130. _Secondary amputations_, or those performed after the lapse of
six or more weeks from the receipt of an injury, when suppuration has
been fully established, are not as successful in military as in civil
hospitals, in which these operations are more commonly performed for
incurable diseases than for injuries. When, however, they are done in
them for injuries, they are not equally successful.
131. In military warfare these amputations are frequently done
from necessity, not choice, after the first forty-eight hours; and
especially after four or five days to the end of six weeks, in
parts which have been lately, or are still affected by some of the
accompaniments of inflammation, or are in a state of irritation. In
these cases the cellular or areolar tissue has become firmer and
more compact than usual; the muscles are not perfectly healthy; the
blood-vessels are larger and more numerous, and ready to assume
actions unusual to them in a state of health. Where the bones have
been diseased, much bony matter may be deposited between the muscles,
and in some cases the vessels even are surrounded by it. After a few
hours’ remission, the constitutional symptoms often return, the wound
sloughs, and secondary hemorrhage is not an infrequent consequence.
The ligatures are a source of irritation, and prevent union, which, in
fact, should not in such cases be attempted, and, if attempted, will as
rarely succeed.
132. In these states of constitutional derangement, inflammation of the
veins and sloughing of the stump are not uncommon, augmented by, if
not dependent in some degree on, the state of the atmosphere, which in
autumn, the season for many military movements, gives rise to endemic
fevers, and even to dysenteries and cholera, which the soldier is often
so unfortunate as to acquire in crowded hospitals. If the man should
escape with life, a joint will frequently be lost which might have been
saved, if the operation had been performed in the first instance below
it. When the injury is in the thigh, this is a most important point for
consideration.
133. If the sufferer should escape these dangers, there remain the
sudden and usually disastrous affections from depositions of matter
in the viscera, alluded to in aphorisms 58, 59, 60, 61, and 62, which
are by no means so common when the patient is in better health; the
connection of these with inflammation of the veins deserves a more
close investigation than has as yet been bestowed upon it by civil or
by military surgeons since attention was first drawn to it by me in
1815.
134. In secondary amputations in parts which have partaken of the
extensive irritation which accompanies the original injury, more of
the soft parts must be preserved, although they cannot be said to be
unsound. In other words, the bone must be cut shorter, or the stump
will be conical and bad, particularly if sinuses containing pus are
found to run up between the muscles, or between them and the bone
itself--a state very likely to give rise subsequently to caries.
In sawing the bone, it may be again stated, the point of the saw should
incline downward, and when two-thirds of the bone have been divided,
it should be made to cut perpendicularly, whereby the _side_ next the
operator is the last part divided; the hazard of splintering the bone
at that moment will then be avoided, particularly if the limb to be
removed be held with great steadiness.
135. In secondary amputations, twice, nay, three times the number of
arteries will often bleed as in primary ones. In the thigh, the femoral
artery should be drawn out with a tenaculum or spring forceps, and tied
firmly with a single thread of dentists’ silk, one of the two ends
being cut off close to the knot. The smaller the vessel, the smaller
the thread required. Torsion or twisting the smaller vessels, so as to
rupture their inner coats, answers very well in cases in which many
small ones bleed. When a nerve is known to accompany an artery, it
should be carefully separated from it.
136. If the bleeding should continue from above the ligature on the
extremity of an artery, it is generally caused by some small branch
given off from it, which has been cut so close to the trunk of the
vessel as not to have been observed. In that case, the artery itself
should be drawn out by the tenaculum or spring forceps until the
bleeding point can be seen, and a ligature placed above it, when the
piece below should be cut off with the first ligature applied. This
inconvenience will be in general avoided by taking care to divide the
principal artery at one stroke of the knife, and with it half an inch
at least of the surrounding tissues, if the operation be done by the
circular incision; if by flaps, the extent of the exposed arteries
should be carefully examined, and the ligatures applied at the highest
point of exposure, when all below should be removed.
137. When a tourniquet is used, and applied too close to the incised
parts, it often prevents, even when loosened, the principal vessel from
being found, from its having pressed on the ends of the muscles. If one
be used, it should be removed as soon as possible after the principal
artery has been secured. The repeated tightening and loosening of the
tourniquet will cause more vessels to bleed in the end, and more blood
to be lost, than if it had not been used; it ought not, therefore, to
be resorted to when good assistance is procurable. In cases of this
kind, in which the stump may not cease to ooze, the circulation being
good, and sponging with cold water not effectual, the wound should
not be finally closed for two, four, or more hours, until the oozing
has ceased, and the parts can be freed from the coagulated blood, and
brought together.
138. In cases in which union is not expected to take place, both
ends of the ligature should be cut off; for union of the external
parts is not to be desired in many instances of secondary amputation,
particularly after serious injuries; the inflammation consequent on
which has in some degree implicated the structures divided in the
operation, rendering them less liable to take on the healthy action of
adhesion. The soft parts should be simply approximated by two or more
sutures, the edges of the wound having a piece of lint or fine linen
between them. This precaution should be particularly attended to after
a great battle, when it is perceived that from the air, the crowded
state of the hospital, or the season of the year, the stumps, although
they may appear to unite in the first instance externally, do not in
reality do so internally.
139. It has been proposed to use ligatures made of cat-gut or other
animal substances, which may be cut short, and left in the wound to
be absorbed. This has taken place in some instances, while in others
little abscesses have followed, allowing their discharge, and not
expediting the cure, so that the practice has not prevailed; it is said
that greater success has attended in America ligatures used in this way
made of very fine shreds of the strong tendons of the large deer of
that country. Ligatures should not be applied on large veins when they
continue to bleed, if it can be avoided, although it has frequently
been done without subsequent inconvenience. A little delay and moderate
pressure will generally suffice to arrest the bleeding.
140. If the surgeon find, after completing the operation, that the bone
cannot be sufficiently covered to make a good stump, a piece should
be sawn off at once, and the error remedied, with little comparative
inconvenience to what would occur afterward, if the bone be too long.
No false shame should prevent its being done. If, however, the error
have occurred, and the end of bone should become uncovered during
the process of healing, it may be allowed to separate of itself, as
it cannot be sawn off at this period without difficulty and much
suffering; for an exposed surface will then remain, from which an
exfoliation will take place before the stump can heal. In cases of
great protrusion, an incision should be made down to the bone, which
should be firmly held by strong forceps, or by a tube in which it
will fit, when it is to be sawn off by the chain saw at a sound part,
above that which has been exposed. The wound, in all cases, should
be well supported by compress and bandage, to secure a good stump;
whence the necessity for the bone being shorter than in those secondary
amputations which are done at the period of election, and which will,
on the contrary, often unite without difficulty. In primary operations,
cold water is most applicable in the first instance; in secondary
amputations, warmth by fomentations, rather than by even the lightest
of poultices.