A Manual of the Operations of Surgery, Joseph Bell [suggested reading .txt] 📗

(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.[48] 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."[49]

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.[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 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