Of AMPUTATION.
A Spreading Mortification has been always esteemed so principal a Cause for Amputation, that it is a fashion with Writers, to treat of the nature of a Gangrene, previous to the Description of this Operation; and, I think they have all agreed, that whatever the Species of it be, if the Remedies they prescribe, do not prevent its Progress, the Limb must be amputated: However, this Operation is spoken of as frequently unsuccessful, and in length of time, its want of Success has been so unquestionably confirmed by repeated Experiments, that some of the most eminent Practitioners here in England, make that very Circumstance an Exception to the Operation, which so few Years since was the great Inducement; and the Maxim now is, never to extirpate 'till the Mortification is absolutely stopped, and even advanced in its Separation.
Gangrenes may be produced two ways: either by Indisposition of Body, or by Accident in a healthful State; for as the Life of a Part depends upon the Circulation of its Fluids, whatever shall make the Circulation cease, will inevitably occasion a Gangrene: Thus a mere Compress preventing the Course of the Blood, as effectually causes a Mortification, as any Indisposition in the Fluids or Vessels.
It frequently happens in old Age, that the Arteries of the lower Extremities ossify, which destroying their Elasticity, must in consequence produce a Gangrene in the Toes first, and afterwards in the Limb nearly as high as where the Ossification terminates; so that in Mortifications arising from this Cause, we at once see why Amputation, during their Increase, is of so little Service, unless performed above the Ossification; but we have no way to judge where the Ossification ends, but by the Inference we make from the Gangrene's stopping: Hence we may learn the Propriety of our modern Practice in this Case.
If by any Accident the Limb has been injured to that violent degree as to begin to mortify, it will be no more fit to operate here 'till it stops, than in the other Instance; because all Parts that are mortified, have had the Disposition to become so, before the Effect is produced: and cutting off a Limb, half an Inch above the absolute dead Skin, is generally leaving a Part behind, with the Seeds of a Mortification in it so, unless we can be sure, the Vessels are not affected in the Place of Amputation, which will be hard to know but from the Consequence, the Operation will be useless.
Sometimes the Fluids of the Body are so vitiated, as to lose their proper nutritious Qualities; and the Limb becomes gangrened, not from any Alteration in its Vessels, but chiefly from its Situation, which being at a great Distance from the Heart, will be more prone to feel the ill Effects of a bad Blood than any other Part, as the Circulation is more languid in the Extremities: and it seems not very improbable that in some Dispositions of the Blood, a Mortification may also be a kind of critical Discharge. When therefore a Gangrene arising from either of these Causes, is running on, Amputation above it, will for the most part be useless; since it is only removing one Degree of the Effects of the bad Juices, and leaving them in the same State to produce the like Mischief in other Parts: Thus we see after Amputations on this account, the Gangrene sometimes falls on the Bowels, or the other Extremities; from which Observation, I think we may conclude it not safe to amputate, 'till the Fluids are altered; and this Alteration will presently discover itself by the Stopping of the Mortification.
I have laid it down as a Rule, that the Mortification should not only be stopped, but advanced in its Separation; the Reason of which is, that tho' the Blood is so much altered for the better as to occasion a Stoppage of the Gangrene, yet at this point of Alteration, 'tis still in a bad State, and should be left to mend, with the utmost Tranquillity of Body, and Assistance of Cordial Medicines, 'till such time as Granulations of Flesh upon the living Part of the Extremity, shew the balsamick Disposition of the Blood: In the meanwhile, to take off the Stench of the Gangrene, it may be wrapt up in spirituous or odoriferous Applications. I have seen some Limbs taken off immediately upon the Mortification's ceasing, when afterwards the Patients have sunk from frequent Effusions of Blood, not discharged by the great Vessels but the whole Stump: These Hæmorrhages I conceive were owing to the Thinness of the Blood, which hardly gave a reddish Tincture to the Cloths and Bandages; on the other band, upon waiting a considerable Time after the ceasing of the Mortification, I have taken off some myself with as good Success as for any other Disorder.
Gunshot Wounds, compound Fractures, and all sudden Accidents requiring Amputation, are attended with the best Success if immediately performed. Disorders of the joints, Ulcers of long standing, and all scrophulous Tumours, do sometimes return on other Parts after the Operation. When a Leg is to be amputated, the Manner of doing it is this.
Lay your Patient on a Table two Feet six Inches high, which is much better than a low Seat, both for securing him steady, and giving yourself the Advantage of operating without stooping, which is not only painful, but inconvenient in the other Situation. While one of the Assistants holds the Leg, you must roll a Slip of fine Rag half an Inch broad, three or four Times round it, about four or five Inches below the inferior Extremity of the Patella: This being pinned on, is to serve as a Guide for the Knife, which without it, perhaps would not be directed so dexterously: The manner of rolling has always been perpendicular to the Length of the Leg, but having sometimes observed, that tho' the Amputation at first be even, yet afterwards the Gastrocnemius Muscle contracting, draws back the inferior Part of the Stump more strongly than the other Muscles can do the rest of it; I have lately, in order to preserve the Regularity of the Cicatrix, allowed for this Excess of Contraction, and made the circular Incision in such a manner that the Part of the Wound which is on the Calf of the Leg is a little farther from the Ham than that on the Shin is from the Middle of the Patella.
In the mean time, one of your Assistants must carry a strong Ligature round the Thigh, about three or four Inches above the Patella, which passing thro' a couple of Slits in a square Piece of Leather, he must twist with a Tourniquet, 'till the Artery is sufficiently compressed, to prevent any great Effusion of Blood; and to do it more effectually, be may lay a Bolster of Tow or Linen under the Ligature, upon that Part where the Artery creeps. It will also be a little more easy to the Patient, to, carry a Compress of Linen, three or four times double, round the Thigh, on that Part where the Ligature is applied, in order to prevent it from cutting the Skin.
The Course of the Blood being stopped, you must begin your Incision just below the Linen Roller, on the under Part of the Limb, bringing your Knife towards you, which at one Sweep may cut more than the Semicircle; then beginning your second Wound on the upper Part, it must be continued from the one Extremity to the other of the first Wound, making them but one Line. These Incisions must be made quite thro' the Membrana Adiposa, as far as the Muscles; then taking off the Linen Roller, and an Assistant drawing back the Skin, as far as it will go, you make your Wound from the Edges of it when drawn back, thro' the Flesh to the Bone, in the same manner as you did thro' the Skin. Before you saw the Bones, you must cut the Ligament between them, with the Point of your Knife, and the Assistant, who holds the Leg while it is sawing, must observe not to lift it upwards, which would clog the Instrument and at the same time, not to let it drop, lest the Weight of the Limb should fracture the Bone, before it is quite sawed thro'.
In amputating below the Knee, it is of Advantage to stand on the Inside of the Leg; because the Tibia and Fibula lie in a Position to be sawed at the same Time, if the Instrument be applied externally: Whereas, if we lay it on the Inside of the Leg, the Tibia will be divided first, and the Fibula afterwards; which not only lengthens the Operation, but is also apt to splinter the Fibula when it is almost sawed thro', unless the Assistant be very careful in supporting it.
When the Leg is taken off, the next Regard is to be had to the stopping the Blood, which must be effectually done before the Patient is put to Bed, or there will be great Danger of bleeding again, when the Fever is excited, and the Vessels of the Stump dilated, both which happen a very little while after the Operation. There is no Method for this Purpose so secure, as taking up the Extremities of the Vessels with a Needle and Ligature in the following Manner. As soon as the Amputation is performed, the Assistant must loosen the Tourniquet for a Moment, upon which the Orifices of the Arteries will appear by the Issue of the Blood. The Operator having then fixed his Eye upon one of the largest Vessels, passes a crooked Needle thro' the Flesh, a little more than a quarter of an Inch above the Orifice, and about the same Depth, in such a Direction, as to make nearly one third of a Circle round the Vessel: then withdrawing the Needle, he a second time passes it into the Flesh and out again, in the same Manner and about the same Distance below the Orifice of the Vessel: By this means, the Thread will almost encompass the Vessel, and, when it is tied (which should be done by the Surgeon's Knot) will necessarily inclose it within the Stricture. All the considerable Arteries are to be taken up in the same manner; that is, the Tourniquet is to be loosened in order to discover the Vessel, and then the Needle is to be passed round it as I have here described This is a much better Way than using the Artery Forceps where the Vessels are apt to slip away out of the Ligature; and as to styptick Applications, their want of Safety is so well known now, that the Use of them, in Hæmorrhages from large Vessels, is almost universally rejected; though it is thought by several Surgeons who have experienced the Virtue of Agaric, that it will be found to be a more powerful Astringent than any hitherto discovered.
It sometimes happens in a large Stump, that ten or more Vessels require tying, which done, you must apply loose dry Lint to the Wound; or in case the small Vessels bleed plentifully, you may throw a handful of Flour amongst the Lint, which will contribute to the more effectual stopping up their Orifices: Before you lay on the Pledgit, you must bind the Stump, and begin to roll from the lower Part of the Thigh down to the Extremity of the Stump, The use of this Roller is to keep the Skin forwards, which, notwithstanding the Steps already taken to prevent its falling back, would in some measure do so, unless sustained in this manner. The Dressing may be secured by the cross Cloth and gentle Bandage; and the Method of treating the Wound, may be learnt from what has been said, with respect to recent incised Wounds.
Before the Invention of making the double Incision I have just now described, the Cure of a Stump was always a Work of length of Time; for by cutting down to the Bone at once, and sawing it directly, the consequence was, that the Skin and Flesh withdrew themselves , and left it protruding out of the Wound two or three Inches in some Cases; so that it rarely happened, that an Exfoliation did not follow, which besides being tedious, also frequently reduced the Wound to an habitual Ulcer, and at best, left a pointed Stump, with a Cicatrix ready to fly open upon the least Accident; all which Inconveniencies are avoided by this new Method; and I know not of any Objection to it, unless that the Pain of making the Wound, is supposed to be twice as much as in the other, because of the double Incision; but when we consider, that we only cut the Skin once, and the Flesh once, though not in the same moment, I fancy upon Reflexion, the difference of Pain will be thought inconsiderable.
It must be confessed however, that notwithstanding we derive such Benefits from the double Incision, the contractile Disposition of the Muscles, and perhaps of the Skin itself, is so great, that in spite of any Bandage they will retire from the Bone, especially in the Thigh, and sometimes render the Cure tedious.
To remove this Difficulty, I have lately in Amputations of the Thigh made use of the Cross-stitch, which I would advise to be applied in the following manner.
Take a Seton Needle, and thread it with about eight Threads of coarse Silk, so that when they are doubled, the Ligature will consist of sixteen Threads about twelve or fourteen Inches long; wax it pretty much, and range the Threads so that the Ligature may be flat, resembling a Piece of Tape , after which, oil both it, and the Edge of the Needle: The Flatness of the Ligature will prevent its wearing through the Skin so fast as it would do, if it was round, and the Oil will facilitate its Passage: Then carry the Needle through the Skin, at about an Inch from the Edge of the Stump, and out again on the Inside of the Stump, after which it must be passed through the opposite side of the Stump, from within outward, exactly at the same distance from the Lips of the Wound; this done, the Silk is to be tied in a Bow-knot. With another Needle and Skain of Silk, the same Process is to be repeated, in such manner, that the Ligatures may cut each other at right Angles. If it is a large Thigh, the Lips of the Wound. maybe made to approach each other so nearly, as that the Diameter of the Wound may be about two Inches long; but in this, and in all other Stumps, the Approximation of the Lips will depend upon the Laxness of the Skin, and the' Quantity preserved by an artful double Incision; for the Skin must not be drawn together so tight as to put it upon the Stretch, lest it should bring on an Inflammation and Pain.
The Manner of applying the Cross-stitch after the Amputation of a Leg has nothing particular in it, only that the Threads must be carried between the Tibia and Fibula, rather than directly over the Tibia; and before the Skin is drawn over the End of the Stump, it will be proper to lay a thick Dossil of Lint on the Edges of the Tibia, in order to prevent them from wounding the Skin. The Dressings must be superficial; and to preserve the Wound clean, an Injection of Barley Water, or warm Milk, may be thrown in, with a small Syringe between the Stitches, which will prevent any Matter from harbouring there.
I have advised the Skains of Silk to be tied with a Bow-knot, that in case of a Hæmorrhage, they might be undone in order to discover the Vessel more easily, and also if any Tension should ensue, that they might be loosened for three or four Days, and then tied again, when the Suppuration comes on, and the Parts are more at liberty.
Perhaps it may be objected that the double Incision is of itself sufficient for answering the Ends proposed by this Measure; but whoever is conversant in this branch of Practice, must know, that notwithstanding the lax State of the Skin and Muscles at the Time of the Operation, yet some Days after, they fall considerably back from the Bone, and in the Thigh particularly so much, that no Bandage will sustain them; the Consequence of which is a proportionable Largeness of Wound, a Tediousness of Cure, and some degree of Pointedness in the Stump. It may be observed too, that the Strictness of Bandage employed for supporting the Skin and Muscles of the Thigh, is not only painful, but in all probability may obstruct the Cure of the Wound by intercepting the Nutrition; for it is certain, that by long Continuance, it often wastes the Stump, and I am jealous it may also be accessary to those Abscesses, which sometimes form amongst the Muscles in different parts of the Thigh.
The Question then remaining is, whether these Stitches will support the Skin and Muscles more effectually than Bandage, without producing some new Evil, a Point which can only be decided by Experiment. It is true that this very Method was followed by some of our Ancestors, and the Objections to it have absolutely prevailed over the Arguments in favour of it; for few People now even know it ever was practised. Yet I cannot help imagining that Caprice may have had more Share in utterly discarding this Method, than Reason and Observation; for it is positively said by some of the most able and candid Practitioners, to have succeeded marvellously; and as the Inflammation and Symptomatick Fever, supposed to be excited by it, were always relievable by cutting or loosening the Stitches, there does not seem to have been reasonable grounds for wholly giving up such great Advantages. But if the Objections to it were of force, when the single Incision was practised, they diminish exceedingly now that we perform the Operation by the double Incision; for though the double incision does not wholly prevent the withdrawing of the Muscles from the Bone, yet it abates the Degree of it so much, that they can suffer the Stitches, without incurring either Inflammation or Pain, to which they were much more liable after the single Incision. It must be remarked, however, that they draw with that Strength as to make the Stitches wear thro' the Skin and Flesh in twelve or fourteen Days; but this is done so gradually, that it causes very little Pain or Inflammation, and tho' they consequently come off with the Dressings, yet by this Time the Skin and Muscles are fixed; and a slight Bandage will be sufficient to maintain them in the same Position.
The two greatest Objections I know of, to this Method, are, the Deformity of the Stumps, and the additional Pain of the Operation: but as a Stump is not exposed to View, after the Cure, its want of Beauty is of no great Consequence; and though it must be granted that the Stitches cannot be made without some Pain, perhaps it will not be found so bad as one is apt at first to suggest; for the mere passing of a large Needle through the Flesh without making a Stricture, is very bearable in comparison of a tight Ligature: but whatever be the Increase of Pain, for the present the future Ease in consequence of it is ample Compensation, and, if I am not mistaken, there is still another Consideration of much higher Importance than any I have mentioned, I mean a less hazard of Life.
For the Symptomatick Fever, and the great danger of Life attendant upon an Amputation, do not seem to proceed purely from the Violence done to Nature by the Pain of the Operation, and the removal of the Limb; but also from the Difficulties with which large Suppurations are produced; and this is evident, from what we see in very large Wounds that are so circumstanced as to admit of healing by Inoculation, or as Surgeons express it, by the first Intention; for in this Case, we perceive the Cure to be effectted without any great Commotion, whereas the same Wound, had it been left to suppurate, Would have occasioned a Symptornatick Fever, &c. but in both Instances, the Violence done by the mere Operation is the same, whether the Wound be sewed up, or left to digest.
Upon this Principle, we may account for the diminution of Danger, by following the Method here proposed; because as the Stitches have a power of holding up the Flesh and Skin over the Extremity of the Stump, till they adhere to each other in that Situation; they actually do by this means lessen the Surface of the Wound; in consequence of that, the Suppuration; and in consequence of both, the Danger resulting from the Suppuration.
In Amputating the Thigh, the first Incision is to be made a little more than two Inches above the middle of the Patella; after the Operation, a Roll should be carried round the Body, and down the Thigh, to support the Skin and Flesh; this is also the most proper Bandage, as Abscesses will sometimes form in the upper part of the Thigh, which cannot discharge themselves conveniently with any other, it being almost impracticable to roll above the Abscess, uness we begin from the Body.
The Amputation of the Arm or Cubit differs so little from the foregoing Operations, that it will be but a Repetition to describe it. However, it must be laid down as a Rule, to preserve as much of the Limb as possible, and in all Amputations of the upper Limbs, to place your Patient in a Chair.
There are in the Armies a great many Instances of Gun-shot Wounds of the Arm near the Scapula, which require Amputation at the Shoulder; but the Apprehension of losing their Patients on the Spot by the Hæmorrhage, has deterred Surgeons from undertaking it. I have known where it has been done more than once with Success; but though it had never been performed, we might learn it is practicable, from the Case of a poor Miller, whose Arm and Scapula were both torn from his Body, by a Rope which was accidentally twisted round his Wrist, and suddenly drawn up by the Mill. Almost every one in London knows the Story, and that he recovered in a few Weeks: It is very remarkable in this Accident, that after Fainting, the Hæmorrhage stopped of itself, and never bled afresh, though nothing but Lint and Turpentine were laid on the great Vessels. In case therefore of a Wound or Fracture near the joint, or incurable Fistulas in the joint, not attended with much Caries, I think the Operation may be performed safely in this manner.
The Patient being laid on his Back, with his Shoulder over the Edge of the Table, make an Incision through the Membrana Adiposa from the Shoulder across the Pectoral Muscle, down to the Armpit; and in order to save as much Skin as possible, begin it about two Inches below the joint, then turning the Knife with its Edge upwards, divide that Muscle, and part of the Deltoid, all which may be done without danger of wounding the great Vessels, which will become exposed by these Openings; if they be not, cut still more of the Deltoid Muscle, and carry the Arm backward: Then, with a strong Ligature, having tied the Artery and Vein, carefully divide those Vessels at a considerable distance below the Ligature, and pursue the circular Incision through the Joint, cutting first into that Part of the Bursal Ligament which is nearest to the Axilla: for if you attempt to make way into the joint, on the upper part of the Shoulder, the Projection of the Processus Acromion and Processus Coracoides, will very much embarrass, if not baffle the Operation, After the Amputation, the Cross-stitch may be practised here with great Benefit.
The Amputation of the Fingers and Toes is better performed in their Articulation, than by any of the other Methods: For this purpose, a straight Knife must be used, and the Incision of the Skin be made not exactly upon the joint, but a little towards the Extremity of the Fingers, that more of it may be preserved for the easier healing afterwards; it will also facilitate the Separation in the joint, when you cut the Finger from the Metacarpal Bone, to make two small longitudinal Incisions on each side of it first. In these Amputations, there is generally a Vessel or two, that require tying, and which often prove troublesome when the Ligature is omitted.
It may happen that the Bones of the Toes, and part only of the Metatarsal Bones are carious, in which Case, the Leg need be cut off, but only so much of the Foot as is disordered; a small Spring-Saw is better to divide with here, than a large one; When this Operation is performed, the Heel and Remainder of the Foot, will be of great Service, and the Wound heal up safely, as I have found by Experience
The EXPLANATION.
A. The Figure of the Amputating Knife. The Length of the Blade and Handle should be about thirteen Inches.
B. The Figure of the Saw used in amputating the Limbs. The Length of the Handle and Saw should be about seventeen Inches.