Читать книгу Commentaries on the Surgery of the Npoleonic War in Portugal, Spain, France, - G. J. Guthrie - Страница 8

Table of Contents

APHORISMS FOR AMPUTATIONS, ETC.

65. Amputation of a limb is the last resource and the opprobrium of surgery, as death is of the practice of physic; it being, notwithstanding, impossible to do impossibilities, and save a limb or a life which can no longer be preserved. Art and science at that point cease to be useful.

66. At the commencement of the war in the Peninsula, all surgeons believed it to be impossible to compress in an effective manner the artery of the thigh against the bone, as it passes over the edge of the pubes, and that the loss of blood on its division must be so formidable as to be murderous. This was merely a surgical delusion, which maintained its ground in London until the end of 1815, when the French soldier, whose thigh I had successfully taken off at the hip-joint, after the battle of Waterloo, without first tying the femoral artery, was shown to all disbelievers. It was the great point in advance in English and European surgery, and one great result of the practice of that war.

67. This great, indeed most important fact, having been established, the surgery of amputation was deprived of nearly all its terrors. Confidence, and with it coolness, were obtained; and many young surgeons diligently sought for an operation on the hip-joint as the ne plus ultra of operative boldness and dexterity, much after the fashion of the young lady pianistes, who do not consider themselves in any way advanced on the road to perfection until they can play at least the overture to Guillaume Tell, if not the Galop Chromatique of Listz, nearly as well as the composer himself.

68. As a tourniquet cannot be applied in this amputation, nor even at that of the shoulder-joint, without doing harm, its inutility in the greatest operations is proved; and recourse should not be had to it in the smaller or less dangerous ones, provided sufficient assistance can be obtained. When the surgeon has only one assistant, he should apply a tourniquet, or even if he should have several bad ones on whom he cannot depend.

69. There is always more blood lost, and particularly in secondary amputations, when a tourniquet is used than when the principal artery is compressed by one assistant, and two others are ready to press on the outside of the flaps, or upon the divided vessels, with the ends of their fingers; the force necessary to prevent the passage of blood through the common femoral, or the axillary artery, being merely that of the finger and thumb, applied in a very gentle manner, or even of the end of the forefinger of a competent person. I have rarely applied a tourniquet since 1812, and few persons have done more formidable operations under more difficult circumstances. The ancient illusion with regard to the necessity for tourniquets in amputation must be given up, except by incompetent persons, or by those who are fearful and superstitious, and do not like to depart from the ways of their forefathers.

70. A tourniquet is useful when loosely applied after an operation, and the attendant should be taught how to turn it, so as to suppress any serious bleeding which may take place until the surgeon can be procured. It may be, although it rarely is, necessary on the field of battle. The surgeon need not, therefore, load himself or his assistant, as formerly, with a sackful, for a thoroughly useful tourniquet can be made in a moment with a pebble and a pocket-handkerchief, or a roller. The great point is to know where and how to apply it. When gentlemen called surgeons by warrant are sent to an army, as many were to that in Spain and France, with only the knowledge of a druggist, having been refused a commission on account of their ignorance, it is necessary this instruction should be especially given to them; and this horrible fact is recorded with the hope it may be useful in preventing any such atrocious proceedings in future. Peace or humane societies, if they cannot prevent a war, may interfere with advantage on this point, to divest it of some of its horrors. At the battle of Inkerman, a young officer, the son of a friend of mine, was wounded in the leg by a musket-ball, which caused much loss of blood. A tourniquet was applied, instead of the required operation being performed, and he was sent on board a transport from Balaklava. The leg mortified, as a matter of course, and was amputated. He died, an eternal disgrace to British surgery, or rather to the nation which will not pay sufficiently able men, and therefore employs ignorant ones—the best they can get for the money.

71. When circular operations were performed in the olden time, particularly on the thigh, the skin, when divided, was dissected, and turned up like the cuff of a coat—a painful proceeding, as unnecessary as it was barbarous. Forty years have elapsed since I demonstrated its absurdity, and showed that the first incision in the thigh should include the fascia lata, any deep attachments it might have should follow, when the parts thus divided ought to be retracted as a whole, to form a proper covering for the stump.

It was at the same time shown that, in whatever way, and however clumsily and tediously, the muscles might be divided, it did not prevent the successful result of the operation, provided the bone was cut short, so as to form a cone, with an elongated or depressed point.

72. The nicking of the periosteum, and pushing it upward and downward, so as to leave a space for the saw, was at the same time forbidden, as leading to necrosis of the part of the bone thus denuded, if unremoved by the saw. The saw was also directed to be held perpendicularly to, and not across, the bone, nor even diagonally to it—an apparently trivial, but yet great improvement. The last part divided is an outer and thin layer of hard bone, which does not so readily splinter on the side as on the under part, by the weight of the leg.

73. The limb to be amputated is not to be held by the assistant in the manner described and usually shown in books: one hand ought not to be above the knee, but below and by the side of it, the other grasping the calf, so that the limb may be duly supported, and drawn inward or outward, in the opposite direction to the saw, as it divides the last layers of the bone.

74. The common integuments of the stump should be drawn together, in primary amputations, by sutures formed of flexible leaden wires; by threads of silk, if leaden wires be not attainable. The vessels which bleed should be carefully secured by single yet fine threads of dentists’ or other strong silk, one end to be cut off in primary amputations. In secondary amputations, when the parts are not always sound, both ends of the ligature should be cut off, and in such cases the edges of the wound should be brought in contact only, with a layer of fine linen between them, without the expectation of, or the desire for, union taking place.

75. The removal of a limb should not occupy two minutes, but the securing the blood-vessels should be done without reference to time; when carefully effected, there is little fear of secondary bleeding, and the stump should be closed at once. It has been lately recommended not to close the stump for four, six, or eight hours after the operation; but this is not advisable, unless the depressed state of the patient, or other causes, should have rendered it impossible to secure, in a proper manner, all the vessels which are likely to bleed. It will be less painful and dangerous to delay, in such cases, than to have to reopen the stump.

76. When the edges of the incision have been brought together by the hands of the assistants, and by the sutures indicated, strips of some kind of agglutinative plaster without resin should be applied between them, and a little wet lint over the incision, retained by two cross-pieces of rollers, the ends of which are maintained in their situation by another roller applied round the body and over the upper part of the thigh, including the extremities of the two cross-pieces; but this roller is not to be applied over the end of the stump. When the war came well in, stump-caps, as they were called, went out, being worse than useless. The stump should be supported on a soft pillow, so as to be as comfortable as possible, and protected by a cradle from accidental injury.

If inflammation, accompanied by pain, should take place, cold or iced water should be applied, particularly in primary amputations. In secondary ones, warm fomentations or light warm poultices will be more advantageous, all constriction by sutures or plasters being removed, the parts being simply approximated to each other. Attention should be paid to the directions in aphorism 61.