A Manual of the Operations of Surgery
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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 passing 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 passing behind the bone, the point must be brought out at the angle on the other side. Both flaps being then held back by an assistant, 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 hæmorrhage, and the risk of pyæmia, 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 anæsthetics 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 assistants are necessary, whose duties are exceedingly important.
The first is to check hæmorrhage. Pressing with a firm pad on the external iliac just as it passes 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 assistant 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 passes 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 assistant 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, assistants 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 rectum, has in many cases proved of great service in preventing hæmorrhage, but has dangers of its own in cases of abnormal position of rectum, or even in sudden movements of the patient.
In every case the abdominal tourniquet will be found of great service in checking hæmorrhage, 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 hæmorrhage 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 masses 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 assistance 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 assisted me, to stitch 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 24½ 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 assistants 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 diminishing 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 assistants 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.52
CHAPTER III.
EXCISION OF JOINTS
Historical.—Beyond a passage ascribed to Hippocrates, but of very doubtful authenticity, and slight allusions in the works of Celsus and Paulus Ægineta, the ancients give us no information whatever on this subject.
Hippocrates says,—"Complete resections of bones in the neighbourhood of joints both in the foot, in the hand, in the tibia up to the malleoli, and in the ulna at its junction with the hand, and in many other places, are safe operations, if that fatal syncope does not at once occur, and continued fever does not attack the patient on the fourth day."
Celsus and Ægineta both advise the removal of protruding ends of bone in compound dislocations, but without giving any cases.
From the days of these classic fathers of Surgery, we have hardly an indication of any attention whatever having been paid to their hints till quite within the last hundred years.
The first distinct publication on the subject was by Henry Park of Liverpool, in a letter to Percival Pott in 1783. He proposed the removal of the articulating extremities of diseased elbow and knee-joints to obtain cures. He says he was led to this by its having been the invariable custom, for more than thirty years, at the Liverpool Infirmary, to take off the protruded extremities of bones in cases of compound dislocation.
The chief credit, however, in practically elevating excisions into the catalogue of recognised surgical operations, is owing, British surgeons most cordially own, to two provincial surgeons of France, the Moreaus (father and son) of Bar-sur-Ornain. They took the lead in the most marked manner, having excised the shoulder in 1786, the wrist and elbow in 1794, knee and ankle in 1792, and had followed this up so well that, in 1803, the younger Moreau could boast, "the town has become in some sort the refuge of the unfortunate afflicted with carious joints, after they have tried all the means usually recommended by professional men, or have had recourse to empirical nostrums, or when amputation seemed to them the last resource."
Moreau's papers and cases, which, between 1786 and 1789, he frequently read to the French Academy, were, some violently opposed, others utterly neglected by his compatriots, and many of them lost and buried in the unpublished papers of that body.
And though diseased joints did not decline in frequency, and though injured ones were extremely numerous during these long years of European war, excisions were but rarely performed.
With the exception of the removal of head of humerus after gunshot injury, hardly any British, and but very few French, limbs were saved by excision taking the place of amputation.
The limbs that were saved by Percy by excision of the head of the humerus really owe their recovery and safety to the elder Moreau; for an operation of his, at which he was assisted by that distinguished military surgeon, gave the latter the hint, which he followed so successfully, that by 1795 he had performed it nineteen times, and had indoctrinated Sabatier, Larrey, and others, and elevated it into a recognised operation of military surgery.
So far, however, as the application of the great improvement of the Moreaus to disease went, the French surgeons have little reason to boast, for it is to English surgery, and especially to one Edinburgh surgeon, that this class of operations owes nearly all its improvement in methods and frequency of performance.
For though (as we shall see under the special heads) here and there one or two cases were performed, it was not till the publication of Mr. Syme's monograph on the excision of diseased joints, in 1831, that the importance and value of the discovery were fairly brought before the profession; and the conservative surgery, of which excision as preferred to amputation is the great type, must ever be associated with British surgeons—Syme, Fergusson, Mackenzie, Jones of Jersey, Butcher of Dublin.
On the Continent—Langenbeck, Stromeyer, Heyfelder, Ollier, Esmarch of Kiel, specially in the surgical history of the first Schleswig-Holstein war, have followed up the example set them here.
Before proceeding to describe the operations on the various joints, one or two questions may be briefly asked and answered by way of introduction.
In what cases, or sorts of cases, are excisions suitable?
1. In cases of compound injury or dislocation of a large joint, as used by Filkin, Park, White, and other English surgeons long ago. In hospital practice, or in private, where there is every advantage of rest, food, and appliances, such operations will frequently be found suitable where the joint is alone or chiefly the seat of injury, and where the general health seems fit to bear a prolonged suppuration. But long and sad experience has shown that, as a general rule in military practice, with the difficulties of transport, the generally bad sanitary state of the hospitals, and the want often of adequate dressings and attention, excisions are much more fatal than amputations, and, except in elbow and shoulder (q.v.), should be as a general rule avoided.
2. Excision for deformity (generally speaking for bony anchylosis) will require for decision the consideration of many points, i.e. the joint affected, the nature of the disease or injury which has caused the anchylosis: and in each case—(1.) the state of health of the patient; and (2.) his occupation, and the consequent position of limb which would suit him best. As a general rule, I believe, experience will prove that such operations on the lower extremity are almost absolutely inadmissible, except under very special urgency on the part of the patient, and a very high condition of health—while in the upper, the elbow-joint is the only one which you will ever be likely to be asked to remedy, or should comply with the request if asked; as the shoulder, even if anchylosed, will (1.) from its own weight generally become so in the most favourable position; and (2.) from the extreme mobility which the scapula can acquire, its anchylosis will not be so much felt.
The elbow, however, from the frequency of fractures of the condyles of the humerus obliquely into the joint, and from the manner in which these are so often neither recognised nor properly treated, very often becomes anchylosed in the most awkward possible position, i.e. nearly straight; and operations undertaken for such deformities are in general both quite safe and very satisfactory. Mr. Syme had one case (resulting from a fall, causing a double fracture), in which both arms were thus firmly anchylosed in such a position that the sufferer could absolutely perform none of the commonest duties of life without assistance. Excision of both joints cured him.
The author excised with success for disease the elbow-joint of a patient whose other arm had required the same operation.
The occupation of the patient must always be taken into consideration when settling the position of an anchylosis, or the necessity or advantage of a resection.
Thus, Bryant53 tells of a painter who wished his arm to be fixed in a straight position, and of a turner whose knee at his own request was permitted to stiffen at a right angle, as that position allowed him to turn his wheel.
3. Excision for Disease of the Joint.—In our cold climate, so cursed by scrofula, and specially among the children of the labouring poor, such joint diseases are very prevalent, and whether the disease commences in the synovial membrane, the articular cartilages, or the heads of the bones, it frequently so disorganises the joint as to make it a question whether something must not be done to preserve the very life of the patient.
The difficulty of diagnosing the cases in which excisions are suitable or necessary is often very great; and we must balance its performance—(1.) against the possibly good results of an expectant treatment; (2.) against amputation of the limb.
(1.) Against expectant Treatment.—The patient has youth on his side, could we give him fresh sea air, good diet, cod oil, etc., we might very likely obtain anchylosis; true, but he may die while trying for this anchylosis, and also this anchylosis, when got, may so lame or deform him that resection may still be required.
These points must all be considered, but as a general rule, I would say that such attempts at preservation of the limb are much more justifiable, and longer justifiable in the hip and knee-joints than in the elbow or shoulder; for the results in the lower limb will probably be as good, if the patient survive, if not better, than those obtained by excision, while the danger of the operation is greater; while in the upper limb, the danger to life in operating is less than that of leaving the limb on, and the results obtained by a successful operation, with well-managed after treatment, are far more satisfactory than the best possible anchylosis.
Another point bearing on this, of very great importance: In children, the most frequent subjects of such disease, excision of the lower limb may, by removing the epiphyses, cause to a very considerable degree disparity in their length, thus rendering them nearly useless, while in the upper such disparity is neither so extensive nor so injurious to the usefulness of the limb, which is not required for purposes of progression.
In the hip-joint especially, all the resources of the art should be tried in the expectant treatment, for amputation at the hip-joint is hardly ever admissible for disease of the joint, while excision has anything but satisfactory statistics.
(2.) Against Amputation.—Many questions must be considered, chiefly under the heads of the separate joints:—
1. As to the difficulties and dangers of the operations contrasted.
Such as the following:—
Excisions give the surgeon more trouble, require more manual dexterity; take longer to perform; are very painful operations. Not valid objections in these days of chloroform and operative surgery on the dead body.
Excisions have the special peculiarity and danger of dealing chiefly with cancellated bone, broadened out, open, with numerous patulous canals for large veins, tending on any irritation or inflammation to set up a diffuse suppuration, and to culminate in phlebitis, myelitis, and other pyæmic conditions.
Excisions are performed through degenerate or disorganised, amputations through healthy, tissue.
Excisions require extreme care and absolute rest (i.e. in lower limb) for many weeks and months after the operation.
But, on the other hand,—
Amputations remove a portion of the body; excisions a much less one. Amputations are always necessarily nearer the centre than the corresponding excisions, and statistics show that the fatality of operations increases in exact proportion as they approach the centre.
A successful excision, especially in arm, saves a limb nearly perfect; an amputation at best is only the stump for a wooden one.
On the whole, there is actually very little difference in the mortality of excisions and amputations.
2. As to the results of the operation on the usefulness of the limb, depending on joint involved, age of patient, and amount of bone removed:—
A. Joint involved.—These must be noticed separately, but one thing is absolutely certain, that a much higher standard of usefulness, both in equality of length, amount of anchylosis, and position, is needed in the lower than in the upper limb. For a leg hanging like a flail, or shortened by some inches, is not so good for purposes of locomotion as a wooden leg is, while an arm, even though powerless at the elbow, and perhaps much shortened, can be so strengthened and supported by slings and bandages as to give a most useful hand, the complex movements and uses of the fingers of which no mechanism can at all imitate.
B. Age of Patient.—It must be remembered that excision in a child removes the epiphyses by which in great measure the growth of the bone is to be managed, and the stunted limb, especially in the leg, will eventually be of little advantage, though after the operation it looked excellently well, if a few years later it be found to be seven or eight inches shorter than its neighbour.
C. Amount of Bone removed.—From an erroneous view of the pathological changes in the bone affected, far too much was removed by many of the earlier operators, especially Moreau and Crampton.
The reason that this is often still the case, is well seen in many preparations. The bones are thickened to a considerable distance, and covered with irregular warty excrescences. These, which used to be considered evidences of disease, are only compact new healthy bone, thrown out like the callus of a fracture in consequence of the irritation.
In a word, what we require to remove is the following:—
1. All the cartilage, dead or alive, healthy or diseased.
2. Only the bone involving the articular extremities, in thin slices, or with the occasional use of the gouge, till a healthy bleeding surface is obtained.
3. The synovial membrane, however gelatinous or thickened looking, really requires very little care or notice; it will disappear of itself, partly by sloughing, partly by absorption during the profuse suppuration.54
Excision of the Shoulder-Joint.—Before considering the method of operating, a word or two is required on the subject of how much is to be removed, and in what cases the operation should be performed. The shoulder and hip joints are the only ones in which partial excision is ever admissible, indeed, in the shoulder excision of the head of the humerus only is in many cases found to be all that is necessary, while in all it is much less dangerous to life than when the glenoid cavity also requires to be interfered with.