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

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.[51]

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