure.)
_b_ _c_, line of incision marked by three sutures.]
81. Amputation by the circular incision is to be done in the following
manner: When a tourniquet is used, which it should not be, if the
surgeon can depend on his assistants, the pad should be firm and
narrow, and carefully held directly over the artery, while the ends of
the bandage in which it is contained are pinned together. The strap of
the tourniquet is then to be put round the limb, the instrument itself
being directly over the pad, with the screw entirely free; the strap
is then to be drawn tight and buckled on the outside, so as to prevent
its slipping, and yet not to interfere with the screw. Should the screw
require to be turned more than half its number of turns, the strap is
not sufficiently tight, or the pad has not been well applied. The
patient being placed on a table at a convenient height, the assistants
are carefully to retract the integuments upward, and put them on the
stretch downward, by which means their division is more easily and
regularly accomplished. The surgeon, standing on the outside, passes
his hand under the thigh and round above quite to the outside, and
there he begins his incision with the heel of the knife, and with a
quick, steady movement, carries it round the thigh until the circular
division of the skin, cellular membrane, and fascia has been completed.
The skin cannot be sufficiently retracted unless the fascia be divided,
and as the division of the skin is certainly the most painful part
of the operation, it ought never to be done by two incisions, when
the largest thigh can most readily and speedily be encircled by one.
If the fascia should not be completely divided by the first circular
incision, it is to be cut with the point of the knife, together with
any attachment to the bone or muscles beneath. The amputating knife
is then to be applied close to the retracted fascia and integuments,
and the outermost muscles are to be divided by a circular incision,
with any portion of the fascia that may not have equally retracted.
This incision completed, the knife is immediately to be placed close
to the edge of the muscular fibers which have retracted, and the
remainder of the soft parts divided to the bone in the same manner.
In making these two incisions, care should be taken to cut at least
half an inch on each side of the great artery by one incision, which
should be either the first or second, as may be most convenient. The
muscles attached to the bone are then to be separated with a scalpel
for about three inches in large thighs, by which means the bone will
be fairly imbedded when sawed off. The common linen retractor is next
to be placed on the limb, and the muscles steadily kept back while the
bone is sawed through. The periosteum may or may not be divided by one
circular cut of the scalpel after the retractor has been put on. The
heel of the saw is then to be applied and drawn toward the surgeon,
so as to mark the bone, in which furrow he will continue to cut with
long and steady strokes, the point of the saw slanting downward in a
perpendicular direction until the bone be nearly divided, when the saw
is to be more lightly pressed upon, to avoid splintering it, which this
manner of sawing will also tend to prevent. During this operation
the thigh should be held steadily above, and in such a manner below
that the part to be cut off does not weigh or drag on the bone above;
at the same time it must not be pressed inward or upward, or it will
prevent the motion of the saw or splinter the bone. The retractor is
then to be removed, the great artery to be pulled out by a tenaculum
passed through its sides, separated a little from its attachments, and
firmly tied with a two-threaded, strong ligature, provided dentists’
silk be not used, and the tenaculum is not to be withdrawn until this
has been accomplished; any other vessels that show themselves may be
secured, and compression should for an instant be taken off the main
artery, when others will start. If used, the tourniquet should now be
removed, and the small remaining vessels will be discovered. If the
great vein continue to bleed after some pressure has been made upon
it, a single-threaded ligature should be put over it; but this should
not be done if it can be avoided, and only when the loss of a little
blood might be dangerous. If the cancellated part of the bone bleed
freely, the thumb of the left hand pressed steadily upon it, while the
vessels are tying, will in a short time suppress the hemorrhage. Any
inequality of bone should be removed by forceps. The ligatures should
now be shortened, one end of each thread being cut off; the stump is
to be sponged with cold water and dried, the bandage rolled steadily
down the thigh; the muscles and integuments brought forward and placed
in apposition, horizontally across the face of the stump, and retained
by leaden sutures and adhesive plasters carefully applied, from below
upward, and from above downward; the ligatures being brought out nearly
as straight as possible, in two or three places between the slips of
plaster, unless both ends have been cut short. A compress of lint is to
be placed over and under the wound, supported by two slips of bandage,
in the form of a Maltese cross, vertically and horizontally, and the
whole secured by a few more turns of the bandage. No stump-cap is to be
applied; the stump is to be raised a little on a proper pillow from the
bed, in which the patient lies on his back; and if the bone appear to
press too much against the upper flap, the body may be a little raised,
which will relieve it.
In secondary amputation of the thigh, the integuments may not be sound,
and will not retract, in which case they must be dissected back to an
equal distance all round. If the muscles are much diminished in size,
or flabby, they should be left even longer than may appear necessary
for the formation of a good stump; and this is to be done more
especially on the under part, for the bone will frequently protrude
under these circumstances, when enough has been supposed to have been
preserved. In all these cases the bone should be shorter than usual,
and the skin should, if possible, retain its attachments to the parts
beneath. No inconvenience can ever arise from too much muscle and skin
in a circular stump; but it does sometimes from too much skin alone.
In primary operations there will be from three to seven vessels to be
tied; in secondary ones, from ten to sixteen, and even then there may
be an oozing from the stump. In this case a little delay in searching
for the vessels is necessary; the tourniquet and all tight bandages
should be removed, and the stump well sponged with cold water before
it is dressed. A certain degree of oozing is to be expected from all
stumps, although it does not always occur: but when there is really
any hemorrhage, so that blood distills freely through the dressings,
the stump should be opened, when the bleeding vessel will generally
be discovered readily, though not visible before. A stump under these
circumstances should not be closed in the first instance; the parts
should be merely approximated until all bleeding has ceased.
When the operation is performed near the knee, the gradual thickening
of the thigh prevents the retraction of the integuments, and has an
effect upon the vessels of the stump; both of which evils are avoided
after the circular incision has been completed, by making a cut, an
inch and a half in length, in the integuments through the fascia on
each side, in the horizontal direction in which they are recommended to
be placed, after the operation is finished; but this will very rarely
be necessary.
82. Amputation of the thigh, by the flap operation, is best
accomplished by the method adopted by Mr. Luke, of the London Hospital,
which is as follows: The patient being placed so that the thigh
projects beyond the table, the surgeon stands with his left hand toward
the body, or on the outside when amputating the right, and on the
inside when amputating the left thigh. The knife to be used ought to be
narrow, pointed, and longer by two or three inches than the diameter
of the thigh at the place of amputation. The point of the knife
should be entered _mid_-distance between the anterior and posterior
surfaces of the thigh, which may be effected with accuracy, if the eye
is brought to a level with the thigh, when the middle point is easily
determined. The posterior flap is to be formed first, by carrying the
knife transversely through the thigh, so that its point shall come out
on the opposite side, exactly midway between the anterior and posterior
surfaces. In traversing the thigh, the knife should pass behind the
bone, and will be more or less remote from it in different individuals,
according to the greater or less development of the posterior muscles,
when, by cutting obliquely downward, to the extent of from four to six
inches, according to the thickness of the thigh, a posterior flap is
formed. The anterior flap is effected, not by making a flap, but by
commencing an incision through the integuments and muscles on the side
of the thigh opposite to the surgeon, at a little distance anterior
to the extremity of the posterior flap. This incision is made from
without inward, through the integuments, so as to form an even curve,
and without angular irregularity, over the thigh, to near the base
of the posterior flap on the side on which the surgeon stands. The
length of this flap is determined by that of the posterior. It will
therefore vary from four to six inches, as before stated; and for its
completion will require a second, or perhaps a third, application of
the knife. In the two flaps thus made, the division of almost all the
soft structures is included, a few only immediately surrounding the
bone remaining uncut. These are to be divided by a circular sweep of
the knife, at the part where it is intended to saw the bone; in this
way it is sufficiently denuded for the application of the saw. The
flaps being held back by an assistant, the bone is to be sawn through
in the usual way. In amputations of the lower part of the thigh it
usually happens that the ischiatic nerve lies upon the surface of
the posterior flap, and should be removed. It occasionally occurs,
although not frequently, that the popliteal artery is cut obliquely at
its commencement; but in amputations above the passage of the arterial
trunk through the tendon of the triceps, this does not take place, the
division of the artery being usually included in the circular sweep
made after the formation of the flaps. The divided arteries having been
carefully secured, the flaps are to be brought together and retained by
three sutures passed through the integuments at equal distances from
each other, and from the extremity or base of the flaps. It appears
to be a matter of considerable importance not only that their edges
should be kept in apposition, but that their _whole surfaces_ should
be kept in accurate contact. For this purpose, the following method of
dressing is adopted: The edges, in the intervals between the sutures,
are to be held together by strips of adhesive plaster about one inch in
breadth. A compress of lint is then to be fitted over each flap, that
upon the posterior being the larger. The compresses are to cover the
flaps only, and not to extend over the extremity of the bone, where
their pressure would probably be ill endured. The posterior compress
is made large, that it may serve as a cushion on which the thigh rests
when the patient is placed in bed. The compresses are to be retained in
position by one or two strips of plaster, and supported by a bandage
applied carefully round the stump. If this be properly accomplished,
the whole surfaces of the flaps will be kept accurately in contact
with each other, and complete union may be reasonably expected. By
securing the perfect apposition and support of the entire surfaces in
accurate contact, the disposition to the issue of blood from small
vessels is also obviated to a great extent, and it is even probable
that vessels of a larger diameter than the smallest, which would bleed
if not restrained, are, by the pressure of the opposing surface,
prevented from doing so, and the probability of secondary hemorrhage
is diminished. Experience has demonstrated the fact that primary
union of the flaps is most effectually procured in the great majority
of amputations thus treated. Indeed, non-union of the flaps is the
exception; union, the rule. In the subsequent treatment of the stump,
care must be taken to prevent an accumulation of discharge in the
tracks of the ligatures; and the dressings must be renewed according to
circumstances having reference to the quantity of discharge, and the
uneasiness of the patient. The line of division of the integuments of
the two flaps is situated, at first, in the center of the face of the
stump; but when the flaps have united, a gradual change takes place in
the position of the cicatrix: it recedes, by degrees, to the posterior
aspect of the thigh, and the bone abuts upon the anterior flap, by
which alone it is eventually covered, and the cicatrix is thus removed
from its pressure.
83. A protrusion of bone is a disagreeable occurrence after amputation;
it will sometimes happen after sloughing of the stump, without any
fault of the operator. If, on completing the operation, it is evident
the bone cannot be well covered, a sufficient portion should be at once
sawn off, and the error remedied.
When the bone protrudes at a subsequent period to the extent of an inch
or more, it should be removed by operation, an incision being made on,
and down to, the bone, and the saw applied where it is sound. The chain
saw, when at hand, answers well, and some should be supplied for the
use of the principal hospitals with every army. The protruded end of
bone should be held steadily by pincers, or it may be introduced into a
hollow tube, which fixes it firmly.
When the bone has been badly sawn through, or split in the act of
dividing the last layer, or the periosteum is unduly separated, the
end will often exfoliate with the split, which may extend up for
several inches, giving rise to the formation of abscesses, causing much
suffering, and occupying a great length of time before the ring of bone
and the split portion exfoliate, and the stump becomes quite sound.
A splinter of this kind may even require to be removed at a late or
at a distant period, from the nervous irritation and suffering it may
occasion. This irritation has been often attributed to the extremity
of the principal nerve, which always enlarges, assumes a bulbous form,
and is painful on pressure, when made for the purpose, although not so
under ordinary circumstances. This enlargement never requires removal,
unless it should adhere to the cicatrix, or be the subject of disease
incidentally occasioned in it. The great sciatic nerve became early
thus enlarged in the thigh of the late Marquess of Anglesea, and was
mistaken for disease, for which he was advised to have it removed, it
being painful on pressure, and therefore the supposed cause of the
tic douloureux under which he labored. Consulted on the propriety of
this operation, his leg-maker, Mr. Pott, being present, who had also
lost a leg above the knee, I requested his lordship to squeeze Mr.
Pott’s bulbous nerve, in the same manner as the doctor had squeezed his
lordship. He did so, and Mr. Pott roared and sprang from the floor in a
manner which quite satisfied Lord Anglesea.