Amputation of the Leg


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[See Also: Civil War Medicine, Amputation Overview, Amputation of the Leg, Amputation Below the Knee, Amputation of the Arm, Amputation of Fingers and Toes]

Amputation: Amputation of the Leg

(From "The Practice of Surgery", by Samuel Cooper, and notes by Dr. Alexander H. Stevens. This book served as the "How To" guide for Civil War surgeons)



The thigh should be amputated as low as the disease will allow. The patient is to be placed on a firm table, with his back properly supported by pillows, and assistants, who are also to hold his hands, and keep him from moving too much during the operation. The ankle of the sound limb is to he fastened, by means of a garter, to the nearest leg of the table.



Photograph of Original Blood Stained Tourniquet Used in Civil War Amputations

The first thing is the application of the tourniquet. The pad of this instrument should be placed exactly over the femoral artery, in as high a situation as can conveniently be done. When the thigh is to be amputated very far up, a tourniquet is inconvenient, and, in this case, an assistant is to compress the femoral artery in the groin by any commodious instrument, having a round, blunt end, adapted for making direct pressure on the vessel, without injuring the integuments.

The latter method should only be adopted when the operation is to be done so high up, that the tourniquet would absolutely be in the way of the incisions. It is generally acknowledged, that some disadvantage results from the application of the tourniquet to a thigh on which amputation is practiced, because the instrument tends to obstruct the full retraction of the muscles after they are divided. Yet, in ordinary cases, it is by no means advisable to prefer compression of the femoral artery in the groin by an assistant, to the employment of a tourniquet. Putting out of present consideration, his being liable to fail in regularly commanding the flow of blood through the artery, on account of the violent struggling of the patient, we are to remember, that besides this vessel, there are others concerned in supplying the thigh with blood, which are branches of the internal iliac, and come out of the lower openings of the pelvis; as, for instance, the arteria obturatoria, the iliaca posterior, or glutea, and the ischiadica. Hence, pressure upon the femoral artery in the groin can never stop the bleeding, but incompletely; and I leave it to every man of experience to contemplate, how many cases there are, in which not a drop of blood should be unnecessarily spilt. I would even urge, that, in numerous instances, in which the patient is much reduced at the time of submitting to the operation, any considerable hemorrhage must be regarded as a fatal occurrence.


The operator is to stand on the right side of the patient, whether the right or left limb is to be removed. By this means, he acquires the advantage of always having his left hand next the wound, so as to be of very essential assistance. This advantage more than counterbalances the inconvenience of having the right limb in the way of the operator, when the left thigh is that which is to be amputated.


Original Scalpels from Civil War Amputation Kit

An assistant firmly grasping the thigh with both hands, is to draw upward the skin and muscles with some force, while the surgeon makes a circular incision, as quickly as possible, through the integuments, down to the muscles. When the integuments are sound in the place of the incision and above it, their retraction by the assistant as soon as they are cut through, and a very slight division of the bands of cellular substance with the edge of the amputating knife towards the point, will generally preserve a sufficient quantity for covering, in conjunction with the muscles cut in a mode about to be described, the extremity of the bone; and the painful method of dissecting up the skin from the fascia, and turning it back, previously to dividing the muscles, may be considered useless and improper in all amputations of the thigh, where the skin retains its natural movableness and elasticity.

This practice of dissecting up and turning back about a couple of inches of the skin in cutting off a thigh, has been censured by some of the first practical surgeons which this country ever produced. Thus it was disapproved of long ago by Bromfield; and even Alanson, who praised the method in the earliest edition of his book, thought proper afterwards, when further experience had brought his judgment to greater maturity, to deliver a very different sentiment upon the subject. From the example set me by some of the former surgeons of St. Bartholomew's hospital, during my apprenticeship there, I also once fancied, that, in amputation of the thigh, a considerable dissection of the skin from the muscles previously to the division of the latter, was a matter of absolute necessity. The experience, however, which I had in the course of the last two wars, soon produced in my mind a different conviction.

For some useful remarks on this point, the profession are indebted to Mr. Guthrie, who has explained, that, in primary amputations, or those done at an early period after the receipt of a gun-shot injury, while the part of the limb, where the incisions are to be made, is in the natural state, and the skin loose and movable, "it will be sufficient to touch the thread of membrane, or fascia adhering below, with the point of the same, (the amputating) knife, to give ample covering for an excellent stump, without putting the patient to the torture of having his skin pinched and dissected back, for the space of a couple of inches, for four or five minutes." At the same time, he particularly insists on the utility of dividing the fascia and integuments together, by which means the latter can be retracted much further than would otherwise happen.

In operations, however, performed from the third to the twelfth day after the receipt of the wound, and near the injured parts, Mr. Guthrie admits the propriety of dissecting the integuments a little way up from the fascia, as in these cases the retraction, effected by the assistant and the natural elasticity of the skin, will not avail in saving enough of it to cover the surface of the stump well; yet even here he rightly disapproves of turning back the separated integuments, as is often done, like the top of a glove.

In secondary amputations, (says he,) with the exception of those, in which the operation is required in parts actually unsound, the integuments may be sufficiently retracted, without any formal dissection of them from the subjacent fascia.

Besides the objection to such dissection, on the ground of the great agony which it excites, it should never be done unnecessarily, on another account, particularly insisted upon by Loder, viz. because a redundance of skin is apt to serve as a lodging place for matter, and be the means of preventing the thing which is always particularly desirable, namely, union by the first intention.

It is difficult to give any exact general rules for determining how much skin is to be saved. According to Loder, the less bulky the limb is, the less need the edge of the integuments project beyond the surface of the divided muscles; and the more fat there is, the greater must be the length of the preserved skin. In the first case, (says he,) about half an inch will be enough; in the second, an inch or more, will be requisite. The more obliquely the incision is made through the muscles, the less necessary will skin be for covering them afterwards, because their edge will be thin. But, in the opposite case, a larger piece of skin will be wanted for covering the bulky ends of the muscles. When the parts are sound above the place of the incision, the greater or lesser breadth of the projecting edge of the skin will always depend upon the retraction of it at the period of its division. If the assistant draw it back with force, more will be saved; and if it be drawn back but a little way, the part projecting beyond the edge of the muscles will be but small. The assistant, in drawing back the integuments, is to be particularly careful to do this evenly and smoothly all round the member, so that the skin may not be wrinkled, nor pulled up more in one place than another.

I have said that the surgeon is to begin the operation by making an incision through the skin all round the limb. The generality of surgeons, very rightly considering this as one of the most painful parts of the operation, do it with as much quickness as possible, and therefore carry the knife all round the member with one sweep, the hand which holds the knife being carried round under the limb until the edge can be placed perpendicularly on the skin covering the extensor muscles. Excepting the appearance of greater skill, and a little greater quickness, however, the forgoing mode of dividing the skin all round the limb with one stroke of the knife, has no particular advantage over the method of completing the cut with two sweeps of the knife.


The ancient surgeons used to cut directly down to the bone at once, and the frequent consequence was a conical, or sugar-loaf stump, extremely unfit for bearing any degree of pressure, and, therefore kept healed with difficulty. The end of the bone in fact, often protruded beyond the soft parts. At length, however, the improvement was made of cutting the integuments through first, and then the muscles: a method well known amongst surgeons by the name of the double incision.

But, although the double incision enables the surgeon to save skin, and saw the bone higher up, a conical stump, and projection of the bone, sometimes followed. The great innovations, which ultimately proved nearly effectual in the prevention of such tedious miserable cases, were, besides the saving of skin, the oblique division of the muscles, suggested by Alanson; the cutting of the loose muscles first, and the fixed ones afterwards, proposed by Louis; and the immediate closure of the wound, after the bleeding had been stopped, the great utility of which was first brought to light in the early trials of what are called flap-amputations.

M. Louis, for whose memory every admirer of surgical science ought to entertain sincere respect, first discerned the principal cause of the projection of the bone. He observed, that the muscles of the thigh became retracted in an unequal manner, when divided; those which are superficial, and extend along the limb more or less obliquely, without being attached to the bone; becoming retracted with greater force, than others, which are deep, and, in some measure, parallel to the axis of the femur, and fixed to this bone throughout its whole length. Their retraction begins at the moment of the operation, and, for some time afterwards, continues unfinished. Hence, the effect should be promoted, and be as complete as possible, before the bone is sawn. With this view, M. Louis practiced another kind of double incision; by the first, he cut, at the same time, both the integuments, and the loose superficial muscles; by the second, he divided those muscles, which are deep, and closely connected with the femur. On the first deep circular cut being completed, M. Louis used to remove the band encircling the limb above the tract of the knife, in order to allow the divided muscles to become retracted without any impediment, and he then cut the deep, muscles on a level with the surface of those which had been first divided, and which were now in a retracted state. In this way, he could evidently saw the bone very high up, and the painful dissection of the skin from the muscles was avoided.

Alanson's mode of amputation was as follows:—The integuments having been divided by a circular wound, the knife was applied close to the margin of the retracted skin, upon the inner edge of the vastus internus, and at one stroke, an incision was made obliquely through the muscles, upward in respect to the limb, and down to the bone: in other words, the cut was made in a direction which laid the bone bare, about two or three finger-breadths higher than a perpendicular incision would have done. The operator now drew the knife towards himself, so that its point rested upon the bone, still observing to keep the instrument in the same oblique position, in order that the muscles might be divided all round the limb in that direction, by a proper turn of the knife. During the performance of this movement, the point of the knife was kept in contact with the bone, round which it revolved.

Many writers have objected to the difficulty of making the oblique incision exactly as Alanson has directed, and Mr. Hey even questions the possibility of the practice, without a different result from what Mr. Alanson intended. It is evident (says Mr. Hey,) that a conical incision through the muscles of the thigh cannot be made with a continued stroke, in the usual mode of amputating. For, supposing the edge of the knife to have once penetrated obliquely through the muscles, so as to be an inch higher, when arrived at the bone, than when it penetrated the surface; if the incision be continued with a flowing stroke, the knife must then cut the surface of the undivided muscles an inch higher, than at the commencement of the incision. How far it is actually practicable to keep the point of the knife in contact with an exact circle on the bone, during the oblique passage of the instrument all round the member, it is not for me to say, because, seeing its difficulty, I have never attempted it; nor can I suppose, that Alanson himself ever really did what he literally recommends. Of one thing also I am sure, that I have seen many surgeons, in their attempt to do this business after Alanson's direction, get so high up as to cut the subjacent reflected skin.

The late Mr. Hey is not the only, nor the earliest writer, who has pointed out the inaccuracy of Alanson's directions. Richter has offered several judicious criticisms upon them, which perfectly coincide with Mr. Hey's views. It is remarked, that when the knife, with its edge turned obliquely upwards, has reached the bone, a flap is actually formed on the side where the incision is practiced: and the edge of the knife is now three inches higher than the cut in the skin. In this state, the surgeon cannot possibly continue the incision. The only thing which he can now do, is to place the knife on the opposite side of the thigh in the same manner, and make a flap there. The operation, says Richter, is then rather a flap-amputation, not done in the best way, than an operation really practiced as Alanson thought possible. By following precisely his instructions, Richter thinks it would be quite impracticable to form a hollow stump, though perhaps it might be done by reiterated oblique strokes of the knife all round the limb. But, he exclaims, what a stump there would then be, and what a method of operating! He comments also on the difficulty of making a knife cut properly by mere pressure, as would be the case, were its point kept unremittingly against the bone, in carrying the incision round the member; on the preferable nature of amputation with a flap to this method, the wound left by which is longer in healing; and on the pain and delay of separating the skin to be saved, a proceeding altogether unnecessary in amputating with a flap." These observations are partly correct; but they are to be regarded as coming from a surgeon, who was extremely partial to the flap-operation, and did not attach the proper value to the suggestion of making in a right manner the oblique division of the muscles.

Many excellent surgeons, whom I have seen operate, do not cut at once obliquely down to the bone, after the integuments have been divided and retracted; but so far adopt the principles of M. Louis, as to divide the loose muscles first, and lastly, those which are intimately attached to the bone, taking care, with a scalpel, to cut completely through the deep muscular attachments, about an inch higher up, than could be executed with the amputating knife itself. This last measure causes very little pain, and has immense effect in averting all possibility of a subsequent protrusion of the bone, or of a bad sugarloaf stump. Such used to be the practice of Mr. Hey, who calls it the triple incision: and Mr. Guthrie, in his account of amputation of the thigh, is a decided advocate for a similar mode. In this method, however, the advantage of the oblique incision through the different layers of muscles, was invariably retained. While I served in the army, I always endeavored, in the performance of amputations, to combine, as far as circumstances would allow, the principles of Alanson with those of M. Louis. This is certainly a better mode of operating, than that in which Mr. Alanson's directions are precisely followed. However, I am obliged to state, that the attempt to divide the loose muscles first, and then the more fixed ones, is apt to make a hasty surgeon cut the whole, or a great part of the same muscle through more than once; a fault in modern practice, which, as far as my judgment extends, deserves reprobation, as much as any proceeding which can be instanced. To say how unnecessary it is to divide any muscle, more than once, is as needless as to remind the reader of its doubling the agony of a most severe operation.

In the descriptions of amputation, usually met with in books, some pains are taken to expose the advantages of holding the limb in a half-bent position while the division of the muscles is going on, in order that the flexor and extensor muscles may be in an equal relaxation. This advice may be good, if it can be followed: and the plan of relaxing each set of muscles as much as possible by a change in the posture of the member when they are about to be cut, as has been sometimes recommended, might be still more rational, as being conducive to the preservation of a greater proportion of flesh. But, unfortunately, the operator, who begins to think of these projects when his patient is upon the table, generally finds them impracticable, the disease, or injury, having already so fixed the posture of the member, that little or no deviation from it can be made, without the greatest difficulty and pain.


Having cut completely down to the bone, a piece of linen, somewhat broader than the stump, should be torn at one end, along its middle part, to the extent of about eight or ten inches. This is called a retractor, and is applied by placing the exposed part of the bone in the slit, and drawing the ends of the linen upward on each side of the stump. Thus the retractor will evidently keep every part of the surface of the wound out of the way of the saw. I have seen the saw do so much mischief, in consequence of neglecting to use the retractor, that my conscience obliges me to censure the employment of the saw, without a defense of the soft parts by this simple contrivance. I think no one will say, that the retractor can do harm; and I know, that many who have been with myself eye-witnesses of the mischief frequently done by the saw in amputations, are deeply impressed with an aversion to the neglect of this bandage. I have often seen the soft parts skillfully divided; and the operators, directly afterwards, lose all the praise, which every one was ready to bestow, by their literally salving through one half of the ends of the muscles, together with the bone. But, besides defending the surface of the stump from the teeth of the saw, the retractor will undoubtedly enable the operator to saw the bone higher up, than he otherwise could do.

Another proceeding, deserving reprobation, is the practice of scraping up the periosteum with the knife, as far as the muscles will allow. This is a sentiment, in which I must still continue to join the experienced and judicious Petit, notwithstanding a modern author has actually devoted a section of his book to the praise of what is here particularly condemned. The chief argument for the practice, urged by Brunninghausen, is, that by scraping the periosteum upwards from the bone, a portion of the detached membrane will yet remain connected to the muscular fibres, thus pushed back, and afterwards admit of being brought down with them over the sawn bone. As, however, I have seen the bone extensively scraped, without an exfoliation being a regular effect of the method, I do not consider, as Petit did, that a part of the bone must inevitably die, after the periosteum is thus freely scraped away; but I look upon the improper and useless separation of this membrane, as one of the circumstances which tend to produce the exfoliations, that sometimes happen after amputations. At all events, it is a superfluous, useless measure; as a sharp saw, such as ought to be employed, will never be impeded by so slender a membrane as the periosteum. All that the operator ought to do, is to take care to cut completely down to the bone, round the whole of its circumference. Thus a circular division of the periosteum will be made, and here the saw should be placed.

In confirmation of the correctness of the foregoing advice, I beg leave to quote what Richter has said upon the subject of scraping the periosteum off the bone. The thin layers of flesh, (says he,) which, when the soft parts are drawn up, usually remain here and there upon the part of the bone about to be sawn, the surgeon should now cut carefully through with a scalpel, together with the periosteum, as high as possible, and close to the slit in the retractor. It is quite unnecessary, he observes, to scrape away the periosteum from the place where the saw is to be applied. Neither this membrane, nor a few slender muscular fibres, can hinder the action of the saw, and, after the last sweep of the scalpel, they are lifeless and insensible.


As Petit justly remarks, this part of the operation is by no means easy to a person unaccustomed to handle a saw. The principal difficulty arises from the bone being sawn up in the air (as it were); at least, the part is in general but very imperfectly fixed by two persons, who, however strong they may be, cannot resist the saw, and hinder the limb from being shaken, whereby the direction of the instrument becomes altered. Besides, the two assistants rarely act so well in concert together, as always to hold the limb in the same direction, and with an equal degree of strength. It is true, such irregularity is not of much consequence at first, while the bone is not half sawn through; but, as soon as the instrument has cut to this depth, the irregular movements of the assistants, who hold the limb, make the sawn surfaces come nearer together, and the saw is so pinched or locked betwixt them, that it cannot stir, in one direction, or the other.

Bone Saws from Civil War Amputation Kit

A skilful surgeon, (observes Petit,) may obviate the difficulty by supporting the part with his left hand, and resisting or yielding at seasonable opportunities to such circumstances as impede the motion of the instrument. But, the difficulty may depend upon the saw itself, when its blade is not duly stretched, the teeth not well turned alternately to the right and left, their points not in good order, their edges not sharp enough, or they are not filed obliquely, so that the bone-dust may be readily thrown off to each side. The latter object requires also, that the blade of the saw at the teeth-part should be rather thicker than the rest of it, or else the fissure in the bone would be completely filled with the instrument, and the bony particles, not easily escaping, would obstruct the movements of the saw. In order to saw the bone as close to the flesh as possible, Petit says the nail of the index-finger of the left hand is to be placed on the point where the sawing is to begin. Many surgeons, however, find it more convenient to use the left thumb-nail for this purpose. The flesh being retracted, the saw is now to be applied exactly at the angle formed by the nail and the bone; and the instrument is to be worked very gently, and with scarcely any more pressure than that of its own weight, until a groove is cut, from which it will not start, when the force is to be gradually increased.

The edge of the saw should cut with both edges, whether the instrument be moved backwards or forwards, by which means, as a modern writer has remarked, the operation will be expedited, and the splintering of the bone, when it is nearly divided, prevented, inasmuch as the surgeon, when he uses a saw, which cuts in both directions, has it in his power to finish the latter part of the division of the bone entirely with backward sweeps of the instrument, which are always the most regular and gentle.

In order to form a groove for the saw, it is best to begin by drawing the instrument across the bone with a backward sweep, the teeth near the handle being first applied to the part close to the operator's left thumb, or fingernail, and the whole extent of the edge is then to he steadily and briskly drawn back to the point. The movements of the saw should never be short and rapid, but every stroke of the instrument should be long, bold, and regular, without too much pressure, which is one common cause of the awkwardness so often displayed in this part of the operation. When about two-thirds of the bone are cut through, the pressure and force must be lessened, and towards the end of the business, two or three gentle movements of the saw backward will complete it, without risk of an extensive splintering. In the latter part of the sawing, the assistant who holds the leg, must be very careful to avoid depressing the condyles of the femur, as it would inevitably break the bone, previously to its complete division. Indeed, it is difficult to say, whether this mismanagement, or the rough unskillful mode of using the saw itself, is the most frequent cause of the latter accident. The assistant certainly has rather a delicate task to perform, because if he raises the limb too much, he pinches the saw; if he depresses it, he breaks and splinters the bone.

Bone Nippers

Bone Nippers from Original Civil War Surgical Kit

If the bone should break, before the sawing is finished, the sharp projecting spiculae, thus occasioned, must be removed by means of a pair of bone-nippers.


After the removal of the limb, the femoral artery is to be taken hold of with a pair of forceps, and tied, without including the accompanying branches of the anterior crural nerve in the ligature. None of the surrounding flesh ought to be tied, though the ligature should be placed round the artery, just where it emerges from its lateral connexions. Desault recommends tying the femoral vein, as well as the artery; because when the former remains open, and the bandage compresses the upper part of the limb too forcibly, the venous blood returns downward, and hemorrhage takes place. Mr. Hey also met with a few instances of bleeding from the femoral vein, and therefore, he generally enclosed it in the ligature along with the artery. When the two vessels lie near each other, as is frequently the case, Desault advises the surgeon to introduce one branch of the forceps into the artery, and the other into the vein: their mouths are then to be drawn out, and tied with one ligature. When, however, they are not so close together, they require two separate ligatures. The smaller arteries are usually taken up with a tenaculum. After tying as many vessels as require it, one-half of each ligature is to be cut off near the surface of the stump. The right qualities of ligatures, used for securing blood-vessels, having been considered in the chapters on hemorrhage and aneurism, it is unnecessary now to return to that interesting topic; nor shall I here speak again of the proposal of removing both ends of the ligature close to the knot.

When the large bleeding vessels have been tied, the tourniquet should be slackened, and the wound well cleaned, in order to detect any vessel, which may lie concealed, with its orifice blocked up by coagulated blood; and, before the dressings are applied, the whole surface of the wound should be examined with the greatest accuracy. By this means, a pulsation may often be discerned, where no hemorrhage has previously appeared, and a small clot of blood may be removed from the mouth of a considerable artery.

As the lodgment of much coagulated blood would be unfavorable to the speedy union of the wound, the surgeon has an additional motive for being careful to make its whole surface clean with a sponge and water, before it is finally closed. The number of arteries, requiring to be tied, will depend very much upon the incision having been done upon sound and uninflamled parts, or upon parts in a state of inflammation, swelling, and disease. This accounts for the truth of an observation made by military surgeons, that, in amputations done immediately, or soon after the receipt of an injury, there are fewer vessels to be taken up, than in what are termed secondary, or long-delayed operations.

I have occasionally seen examples, in which it has not been necessary to take up a single artery. A young child was run over by a hackney coach, the wheel of which crushed the lower part of the leg, and rendered immediate amputation necessary. The operation was done by the late Mr. Ramsden without delay; no vessel was tied; and the stump healed without any subsequent bleeding. This was one case which I saw, and attended myself. In St. Bartholomew's Hospital, some instances also fell under my notice, where arteries like the ulnar and anterior tibial, even in adults, required no ligature. The absence of hemorrhage is sometimes explicable by the clot of blood, formed in the large vessels in cases of gangrene. Thus, a modern surgeon tells us, that he amputated the arms of two Cossacks, four months after the limbs had been shot through above the elbow, and while they were affected with hospital gangrene: not a vessel was tied; no secondary hemorrhage arose; and the stumps healed in the most favorable manner.


The skin and muscles are now to be placed over the bone, in such a direction, that the wound may appear only as a line, across the face of the stump, with the angles at each side, from which points, the ligatures are to be left out, as their vicinity to either angle directs. The skin is commonly supported in this position, by long strips of adhesive plaster, applied from below upwards, across the face of the stump. Over these, and the ends of the ligatures, it is best to place some pieces of lint, spread with the unguent. sperm. cet., in order to keep them from sticking, which becomes a troublesome circumstance, when the dressings are to be removed. I am decidedly averse to the plan of loading the stump with a large mass of plasters, pledgets, compresses, flannels, &c. I see no reason, why the strips of adhesive plaster, and a pledget of simple ointment, should not suffice, when supported by two cross-bandages and a common linen roller, applied in a spiral way round the limb, from above downward. The first turn of the roller,  indeed, should go round the patient's body; and, being continued down, will fix the two cross-bandages over the end of the stump. Here, as after all other operations, the dressings should generally be superficial, and make no compression: if the vessels have been properly secured, there is no risk of hemorrhage; and if they have not, is it not a little degree of constriction that will hinder bleeding. Besides, much pressure has the serious inconvenience of irritating the parts, exciting inflammation and suppuration, causing absorption of the cellular membrane, and a sugar-loaf stump.

The elastic woolen cap, sometimes placed over all the bandages and dressings, if not put on with a great deal of care, has a tendency to push the skin backward from the extremity of the stump, and, as it must also heat the part, its employment should be discontinued.

AmputeeThe stump should rest upon a pillow of moderate thickness, for, bending the thigh-bone too much, produces a retraction of the flexor muscles. If possible, the dressings should never be removed before the third day; but, in general, it is quite soon enough to change them on the fourth or fifth: when the weather is hot, and there is much discharge, they should be taken off earlier than under other circumstances. The favorable healing of a stump will depend very much upon the skill and tenderness with which the dressings are changed, more especially the first dressings. In order to facilitate the removal of the plasters, they should be first thoroughly wet with warm water, which is not to be rubbed upon them with a sponge, but allowed to drop, or flow over them. Each strip of plaster should be taken off, by raising its ends and drawing them gently up together towards the extremity of the stump, by which means, the surgeon will avoid pulling the recently united parts away from each other. During the change of the dressings, an assistant is always to support the flesh, and keep it from being retracted, and for the more complete prevention of the same disadvantage, it is a good rule never to let every strip of plaster be off the limb at one time; but, as soon as some are removed, to put on others, before the rest are loosened and taken away. It is hardly necessary to add, that, when matter is collected within the stump, it should be very gently compressed out with the sponge, in doing which, the pressure should be so regulated, as not to force back the flesh.

At the end of five or six days, the surgeon may begin to try, in a very gentle manner, whether any of the ligatures are loose. However, he should not use the smallest force, nor persist, if the trial create pain. One would hardly try, whether the ligature on the great artery were loose, before the eighth or ninth day.


Although this operation is not generally regarded as the best method for ordinary cases, its advantages, under particular circumstances, begin to be acknowledged by many surgeons of judgment and experience. In Germany, as far as I can judge from the latest works published there on the subject of amputation, flap-amputations have numerous advocates; and, I believe, that whoever will take the trouble of inquiring into the actual state of surgery in that country, will find this method of operating quite as frequently practiced as the circular incision. Desault employed both modes on the thigh, or arm, indifferently; though he did not apply the flap-amputation to the leg, or forearm. In England, where the latter method first originated with Lowdham, and where it has at various periods been strongly commended and improved by several men of great eminence, it has not many advocates for its general adoption, though Mr. Liston, Mr. Symes, and some other respectable surgeons at Edinburg, urgently recommend it for ordinary practice. The chief objections to the operation, when proposed as the common method, arise from two considerations: first, its greater pain, than that of the usual mode: secondly, its shortening the limb more than is necessary. Yet, all British surgeons agree that flap-amputations are generally best, when a limb is to be taken off at a joint, and also, in every instance in which the skin and soft parts are quite sound on one side of a member, while, on the other, they are diseased, or destroyed for a considerable extent, upwards. Here, amputating with a flap will be the means of preserving more of the limb, than could be saved by the circular incision, and becomes praiseworthy on the very same principle, which renders the latter method most eligible under ordinary circumstances.

As Mr. Hey has remarked, sometimes the integuments of the thigh are in a morbid state on one side of the limb, while they are sound on the other. In this case, a longer portion of integuments and muscular flesh must be left on the sound side; which will not prevent the formation of a good stump. The morbid state of the anterior or posterior side of the thigh sometimes extends so far above the knee, that it is advisable to amputate with a flap.

At the upper part of the thigh, Mr. Guthrie prefers amputating with a flap as a general practice; but, unless there were some particular circumstances present, some motives like those already suggested, I should not be disposed to select, what is allowed to be by far the most tedious and painful method of amputating. Were the thighbone, however, injured high up, and had gangrene extended about the trochanter major and posterior upper part of the thigh, if the head of the femur were sound, and the patient able to bear the operation, I would then do as Klein did—make a flap at the inner and upper part of the member. The execution of a flap-amputation of the thigh will be attended with some difference, according as the soft parts on all sides of the limb are sound, or not, When, in consequence of the flesh being injured or diseased on one side, the flap must be entirely formed on the other, it will be necessary to save more skin and muscle in the latter situation, than if the surgeon had it in his power to form two flaps for covering the end of the bone. In performing the latter operation on the thigh, Desault used to grasp the flesh on its inner side with his left hand, and pass a straight, narrow, sharp-pointed knife, with its edge turned towards the knee, through the soft parts thus taken hold of, pushing it on from the fore-part of the thigh, until the point come out at the back of the limb. The incision was then extended obliquely downwards, so as to make a flap about four inches in length, comprehending part of the cruralis, the vastus internus, the femoral artery and vein, the anterior crural nerve, the triceps, sartorius, gracilis, semi-membranous, and semi-tendinosus muscles. This first flap was then reflected, and the femoral artery and vein, and the trunk of the profunda, tied. The external flap was next formed in a similar way, and consisted of the rest of the cruralis, the rectus, the vastus externus, and biceps. The two flaps were then held back, the bone sawn through as high as possible, the other bleeding vessels secured, and lastly the flap brought down, so as to meet in a perpendicular line, and cover the end of the bone.



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