Читать книгу Commentaries on the Surgery of the Npoleonic War in Portugal, Spain, France, - G. J. Guthrie - Страница 9

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77. This amputation essentially owes its existence to the wars of the French Revolution. M. Bourgery says Blandin performed it three times in 1794; once successfully. Baron Larrey did it seven times during his different campaigns, and he says one or two persons who had survived were seen during their cure by an officer in Russian Poland, but they never reached France. Nevertheless, I always assume that one at least did recover, whether he was really seen or not, being a compliment and a reward justly due to the zeal and ability of my old friend the Baron, to whom the surgery of France is so much indebted. This operation was first done in Spain by the late Mr. Brownrigg, at Elvas, in 1811, and by myself after the siege of Ciudad Rodrigo, but none of our patients ultimately recovered. I operated on a French soldier at Brussels soon after the receipt of the injury at Waterloo; he survived; and he was the first and the only man seen for a long time afterward in either London or Paris. The biographer of Baron Larrey says he was present at, and advised the operation to be done; but that is an error, as the Baron did not visit Brussels until after I had left it for Antwerp; neither had I any knowledge of the Baron’s writings in 1811 or 1812, when my first operation was done in Portugal. Eighteen or twenty ways have been suggested for doing this operation, and twenty persons are believed to have survived its performance, several of whom may be living at the present time.

A very extensive destruction of the soft parts, the femur remaining entire, does not authorize the removal of the limb in the first instance, unless the main artery be also injured. Captain Flack, of the 88th Regiment, was struck by a large cannon-shot at Ciudad Rodrigo, on the outside and anterior part of the left thigh, which tore up and carried away nearly all the soft parts from the groin, or bend of the thigh, below Poupart’s ligament, to within a hand’s-breadth of the knee. It was an awful affair. He was supposed to be dying, was returned dead, and his commission was given to another. Left to die in the field hospital after the town was stormed, and finding himself thus deserted by his own friends, he claimed my aid as a stranger. I took him five leagues to my hospital at Aldea del Obispo. The femoral artery lay bare for the space of nearly four inches, in a channel at the bottom of the wound; the whole, however, gradually closed in, and he recovered.

If the injury is on the back part, a flap should be made in amputation from the fore part. If the wound should be on the outside, the flap is to be made from the inside, and vice versa, the object being to make the stump as long as possible. A wound of the artery, accompanied by a fracture of the femur, requires amputation, for although many would survive either injury alone, none would, it may be apprehended, surmount both united.

If after a fracture in course of treatment, the principal artery should be wounded by some accidental motion of the bone, amputation should in general be resorted to. A ligature on the artery higher up would fail, and the operation of seeking for both ends of the injured vessel would cause so much mischief in an unsound part that the consequences would in all probability be fatal.

78. When the femur is suffering from a malignant disease, commencing in the periosteum, or in its cancellated internal structure, I am reluctantly obliged to say, from experience, that the removal of the whole bone at the hip-joint offers the best, perhaps the only chance of success. In such cases, the operator has in general the power of selecting his mode of proceeding.

It may be laid down as a principle in all cases of accident, whether from shot, shell, or railway carriages, that no man should suffer amputation at the hip-joint when the thigh-bone is entire. It should never be done in cases of injury when the bone can be sawn through immediately below the trochanter major, and sufficient flaps can be preserved to close the wound thus made. An injury warranting this operation should extend to the neck, or head of the bone, and it may be possible, as I have proposed, even then to avoid it by removing the broken parts.

79. The principle being established, as a general rule in all cases of recent injury, that the femur must be broken at least as high as the trochanter to constitute an imperative case for this operation, the next point of importance relates to the manner of forming the first incisions. The instructions and recommendations to be found in books for the performance of this operation are frequently inapplicable, and are not to be depended upon; the errors occurring from the operation having been considered and performed on the dead body and not on the living; on the normal and not on the injured state of parts. Thus, for instance, it is recommended that an assistant should rotate the knee outward or inward, to show the head of the femur; to which recommendation there is the insuperable objection, that no person should suffer this operation who has a knee, or half a thigh, or even a third of one, to move by the rotary process. Pure theorists in surgery have decided upon having a large flap made on the fore part of the thigh, and a smaller one behind, regardless of the fact that this cannot be done in many cases requiring a primary operation from the nature of the injury; although it may be done in many secondary cases, in which this severe operation would not have been required if the limb had been amputated in the first instance. It is the mode recommended by Mr. Brownrigg, who in his operations, which were secondary ones, had a choice of integument, and it is, perhaps, under these circumstances, the best.

Baron Larrey tied the femoral artery in the first instance, and then made two lateral flaps; but this operation, dependent on the fear of hemorrhage, was never performed in the British army.

80. My first successful operation, performed in 1815, was done from without inward, the flaps being anterior and posterior, the artery being compressed against the pubis.

The patient is to be laid on a low table, or other convenient thing, in a horizontal position; an assistant, standing behind and leaning over, compresses the external iliac artery becoming femoral, as it passes over the edge of the pubis. The surgeon, standing on the inside, commences his first incision some three or four inches directly below the anterior spinous process of the ilium, carries it across the thigh through the integuments, inward and backward, in an oblique direction, at an equal distance from the tuberosity of the ischium to nearly opposite the spot where the incision commenced; the end of this incision is then to be carried upward with a gentle curve behind the trochanter, until it meets with the commencement of the first; the second incision being rather less than one-third the length of the first. The integuments, including the fascia, being retracted, the three gluteal muscles are to be cut through to the bone. The knife being then placed close to the retracted integuments, should be made to cut through everything on the anterior part and inside of the thigh. The femoral or other large artery should then be drawn out by a tenaculum or spring forceps, and tied. The capsular ligament being well opened, and the ligamentum teres divided, the knife should be passed behind the head of the bone thus dislocated, and made to cut its way out, care being taken not to have too large a quantity of muscle on the under part, or the integuments will not cover the wound, under which circumstance a sufficient portion of muscular fiber must be cut away. The obturatrix, gluteal, and ischiatic arteries are not to be feared, being each readily compressed by a finger until they can be duly secured. The capsular ligament, and as much of the ligamentous edge of the acetabulum as can be readily cut off, should be removed. The nerves, if long, are to be cut short. The wound is then to be carefully cleansed, and brought together by three or more soft leaden sutures in a line from the spine of the ilium toward the tuberosity of the ischium. The ligatures are to be brought out between the sutures, and some adhesive strips of plaster applied to support them. A little wet lint is to be placed over the wound, and some well-adapted compress under the lower flap; the whole to be retained by a soft bandage. In my successful case there was a shot-hole in the under flap, which did good service; and from having seen its use, I have no objection to a small perpendicular slit being made in the lower flap, and a strip of linen introduced to prevent adhesion. The immediate union of the flaps cannot be expected, nor is it often to be desired.

This mode of proceeding is more certain of making good flaps where integuments are scarce. Where the integuments will admit of the anterior flap being made by the sharp-pointed puncturing knife dividing the parts after it has been passed across from without inward, there is no objection to this proceeding, and some prefer it. I have had two such knives added to each of the cases of instruments supplied to the army for the purpose.

Professor Langenbeck, when lately in London, informed me he had performed amputation at the hip-joint several times in the Holstein war, and he believed more than once successfully; making the anterior flap by the pointed knife, cutting from within outward, but the posterior one by cutting through the integuments from without inward, as I have recommended in high amputation below the joint, in order to make the flap of a more equal and proper thickness. One point to be attended to is to leave as little as possible of the internal tendinous structure of the great gluteus muscle, as it does not readily unite with other parts; a second, not to leave too much muscle on the under part; and a third, to remove as much as possible of the ligamentous structure about the joint. The after-treatment will be the same as in other formidable cases. The shock, however, of the injury, and of the amputation, will render blood-letting unnecessary. Cordials, in small quantities, with opiates and a good but light nourishing diet, should be given. The wound should be wetted with cold water, and the patient constantly watched, so that hemorrhage may be arrested if it should take place. In an otherwise successful operation performed by Mr. C. G. Guthrie, at the Westminster Hospital, the patient was lost on the third day from this cause.

Mr. Brownrigg’s operation is to be done in the following manner: The patient is to be placed on a low table and properly secured, with the nates projecting over its edge, the artery being compressed. The surgeon enters the pointed knife between the spine of the ilium and the trochanter major, and carries it across the thigh, as near as may be to the head and neck of the femur, until the point appears on the inside, near the scrotum, which should have been previously drawn away. The knife is to cut slowly downward, to make a flap, under which, and behind the knife, an assistant inserts his four fingers, in order to be able to grasp the flap and aid in compressing the principal artery, as the operator completes the flap, which it is intended should be a large one, as shown in the diagram, fig. 1.

Fig. 1.

Amputation of the Hip-joint as performed by Mr. Brownrigg.

(Upper figure.)

a a a, anterior flap in dotted lines; c, thumb compressing the artery on the pubis; d, fingers introduced under the flap; e, the straight knife, entrance and exit of.

(Lower figure.)

Flap Amputation as performed by Mr. Luke, on the lower half of the thigh.

A, middle of the outside of the thigh and point of entrance of knife; B, under part; C, upper part; A to E, the under flap; G to F, dotted line of upper flap, beginning short of commencement of under flap.

The assistant holding up the flap, the surgeon cuts the attachment of the gluteus medius muscle, from the upper edge of the trochanter, if it has not been already done, opens the capsular ligament of the joint, and divides the ligamentum teres. The head of the bone can then be readily withdrawn from the acetabulum. The knife being placed behind the head of the bone and the trochanter, should be carried obliquely downward and backward, so as to form a shorter flap behind than was made before. The amputations of the hip-joint, performed in the Crimea, have not, I understand, been as successful as the ability with which they were performed might have led the operators to expect.

Fig. 2.

Mr. Guthrie’s operation.

Left side—

a, anterior superior spine of ilium; b, commencement of anterior incision, continued by the black line; c, the posterior incision joining the anterior one.

(Second figure.)

b c, line of incision marked by three sutures.

81. Amputation by the circular incision is to be done in the following manner: When a tourniquet is used, which it should not be, if the surgeon can depend on his assistants, the pad should be firm and narrow, and carefully held directly over the artery, while the ends of the bandage in which it is contained are pinned together. The strap of the tourniquet is then to be put round the limb, the instrument itself being directly over the pad, with the screw entirely free; the strap is then to be drawn tight and buckled on the outside, so as to prevent its slipping, and yet not to interfere with the screw. Should the screw require to be turned more than half its number of turns, the strap is not sufficiently tight, or the pad has not been well applied. The patient being placed on a table at a convenient height, the assistants are carefully to retract the integuments upward, and put them on the stretch downward, by which means their division is more easily and regularly accomplished. The surgeon, standing on the outside, passes his hand under the thigh and round above quite to the outside, and there he begins his incision with the heel of the knife, and with a quick, steady movement, carries it round the thigh until the circular division of the skin, cellular membrane, and fascia has been completed. The skin cannot be sufficiently retracted unless the fascia be divided, and as the division of the skin is certainly the most painful part of the operation, it ought never to be done by two incisions, when the largest thigh can most readily and speedily be encircled by one. If the fascia should not be completely divided by the first circular incision, it is to be cut with the point of the knife, together with any attachment to the bone or muscles beneath. The amputating knife is then to be applied close to the retracted fascia and integuments, and the outermost muscles are to be divided by a circular incision, with any portion of the fascia that may not have equally retracted. This incision completed, the knife is immediately to be placed close to the edge of the muscular fibers which have retracted, and the remainder of the soft parts divided to the bone in the same manner. In making these two incisions, care should be taken to cut at least half an inch on each side of the great artery by one incision, which should be either the first or second, as may be most convenient. The muscles attached to the bone are then to be separated with a scalpel for about three inches in large thighs, by which means the bone will be fairly imbedded when sawed off. The common linen retractor is next to be placed on the limb, and the muscles steadily kept back while the bone is sawed through. The periosteum may or may not be divided by one circular cut of the scalpel after the retractor has been put on. The heel of the saw is then to be applied and drawn toward the surgeon, so as to mark the bone, in which furrow he will continue to cut with long and steady strokes, the point of the saw slanting downward in a perpendicular direction until the bone be nearly divided, when the saw is to be more lightly pressed upon, to avoid splintering it, which this manner of sawing will also tend to prevent. During this operation the thigh should be held steadily above, and in such a manner below that the part to be cut off does not weigh or drag on the bone above; at the same time it must not be pressed inward or upward, or it will prevent the motion of the saw or splinter the bone. The retractor is then to be removed, the great artery to be pulled out by a tenaculum passed through its sides, separated a little from its attachments, and firmly tied with a two-threaded, strong ligature, provided dentists’ silk be not used, and the tenaculum is not to be withdrawn until this has been accomplished; any other vessels that show themselves may be secured, and compression should for an instant be taken off the main artery, when others will start. If used, the tourniquet should now be removed, and the small remaining vessels will be discovered. If the great vein continue to bleed after some pressure has been made upon it, a single-threaded ligature should be put over it; but this should not be done if it can be avoided, and only when the loss of a little blood might be dangerous. If the cancellated part of the bone bleed freely, the thumb of the left hand pressed steadily upon it, while the vessels are tying, will in a short time suppress the hemorrhage. Any inequality of bone should be removed by forceps. The ligatures should now be shortened, one end of each thread being cut off; the stump is to be sponged with cold water and dried, the bandage rolled steadily down the thigh; the muscles and integuments brought forward and placed in apposition, horizontally across the face of the stump, and retained by leaden sutures and adhesive plasters carefully applied, from below upward, and from above downward; the ligatures being brought out nearly as straight as possible, in two or three places between the slips of plaster, unless both ends have been cut short. A compress of lint is to be placed over and under the wound, supported by two slips of bandage, in the form of a Maltese cross, vertically and horizontally, and the whole secured by a few more turns of the bandage. No stump-cap is to be applied; the stump is to be raised a little on a proper pillow from the bed, in which the patient lies on his back; and if the bone appear to press too much against the upper flap, the body may be a little raised, which will relieve it.

In secondary amputation of the thigh, the integuments may not be sound, and will not retract, in which case they must be dissected back to an equal distance all round. If the muscles are much diminished in size, or flabby, they should be left even longer than may appear necessary for the formation of a good stump; and this is to be done more especially on the under part, for the bone will frequently protrude under these circumstances, when enough has been supposed to have been preserved. In all these cases the bone should be shorter than usual, and the skin should, if possible, retain its attachments to the parts beneath. No inconvenience can ever arise from too much muscle and skin in a circular stump; but it does sometimes from too much skin alone.

In primary operations there will be from three to seven vessels to be tied; in secondary ones, from ten to sixteen, and even then there may be an oozing from the stump. In this case a little delay in searching for the vessels is necessary; the tourniquet and all tight bandages should be removed, and the stump well sponged with cold water before it is dressed. A certain degree of oozing is to be expected from all stumps, although it does not always occur: but when there is really any hemorrhage, so that blood distills freely through the dressings, the stump should be opened, when the bleeding vessel will generally be discovered readily, though not visible before. A stump under these circumstances should not be closed in the first instance; the parts should be merely approximated until all bleeding has ceased.

When the operation is performed near the knee, the gradual thickening of the thigh prevents the retraction of the integuments, and has an effect upon the vessels of the stump; both of which evils are avoided after the circular incision has been completed, by making a cut, an inch and a half in length, in the integuments through the fascia on each side, in the horizontal direction in which they are recommended to be placed, after the operation is finished; but this will very rarely be necessary.

82. Amputation of the thigh, by the flap operation, is best accomplished by the method adopted by Mr. Luke, of the London Hospital, which is as follows: The patient being placed so that the thigh projects beyond the table, the surgeon stands with his left hand toward the body, or on the outside when amputating the right, and on the inside when amputating the left thigh. The knife to be used ought to be narrow, pointed, and longer by two or three inches than the diameter of the thigh at the place of amputation. The point of the knife should be entered mid-distance between the anterior and posterior surfaces of the thigh, which may be effected with accuracy, if the eye is brought to a level with the thigh, when the middle point is easily determined. The posterior flap is to be formed first, by carrying the knife transversely through the thigh, so that its point shall come out on the opposite side, exactly midway between the anterior and posterior surfaces. In traversing the thigh, the knife should pass behind the bone, and will be more or less remote from it in different individuals, according to the greater or less development of the posterior muscles, when, by cutting obliquely downward, to the extent of from four to six inches, according to the thickness of the thigh, a posterior flap is formed. The anterior flap is effected, not by making a flap, but by commencing an incision through the integuments and muscles on the side of the thigh opposite to the surgeon, at a little distance anterior to the extremity of the posterior flap. This incision is made from without inward, through the integuments, so as to form an even curve, and without angular irregularity, over the thigh, to near the base of the posterior flap on the side on which the surgeon stands. The length of this flap is determined by that of the posterior. It will therefore vary from four to six inches, as before stated; and for its completion will require a second, or perhaps a third, application of the knife. In the two flaps thus made, the division of almost all the soft structures is included, a few only immediately surrounding the bone remaining uncut. These are to be divided by a circular sweep of the knife, at the part where it is intended to saw the bone; in this way it is sufficiently denuded for the application of the saw. The flaps being held back by an assistant, the bone is to be sawn through in the usual way. In amputations of the lower part of the thigh it usually happens that the ischiatic nerve lies upon the surface of the posterior flap, and should be removed. It occasionally occurs, although not frequently, that the popliteal artery is cut obliquely at its commencement; but in amputations above the passage of the arterial trunk through the tendon of the triceps, this does not take place, the division of the artery being usually included in the circular sweep made after the formation of the flaps. The divided arteries having been carefully secured, the flaps are to be brought together and retained by three sutures passed through the integuments at equal distances from each other, and from the extremity or base of the flaps. It appears to be a matter of considerable importance not only that their edges should be kept in apposition, but that their whole surfaces should be kept in accurate contact. For this purpose, the following method of dressing is adopted: The edges, in the intervals between the sutures, are to be held together by strips of adhesive plaster about one inch in breadth. A compress of lint is then to be fitted over each flap, that upon the posterior being the larger. The compresses are to cover the flaps only, and not to extend over the extremity of the bone, where their pressure would probably be ill endured. The posterior compress is made large, that it may serve as a cushion on which the thigh rests when the patient is placed in bed. The compresses are to be retained in position by one or two strips of plaster, and supported by a bandage applied carefully round the stump. If this be properly accomplished, the whole surfaces of the flaps will be kept accurately in contact with each other, and complete union may be reasonably expected. By securing the perfect apposition and support of the entire surfaces in accurate contact, the disposition to the issue of blood from small vessels is also obviated to a great extent, and it is even probable that vessels of a larger diameter than the smallest, which would bleed if not restrained, are, by the pressure of the opposing surface, prevented from doing so, and the probability of secondary hemorrhage is diminished. Experience has demonstrated the fact that primary union of the flaps is most effectually procured in the great majority of amputations thus treated. Indeed, non-union of the flaps is the exception; union, the rule. In the subsequent treatment of the stump, care must be taken to prevent an accumulation of discharge in the tracks of the ligatures; and the dressings must be renewed according to circumstances having reference to the quantity of discharge, and the uneasiness of the patient. The line of division of the integuments of the two flaps is situated, at first, in the center of the face of the stump; but when the flaps have united, a gradual change takes place in the position of the cicatrix: it recedes, by degrees, to the posterior aspect of the thigh, and the bone abuts upon the anterior flap, by which alone it is eventually covered, and the cicatrix is thus removed from its pressure.

83. A protrusion of bone is a disagreeable occurrence after amputation; it will sometimes happen after sloughing of the stump, without any fault of the operator. If, on completing the operation, it is evident the bone cannot be well covered, a sufficient portion should be at once sawn off, and the error remedied.

When the bone protrudes at a subsequent period to the extent of an inch or more, it should be removed by operation, an incision being made on, and down to, the bone, and the saw applied where it is sound. The chain saw, when at hand, answers well, and some should be supplied for the use of the principal hospitals with every army. The protruded end of bone should be held steadily by pincers, or it may be introduced into a hollow tube, which fixes it firmly.

When the bone has been badly sawn through, or split in the act of dividing the last layer, or the periosteum is unduly separated, the end will often exfoliate with the split, which may extend up for several inches, giving rise to the formation of abscesses, causing much suffering, and occupying a great length of time before the ring of bone and the split portion exfoliate, and the stump becomes quite sound. A splinter of this kind may even require to be removed at a late or at a distant period, from the nervous irritation and suffering it may occasion. This irritation has been often attributed to the extremity of the principal nerve, which always enlarges, assumes a bulbous form, and is painful on pressure, when made for the purpose, although not so under ordinary circumstances. This enlargement never requires removal, unless it should adhere to the cicatrix, or be the subject of disease incidentally occasioned in it. The great sciatic nerve became early thus enlarged in the thigh of the late Marquess of Anglesea, and was mistaken for disease, for which he was advised to have it removed, it being painful on pressure, and therefore the supposed cause of the tic douloureux under which he labored. Consulted on the propriety of this operation, his leg-maker, Mr. Pott, being present, who had also lost a leg above the knee, I requested his lordship to squeeze Mr. Pott’s bulbous nerve, in the same manner as the doctor had squeezed his lordship. He did so, and Mr. Pott roared and sprang from the floor in a manner which quite satisfied Lord Anglesea.