/I
4S%
        ■if   ON AMPUTATION  OF THE THIGH.
By John Green, Fellow op the Massachusetts Medical Society, late Acting
          —.11,         Assistant Surgeon U.S.A.
        [Communicated for the Boston Medical and Surgical Journal, June, 1863.]
It has been my duty during the past year to direct the treatment of
a large  number of soldiers who had  suffered primary or secondary
amputation of large limbs.  Some of these cases were received im-
mediately after the performance of the operation; the others after
intervals varying from two or three  days to as  many weeks.   An
opportunity was thus afforded  to  observe the  effects, in  some in-
stances, of neglect, and in others  of good treatment, and to com-
pare the results of various operative methods as practised by differ-
ent surgeons.  The study of these  cases, followed by a partial re-
view of the history of amputations, has led me  to some conclusions
which may perhaps be of interest  to others.
   I propose, therefore, to study some of the  general  questions con-
nected  with the subject  of amputation of the thigh, adopting the
usual division into circular and flap methods.
              Circular  Amputation of the Thigh.
   Before discussing any  of the ordinary methods of operating, it
may be profitable to  study the very simple case of a circular ampu-
tation of  the thigh in which all the soft parts are  divided  by a  sin-
gle sweep of the knife, and the bone sawn at the same level.  After
such an operation, the end of the  stump at once assumes  a  conical
form, from the retraction of the muscles; the muscular fibres which
lie nearest to the bone, and which arise from or are inserted into it
near its sawn extremity, contract but little, while the longer fibres
and muscles, which are farthest removed from the axis  of the limb,
contract most, drawing with them the cut margin of the skin.  This
muscular cone soon becomes covered with granulations, which also
arise at a later period from the cut end of the bone.   As the pro-
cess of cicatrization advances, the edges of the  skin are  gradually
drawn towards  the centre of the stump, and the superficial cells of
                 1 
2                  Cto Amputation of the Thigh.

the granulating bone become  developed into  an imperfect cuticle,
which remains always tender, and from its exposed situation is sub-
ject to continual abrasions.  Often the extremity of the^ bone exfo-
liates, after  a tedious suppuration, a result much desired  by the
older surgeons, who were always careful to promote necrosis by the
use of the hot iron and of caustics.  The legitimate result, then, of
such  an operation is the miserable failure  known as a  "conical
stump ";  granulations form upon the soft parts and begin to retract
before they have appeared  at all upon the  compact  tissue of the
bone, and  the contraction of the  cicatrix tends quite  as  much to
draw the  flesh away from the bone as to draw the skin towards it.

    Old or  " Common " Circular Amputation of the Thigh.
   The defects of this primitive  kind of amputation were  early re-
cognized, and  attempts were made  to  preserve enough of the soft
parts to cover the end of the bone.  This covering may be either of
skin, or muscle, or both.
   The origin of  the  practice of saving skin  as  a covering to  the
stump, is attributed to  Cheselden and to J. L. Petit.   These sur-
geons made  first a circular incision  of the  skin and  subcutaneous
tissue, which was  then  drawn upwards by an assistant, or  turned
over  like the cuff of a sleeve.  A single sweep of the knife, applied
close to the  margin of the retracted skin, divided  the remaining
soft parts, which were drawn upwards  by means of a " retractor,"
and the bone was sawn, as nearly as possible, at  the  level  of the
section of the muscles.   This was a  great improvement, and was at
once  adopted by English and French surgeous, but it  by no  means
fulfils all the conditions of a good  amputation, as I can testify from
the study of several cases which I have had to treat.  These stumps,
a  few days after the  operation, generally presented a conical mass
of retracted and granulating muscle, from  the apex of which pro-
jected the end of the bone, not  yet  covered with granulations, and
often denuded and dead for perhaps  half an inch from its extremity.
Surrounding the base of this cone of retracted  muscle was the cuff
of skin, barely sufficient, when brought together, to cover the end of
the  muscular mass, leaving the  bone either wholly exposed between
its lips, or else pressing  so  hard against the  thin covering as to
cause much pain, and even sometimes to  make its way through  by
inducing  rapid ulceration or sloughing.  Even if the  lips of the
wound had  already  united by first  intention,* the pressure of the
still sharp end of the bone against the skin  or new cicatrix threaten-
ed to open it again.  At the best, the result was very imperfect, for

  * I use this term in the sense in which it is employed by modern writers on surgery, in-
cluding under it the two processes described by Hunter as "union  by first intention " and
" union by adhesion or adhesive inflammation," and which are more accurately designated
by Mr. Paget by the names " immediate union"  and " primary adhesion."  In the healing
of large wounds it is not easy, practically, to discriminate between these two modes of re-
pair, and it is therefore convenient to retain this expression for the union which takes place
prior to and independent of the formation of granulations. 
On Amputation of the Thigh.
3
the bone always remained very prominent, even if it became covered
by skin, which was seldom the case.
  The idea  of protecting the end of the bone by  preserving a
cushion of muscle is as old as the time of  Celsus,* who directs that
the  bone be separated  from its attachments, for some  distance
above the level of the section of the muscles, and sawn as  high as
possible.   Let us now  study the effect of this  shortening  of the
bone upon the progress and nature of the cure.   The muscular sec-
tion assumes, as  in the last case, a conical  form, owing to the greater
retraction of the more superficial muscles, but the end of the bone,
instead of forming the  apex of the cone, lies buried among  the
muscles at the bottom of a deep pit or  crater.  As cicatrization
advances, the edges of this crater are gradually drawn outwards to-
wards the skin, whose margins are at the  same time being drawn in-
wards towards the bone.   The consequence is, that the crater becomes
shallower, but the bone,  if it has  been cut short enough, and  has
not been separated from its attachments  above the point where it
was sawn, will still lie, safe from external injury, at the bottom  of a
little cavity  in the end of the stump.
   This precept of Celsus seems to have been forgotten until about
the middle of the eighteenth century, when it was revived  by Mr.
 Gooch,f  an  eminent surgeon of Shottesham,  in Norfolk,  in Eng-
land.   Gooch commenced his operation by dividing the soft parts,
in  the manner of Cheselden and Petit, by a double circular incision,
but his great improvement consisted in the separation from the bone
 of the deep  muscles and  fasciae to the additional height of about two
 inches, and sawing the bone at this higher level.   Precisely the same
 operation was described several years later, by Mr. Benj. Bell,t who
 was perhaps the first to  distinctly inculcate the principle of " saving
 as much of the muscular substance of the limb as will completely cover
 the bone, together with as much skin as will cover the whole surface
 of the stump."§   Bell states that by this method " the  stump is cover-
 ed with sound skin, as well as with some muscular substance, which
 admits of the patient resting upon  it with freedom " ;|| and Gooch,
 in the description of a case, says that " the cicatrix was  but a few
 lines broader than the   diameter of the  bone, which was  left con-
 cealed in a  little cavity."1[   In the operation of Gooch and B.  Bell,
 the separation of the muscles from  the bone was effected by plung-
 ing a sharp-pointed knife or scalpel perpendicularly into  the face of
 the stump, by the side of the femur, and carrying it, in the  same po-
 sition, entirely around the bone.   In executing this manoeuvre there
  * Celsus. De Medicina. Lib. vii., cap. xxxiii., De Gangrena.
  t Cases and Practical Remarks in Surgery, &c. By Benjamin Gooch, Surgeon.  London,
1758. Page 124.
  + A System of Surgery.  By Benjamin Bell. Edinburgh, 1783.  Vol. vi., p. 301 et seq. on
Amputations.
  6 Ibid, vol. vi., p. 357.
  |1 Ibid, vol. vi., p. 378.
  f Cases in Surgery, p. 126. 
4
On Amputation of the Thigh.
  is danger of separating the bone unequally from its attachments, and
  it may easily happen that the bone will be denuded, upon  one side
  or the other, higher than the point where it is to be sawn.   From
  this cause partial exfoliation of the bone may occur, with the effect
  both of retarding the cure and impairing  the final result.*  A bet-
  ter way of effecting the same object is to apply the retractor imme-
  diately upon the completion of the circular section of the  muscles,
  and then to divide, in succession, with the edge of the  amputating
  knife, such bridles of tendon or  fascia as  oppose  themselves to the
  retraction.   The chief obstacles to the retraction of the muscles will
  be found at the back part of the femur,  in the aponeurotic  tissues
  which are inserted into  the linea aspera;  and  by  dividing  these  in
  the manner described,  the bone may be  denuded to any desirable
  extent.  After a sufficient portion of the bone has been thus  exposed,
  it is well to make a final circular sweep of the knife close to the
  retractor, so as to divide the periosteum  and  thus guard against its
  possible laceration by the teeth of the saw.f
  ^  This improved circular amputation, excellent as  it is,  has still an
  important defect.  The muscles, which are divided  in a plane per-
  pendicular to the  axis  of the  limb,  immediately retract,  and the
  section, from causes already explained, assumes the form of  a cone.
  It would evidently be better if the cut surface of the  muscles were
 made flat, instead of conical, for the bone would be better protected,
 and less skin would be required for a  covering.  This  idea  was in
 fact put in execution by the great French surgeon Ambrose Pare,t
 who anticipated the retraction of the muscles by drawing them firmly
 upwards and holding them there while he made a  single circular in-
 cision of all the soft parts.  The same advice is also  given  by  the
 distinguished Scotch anatomist and surgeon, Alexander Monro.S who
 expressly states that his  object is to  secure a perfectly flat section of
 all the tissues of the limb.  This flatness of the muscular tissue is
 most easily  and, at the same  time, most surely attained by dividing
 ™t±TJ  JT 0f,muscle  twice-  After  the first section of  the
 muscles the soft parts are drawn upwards by an assistant,!! and  the
 deeper fibres again divided down  to the  bone.   The retractor is

»^^&%fi££^*A £**» Pfhrt f «-  operation, a knife bent
  t The retractor invented bySaiffiSdW??,dfipth t0 7"*? lt could enter-
which has the great advantage oveV Unen or cnK tL,-V^11 Was made of stron* leather>
saw by catching its teeth.  This is amXr nf S^'o  • l ^J?068 noJ imPede the action of the
cut the bone half an incltooSw raXrh™ ™?hUUP?ta?ce' for  I have seen a surgeon
caught in the threads of theinfffiZwff^1^ the tecth of the saw
the retractor altogether, at the riskh^w ill? •  !J)eSn led' for the same rcason>  *>  discard
by the saw-which, to say the least Drof?ncPTnng th? bone t°°.lon-'' and of faring the flesh
the bystanders.       y   ieast» Produces an  unfavorable impression on the  minds of

  1 The aid of a/assisint taffi^Jf%wdinbl?Fh'.17?5i VoL iv" **• x*ii.
finned under the influence ofSaJ£*^a^Et^f^fP?S^ta amP^tions per-
speak of the spontaneous retraction of th/™^^ °f the st*"Klard writers on surgery
but this spontaneous muscular retraction «ffinot ™ m,stant °f their division by the knife;
^IwndedlvafWldoseofetherwThSrSta       when the reflex ncrvoii action is 
On Amputation of t/ie lliigh.
5
then applied, the tendinous attachments  at the  linea aspera are di-
vided, and the bone is sawn as high as may be thought proper.
   This completes the history of one form of the  circular amputation
in the thigh.   The essential points to be observed in its performance
are—1st, To preserve skin enough to cover completely the  end  of
the stump, without stretching.   This rule is imperative if we  hope
for a cure by first intention,* but it need not be  so strictly observed
in cases where the wound is to be  left  to  heal, from  the first, by
granulation.    2d, To divide the muscles so as to make the section
as flat as possible.   This  is  best  effected  by dividing the  muscles
down to  the bone by two successive sweeps of the knife,  beginning
the second cut at the base  of the cone formed by the retraction  of
the outer and longer muscular  bundles.   3d,  To separate the femur
from its attachments at the linea aspera, and  to saw the bone  so
high  that  it may be completely hidden  in the muscles after the re-
moval of the retractor.
   In the normal condition of the tissues  of the thigh, this operation
may be  easily  and  expeditiously  performed;  the  divided  integu-
ments are  easily retracted to the requisite extent  by simply cutting
the few bridles of loose connective tissue  which tie it down  to the
fascia, and the muscles are as easily separated from the bone by di-
viding  their  attachments at  the linea aspera.   This  operation  is,
therefore, well  adapted to cases of primary amputation  for injury,
and to such chronic cases as have not  been attended with inflamma-
tion of the parts in which  the  incisions  are to be made.   If, on the
other hand, we have to  deal with a case  in which  the  limb has be-
come inflamed, we shall  find  the various tissues   so firmly glued to-
gether that it will  require a laborious  dissection to separate them.
The skin will  no  longer slide upon the  fascia, but will  have to be
carefully dissected from it and turned back  like a sleeve; the mus-
cles, too, cannot be  retracted, at the  time of the operation, without
much difficulty, but will make  up for  this by excessive shrinkage at
a later period.  There  is danger,  therefore, that  the bone may not

  * The skin saved for this purpose need not be in the form of a  cuff; in fact, this form is
not that best adapted to the formation of a symmetrical stump, for there will always be pro-
minent " ears " of skin at the angles of the wound,  which never wholly disappear. The more
perfect (i. e. the flatter) the form of the muscular section, the worse does the cuff fit, and the
more prominent are the " ears " of skin.  It has been proposed to remove the projecting an-
gles at the time of the operation, or what amounts to nearly the same thing, to modify the
first incision of the skin by cutting it in the form of semi-elliptical flaps.  Sir Charles Bell cut
the skin in this form with the edge of the amputating knife, by changing its direction in dif-
ferent parts of the circumference of the limb (sec Illustrations  of the Great Operations of
Surgery, folio, London, 1821).  Sddillot (Traits de Mt-decine Operatoire, &c, 2me Ed., Paris,
18-53, tome i., page 454) made two very thin flaps by transfixing the limb, and completed the
section of the soft parts by a circular incision.  The most perfect adaptation of the skin to the
subjacent cut surfaces may be obtained by fashioning it in the form of either one or two flaps
of a breadth equal to or alittle greater than the diameter of the limb. If a singlefiap be cho-
sen, its free extremity must be rounded, and its length should be slightly greater than the
diameter of the limb.  If, on the other hand, two flaps be made, they must be cut of a rec-
tangular form, and may be either of equal or unequal dimensions, taking care, however, that
their united lengths shall somewhat exceed the diameter of the limb.  The choice between
these different plans must often be decided by the state of the integuments on different sides
of the limb, and will therefore depend, in a great  degree, upon the nature of the lesion for
which the amputation is performed. 
6                   On Amputation of the Thigh.

be sufficiently protected by the soft parte, and a bad stump may be
the consequence.   This operation, therefore, answers better for pri-
mary than for secondary amputations, and  I think  it can be shown
that for the latter  class of  cases, another  method  (the double-flap
operation of Vermale) is to be preferred.
   The  results of  this ©peration, when performed  upon a proper
class of subjects and  with a due regard to the three  points  above
enumerated, are such as leave little  to  be desired, whether the cure
be effected by first intention or by granulation.   The  end of the
stump will be flat, or perhaps slightly rounded,  with a central de-
pression corresponding  to the end of the bone, and will in most in-
stances be capable of sustaining considerable pressure.   The  whole
stump tapers symmetrically, and  is admirably fitted to support the
weight of  the body in the conical socket of a modern artificial limb.
If this  method is adopted in cases in which the tissues have become
consolidated and adherent  to each other from the effect of previous
inflammation, it will be easier to dissect up the  skin in  the form of
flaps than  of a cuff, and especial  care must be taken to retract the
muscles strongly, and to saw the bone  at the highest possible point
above the  level of the section of  the soft parts.

Circular  Amputation op the Thigh, in which the Incisions are
           so managed  as to give to the  Section  the
                    form op  a  Hollow Cone.
   Larrey  and Dupuytren adopted, in the amputation of the thigh
and arm, a method by circular incisions  which  is, nevertheless, so
different from the common operation as to demand a special descrip-
tion.   Its  chief peculiarity consists in the form of the section, which
is that of  a deep hollow cone,* of  which the cut margin of  the skin
forms  the base, and  the end of the  bone the apex.  This form is
the  result of several consecutive circular  incisions, and  is most
readily obtained by the method of Dupuytren.   An assistant  draws
up the skin and flesh as much as possible, and the surgeon, by a sin-
gle  circular sweep of the knife, divides all the soft parts nearly or
quite to the bone.   The cut  surface of the muscles at once assumes
the  form of a cone, at the base of which the knife is again applied,
and again carried round  the limb, dividing everything to the bone.
A third, and, if necessary, a fourth or fifth, circular section  of the
deepest muscular  layers may be made with  the greatest rapidity,
and the bone is sawn in the track of the last incision.   In this way
the  bone may be sawn as high even as six inches above the first in.

  * Several older surgeons use this expression as applicable to their own operations, but it
docs not appear that they really attained, or indeed aimed at, anything more than  a flat,  or
at most a slightly concave section of the muscles. Mr. Hey, whose description of his method
is nearly identical with that of Larrey, says, in fact, that " the most perfect union of the soft
parts would be produced by making an incision through them all in a conical form; but
[that] such an incision is impracticable in the ordinary mode of operating, nor is it  necessary
tor the formation of a good stump."—(See Practical Observations in Surgery, &c, by Wil-
liam Hey. 2d Ed., London, 1810, p. 529.) 
4ffl
                   On Amputation of the Thigh.                  7

cision of the soft parts *  and the extremity of the stump presents
the form of a deep conical cavity with the bone at its apex.   Lar-
reyf operated  in the same  manner, with the single exception that
in the first incision he divided only the skin and subcutaneous tissue
which were retracted by an assistant, during the performance of the
rest of the operation.  DesaultJ  made several  circular incisions,
dividing the soft parts layer by layer, instead of dividing all by one
sweep of the knife.
   In this amputation, which as simplified by Dupuytren is extremely
rapid and brilliant, the nature of the cure will depend almost wholly
upon the height  above the first incision at which the bone is sawn.
If the  conieal  cavity be made too shallow, or if it become so from
subsequent shrinking of the  soft parts, the operation will approach
in character the very imperfect one of Pare; but if, on the other
hand, it be of sufficient depth to admit of the coaptation not only
of the skin but  also of the  muscular  sides of the cavity, extensive
union may take place  by first  intention  or  by the  adhesion of the
granulating surfaces, and the end of the stump will be well rounded,
with the bone deeply buried at its centre.  It is highly important
to know the measurements  which will  probably ensure  this result.
The question  has  been discussed by Sedillot,§ who has arrived at
the  conclusion  that the  distance between  the level of  the first in-
cision and that of the section of the bone should  be equal at least
to three fourths of the diameter of the limb, and may generally be
made even greater with advantage.   The great danger, particularly
in a very long  stump, is that the  bone  will  be sawn too low, thus
causing much trouble and anxiety in the after-treatment of the case,
and ending perhaps in a conical  stump.  No harm can arise from a
redundancy of soft parts, and much evil may result from not saving
enough.
   The  rapid  performance of this operation, in the way described,
depends, as in  the older circular method, upon  the lax condition of
the subcutaneous and intermuscular areolar tissue; if there has been
much inflammation of  the fimb it will  be difficult, if not impossible,
to retract the  soft parts sufficiently.  The principal advantage of
this mode of amputating is the facility which it affords  for the per-
fect adaptation to each other, throughout  their entire extent, of the
cut  surfaces both of muscle and  of integument; a condition  emi-
nently favorable to extensive  union by first intention.   The sides
of the  wound are easily brought together, and may  be kept in place
by a few strips of adhesive plaster, while the deeper muscular sur-
faces are as easily held  in contact with each other by soft  com-
presses  placed on  opposite sides of  the stump and confined by a

  * Dupuytren.  Legons Orale de Clinique Chirurgicale. 2me Ed.,  Paris, 1839, tome 2,
page 333.
  t Larrey. Memoir on Amputation.
  t Desault.  ffiuvres Chirurgicales, par X. Bichat.  Paris, 1796.
  $ Sidillot.  Trait* de MSdecine Op^ratoire. 2me Ed., Paris, 1853, tome 1, p. 327. 
8                  On Amputation of the Thigh.

few turns of a roller.   Excellent stumps may be made by this me-
thod, which, however, except in the manner of its performance, has
less  resemblance to the  ordinary circular, than to the  double-flap
operation.
                Flap  Amputation of the  Thigh.
   Method with two equal Flaps.—This method was brought forward,
at about the same time, by Vermale* and Ravaton.f   As performed
by the latter surgeon, it is but a modified circular operation, in which
no special covering of  skin  is preserved, and in which thc^denuda-
tion  of the bone is^effected by means of  two longitudinal incisions
upon opposite sides of the limb.   In its results  it closely resembles
the operation of Celsus, with the advantage over  it that the  bone
may be largely denuded with much greater  ease,  and is therefore
more likely to be sawu at a sufficient height above the level of the
section of the soft parts.   Vermale operated by transfixing the thigh
with a long  knife, thus cutting the flaps from within outwards.  The
result  is substantially the same as in  the  method  of Ravaton, but,
from the manner of cutting the flaps, they are more or less rounded
and  thinned at their free extremities, so as to admit of the margins
of the  skin being drawn together to form  a covering for the end of
the stump.  In this operation the whole muscular substance  of the
limb is preserved for several inches below the point of section of the
bone;  the tissues, of which the flaps are formed, lie in  their original
position, and in most cases readily adhere to each other, forming  a
round  and fleshy stump; the bone does not incline to  protrude be-
yond the soft parts, because the deepest muscular fibres, which are
attached immediately to the femur and therefore  retract but little,
are preserved of nearly the same length as the superficial muscles;
and, finally, there are  no angles of skin to  form " ears," as in the
common circular operation.
   The double-flap amputation is generally performed in one of two
ways—either by transfixing the limb  and cutting  the flaps  from
within outwards, or  by cutting them from without inwards.  In the
operation by transfixion, the point of the knife is plunged  at  once
to the bone, with which it should be kept closely in contact as it is
pushed onward  in its course through the limb.l   The knife is then
carried downwards with a sawing motion, still grazing the bone, un-
til about half the length of the  flap has been cut; the edge of the
knife is now to be turned obliquely outwards, and the section com-
pleted, thus giving to the extremity of the flap a curved outline. The
other  flap is formed in the same manner.  An inexperienced operator
may fail to  transfix the limb  symmetrically—that  is, he may not
make  the knife come out through the skin  at a point exactly  oppo-
site to that at which it entered.  This is a  matter of very little con-

   * Manheim, 1767.                        t Paris, 1768.
   X The object of this direction is to insure the preservation of the deepest muscular fibres,
which are of very great importance as a protection for the end of the bone. 
                                                           Aw
                   On Amputation of the TJiigh.                 9

sequence, but a beginner may easily guard against it by first mark-
ing two dots upon opposite sides of the limb, or he may take the
measure  of the circumference of the thigh by encircling it  equally
with the  thumb and fore- or  middle-finger of both hands, and then
allowing the left  hand to remain in the  same  position, as a  guide
to the knife in the transfixion.  Langenbeck* cut both flaps from
without  inwards,  first  grasping with  the  left  hand  the  tissues
from  which the flap is  to be made.   In a double-flap operation,
described about the beginning of the present century by Professor
Nathan  Smith,f of Yale College, the form  of the flaps was first
marked out in ink,  using as a guide a piece of paper cut in the form
of a semi-circle, whose radius was equal to a fourth of the circum-
ference of the limb at the point selected for the section of the bone.
An incision was made in the course of the  lines thus marked out,
through  the integuments first, which were drawn upwards by an as-
sistant, and then obliquely  through the  muscles.  After  the soft
parts were thus completely divided, the retractor  was  applied,
and the bone sawn  as high as possible between the flaps.  In this
operation the form of the flaps, owing to the tapering of the  thigh,
is almost exactly the same as in the method by transfixion as just
described, but the separate division and retraction of the skin  facili-
tates the coaptation of the soft parts and diminishes the danger  of
injurious tension  upon the  sutures.   Another, and by no means the
least, merit of this  operation is the certainty with which it  enables
an inexperienced operator to make  a good  stump.   In this opera-
tion the  length of the flaps must  depend  in  some  degree  upon the
range of contractility of the muscles which  enter  into their forma-
tion, or,  in other  words, the nearer to the knee the  amputation  is
performed the longer should  the flaps be  cut.   As a  general rule,
the length of the flaps should be equal to three fourths or  seven
eighths of the diameter of the limb at the point where the  bone is
to be sawn.  Great care  should  be taken  to  preserve the  whole
thickness of the  muscles at the base of the flaps, and not to thin
them except in the  distal  half of their length.  The operation  by
transfixion is the most rapid, and is the one generally to be prefer-
red, but  there is no objection to  either  of the other  methods.   In
cutting from within outwards, a little additional  skin may be  saved
by drawing the integuments gently upwards towards the body before
cutting them through.  The flaps may be held in pretty good con-
tact with each other by strips of adhesive plaster, but it is  better,
perhaps, to use a few sutures besides.  The direction of the flaps
may be varied almost indefinitely, and will sometimes be determined
by the nature of  the injury; as in the case  of gun-shot fracture of
the femur, in which the flaps should be so planned as  not to include
 * Gottingcn, 1820.
 t Medical and Surgical Memoirs, by Nathan Smith, M.D.  Edited by Nathan R. Smith,
M.D.  Baltimore, 1831, page 215, et seq.
              2 
^9/
 10                 On Amputation of the Thigh.

 in them the tissues lacerated by the ball.  As a general rule, however,
 antero-posterior flaps are to be preferred to lateral ones, for in the
 latter case the end of the bone is in rather close proximity to the an-
 terior angle of the wound, and may even be  made to protrude by the
 action of the psoas-iliacus muscle flexing the femur upon the pelvis.
 The sciatic nerve is  sometimes seen extending  nearly to  the extre-
 mity of the posterior flap; if  this happens to be the case, it should
 be drawn out of its  sheath and divided as  high  as possible, lest it
 become engaged in the cicatrix and cause a  painful or tender stump.
   The  double-flap operation  may be  performed with nearly equal
 facility in all conditions  of the tissues, from  the. state  of perfect
 health, as in primary amputation for sudden injury, to the firm consoli-
 dation of the parts which results from the effusion and  organization
 of inflammatory products.  In the latter class of cases, therefore,
 it offers material advantages  over  any  of the  approved circular
 methods, both in ease and rapidity of performance and in the per-
 fection of the immediate result.  The form  of the wound is favora-
 ble to the exact coaptation of the soft parts, whether we hope for
 union by first intention or by the adhesion  of  the  granulating  sur-
 faces.   The vascular connections of  the flaps are not disturbed, and
 their nutrition is therefore more perfect than in the case of a cuff or
 flaps of integument only.  The end of the bone is deeply buried be-
 tween the flaps, but  it does not press upon  them, for it is protected
 by  the  projection beyond  it  of the  deep  muscular fibres.   The
 stump bears neglect and bad  usage  during the after-treatment re-
 markably well, and will generally turn out well even in the hands
 of a very unskilful dresser.

 Flap Amputation op the Thigh performed with  a Single Flap,
                   or with two Unequal Flaps.
    Method with a single Flap.—This method, invented by Lowdham*
 about the middle  of the  seventeenth century, was  at first employ-
 ed  chiefly in amputation of the leg.  As performed in  the thigh
 it is well described by Benjamin  Bell,t  who,  however,  did not
 often employ  it; by William HeyJ and Charles  Bell,§ who  ad-
 vised it in certain  exceptional cases, and  by  Sedillot,|| who adopts
 it as the   regular  operation,  cutting  the  flap from  the  front  of
 the  limb.   This method may  be employed with  advantage when
 the disease or injury for which we amputate has  destroyed  the  tis-
 sues upon one side  of the limb, leaving enough sound  material to
 form a flap upon the opposite  side; we may thus, in injuries by shell
 or by cannon-shot, occasionally preserve a much longer stump  than
 * Yonge. Cursus Triumphalis, &c, quoted by various authors.
 t Bcnj. Bell.  Op. cit.  Vol. vi., page 398 et seq.
 t William Hey.  Op. cit. Page 531 et seq.
 I Charles Bell. Illustrations of the great operations of surgery.  London.  1821.  Pages
66 and 67.
 || Sedillot.  Op. cit.  Tome i., page 455 et seq. 
                                                            A?£
                   On Amputation of the Thigh.                11

could be made by a more symmetrical  operation, a result which is
often of very great importance in fitting and using an artificial limb.
   The  operation may be performed either by transfixion or by cut-
ting from without inwards.  The flap should be cut  rather  thin, in
order that it may be easily bent over the face of the stump, and it
must be large enough to cover the whole cut surface without stretch-
ing ; in length and in breadth it should somewhat exceed the diame-
ter of the limb at the point where the bone is to be sawn.   After
cutting the flap it is lifted up, and the section of the soft parts is com-
pleted by a single circular sweep of the knife.   The attachments of
the bone at the linea aspera should then be divided, the retractor
applied, and the femur sawn an inch or two above the  transverse
section of the muscles.*  Care must  be taken not to include any
large vessel  or nerve in the thickness of the flap, else there  will be
danger, in the former case, of secondary haemorrhage, or, in the lat-
ter, of  a painful or tender stump.  In dressing the wound, the flap
should be folded neatly over the end of the stump and  retained in
its place by a few sutures, aided by strips of adhesive plaster.
   The single-flap  operation, when  performed in this manner, does
not differ materially in principle from the common circular  method;
the chief  difference consists in the form given to the  covering  of in-
tegument, by which the cicatrix is made to fall upon one side of  the
axis of the limb, where it  is, perhaps, more  in  the way of pressure
and of  accidental injury than if it were central.
   Method with two unequal Flaps.—The denudation of the  bone in
the last operation may be effected also by slitting up the soft  parts
for a couple  of inches, thus lengthening the principal flap, and form-
ing a second shorter flap upon the opposite side of the  limb.   For
this purpose it is not  necessary to make a separate incision, for we
need only transfix the limb at a higher point and cut the long flap
at once of the  requisite additional length; the  short flap may then
be cut off at the same point at which  its tissues would  have been
divided had the denudation of the  bone been effected as in the com-
mon circular operation.  The operation then resembles  the  double-
flap method of Ravaton, with one of the flaps elongated and round-
ed at its free extremity, so that it may be bent  over and made to fit
the whole face of the wound.   Such, in fact, is  the well-known flap
amputation below the knee, as performed by Liston, Fergusson and
others, in which a long flap is cut from the tissues of the calf,  and a
short one in front.
   If, now, the flaps have been cut of just the right length, they will-
fit  admirably to  each other, forming a well-rounded stump, with a
lateral cicatrix; but it sometimes happens, in the course of the  after-

  * This manoeuvre is of the same importance here as in the common circular operation, and
for the same reason; the bone is to be protected by the projection beyond it of the muscles
which arc immediately attached to it, and not by attempting to make a thick cushion of soft
tissues over its extremity. 
UC/3
12                 On Amputation of the TJiigh.

treatment, that the flaps shrink, so as no longer to cover  the bone*
A common cause of this accident is the tension dependent on a de-
ficient length of the flaps, and the remedy consists simply in cutting
one flap or both of more ample dimensions.  In the  latter case, no
change in their form will be required, but if any considerable addi-
tion is made to the length of the long flap only, it will be necessary
to double it upon itself, and it will no  longer fit  neatly in its new
position.   This leads us to the operation lately introduced by Mr.
Teale,* which consists in making the long flap four times as long  as
the short one,t and cutting both with square instead of rounded ends.
The wound is closed by doubling the long flap upon itself and secur-
ing its free extremity, by sutures, to the short one.   Mr. Teale gives
the important direction to  make the long flap from " such parts  as
do  not contain the larger bloodvessels and nerves," and  it  happens
that " a flap so formed will be  for the most part anterior in position
as far as regards the general aspect of the body, but superior when tho
patient is in the recumbent posture "; this is, of course, a very " fa-
vorable position for allowing a free outlet for purulent and other dis-
charges."  Mr. Teale's operation certainly avoids tension, and gives
an  abundant covering of soft parts for the end of the bone, but it is
by  no means clear that the result is in any respect better than in the
case of more nearly equal flaps.  In fact, the shortening of the stump,
owing to the extraordinary length  of the long  flap, which  exceeds
the short one by three eighths of the circumference  of the  limb, is,
in the thigh, a sufficient reason for rejecting this method  for all but
a few exceptional cases.

 Comparison op the relative   Merits op the  Different Methods
                   which  have been  Described.
   Each of the methods which have been described  has  its  advan-
 tages and disadvantages,  which must  be carefully weighed  before
 we can decide between them.   This is a task of some difficulty, for
 almost every surgeon becomes wedded to a particular operation which
 he learns to perform well, and it often  happens that he attributes
 his success to the excellence of the general method which he follows,
 when in fact it is chiefly due to his own  skill in executing it.  A good
 surgeon will overcome the defects of a  bad method, and  thus pro-
 duce better results than can be obtained by the  best operation  in
 the hands of a bungler.   It is most important, then, that every ope-
 ration should be excellent of its kind, and I have  already attempted
 to  show how this  excellence maybe obtained in each  of the four
 principal methods which have been described.  It is true,  neverthe-

  * See abstract of Mr. Teale's paper in Braithwaite's Retrospect, Part xxxviii  1859
  t The long flap is a perfect square, its  length and breadth  being equal to half the circum-
 ference of the hmb at the place of amputation; the short flap is of the same width, but of
 only one fourth of the length of the long one. Mr. Teale marks out the flaps in  ink and cuts
 UcThfTbT tousfixio^' bUt thCy ma7 bC made m°rC e3£ily and With ^eatcr raPidit7>in 
                   On Amputation of the. Thigh.                 13

less, that there is almost always a choice between several  methods,
and  it is  important  to  know the general  principles  by which the
choice is  to be decided.   Good  stumps may be  made  by almost
every method, but it is also true that no method affords perfect se-
curity against failure.   There is  little doubt, however, that in this
respect some operations are better than others, both as making  bet-
ter stumps and more of  them.   All methods are not equally favora-
ble to the formation of a good stump by the process of granulation,
yet we can  never  be  certain, in any particular case, that the cure
will not have to be effected in this way.   No operation, therefore,
can be accepted as  good  unless  it is well adapted  to  a cure by
granulation; but it is none the less essential, in the majority of in-
stances, to  encourage  union by first  intention, by so shaping the
incisions as to secure the accurate coaptation of the  cut surfaces,
both of the skin and  of the muscles.   Some methods admit of great
precision  in planning and executing the several steps  of the opera-
tion, and  may therefore prove  especially valuable to an inexperi-
enced operator, who on a sudden emergency finds himself compelled
to amputate.   Other methods are comparatively free from  the dan-
ger  of untoward accident occurring in the course of the after-treat-
ment, and are therefore  to be preferred in  cases where the care of
the patient  must be entrusted to  persons  of doubtful competency.
Extreme rapidity of performance is of less  importance now than it
was before  the discovery of artificial anaesthesia, but there  are still
instances  enough, especially in military surgery, in which the opera-
tor will have need of all the dexterity which he may possess.
   In studying this division of the subject, I shall try to answer the
following  questions:—
   1st. What constitutes a good stump, and what  methods are best
calculated to secure this result ?
   2d. What methods are best adapted to the process  of healing by
granulation, and which of them  are also favorable to union by first
intention ?
   3d. What methods are capable of the greatest precision in their
execution, and are therefore most likely to  insure a good stump in
the hands of an inexpert operator ?
   4th.  What methods are least liable to after-accidents, and  there-
fore require the exercise of the  least skill and attention on the part
of the dresser?
   5th.  What methods are the most rapid and easy of  performance ?
   It has always been  a great desideratum in amputations of the
thigh to make a stump  capable  of sustaining upon its extremity a
part of the weight of the body.  This result was  actually attained
by Gooch, Alanson, Benjamin Bell, and by John  and  Charles Bell,
who all amputated by the circular method as described in the early
part of this paper.  Benjamin Bell* states  expressly that the stump
* Benj. Bell. Op. cit., vol. vi., p. 378. 
 14                On Amputation of the Thigh.

 of the thigh made by his method " admits of the patient resting upon
 it with freedom "; and Sir Charles Bell* writes, " having occasion to
 see the amputation well performed by the double circular  incision,
 the bone well covered, the cure rapid, the face of the stump broad
 and large, with a mere line marking the surface of the skin, I was
 convinced  that the circular operation could  not be improved."  Of
 the nature of the best results attained  by Larrey and Dupuytren, I
 cannot find any satisfactory account, but I believe that the  plan of
 cutting the deepest muscular fibres at the same level as the  section
 of the bone is essentially bad, and cannot but be prejudicial to the
 character of the stump; it is stated by Dr. King,f at one time house-
 surgeon (interne) at Hotel Dieu,  that Dupuytren's stumps " were
 often conical in the wrong sense, and that sometimes even the  bone
 was salient and afterwards exfoliated."  The  double-flap operation
 may be performed by transfixion, so as either  to save or to  sacrifice
 the greater part of the deep fibres, and in proportion as the former
 plan is adopted will be the degree of pressure which the end of the
 stump will sustain.  If the incisions are made  according to  the rule
 established by Professor Nathan  Smith, the deepest  fibres will  be
 preserved for an inch or more beyond the end of the bone, and this
 explains his statement % that, "for twenty  years, during which he
 performed the operation a great number of times, he never  made a
 bad stump."   The successful  result of the single-flap method will
 depend much,  as  has been  already explained, upon  the  height at
 which the bone is sawn above the level of the  section of the deepest
 muscles, and in the excellent operation of Mr.  Teale, the deep mus-
 cles are preserved throughout the  entire  length of both  flaps.  It
 will be seen from these statements that I do not attribute the power
 of resisting pressure to any thickness of tissues which may be piled
 upon the end of the bone, but that my ideal   of a  good stump is
 rather one in which the soft parts form a ring-shaped cushion around
 the bone, and extending  so far beyond it as to shield it and its cica-
 trix from chance knocks  and to lift it from  actual contact with any
 surface upon which the stump may rest.   I believe that this general
 character may  be given to the stump by either of the four principal
 methods already described, but  that the circular operation of Du-
 puytren is  that least  adapted to this end.  Such stumps are, how-
 ever, comparatively rare, but the surgical mechanicians have effected
 a great deal in the way of relieving patients from the consequences
 of bad amputations.  It happens  that many  a stump which could
 not endure the direct pressure of a single pound upon its extremity,
 will nevertheless bear a pretty powerful tensible strain when applied
 to its periphery.   This fact lies at the foundation of the modern art

/pS^Sa^                           3d edition. London, 1814.  Vol.
 jfeM.PS!,S^,Sr-  London'1841- ^142.  Art., Amputation. 
On Amputation of the Thigh.
15
of making artificial legs; the upper part of the limb is fashioned into
a conical socket, the sides of which are  made to correspond, more
or less exactly, to the tapering form of the stump, thus  distributing
the bearing over the greater part of its lateral surface  and letting
the end of the  stump hang free  in the  centre.   The effect of this
arrangement is to draw upon the cicatricial  tissues which bind the
skin and other soft parts to the end of the bone, at  the  same time
that the immediate coverings of the bone are relieved from all pres-
sure, and in this way a handsome and pretty serviceable limb may
be fitted to a very bad stump.  In  other  cases,  when the  stump is
very short, or very tender, it is allowed to hang  loose in the socket,
and the whole weight of the body is supported upon the tuberosity
of the ischium.   Great as have  been the triumphs of modern me-
chanical surgery, there is still no doubt that a stump which is fitted
to bear considerable pressure upon its extremity will also best sus-
tain the weight  of the  body in the conical socket  of an  artificial
limb ,• I think, therefore, that Mr. Teale deserves our gratitude for
bringing forward a method whose results are eminently calculated
by contrast to compel the attention of surgeons  to the great defects
in many of the common methods of amputating.
   To promote the process of healing by granulation, either the inci-
sions should be so planned as to allow the opposite surfaces of the
wound to lie loosely in contact with each other, in order that adhe-
sion may take place speedily between them;  or else, if the wound
is to be left entirely open, as was the  practice of the older surgeons
who employed the  circular method, the bone must be sawn very
much shorter than the muscles, and at the same time the skin  must
be preserved of good length that it may be  the more readily drawn
inward towards the centre of the stump by the  contraction of the
cicatrix.   The former of these conditions is well fulfilled in the flap
operations, and less perfectly in the circular method  of  Dupuytren;
the latter, in the common circular  operation.  The  flap  operations
and the circular of Dupuytren are eminently favorable to union by
first intention; the common circular is less  so.  For the  precision
with which the work is laid out before hand, the  preference must be
awarded to the double-flap  operation of Professor  Nathan Smith,
and  the  method of Mr. Teale with rectangular flaps; in both of
these methods the flaps may also be cut  by transfixion after  they
have been marked out in ink upon the limb.  In the common circu-
lar operation, however, it is not difficult to remember to retract the
skin until a breadth of fascia has been uncovered equal  to  half the
diameter of the limb, and to denude the bone before  sawing it, for
a couple of inches above the plane of the section  of the  muscles.
In this respect, also, the circular operation of Dupuytren is deficient,
as its proper performance depends mainly upon an accurate eye and
correct judgment at the moment of the incisions.
  The local accidents which may result to a greater or  less extent 
4?7
 10                 On Amputation of the Thigh.

 from a defective manner of operating, are inflammation and slough-
 ing, as. a consequence of tension  of the  soft  parts;  abscesses and
 sinuses, dependent in part on a bad form of the coverings; conical
 stump and necrosis, from excessive muscular retraction; and haemor-
 rhage, which has been supposed to depend in part upon the  extent
 of the wound and upon the oblique section of the arteries.  Some
 of these  accidents may be  averted by proper treatment,  but if
 neglected, may become  truly  formidable.    Tension of the  co-
 verings is a very common cause  of pain and inflammation in  the
 early stages  of the treatment,  and often leads  to extensive  loss
 of substance  by sloughing.   The best safeguard  against  it con-
 sists in preserving a large  quantity of skin and muscle, for it is
 hardly ever the case that any inconvenience results from too  ample
 coverings, however redundant they may appear at the time of  the
 operation.  Sinuses and collections of pus are  sometimes  caused
 by the too close confinement of the  edges of the wound, while the
 deeper tissues are allowed to lie separated from each other, forming
 cavities for the lodgment of blood and matter.   This  is very apt to
 occur after the operation with a single posterior flap, in which case the
 weight of the  flap drags upon the sutures in front, and tends to form
 a large pocket in a situation unfavorable to the escape of discharges.
 Conical stump and  exfoliation of the end of the bone, as dependent
 upon original  deficiency of the soft  parts, or  upon their  excessive
 retraction, has been  already  treated of in the  description  of the
 common circular operation, and it need only be repeated in this
 connection, that the surest preventive of this unfortunate accident
 consists in the preservation of such of the  soft parts  as are  them-
 selves least prone to  retract, that is, the deep  muscular fibres which
 arise from or  are inserted into the femur near  its sawn extremity.
 The occurrence of haemorrhage within a few hours after the  opera-
 tion is very frequent  after secondary amputations performed in  the
 neighborhood  of inflamed parts; in such cases all the tissues of the
 limb are congested with blood, and the number of bleeding vessels
 is often very large,  so that it may  readily be believed that the larger
 the wound, the greater the probability that some of the dilated vessels
 may  escape  being tied.   The danger  of haemorrhage from this
cause may be greatly diminished, however, by leaving the wound open
to the air for  a few hours until its surface has  become " glazed."*
Of the different operative  methods which  admit of the perfect clo-
sure of the wound, the circular operation of Dupuytren exposes the
least extent of cut surface;  next to this, and exceeding it  but very
slightly, comes the double-flap operation of Vermale, Langenbeck and
Nathan Smith.  The  common circular method exceeds these in  the
ratio of about three  to two;  and  the operation of Mr. Teale, with

  * This "glazing  " of the cut surfaces seems not to interfere with the healing of the wound
by primary adhc.s.on, and it indirectly promotes this result by the incrcSKuritv wlS
it affords against the separation of the flaps by coagula of blood.   lULn"lbeu secumy WU1CU 
                                                                    4?f
                      On Amputation of the Thigh.                  17

 rectangular flaps, exposes a greater extent of cut surface  than  any
 of the others, bearing the ratio to the first of 3£  to 2.*   The  ob-
 lique division of some of the soft  parts in the flap  operations can
 only affect the form of the section of the   principal  arteries, which,
 from their size and known position, can  be  secured without difficul-
 ty ; the smaller  vessels,  whose  enlargement by inflammation is  the
 chief cause  of  this form  of haemorrhage, are very  irregular in their
 course, and  are perhaps  as likely to be  cut off  obliquely in  the cir-
 cular as  in the flap  methods.   It is, of course, possible, occasionally,
 to split the femoral artery in transfixing the  limb,  but a very slight
 acquaintance with the anatomy of the thigh will  enable the  opera-
 tor to avoid the  vessel by varying slightly the direction of the flaps.
 Out of a  considerable  number  of stumps of the  thigh which had
 been wholly neglected for a week or two after  the  operation, I have
 seen by far  the best results in cases  in which the  amputation had
 been  performed by the  double-flap method.   I have  little doubt,
 however, that under similar circumstances,  equally  good results may
 be  obtained by other methods,  provided  only that  the  operation,
 whether flap or circular,  is good  of its kind.   I  have  seen  two  or
 three very handsome stumps  made by the method of Dupuytren, but
 they had received excellent care and had healed by first  intention.
 I have seen  many miserable failures in  amputations performed  by
 circular incisions, but I think that, in these  cases, the fault lay rather
 with the operator than with the method.

   * The relative extent of the cut surface is pretty accurately shown by the following de-
 monstration, based upon the assumption that the thigh is a cylinder:—
   Representing the radius of the cylinder by r, let s stand for the area of the cut surface in
 the common circular operation, s' in the circular of Dupuytren, s" in the double-flap opera-
 tion, and s'" in the operation of Mr. Teale.
   In the common circular operation, the area of the cut surface is equal to the area of the
 cross section of the cylinder, plus the area of the inner surface of the cuff, plus the muscular
 surface exposed by the denudation of the bone. The thickness of the tissues  of the cuff is
 about equal to half the diameter of the bone; the cut  surface, therefore, will be equal to
 the area of the cross section of the cylinder, plus the area of the outer surface of the cuff,
 which makes
                            s=ir t2-\-2tt rs=3 ir r2
   In the circular operation of Dupuytren, the cut surface has nearly the form of a hollow
 cone, the circumference of whose base is equal to the  circumference, and whose oblique
 height is about equal to the diameter of the cylinder.  The area of this cone is half the pro-
 duct of its oblique height by the circumference of its base, which gives
                            2r+2,rJ^_9Tr8
                                2      2
   In the double-flap operation, as it is usually described, assuming that the bone is sawn at the
 same level as in the circular operation of Dupuytren, the form of the cut surface will be that
 of two semi-ellipses, which are together equal to an ellipse whose conjugate and transverse
 diameters are 4r and 2r, and whose area is 2 n r2.  If, however, the  operation is performed
 as described in this paper, the area of the cut surface will be greater in the ratio of about
 6 : 5.  This gives, therefore,
                             s"=2 7r r« or 2| n r2
  In the operation of Mr. Teale, the fire i of the cut surface is equal to the area of the cross
section of the cylinder, plus the area of the lateral surface of the long flap, plus the area of
the lateral surface of the short flap, therefore
                       b'"=7t r'+2 tt r3-H w &=H t r»
  Comparing the several values of s, s', s", and s'", we have the proportion
      s : s'; s" : s'"^3 n r2: 2 tt r2 or 2| n r8: Zh v r* =  3 ; 2 : 2 or 2|: 3£
                        3 
18                 On Amputation of the Tliigh.   .

  For ease and rapidity of execution, the double-flap operation by
transfixion, and, in cases suited to it, the circular of Dupuytren, stand
first; the processes of Nathan  Smith and of Mr. Teale, and the
common circular method, involve a more deliberate dissection, and
therefore require more time for their proper performance.
  The choice, then, of the operative method best suited  to any par-
ticular case, may generally be decided by  a reference to the follow-
ing points:—
  1st. In cases where the injury or disease is confined to one side
of the limb, the method with a single flap, or that of Mr.  Teale with
unequal rectangular flaps, is especially indicated, and its adoption
may result in a saving of several inches in the length of the stump,
which would be sacrificed by a more symmetrical operation.
  2d. If the incisions are to be  made in tissues consolidated  by in-
flammation, the operation can be performed better and with greater
ease by flaps than by either of the circular methods.
  3d.  If there is a probability that the after-treatment will have to
be conducted under unfavorable circumstances, or by unskilful per-
sons, the circular operation  of Dupuytren is that least likely to give
a good  result.
  4th.  If the operator himself be unused to amputating, he  will  do
much towards ensuring a good result by first marking out the out-
lines of the flaps,  or, if he adopts the common circular operation,
by pausing to estimate the  progress of his work, both after the  re-
traction of the cuff of skin, and before sawing the bone.
  Finally, if the operator is expert, the  parts  healthy, and  all the
circumstances of the case favorable to a  speedy union, it  matters
but little, comparatively, which method is adopted.  If, however, I
were called on to name the method which is applicable to the great-
est number of cases as they occur in practice, I should have  little or
no hesitation in awarding that distinction to the double-flap opera-
tion performed by transfixion, as I have described it; and I  would
especially advise an inexperienced  operator first to  mark  out the
flaps, in the manner taught by Professor Nathan Smith.

   Two or three especial points deserve notice  in  connection  with Ampu-
tation of the Thigh.
   A bad position  of the patient upon the table may give rise to great
embarrassment in the retraction of the soft parts.   All trouble from
this cause may be avoided by drawing the  body well  down, so  that
the nates may rest upon the edge of the table.
   The  position of the limb during the operation is a matter deserv-
ing of more attention than is usually bestowed upon  it.   It is well
known  that after amputation of  the thigh the stump inclines to turn
upward, through the action of the psoas-iliacus muscle.   In propor-
tion as this elevation takes  place, the muscles  on  the back part  of
the thigh (the long head of the biceps, the semi-membranosus, semi-
tendinosus, and adductor magnus), which  all  arise from the tube- 
d'OO
                   On Amputation of the Thigh.                 19

rosity of the ischium at a point about two inches diagonally behind
and below the centre of motion of the head of the femur, are drawn
away from the end of the bone, while the vasti and crureus, which
arise from the front and sides of the femur, are  not at  all relaxed
by the change in position.  This fact, which has been long recog-
nized, has led to the direction, either to leave the soft  parts longer
behind than in front,* or to confine the thigh by straps in a horizon-
tal position during the course of the after-treatment, f   It is an ex-
cellent plan,  in this and  in some other amputations, to operate upon
the limb in the same  position which  it is  likely to assume during
the after-treatment, and  this position, in the  case of the thigh, will
be that of partial flexion on the body.  The thigh  may be  still far-
ther elevated, before sawing the bone, with the advantage of greatly
facilitating the separation of the muscular and tendinous attachments
at the  linea aspera4
  The dread of lacerating the periosteum  has  led  to the precept
never to apply the saw until this membrane has been  divided  by a
circular sweep of the knife.   This is a necessary precaution in very
young persons, in whom the periosteum is  easily detached from  the
bone, but is superfluous in the case of adults. It is  of much greater
importance carefully to avoid  denuding the bone above the point of
its section, even  if we  have  to divide  a  few muscular fibres with
the saw.
                          ELemorkhage.
   The control of the hemorrhage during the operation is effected either
by pressure upon the femoral artery, or by tightly encircling the whole
limb with a fillet; or the two methods may  be  combined,  as is the
case in the tourniquet of Petit, which is  now in  common use.   The
old method of tying the fillet tightly around the limb has the great
disadvantage of acting slowly, thus compressing  the veins before
the arteries, and allowing the whole limb to  become congested with
blood  before the operation is  commenced.   The introduction of the
" garrot,"'  however, by Morel, rendered  the  method nearly perfect.
The fillet is tied loosely around the thigh, and  is tightened, at  the
very instant of making the first  incision,  by twisting with a short
stick placed beneath  it.   The action of the " garrot"  is almost  in-
stantaneous, and it is powerful enough completely to arrest the  cir-
culation in all the vessels, both great and small.   The tourniquet of
Petit is a strap adjusted by a buckle, and capable of being tightened
by turning a screw, which at the same time compresses the main ar-
tery by means of a wooden pad.  The action of this instrument is
slower and  less powerful  than that of  the  " garrot," and it allows
the limb below it to become engorged with blood, without affording
absolute security against arterial haemorrhage.  The " compressor "
of Dupuytren consists of two pads connected with  each other by  a
* Malgaigne.                t B. Bell.  Liston.
X Charles Bell. Great Operations, op. cit., p. 60. 
60/
20                 On Amputation of the Thigh.

strong arc of steel.  The larger pad, which  is made flat, is  applied
to the side of the limb opposite to the  main artery, and serves  as  a
point of resistance to the smaller pad, which is forced down upon
the vessel by turning a screw.   This  instrument does  not  prevent
the return of the blood through the veins, and it may be applied, as
may also the tourniquet of Petit, to  compress  the  femoral artery
against the horizontal ramus  of the pubes where it emerges  from
the pelvis.
  All instruments  for the compression of the femoral artery  have
the disadvantage that they cannot be  easily applied so high as is
often desirable, and when placed too near the point of amputation
they interfere with the proper retraction of the  soft parts, if indeed
they do not become loose or slip off altogether  at the  very moment
when they are most needed.   They are therefore better adapted to
amputations in the lower than in the upper half of the thigh, and
they interfere less with the performance  of the operation  by  flaps
than by the circular methods.  The best method of compressing the
femoral artery is by the fingers of a thoroughly competent assistant.
Slight pressure suffices, and  it is  applied at the exact point where
the pulsation  of the vessel is felt.  The  pressure may be  kept up,
with but little fatigue, for an hour or more, if necessary, and it may
be relaxed or resumed in an instant.   The  compression of the femo-
ral artery may be  made most conveniently against the pubes, and at
this point  it offers  no impediment to the retraction of the  soft
parts.  In the absence of a competent assistant, the  " garrot," or
handkerchief and stick, is probably a more efficient instrument  than
the common tourniquet.*
  Every surgeon has observed that, at the  moment  of making the
incisions, quite as  much  blood  often flows  from the vessels of the
severed limb as from those which remain connected with the heart.
The hemorrhage from this  source is often greatly increased  by the
unskilful manner in which the tourniquet is applied;  but even under
the most favorable circumstances the loss of blood will be  equal to
the quantity originally contained in  the limb, in  addition  to  that
which escapes, owing to the  imperfect  suspension of the  arterial
circulation.   The idea of emptying, in part, the vessels of the  limb
before the operation, is found in the writings of Prof. Nathan Smith f
and of Sir Charles Bell.  The former  surgeon proposed  either to
elevate the limb above the level of the bodv, or to compress the main
artery for a few minutes before  tightening the handkerchief which
he used instead of the tourniquet. Sir Charles Bell's^ plan is more
efficient; it  consists  in  applying a roller firmly and evenly to the
whole limb before operating, by which course « the veins are emptied
into the general system, and blood is  saved instead of beino- with
t Op6 S! p'age8^' °P' dt" P> m' MS° DlW^ ^cons Oralcs, tome Sine, p. 381.
j Charles Bell.  Great Operations, page 58, note. 
                                                              SO£

                   On Amputation of the Thigh.                 21

drawn."   This application of a roller  to the limb  may be  of the
greatest service in a very exhausted state of the patient, and  there
is no good reason why it should not  be generally adopted  in  the
case of the larger amputations.
  For the  arrest of the hemorrhage  after amputation,  very many me-
thods have been employed at  different times, but they may  all be
divided into two classes, according as they are applied  to the main
artery only or to the whole cut surface.   Of the  former methods the
ligature deservedly stands first.   The common direction is to draw
out the end of the artery from  its sheath by forceps* or by a tenacu-
lum, and  to tie it with strong silk or  linen thread.  In a healthy
state of the tissues  this is easily effected; the  artery is connected
with the surrounding parts by  lax areolar tissue, and can readily be
drawn out for half an inch or more, retracting again into its  sheath
as soon as it is released.  In a limb, however, which has been the
seat of inflammation, this areolar tissue is often found consolidated
by a deposit of coagulated lymph, which glues  the artery firmly to
its sheath.  In this state of  the parts, which  is frequently observed
in secondary amputations, it is often  impossible to isolate the arte-
ry^  and  the  only alternative then  is  to include some of the sur-
rounding  tissues in the ligature, taking care,  however, not to tie up
any  large nerve.  This " mediate " ligature is best applied with the
aid of a curved needle or  tenaculum.   The point of the instrument
is passed  into the face of the stump a short distance from the mouth
of the vessel, and is carried across in such a way as to transfix the
walls of the artery, emerging on the other side;  the ligature  is now
tied firmly behind the tenaculum, and  thus the vessel is constricted
just  above the point  where  it has been transfixed.   Applied  in
this   way,  the  ligature  is more liable  to  slip off than when it is
placed immediately upon the artery, and the larger the mass of flesh
is which is encircled  by the thread, the greater will be the proba-
bility of its shrinking under the pressure and  allowing  the ligature
to become loose.  In cases where it is necessary to trust to this me-
thod for the closure of the femoral artery, it may be well to use a
small curved needle instead  of the tenaculum, tying the ligature be-
hind it, and leaving  the needle in its place  for several days; the
needle might be drawn out at  any  time by means of a thread  passed
through its eye.   The " mediate " ligature is  especially useful in the
case of the smaller muscular branches, which are not easily isolated
and  at the same time  become very soon  obliterated.   The  thread
used for ligatures should be strong enough to bear considerable ten-
sion, in order that it may sink a little  into the  walls of the vessel,
and   thus  afford  the greater security  against  slipping.  A  very
fine  ligature  is seldom of  sufficient  strength to  constrict a large
artery, and is liable,  also, to cut through the  tissues; a coarse cord,
* Pare.
t Liston.  Elements of Surgery, Am. Ed., 1837, p. 518. 
603
22                  On Amputation of the Thigh.

on  the  other hand,  cannot easily be  tied  with  sufficient firmness
about a small vessel,  especially if  the  so-called surgeon's  knot is
employed.   The  size of the ligatures should  bear a  certain relation,
therefore, to the diameter of the vessel, ranging from  coarse sur-
geons' or saddlers' silk, or coarse linen thread, for the largest artery,
to fine sewing silk for the smaller vessels.  It would probably afford
additional  security against slipping when  the knot  is  tied, if the
thread,  instead of being  simply waxed,  were prepared  beforehand
by soaking  it in  melted wax,  or in a mixture  of wax with a little
pitch or resin.
   The proper disposition to be made of the free ends  of the liga-
ture has long been  a subject of dispute, and is not  yet  altogether
settled.  In an open wound, healing  by granulation, the  ligatures
are thrown  off with  the discharges  long before the process  of cica-
trization is  far enough  advanced to be injuriously affected by their
presence.    In such a case, therefore, it  is best  to cut off both ends
of the ligature pretty close to  the knot.  In cases, however, where
union of the soft  parts takes place by first intention, the  knots often
become enclosed in  the tissues and give rise  to  irritation  which may
continue for a long time, until the offending thread is discharged by the
formation of an abscess.  To avoid trouble from this cause, one end
of each ligature is generally left projecting between the  lips of the
wound,  in order that the knot  may be  drawn  out as soon as it be-
comes detached  from  the  mouth of the artery.   A few surgeons
still adhere to the bad  practice of cutting off both ends of the liga-
ture close  to the  knot ;*  others  have  recommended fine catgut or
shreds of split tendon, upon the  erroneous supposition that such
substances become speedily absorbed when buried in living tissues.
   Torsion, or violent compression of the walls of the artery, is often
employed with advantage for small  vessels whose muscular  coat  is
easily stimulated to  contraction, but it is both troublesome and unsafe
when applied to the larger arteries.
   Dr. Simpson,t of Edinburgh, has recently called attention to a very
useful invention which he  calls " acupressure."    It consists in com-
pressing the artery at a single point of its length by means of a strong
pin of about the size  of an ordinary knitting needle.   The pin is thrust
through the skin and other tissues of the stump on one side  of the
artery,  in such a direction that its point  passes  quite  near the ves-
sel,  against which  it is made to  press pretty firmly by  suddenly
changing its direction and  thrusting it  onward until it emerges on
the other side.  The pressure  should not  be  very powerful, for a
very moderate force suffices to control the circulation in  the  artery,
  * Almost all authorities concur in recommending the removal of one end only of each
ligature, the practice of cutting them short having been thoroughly tested by Lawrence, Lis-
ton and others, who all unite in condemning it. Very lately, however, Heyfelder has de-
nounced the custom of leaving one end as " neither necessary nor useful, hut altogether in-
jurious and wholly unjustihable."  (See the New Sydenham Society's Year Booli for 1K60
page 271.)
  f Edinburgh Medical Journal, January, 1860. 
60*/
                   On Amputation of the Thigh.                 23

and any unnecessary compression would only cause  inconvenience,
and might endanger the vein or nerve.   The theory of acupressure
is aptly illustrated by Dr. Simpson, who compares the vessel to the
stem of a flower fastened by a pin to the lapel of a coat.   This me-
thod, which is very easy of application, seems destined to more ex-
tended use in surgery, and may even deserve a trial as a substitute
for the ligature in  the treatment of aneurism.   Acupressure  seems
hardly indicated in ordinary cases  of amputation, and is  not  appli-
cable to secondary amputations in inflamed or congested tissues, but
in  the treatment of secondary haemorrhage it promises  to render
good service.
   The actual cautery has been properly abandoned for very large ves-
sels, owing to the uncertainty of its immediate action, and the very great
liability to the recurrence of dangerous  haemorrhage upon the sepa-
ration of the eschar.  For small  arteries, the hot iron is both effi-
cient and  easy of application, and  might  be employed with advan-
tage much oftener than  is now the fashion.  Caustics, such  as the
old " button of vitriol," &c, are more painful and less efficient than
the actual cautery, and  it is almost  impossible  to confine  their ac-
tion to the bleeding point.
   The alleged advantage of many of these substitutes for the liga-
ture is that  they do not interfere  with  union  by first intention by
interposing any foreign  substance  between the opposite surfaces of
the  wound.  This advantage, however, is unreal  in the case of am-
putations, for the sharp end of the  bone  always excites more or less
of  inflammation, attended by suppuration in  the very deepest part
of the wound;  the ligatures, therefore, do good, for they prevent the
formation of sinuses and abscesses by keeping open a free passage
for  the discharge of the matter.   It  will  generally be found  most
convenient to  collect the  several ligatures into a single bundle,
bringing them out together at the most dependent part of the wound.
It is better to leave but one end  to each ligature, and it  is well to
distinguish the ligature of the main artery from  the others  by tying
a knot in it.
   Two cases are occasionally met  with  in practice, in which it is
impossible to close the artery by the ligature.   When  the nutritive
artery of the tibia is divided a little below the point at  which it
enters the bone, it sometimes throws out a  smart jet of blood which
does not  readily stop of itself.   In this case compression with the
finger, plugging the hole with wax, &c, have been proposed, but the
simplest and most effectual plan is that adopted by Mr. Liston, which
consists in driving  in a small peg of soft wood and withdrawing it
after a day or two by means of a bit of string tied to it.   The other
case occurs occasionally in old persons, in whom  the walls of the
arteries are often indurated  by calcareous  deposits.   The most ob-
vious course  to pursue in this condition  of  the vessels, would seem
to be the insertion  of a plug into its open mouth, tying the ligature
over it. 
SOS
  24                 On Amputation of the Thigh.

    Haemostatic agents which are applied to the whole surface of the
  wound, may be divided into two classes,  according  as they promote
  or impede the accomplishment of  union by first intention.  Of the
  latter class are the ancient  methods of searing with a hot iron, cut-
  ting the soft parts with a red-hot knife, dipping the end of the stump
  in hot pitch or oil, strewing the raw surface with astringent or es-
  charotic powders,  binding agaric or  sponges tightly  against the
  bleeding surface, &c. &c.   To these may be added the  plans recently
  put forward of dividing the soft parts by the  galvanic cautery,* or
  by the extemporaneous ligature (eoraseur);t also, the employment
  of powerful styptic solutions of sesqui-chloride of iron,  &c.   Some of
  these methods may be adopted with  advantage in  certain cases of
  secondary haemorrhage, but  they ought never to be used  in any case
  in which union by first intention is possible.
    Of the local applications which  may arrest  haemorrhage without
  impairing the chances of speedy union, the free use of  cold water
  and  the exposure of the  raw surface  to  the action of the air, are
  among the  most important.   Dashing or sponging the  wound freely
  with cold water causes the immediate  contraction of the  mouths of
 the smaller  vessels, but bleeding  is very  apt to recur whenever re-
 action  takes place.   The use of cold applications, therefore, to be
 effectual, must be continued for a considerable time, and great care
 must be taken to protect the patient from  the discomfort of cold and
 wet bed clothes.  The exposure of the open wound to the air acts
 in part, doubtless, by the cooling effect of  evaporation, but its chief
 efficacy is probably due to the stimulating  action of the oxygen upon
 the tissues.  A wound thus exposed for a time to  the air, is very
 much less likely to bleed after it is done up than if treated by cold
 applications.   The formation of clots between  the opposite cut sur-
 faces, which is one of  the greatest obstacles  to their early union,
 is prevented, and  the dressings, when  once applied,  seldom require
 to be disturbed for several days.   If sutures are used, they may be
 inserted at the time of  the operation, while the patient is yet under
 the influence of chloroform, and  loosely knotted together until the
 time arrives for finally adjusting them.
   The local use of strong alcohol as a styptic, has been lately advo-
 cated in France.^   When used of  the  strength of  36° Cartier
 ( = 89.6°), it coagulates the albumen on the  surface of the wound,
 forming a greyish-white pellicle, and stops  the haemorrhage from the
 sural  vessels.   It is  also  said  to hasten the secretion of plastic
lymph and to prevent diffuse suppuration by coagulating the alba-
men of the  cellular  tissue.   At first view, it would  seem that the
contact of so powerful an agent with a fresh wound would almost of
necessity cause the death of its surface, and  thus entail a more or less
tedious ^ajUDuratupn^ Experiments  have   proved,  however, that
  * MidJeldorpf.
  t M.iisonneuve.
 pi^WBO.81"1 MC°h0liC ***■"«*»» * Surgery, &c.  By F< j. Bataim, &nd Ad> ^^ 
On Amputation of the Thigh.
25
 strong alcohol may be applied  to fresh wounds without exciting in-
 flammation, and it seems indeed to favor union by first intention, by
 thoroughly arresting the haemorrhage from the small vessels.*  Al-
 cohol is moreover powerfully antiseptic, and offers  many advantages
 over the solution of hypochlorite of soda as an application to slough-
 ing and bleeding sores.
   Primary Hemorrhage after Amputation  is a very common  occur-
 rence, and  depends  upon the imperfect closure of the smaller ves-
 sels, or possibly upon the accidental loosening of a  ligature.  Under
 the stimulus of the knife and of the exposure of the cut surface to
 the air, the muscular walls of  the  smaller  vessels contract so as
 speedily to arrest the  flow of blood from them.  This contraction
 generally continues until coagula have formed, and  the natural pro-
 cesses of repair have commenced.   In other cases, however, the first
 arrest of the bleeding is rather the  result  of faintness  than of arte-
 rial contraction, and the recovery of the patient  from the shock
 may be attended by a renewal of the haemorrhage.   The  best  pre-
 ventive of this accident, as has  been already stated, is to leave the
 wound open to the air until its  surface becomes glazed, and if bleed-
 ing recurs after the wound has been  dressed, it  should be immedi-
 ately opened, so as again to expose its whole surface.  If the bleeding
 artery can be found, it should be tied or twisted; but if the flow of
 blood  ceases of itself, as it often does in  such cases, the wound
 should be left open for an hour  or two to  glaze.   Should the liga-
 ture slip off from the main artery, it should be secured again in the
 wound, or by an acupressure pin passed through the flap  above; in
 either case, however, the wound should be freely opened, lest the
 cure should be impeded by the  presence of clots between the cut
 surfaces.
   The term secondary hemorrhage should be confined to those cases
 in which bleeding occurs from the failure  of the natural processes
 by which the permanent closure of the vessels is effected.  It often
 occurs at the  time  of the separation of  the  ligatures, and it may
 happen at  any time by the  gangrene or  ulceration of the walls of
 the vessels. At this period a considerable part of the wound may have
 already healed, and its surface  will  have become so changed by the
 morbid action as to  make  it very difficult to find the end of the
 artery; and even  if it could be easily found, its altered and friable
 walls are no longer fit to receive a ligature.   In  this state of  things
 it is, folly to tear or cut the wound open in the  attempt  to apply a
 ligature to the mouth of the artery.   Stuffing the  wound with lint or
 sponges may arrest  the haemorrhage for   the moment, especially if
 aided by the use of styptic solutions, such  as the  sesquichloride of
iron.  The actual cautery is  even less certain in secondary than in
primary haemorrhage from large arteries.  All such local  measures
* Alcohol and Alcoholic Preparations in Surgery, &c.  Pages 4 and 20.

         4 
60/
26
On Amputation of the Thigh.
 for the arrest of secondary haemorrhage are extremely uncertain, and
 have  besides  the great  disadvantage of interrupting the  healing
 process.
    Secondary haemorrhage may also be  treated by compressing the
 artery above the  wound where its walls are probably healthy.   In a
 few cases it may  be sufficient to maintain constant pressure with the
 tourniquet for several days, until a clot has formed in  the mouth of
 the artery, but as a general rule more decided measures are necessa-
 ry.  Under these circumstances, the choice must  be made between
 acupressure and the ligature of the arterial trunk.   Acupressure is
 readily applied at any desired point in the course of  the vessel; it
 inflicts very slight  injury upon the limb, and  may therefore be re-
 peated several times if it should be necessary.  The  needle should
 be passed into the  skin, at  a distance to  one side of the artery
 somewhat greater than the depth of the vessel  below the surface,
 and its point carried  as nearly as possible beneath the artery.   The
 outer end of the  needle is then depressed, so as  to compress the
 artery between the needle and the skin, and the needle is  then push-
 ed onward until its point emerges  through the skin  on the other
 side of the vessel.  Should the pressure of the needle be insufficient
 to control the bleeding, its action may be aided by  a  few turns of
 the twisted suture  taken over a compress laid along the  course  of
'the vessel.*  Acupressure should be  practised  as near  as possi-
 ble to the open end of the artery, for fear of the continuance of the
 haemorrhage by anastomosing branches.   This  method promises  to
 render excellent  service in the treatment of secondary haemorrhage,
 and should be fairly tried before undertaking the much more serious
 operation of tying the femoral artery.  Should acupressure  fail, we
 have still the resource of laying bare  the artery and tying it, which
 should be done either very near the end of the stump, or  else above
 the point of origin of the larger collateral  branches.   Thus in  am-
 putations in the upper part of the thigh, it will probably be safest to
 tie the femoral artery above the origin of the profunda, and in any
 case, if a first ligature placed near Che  end  of the stump  fails  to
 arrest the haemorrhage, there need be but little fear of danger in ty-
 ing the artery again at a higher point.f
    After the haemorrhage has  been arrested, the  chief care of the
 surgeon should be directed to the promotion of a healthy process of
 repair by granulation.   It  is  not  advisable,  as  a  general  rule, to
 separate the flaps, or in any way to disturb the existing  adhesions;
 but if  partial union has taken place in such  a way  as to form,  cavi-
 ties for the lodgment of matter, they should be freely opened at the
 * A needle with a curved point, such as has been used by Mr. Startin in the treatment of
varicose veins, would probalily be better for this purpose than the straight acupressure needle
used by Dr. Simpson.  (Sec Bniithwaite's Retrospect, Vol. xlii., page 161.)
 f See Nekton,  Pathologic Chirurgicale, Tonic Ire, page 235.  Also for a discussion of
the question of the high ligature of the femoral artery, sec a paper by Mr. Porter in the Dub-
lin Quarterly Journal for November, 1860, and Braithwaite's Retrospect, Vol. xliii., page 124. 
                                                                60S
                    On Amputation of the  Thigh.                  27

most dependent part, and the walls of the cavity kept in contact  by
means of a roller and compresses carefully adjusted at every dress-
ing.  If the haemorrhage has been the result of rapid ulceration  or
sloughing, it is probably dependent upon  impaired constitutional
power, and its recurrence is to be opposed by a generous diet and
tonic remedies.

            Dressing  and  After-treatment of  Stumps.
   Before considering the subject of dressings, it may be well briefly
to  review the history of the processes of repair so  far as they are
concerned in the healing of the wound made by amputation.   First
of  all, it must be remembered that we have to  deal with two totally
distinct classes of tissues:—1st, The soft  parts, consisting of skin,
areolar tissue, muscle, and dense fibrous tissue, which may all heal
by the processes of immediate union, primary adhesion, adhesion of
granulating surfaces, or by the slow  process of granulation and cica-
 trization; and 2d, the bone, in which, even in subcutaneous injuries,
 as  in simple  fracture, the process of repair does not begin until
 after eight  or ten days* and  upon whose  sawn extremity granula-
 tions do not appear until  the tenth  day or  later.f  Now it  is  evi-
 dent that the soft  parts may unite  by either  of the three methods
 first mentioned,  before the slightest change has taken place in  the
 bone, for the soft parts probably never unite with the compact  tissue
 of the sawn end of the bone by any much  speedier process than the
 slow one of granulation.   It is idle, therefore, to talk  of the com-
 plete cure of a  stump  by first intention,  for  the sharp end of the
 bone will  act for a considerable time  as a foreign  body,  and  will
 always  excite  more or less of suppuration in its neighborhood.;
 We must not, therefore, be over anxious about the  ligatures, for they
 really act beneficially by keeping  open a convenient outlet for the
 discharges, which might otherwise  burrow among  the muscles  and
 at last find vent in an abscess.§

   * Paget.  Lectures on Surgical Pathology. Lecture XL, on Repair of Fractures.
   + Ibid.  Lecture IX., on Healing by Granulation.
   \ Sec Sedillot.  Op. Cit. Tome !re, page 344. Also Dupuytren, Lecons Orales, tome 2me,
 P'rThCerceh;.sbccn much unprofitable discussion during the present century between t^
 partisans and opponents of the practice of healing stumps and incised wounds  geneially by
 first intention.  The early advocates of this plan of treatment m amputations wcic English
 suf4ons who practised cluefly in  the provinces, amid favorable atmospheric and  hyg.ee
 iSnces  The chief opponents  of early union were found among  the distinguished s -
 Leons of Pait who have always had to contend against the enormous sanitary evils which
 fS in the great public hospitals of that city.  As often happens,  m suchl disnu e.both
 mrties were right, aud each adopted that line of practice which load  experience urfjown
 to be oest  In country practice/and even in towns of moderate size wounds go. cia ly heal


 S4t S,ral°ly w ctoc thewhole wound V «..turc» ami plotters or ton a channel 
50<f
28
On Amputation of the Thigh.
  In dressing a stump, then, we must aim to fulfil  two distinct indi-
cations:—1st,  To promote the union of the soft parts;  and, 2d, to
protect the soft coverings from the sharp end of the bone.
  I  have already insisted  upon the importance of so arranging the
successive steps of the operation as to secure a just relative propor-
tion between the different  tissues left for  the  purpose  of  covering
the bone.   The bone must be  thoroughly protected by the preserva-
tion of a sufficient length of the deep muscles, which should, in turn,
be covered either by integument or by a thin flap  composed of skin
and  muscle.  According as these  conditions have been fulfilled, will
be the possibility of effecting a cure mainly by  first intention.  The
soft  parts should  be so  ample as to admit of the complete approxi-
mation of the opposite cut  surfaces  throughout their entire extent,
and  that without exposing  them  to the slightest  tension.   Tension
of the coverings is one of  the most  fruitful causes of failure in the
attempt to secure union by first intention, and  the irritation which
it produces is often the beginning of a formidable train of accidents.
Rather, therefore, than to expose  the  soft parts to any strain in the
early dressings, the wound should be  left open, according to the pre-
cepts of the older surgeons,  and allowed  to heal  by cicatrization
from the circumference to the  centre.
  In order  to  promote the  union of the soft  parts, they  must  be
held in accurate contact with  each other, skin with skin  and muscle
with muscle.   This contact with the muscles should be aided by mo-
derate pressure, applied to opposite sides of  the stump,  near its ex-
tremity, by means of soft  compresses and  a roller.*  The margins
of the skin should  also  be brought  together and held  in  place by
the interrupted or twisted  suture, or by strips of plaster.   In circu-
lar amputations  the wound  can, in most cases, be easily closed  by
strips  of plaster  alone; but  in the  flap operations, a few points of
suture  are  generally employed in addition.  If the interrupted  su-
ture is used, the threads may be inserted at the time of the opera-
tion and loosely knotted together until  the time arrives for finally
adjusting them.   The twisted, or hare-lip  suture, holds the parts
more firmly in place than  any other, but its very firmness  may be-
come a source of serious  danger should swelling  or retraction of
the soft parts take place.   The small spring forceps, called " serres
fines,11  have at least the advantage that  they slip off before the ten-
pie or a strip of linen.  No author at the present day, so far as I know, advises a return to
the ancient practice of leaving the wound entirely open and waiting for it to heal by the
gradual drawing in of the integuments, from the  circumference to the centre, by the con-
traction of the cicatrix.  The difference between the hygienic influences of city and country
can hardly be too strongly presented, for it has  a most important bearing, both upon the
treatment to be adopted as well as upon the probable result of a surgical operation. Thus
many operations which are attended with very considerable danger in the practice of the
great metropohtan hospitals, seem to be almost unattended by serious risk when performed
in the country.  A notable illustration of this point is found in the statistics of lithotomy as
performed in the Western United States and the hospitals of Paris and London.
  * In the operation with a single flap, the nature of the support given to the flap must de-
pend upon its form and position; in Mr. Teale's operation no such support is needed. 
s/o
                    On Amputation of the Thigh.                 29

sion can become excessive.   If sutures are used  they must be care-
fully watched, and removed upon the first sign of their  causing pain
or irritation.   As a general rule they should be supported by strips
of plaster placed between them, taking care, however, not  to cover
the wound so closely as to confine  the discharges.  Plasters are, on
the whole, safer than  sutures, especially if  the case is to be left to
the  care of unknown or  unskilful persons, and they  can almost
always be applied with sufficient exactness if the  operation has been
even tolerably performed.*   If the  common adhesive  plaster (era-
plastrum resina>) is used, it should be freshly spread, as it is apt to
become brittle  and  non-adhesive when old.  As commonly prepar-
ed, it  is spread upon heavily-sized cotton  cloth, and consequently
separates from'"the cloth when wet.   It is much  more  useful  when
spread upon old or unglazed cotton, for it then penetrates  the fibre
and renders  it partially water-proof.  As all resinous plasters are
somewhat irritating  to fresh wounds, it may frequently be  advanta-
geous  to employ the isinglass  plaster of Liston, which, when pro-
perly prepared, is nearly identical  with the  best water-proof court-
plaster.f  It should be spread upon  some fabric impervious  to wa-
ter, or it will be loosened by the slightest moisture.
   There is often considerable difficulty in applying  plasters neatly
and firmly, owing to the elasticity of the soft parts causing the wound
to gape.   To obviate this inconvenience, Liston  was in the habit of
securing the flaps by means of a few sutures, removing  them as soon
as the  plasters become fixed.  I have often  found it convenient  to
apply the strips of plaster in  the following manner, suggested by
the common uniting bandage.  The strips are applied  in pairs, one
strip of each pair being  made narrower  than  the other, so  that it
may pass  easily through a buttonhole cut  transversely in  the wide
strip,  at  about the  middle of its  length.   The  wide  and  narrow
strips are applied alternately to the sides of the stump, so that  the
holes in the  wide strips fall a little above the cut edge of the inte-
gument; the free end of each narrow strip  is then passed through
the hole in the opposite wide one, and  by drawing upon  the two
ends the lips of the wound are closely approximated.   When every-
thing is adjusted, the ends of the plasters are secured by sticking
them down smoothly in the position they happen to  assume.   Used
in this way the plasters offer many of the advantages  generally as-
cribed to sutures, and they can besides be readily loosened and re-
adjusted without disturbing other parts of the wound.J
   The next condition for the accomplishment of  speedy union is the
  * I have been led to the discussion of this question by the experience of several cases oc-
curring in the army, in which serious and sometimes fatal accidents appeared to depend upon
the tension of flaps confined by strong thread or wire sutures.  See, also, Larrey's Campaign
in Saxony, in the last volume of the Memoirs.
  t Liston's plaster, as finally improved by the inventor, " is composed of a solution of isin-
glass in spirit spread on slips of oiled silk; or silk glazed on one side only, and on the un-
glazed side." (Liston's Practical Surgery, ch. ii., on the Union and Dressing of Wounds.)
  + Since adopting this plan in the army hospitals, I find that  something very similar is de-
scribed and strongly recommended by Prof. Nathan Smith. (Op. cit., page 222.) 
6/7
30                 On Amputation of the Thigh.

absence of inflammation,* for the slightest  inflammatory action  is
sufficient  to prevent immediate union, and but a slight degree of it
is consistent with union by primary adhesion.   The dressings, there-
fore, for the first few days, should be such as are least likely to irri-
tate the freshly divided tissues;  all  greasy applications  should be
avoided, and  the  parts  should be disturbed  as  little as possible.
The free use of water at this period generally does more  harm than
good, for it loosens the plasters and  thus disturbs the apposition of
the parts.  Perhaps the best dressing  is a narrow compress of soft
linen, moistened  with water  and covered with oiled silkf  to prevent
evaporation;  this will not need to be removed oftener than once or
perhaps twice a day, and  it  is both neat  and unirritating.  After
suppuration  begins, the  lateral compresses should be carefully ad-
justed at  each dressing, so as  to keep  the granulating surfaces in
contact with each other, and  to prevent the accumulation  of pus be-
tween them.   At this stage, if the suppuration is abundant, no other
dressing is required than lint or tow  in sufficient quantity to absorb
the matter discharged  in  the interval between two successive dress-
ings ;X  should the discharges  be scanty, however, it will be best to
apply to the wound a narrow  strip of  linen greased with tallow or
simple cerate.  Saturating the dressings  with water can be of  no
conceivable use during the progress of granulation;  it is  a slovenly
practice, and  "enerally causes much  discomfort  to  the patient  by
wetting the  bedding.   The  stump should be  lightly covered, and
protected from the  weight of the bedclothes.  An excellent cover-
ing for  the end of the  stump  may be made of a  handkerchief, or a
square  piece of cotton or linen cloth, confined by a couple of turns
of a roller; this  will prevent  the access of flies "to the wound, and
will  thus afford  an effectual  protection against  the  development
of maggots.§
   The danger of accident from the pressure of  the bone against the
soft-coverings depends, as has already been shown, upon  the pro-
gressive retraction of the muscles, and it must be met, if at all, by
combating this cause.  This  may be effected in two wavs:__1st,  by
position, which, however,  is  more effectual  in the leg 'than in the
thigh; and 2d, by the application of  a roller to the whole length of
the stump.
  The muscles of  the thigh, whose tension is  affected by changes in
the position of the limb,  are chiefly those  upon  the  posterior and
  * See Pagct's Lectures on Surgical Pathology, chap. ix.. p  133 of 2d Am VMtim
thm^reewS'n-onfter ^T" ***** °^U **"• "W^BhS SffiS,'Hn foil,
&c.Vc            GU  dlCStS* °r' 0U au Sweeney, a thick leaf, or a bit of soft bark)

iJ^J^R^F,Jrhuitate,y rCrml hl amy Practi(>e' where there is no time




end may u mud, teuer attain Uy tola. % SafeS.a!uteS.££f"' "" """ 
                                                                S72
                    On Amputation of the Tliigh.                 31

inner aspect of the femur.*  The great mass of the muscles of this
region, which arise from the tuberosity of  the ischium, are put  in a
state of  tension when the  end  of the stump is elevated, but  are re-
laxed when the thigh is extended nearly in a line with the body.
Three of the four anterior  muscles, on the other hand, arise from
the femur, and  are therefore unaffected by the change in position.
A change, therefore, from the elevated  position which  the stump is
apt  to assume, to the horizontal, may suffice, of itself, to relieve a
slight degree of tension of the coverings, and is, besides, a valuable
adjuvant to the method next to be described.?
   The use of the roller to prevent muscular retraction depends up-
on the principle that when a muscle contracts in  length it increases
proportionally in diameter; if, therefore, this increase  in diameter
be prevented, the muscular contraction cannot take place; and this
is as true of a limb as of a single muscle.  The remedy, then, for
the  tension which depends  upon the retraction of the muscles, con-
sists simply in applying a roller firmly and evenly to  the  whole
stump as far as the next articulation, thus  compressing all the  mus-
cles and effectually preventing their contractions.  The roller should
not  be changed until it  becomes  soiled or loosened, and it is well to
apply it in two parts, letting the main  roller extend to within two
or three inches of the end of the stump, and finishing the operation
with a second shorter piece which may be changed at each dressing.
The use of the roller in the manner and  for the purpose just de-
scribed, although taught by almost every surgeon of  note who has
written  on the subject of amputations,^: has, nevertheless, fallen of
late into comparative neglect.  A few  surgeons,§  who have adopted
flap methods with flaps  of  very great length, have been able safely
to dispense with  the roller in a great  majority of cases, but  even
after the best operation the flaps may slough, or  unexpected retrac-
tion may take place, so as, after  all, to render  some artificial sup-
port necessary.   In the  common circular operation, as performed by
Gooch,  Alanson, Benj. Bell,  Hey, and John  and Charles Bell, the
roller always formed  an  essential  feature  in  the after-treatment,
although these surgeons all  inculcate  the necessity of sawing the
bone  as high  as it can be denuded, by the use of the retractor,
after dividing the muscular and  tendinous attachments at the  linea
aspera.   I am  not prepared, however, even in the case of  circular
operations, to deny the  possibility, under  favorable circumstances,
  * The long head of the biceps, the semi-membranosus, semi-tendinosus and adductor
magnus.
  f In the middle and upper thirds of the leg, where the muscles of the calf preponderate
enormously over all the others, a bent position of the knee affords very great relief by re-
lieving the tension of the coverings and preventing perforation of the skin by the sliarp spine
of the tibia.  So great is the advantage  derived from this position, that I always adopt it,
turning the patient upon his side, whenever there appears to be the slightest tcusion of" the
integuments in front.
  X Gooch.  Alanson.  Louis.  "Benj. Bell.  Richcrand.  Astlcy Cooper.  Hcnnen. John
and Charles Bell. Guthru;.  Sddillot and others.
  § Liston. Teale. 
82                   On Amputation of the Tliigh.

of sawing the bone high enough to enable the dresser safely to dis-
pense with the roller, but I am confident that, to  ensure this safety,
the bone  must  be sawn so much  higher than is the usual  practice
as to render the circular methods, in many cases, extremely difficult
of performance.   With the  exception of a very few double-flap ope-
rations, I  have scarcely ever seen  a stump of  the thigh in  which the
use of the roller was not  indicated during  the greater part of the
after-treatment;  and whenever it has been tried, 1 have never known
it  fail  to produce  very decided benefit.*   In applying the roller,
certain precautions are necessary—it should  be applied from above
downwards, beginning in the vicinity of the articulation next above
the point  of amputation, and it  should extend nearly or quite to the
extremity of the stump, in order that  it may compress the muscles
of the limb throughout their entire length.   Thus in the thigh, a few
turns should be first  taken around  the pelvis, and the thigh approach-
ed in the  manner known as  the  " spica."   If  the  soft parts are defi-
cient, or  if they show a tendency  to  retract  to an  unusual degree,
the bandage must be very firmly but smoothly applied, and for this
purpose  the roller with two  heads  is to  be preferred.   There is
  * A late writer (Symonds, Med. Times and Gazette, Sept. 8, 1860, p. 230) has doubted the
efficacy of the roller in preventing muscular retraction after amputation.  It may be well,
therefore, briefly to state my own experience.  1st. I have seen a few excellent stumps of the
tliigh in which the roller had not been used during any part of the treatment, but in all
these cases the coverings were left very long, and extensive union took place by first  inten-
tion.  This was especially true of amputations performed with two equal  flaps, which ac-
cords witli the results given by Mr. Teale, in whose operation, also, the flaps are of very am-
ple length.  2d. I have seen a large number of cases in which union by first intention  has
either failed  or has been confined to the integuments, and in which retraction of the soft parts
has taken place to such an extent  as either to tear open the newly-formed adhesions or to
threaten perforation of the coverings by the pressure of the end  of the bone against  them.
In all cases of this character, I have immediately applied the roller in the manner described,
and in every instance with the happiest result.  In this  way I have generally  succeeded in
covering the bone, even in cases in which the soft parts have been very deficient, and in all
cases in whijh the bone has not already found its way through the coverings, I have been
able to relieve the tension and prevent the occurrence of this accident.  In other cases, where
the stump has been very painful from the same cause, although there was probably no great
danger of perforation, I have at once relieved the pain and completely arrested the spasmodic
twitching of the muscles, which was often present as the result of the irritation. 3d. In am-
putations of  the leg near the ankle, the roller is of but little use, for the integuments are firm-
ly tied to the bones by the inter-muscular and inter-tendinous fascia;, and the retraction of
the great muscles of the calf only  tends to draw the tendo Achillas a little higher in its
sheath.  The same is undoubtedly true of amputation at or near the wrist, of the toes, fin-
gers, &c., but in the fleshy part of the leg, and often in the fore-arm, the roller  may be made
to render good service. In the middle and upper part of the  leg the relaxation of the soft
parts may be greatly assisted by flexing the leg upon the thigh, allowing the patient to lie on
his side, as was practised, for the same reason, by Mr. Pott, in fractures of the  leg and thigh,
and I have in this way several times prevented the perforation of the integument by the sharp
angle of the tibia.
  Since I have had this paper in preparation, I have requested my friend and former pupil, Dr.
A. M. Wilder, Surg. U. S. Vols., to report to me such cases of amputation as might fall under
his observation.  I am indebted to him for notes of fourteen cases, of which nine were of
the thigh, two of the arm, and three of the leg. Of the nine amputations of the thigh, one
was treated with  the roller  from  the beginning; no protrusion  of the bone took place, but
the patient  died from exhaustion a fortnight after  the operation.  Of eight cases treated
without the roller, the bone protruded in six, and in the other two the coverings were tense
and painful  where they pressed upon the end of the bone.  Five of the eight stumps were
then dressed with the roller, with immediate rehef to the bad symptoms; the three stumps
not rolled became conical.   Of two stumps of the arm, one,  treated without  the roller, be-
came conical; the other, which was very painful and threatened perforation, was completely
relieved by the roller.  The  three cases in the leg were all treated by the roller, and the mus-
cles of the calf were also relaxed by keeping the knee bent at nearly a right angle to the
thigh; they  all did well. 
s///
                    On Amputation of the Thigh.                33

scarcely any danger of rolling a stump too tightly, if only the press-
ure is equally distributed, and although great trouble may be caused
by the unskilful use of the roller  after amputations, it is not to be
compared  to the danger which would attend the same lack of  skill
in bandaging a fractured limb.*   A second use of the roller  is to
prevent the burrowing of pus among the muscles and  other tissues
of the stump.   This accident is of pretty frequent occurrence after
amputation  of the  thigh,  owing  in  part to the elevated position
which the stump generally assumes during the progress of the case,
and still more to ill-advised attempts to secure early union by the
use of sutures.   In  such  cases the careful use of the roller is of the
greatest benefit.
   The  soft parts may also be relaxed in some cases, by  means of
two or  more strips  of adhesive plaster applied to  the sides of the
stump and connected with a weight  hung over the foot of the bed-
stead.  In this method,f however, a roller should be applied to pre-
vent  the slipping of the plasters,  and the result  is  no better  than
that which follows the use  of the roller alone.
   A kind of paraphymosis or strangulation of the end of the stump
by the skin is  described  by several writers.   It can only occur when
the skin and muscles  have be^n  divided nearly at the same level,
but in such a case it may give  rise to serious complications.   It is
rarely possible to make a good stump under such circumstances, but
much benefit  may result from the application  of  a roller, so as to
relax the superficial muscles  and  permit the skin to be drawn down
beyond the other soft parts.  If the strangulation has  existed for
some time it may be necessary to divide the skin longitudinally for
an inch or two on each side of the limb, especially if it has already
become adherent to the subjacent muscles.
   Great retraction  of the integuments, accompanied  by more or
less protrusion of the bone, is often observed in stumps which  have
been badly managed.  This  may often be much relieved by the ap-
plication of the roller, although the stump will be always  defective
from the want of soft parts to  protect the end of the bone.   In one
or two  cases of this kind, I have succeeded in materially  improving
the result by removing the prominent apex of  the  cone, which  pro-
jected through the coverings, and sawing off the bone  at  the  same
level.   By  this comparatively trivial operation nothing was remov-
ed, except about an inch of the bone and a ring of thickened and
partially ossified  periosteum (callus).  No further retraction  took
  * This is perhaps the place to mention a common and very bad use which is often made of
the roller, and which is taught in many of the handbooks on minor surgery. I allude to
the " capelline " or recurrent bandage, in which the roller is so managed as to cover the end
of the stump like a cap.  The capelline was originally employed for the purpose of mould-
ing the end of the stump into a symmetrical form, but this  slight advantage is more than
neutralized by its tendency to push up the soft parts and thus denude the  bone.  See Thil-
lage, Traite des Bandages, &c, 2me Ed., Paris, 1809, p. 269.
  + Attributed by Malgaigne  to Follioy, of Brest.  See Manuel de Medccine Operatoire,
chap, xi., on Amputations. 
34                On Amputation of the Thigh.

place, and the skin was readily drawn together over the whole end
of the stump by means of strips of plaster, used  in the  manner
already described  (page 29).  The  stump  was quite handsomely
rounded, and its  only defect  was that the bone was not so well
protected  by projecting muscle as it would have been had the bone
been cut shorter at the time of the amputation and the stump been
more judiciously treated.