A Manual of the Operations of Surgery Part 10

SPENCE'S AMPUTATION BY A LONG ANTERIOR FLAP.[50]--The method used by Mr.

Spence in amputations just above the knee-joint obtains the advantages of Teale's method, and avoids many of its disadvantages. He makes two flaps. The anterior one, which is to fall loosely over and cover in the posterior segment of the stump, must have a breadth fully equal to one-half of the circ.u.mference of the limb, and must be gently rounded at its extremity, so as to adjust itself readily to the curve of the cut margin of the posterior half of the stump. He begins the anterior incision below, or on a level with, the lower margin of the patella, and when the skin is retracted to a little above the patella, cuts down _obliquely_ to the bone, so as to divide the soft parts up to the base of the flap. For the posterior incision, he begins about two fingers'-breadth below the base of the anterior flap, and the a.s.sistant retracting the skin, the edge of the knife is carried obliquely up to the bone (in Alanson's manner) and the posterior soft parts divided, the bone is sawn through--or immediately above--the condyloid portion. Mr.

Spence does not advise or practise this method high up. The results are good, for by these means the end of the bone has a thick covering, including muscular fibres, over it, and the cicatrix is not pressed upon in walking. The stump remains full, mobile, and fleshy, as in Mr.

Teale's method, without the disadvantage which it has, in requiring the bone to be divided so far above the seat of injury or disease. This is an exceedingly good method of operating in the lower third of the thigh, in muscular patients the very best, and in all cases only equalled in value by Carden's method.

The next is now hardly ever used here, except in cases where the skin over the patella is destroyed.

MODIFIED CIRCULAR AT LOWER THIRD OF THIGH (Syme's).--Two equal semilunar flaps of skin should be cut (Plate I. fig. 20, Plate III. fig. 6), one anterior, the other posterior, their convexities being towards the knee.

The skin and subcutaneous cellular tissue should be raised from the fascia, and then retracted to a further distance of at least two inches; the muscles should then be divided right down to the bone, on a level as high as they are exposed in front, and as low as they are exposed behind. This allows for the different amount of retraction at the two sides of the limb, and leaves the muscles cut on a level; the whole ma.s.s of muscles should then be drawn well up, and the bone exposed, and sawn through at a level about two inches higher than where it was first exposed by the anterior incision through the muscles.

In very weak thin flabby limbs this process may be simplified by just at once including the muscles in the skin flaps, and carefully exposing the bone higher up. In performing the retraction the a.s.sistant should be cautioned not to overdo it, lest he strip the periosteum from the bone higher than is necessary. This is very easy to do in the weak limbs of strumous patients, and may cause exfoliation, and greatly delay cure.

AMPUTATION IN THE MIDDLE THIRD OF THE THIGH.--A very short notice will suffice here. The exact position, shape, and size of the flaps must in every case be modified by the nature of the injury for which the operation is performed, taking the flaps where they can be obtained. As a general rule, a long anterior flap with a short posterior, on the principle described above, should be preferred. In cases where the long anterior cannot be obtained, two equal flaps should be made by transfixion. The flaps should always be antero-posterior, the lateral flaps introduced by Vermale, and indorsed by Chelius and Erichsen, having the great disadvantage of allowing the bone, which is drawn up by the psoas and iliacus, to project at the upper angle.

Supposing the right thigh is to be amputated, the surgeon, standing on the inside of the leg, should raise the skin and muscles of the front of the limb in his left hand, and entering the knife just in front of the vessels, should transfix the limb, the knife pa.s.sing in front of the bone, and including as nearly as possible an exact half of the limb (Plate IV. fig. 19); having by a sawing motion brought out the knife and cut a flap of the required length, the knife is re-entered at the same place, and pa.s.sing behind the bone, the point must be brought out at the angle on the other side. Both flaps being then held back by an a.s.sistant, the bone is cleared by a circular turn of the knife, and the saw applied, the vessels are found cut high up in the inner angle of the posterior flap.

In muscular patients it is often better to make the incision through the skin first and allow it to retract before transfixing; this is slower and not so brilliant looking, but avoids redundancy of muscle.

AMPUTATION AT THE HIP-JOINT.--This operation, exceedingly dangerous from the amount of the body removed, the great haemorrhage, and the risk of pyaemia, is of comparatively modern invention. Though the proportion of recoveries is at present to that of deaths about one to two or two and a half, it is still a perfectly justifiable operation in many cases of disease and injury.

Like amputation at the shoulder, amputation at the hip has given rise to very many various methods of performance. Under the heads of single flap, double flap, oval, circular, and mixed flap and circular, at least twenty distinct methods have been put on record, and, including modifications, there are thirty-seven or thirty-eight different surgeons who have each their own plan of operation.

The reason of this fearful complexity in its literature depends on this fact, that this amputation has generally been performed for cases of such severe injury of the limb, that no milder amputation was possible, and thus the flaps had to be taken just where the surgeon could get them best. And this will have to be the guiding principle in most amputations at this joint; the surgeon must just cut his coat according to his cloth--get his flaps where and how he can.

In cases, however, where it is possible to have a choice, and to select the flaps, the following is, I believe, both the best and quickest method:--

This is one of the very few operations in which quickness of performance is a desideratum; the use of anaesthetics has, in most other cases, given time for elaboration of flaps, and careful dissection; here the risk of loss of blood, specially from the posterior flap, renders rapid disarticulation imperative.

_Amputation by double flap, anterior the longer._--In hip-joint amputations, besides the ordinary sponge-squeezers, two a.s.sistants are necessary, whose duties are exceedingly important.

The first is to check haemorrhage. Pressing with a firm pad on the external iliac just as it pa.s.ses the bone, he must be prepared, the instant the anterior flap is cut, to follow the knife and seize flap and artery in his hand, and he is to hold it there till all the vessels in the posterior flap are first tied.

The second has to manage the limb, and on the manner in which he performs his duty much of the success and nearly all the celerity of the operation depend. While the surgeon is transfixing the anterior flap, this a.s.sistant is to support the limb in a slightly flexed position, so as to relax the muscles; the instant the flap is cut he is to extend the limb forcibly, and at the same time be careful not to abduct it in the least, but to turn the toes inward so as to bring the great trochanter well forwards on a level with the joint; if this precaution is neglected, the operator in making the posterior flap is almost certain to lock his knife in the hollow between the head of the bone and the great trochanter.

If it is the left side, the operator, standing on the outside of the limb, enters the point of a long straight knife midway between the anterior superior spinous process of the ilium and the great trochanter, and pa.s.ses it as close to the front of the joint as possible, making the point emerge close to the tuberosity of the ischium (Plate IV. fig.

20-20). With a rapid sawing movement he then cuts a long anterior flap, avoiding any pointing of it, and endeavouring to make the curve equal.

The fingers of the a.s.sistant must be inserted so as to follow the knife and seize the vessel even before it is divided. The flap being raised out of the way, the surgeon, without changing his knife (as used to be advised), opens the joint, divides the ligaments as they start up on the limb being extended and adducted, the round ligament, and the posterior part of the capsule; and then getting the knife fairly behind both the head of the bone and the trochanter, cuts the posterior flap as rapidly as possible. Instantly on the limb being separated, a.s.sistants should be ready with large dry sponges or pads of dry lint to press against the surface of the posterior flap, till the large branches, chiefly of the internal iliac, which are cut in it, are tied one by one.

The lever invented by Mr. Richard Davy, by which the common iliac is compressed from the r.e.c.t.u.m, has in many cases proved of great service in preventing haemorrhage, but has dangers of its own in cases of abnormal position of r.e.c.t.u.m, or even in sudden movements of the patient.

In every case the abdominal tourniquet will be found of great service in checking haemorrhage, during the operation of amputation at the hip-joint. It consists of an arch of steel fitted with a pad behind, which rests against the vertebral column, and a pad in front playing on a very fine and long screw, through an opening in the arch. When screwed down tightly on the aorta just before the incisions are commenced, it checks haemorrhage admirably without injuring the viscera. When this is applied, a method of amputation once practised by Mr. Syme, though not so rapid as the double-flap method by transfixion, will be found very easy, and to result in most excellent flaps. He cut an anterior flap in the usual manner by transfixion, then made a straight incision from its outer edge down to about two inches below the great trochanter, thus exposing it fully, and from the lower end of this incision transfixed again, cutting a posterior flap nearly equal in size to the anterior; a few strokes of the knife round the joint finished the disarticulation.

The resulting flaps came together with great accuracy, and were not burdened with the great unequal ma.s.ses of muscles so often noticed in the posterior flaps which are made by cutting from within outwards _after_ disarticulation.

In some cases of amputation where the femur has been badly shattered, it is a good plan to amputate through the upper third of thigh, tie all the vessels, and then, aided by an incision at outer side, dissect out the head of the bone.

Mr. Furneaux Jordan of Birmingham carries out this principle by first dividing the soft parts in circular direction low down the thigh, and then dissecting out the head of the bone from the muscles by a long incision on the outer aspect of the limb.

_Note._--In severe cases of smash when both lower limbs have required amputation, the author has derived much a.s.sistance from the method of managing the operation detailed below:--

_Double Primary Amputation of (both) Thighs from railway smash_--_Rapid recovery._--G., a healthy-looking man, aged twenty-seven, but looking much older, while driving a horse near Granton, caught his foot on the edge of a rail at a point, fell, and both his legs were run over by several loaded wagons. A special engine was procured, his thighs tightly tied up, and he was sent up to hospital at once.

I was in hospital at the time, so with as little delay as possible he was placed on the operating table, and the necessity for amputation being too evident, I obtained his leave to remove both his legs above the knee; but his pulse was very feeble, and he was intensely nervous, throwing his arms wildly about, panting for breath, and looking very ill, cold, and exhausted.

I determined that by great rapidity he might be got off the table alive, so operated in the following manner:--Fixing the tourniquet firmly near both groins, I first amputated the right leg by Carden's method, and tied the femoral only, wrapped up the stump in a towel wrung out of carbolic solution 1-20, then took off the other limb by Mr. Spence's method,--it had been injured higher than the right, so that I could not save the condyles of the femur,--then tied the femoral there, and fixed it up with another towel; then returning to the first, I tied one or two large branches which spouted, and rolled it up again, then back to the left one, doing the same, and getting the tourniquet off both limbs. On going back to the right the surface was nearly dry and glazed, so, asking Dr. Maclaren, who a.s.sisted me, to st.i.tch it up and insert a drainage-tube, I did the same for the left, so rapidly that the patient was in his bed with his limbs dressed and bandaged in 24-1/2 minutes from the time he entered the hospital gate.

The strictest antiseptic precautions were observed, two engines being used to furnish spray. Of course this great rapidity was due to the fact that everything was ready, the a.s.sistants all in hospital, admirably disciplined, and steam had been up in the spray engines. Shock was comparatively trivial; his temperature once, and only once, reached 100. His stumps healed by first intention, and he was in the garden on the seventh day after the operation.

I have now in three cases found the benefit of this mode of dealing with double primary amputation in avoiding shock, lessening the time needed, and greatly diminis.h.i.+ng the number of vessels requiring to be tied. In a previous case of double amputation for railway smash at the knees, the patient was almost pulseless, and had he been kept many minutes more on the table would not have left it alive. He also rapidly recovered.

The case is interesting also as showing that, when the a.s.sistants know their work, the strictest adherence to antiseptic precautions need not in itself make either the operation or the dressing tedious, though it can easily be made an excuse for much fussing and many delays.[51]

FOOTNOTES:

[24] For details see article "Amputation" in Cooper's _Surgical Dictionary_, and the short sketch of the history in Mr. Lister's paper in the third volume of Holmes's _System of Surgery_.

[25] See a most interesting foot-note to Professor Lister's paper on "Amputation," in Holmes's _System of Surgery_, vol. iii. pp. 52, 53.

[26] _Manuel d'Operations chirurgicales._

[27] FIG. IV. shows dorsal view of incision. FIG. III. shows face of completed stump; R, radial; U, ulnar.

[28] As the surgeon will find it most convenient to stand on his own right side of the limb to be removed, the knife will be entered on the palmar side of the radius of the right arm, of the ulna of the left.

[29] Teale, _On Amputation by Rectangular Flaps_, pp. 46-48.

[30] Johnson's folio ed., p. 342.

[31] Gross's _Surgery_, 6th ed. vol. ii. p. 1103.

[32] _International Encyclopaedia of Surgery_, vol. i. p. 641.

[33] Spence's _Surgery_, pp. 800, 801.

[34] Gross's _Surgery_, 8vo., 6th ed., vol. ii., p. 1106.

[35] _Excision of Scapula_, p. 33.

[36] Hey's _Observations_, 3d ed. pp. 552, 556.

[37] Roux's _Parallel between English and French Surgery_. Translation abridged from Cooper's _Surgical Dictionary_, p. 106.

[38] Syme's _Principles_, 4th edit. p. 145.

[39] _International Encyclopaedia_, vol. 1. p. 655.