Amputation of the Thigh.—Amputation of the thigh has been the favourite battle-ground where flap and circular, antero-posterior and lateral, long and short flaps, double, triple, and conical incisions, have striven with each other; so were I to attempt to describe one quarter of the various methods employed, I should need to rewrite the history of Amputation.
It will suffice merely to describe the best modes of amputating the thigh through its lower, middle, and upper thirds respectively, and at the hip-joint.
In one word, it may be stated that, with the exception of those amputations performed through the lower third of the bone, the flap method is to be preferred, and the flaps should in almost every case be made by transfixion.
In the lower third, however, the flap method, though exceedingly easy, and capable of very rapid performance, has certain defects; the chief of these being the tendency which the muscular flaps (the necessary result of transfixion) have to cause undue retraction, and hence protrusion of the bone. This is seen specially in the hamstrings, which from the great distance of their origin, and the purely longitudinal direction of their fibres, retract to a very great extent, much more than the anterior muscles can do from the pennate direction of their fibres, and the manner in which they are mutually bound down to each other and to the bone.
Even in this one position, the lower third of the thigh, the methods that may be needed are various, and require separate notice;—for operations here are extremely frequent from the frequency of strumous disease of the knee-joint in our variable climate, and from the fact that compound fractures or dislocations of the knee-joint so very often necessitate amputation.
In cases where the skin over the patella is uninjured and available, the operation by long anterior flap (either by Teale's method, or by Mr. Spence's modification of it, which curiously is almost exactly similar to the amputation of Benjamin Bell by a single flap) is suitable enough. But, I believe, preferable to either of these is the operation of Mr. Carden, already described. In cases where the knee-joint is injured, and the skin over the patella unavailable, and yet where it is not necessary to go higher up the limb, the modified circular amputation of Mr. Syme will be found very suitable.
As it is in this lower third of the thigh that a very large proportion of the cases requiring a long anterior flap is to be found, it affords the best opportunity for comparing in their detail the three almost similar plans of B. Bell, Teale, and Spence—after which Mr. Syme's modified circular may be described.
Benjamin Bell's Flap Operation above the Knee (reported in his own words, slightly abbreviated).—"When this operation is to be performed above the knee, it may be done either with one or two flaps, but it will commonly succeed best with one. The flap answers best on the fore part of the thigh, for here there is a sufficiency of the parts for covering the bones, and the matter passes more freely off than when the flap is formed behind.... The extreme point of the flap should reach to the end of the limb, unless the teguments are in any part diseased, in which case it must terminate where the disease begins, and its base should be where the bone is to be sawn. This will determine the length of the flap, and we should be directed with respect to the breadth of it by the circumference of the limb, for the diameter of a circle being somewhat less than a third of its circumference, although a limb may not be exactly circular, yet by attention to this we may ascertain with sufficient exactness the size of a flap for covering a stump (Plate IV. fig. 17). Thus a flap of four inches and a quarter in length will reach completely across a stump whose circumference is twelve inches; but as some allowance must be made for the quantity of skin and muscles that may be saved on the opposite side of the limb, by cutting them in the manner I have directed, and drawing them up before sawing the bone, and as it is a point of importance to leave the limb as long as possible, instead of four inches and a quarter, a limb of this size, when the first incision is managed in this manner, will not require a flap longer than three inches and a quarter, and so in proportion, according to the size of the limb. The flap at its base should be as broad as the breadth of the limb will permit, and should be continued nearly, although not altogether, of the same breadth till within a little of its termination, where it should be rounded off so as to correspond as exactly as may be with the figure of the sore on the back part of the limb. This being marked out, the surgeon, standing on the outside of the limb, should push a straight double-edged knife with a sharp point to the depth of the bone, by entering the point of it at the outside of the base of the intended flap; and carrying the point close to the bone, it must here be pushed through the teguments at the mark on the opposite side. The edge of the knife must now be carried downwards in such a direction as to form the flap, according to the figure marked out; and as it draws toward the end, the edge of it should be somewhat raised from the bone, so as to make the extremity of the flap thinner than the base, by which it will apply with more neatness to the surface of the sore. The flap being supported by an assistant, the teguments and muscles of the other parts of the limb should, by one stroke of the knife, be cut down to the bone, about an inch beneath where the bone is to be sawn; and the muscles being separated to this height from the bone with the point of a knife, the soft parts must all be supported with the leather retractors till the bone is sawn," etc., arteries tied, and dressings applied.48
Amputation of Thigh by Rectangular Flap—(Teale's).—I take the opportunity here of describing fully, and as far as possible in his own words, Mr. Teale's method of amputating, this being the situation where his method is most frequently available. The same principle may be applied to amputations at almost any other part of the body.
After advising the surgeon to mark out the proposed line of incision with ink before the operation, he gives the following directions for fixing the exact size of the flap:—"Supposing the amputation to take place (Plate II. figs. 9, 10) at the lower part of the middle third of the thigh, the circumference of the limb is to be measured at the point where the bone is to be divided.49 Assuming this to be sixteen inches, the long flap is to have its length and breadth each equal to half the circumference, namely, eight inches. Two longitudinal lines of this extent are then traced on the limb, and are met at their lower points by a transverse line of the same length. The inner longitudinal line should be first traced in ink as near as practicable to the femoral vessels, without including them within the range of the long flap. The outer longitudinal line, which is somewhat posterior, is next marked eight inches distant from the former and parallel to it. These two lines are then joined by a transverse line of the same extent, which falls upon the upper border of the patella, or upon some lower portion of this bone. The short flap is indicated by a transverse line passing behind the thigh, the length of this flap being one-fourth that of the long one; or, assuming the circumference of the limb to be sixteen inches, and the length of the long flap eight inches, the length of the short flap is two inches. The operator begins by making the two lateral incisions of the long flap through the integuments only. The transverse incision of this flap, supposing it to run along the upper edge of the patella, is made by a free sweep of the knife through the skin and tendinous structures down to the femur. Should the lower transverse line of the flap fall across the middle or lower part of the patella, the transverse incision can extend through the skin only, which must be dissected up as far as the upper border of the patella, at which place the tendinous structures are to be cut direct to the thigh-bone. The flap is completed by cutting the fleshy structures from below upwards close to the bone. The posterior short flap, containing the large vessels and nerves, is made by one sweep of the knife down to the bone, the soft parts being afterwards separated from the bone close to the periosteum, as far upwards as the intended place of sawing.... In adjusting the flaps, the long one is folded over the end of the bone, and brought, by its transverse line, into union with the short flap, the two corresponding free angles of each being first united by suture. One or two additional stitches complete the transverse line of union. Care is now required in arranging the two lateral lines of union. As the long flap is folded upon itself so as to form a kind of pouch for the end of the bone, it is requisite that it should be held in its folded state by a point of suture on each side. Another stitch on each side secures the lateral line of the short flap to the corresponding part of the long one. A longitudinal line of union thus passes at right angles each end of the transverse line."50
Mr. Teale's account of the resulting stumps is too long to quote entire, but in a few words, we find that by retraction of the short posterior flap, the cicatrix is drawn up quite behind and out of the way of the bone, that a soft mass without any large nerves or vessels is the result of the partial atrophy of the long flap, and that the patient is able to bear one-half, two-thirds, or even in some cases the entire weight of his body on the face of the stump. Such a power of support is to be found in no other flap except in Mr. Syme's amputation at the ankle-joint.
Spence's Amputation by a long Anterior Flap.51—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 circumference 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 assistant 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 mass 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 assistant 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 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