Having made these observations on the different modes of amputation hitherto in use, we shall de scribe that practised by ourselves, to illustrate which the thigh is selected, that being the extremity to which the preceding modes chiefly apply. The patient being placed as usual on a low firm table, with the leg held by an assistant, and the tourni quet applied as directed, the operator stands on the left side of the patient, and when all is pre pared, the screw of the tourniquet is tightened, and the operator with the knife delineated in Fig. 2 of Plate DXVI. makes a lateral incision nearly transversely to the bone on the outer or fibular as pect of the thigh, its direction pointing a little ob liquely upwards or proximad, as represented in Fig. 3 of Plate DXVII. then with the same sweep of the knife he cuts upwards or proximad along the same side of the bone, to an extent equal to the diameter of the limb; then an assistant takes hold of this flap when cut, and a corresponding flap is then made, on the inner or tibial side of the thigh, which is also held by the assistant, who now gently retracts them both, since, if any bleeding occurs, he can thus easily command it. The sur geon then divests the bone of any muscular fibres at the root of these flaps, and saws it. The arte ries are next secured and both ends of the ligatures cut off. Whenever the trunk of the femoral arte ry is secured, the tourniquet should be suddenly slackened, to enable the operator to find the smal ler branches, and may be tightened again or not, as necessity requires. The instant all the arteries are secured, it should be completely loosened. The wound is then cleaned with warm water, and if the weather be sultry, and the patient flabby, it should be afterwards sponged with cold water. In sum mer, the wound should be stitched, and no bandage applied; while in winter, a roller is brought loosely down along the thigh from the loins until the near end of the bone, when the flaps are approximated by adhesive straps, the wound covered slightly with two pieces of lint placed across, and the roller continued down to the end of the stump, and after wards a little upwards. With the tourniquet loose around the limb, the patient is carried to bed, the stump placed on a pillow, and left uncovered, and a draught containing 50 drops of laudanum given. A diagram, representative of this mode of opera ting, is given in Fig. 3, Plate DXVII. This mode of operating seldom requires more than thirty seconds, and is preferable to transfixion, on the following grounds:—The flaps are more easily made, are fuller and thicker, and can be lengthen ed, if they appear too short, after the same manner of incision, and a third flap can scarcely occur. When sawing a bone, the saw should be swept lightly from heel to point, and no weight or pres sure whatever used. In all operations the patient should take a dose of physic the preceding clay, and after amputation, he is to be kept quiet, on low diet, with an assistant at his bed side for at least thirty hours, in case of primary hemorrhage. As for secondary hemorrhage, we have seen it vary from two to thirty days. When hemorrhage oc curs, the bandage should be examined, and if found in the least degree tight, ought to be instantly loosened, as pressure is very liable to check the cutaneous venous circulation, and thus produce venous hemorrage; and this occasionally arises not from the bandage being applied too tight at first, but from the wound becoming tumefied. If the slackening of the bandage does not stem the bleed ing, and the latter appears to be trifling, cold Iva ter, with a little vinegar in it, should be used; but if profuse, or not stopt by this means, the wound must be opened, and the bleeding arteries secured with ligatures, or sponge applied in the form of compression. If the bleeding takes place within the first two or three days after the operation, it is then from small arteries, but if afterwards, it is most probably from the trunk, in which latter case, the artery high up in the thigh must be secured, a plan superior to another or secondary amputation, as recommended by some authors. Spasmodic action of the muscles sometimes occurs to such a degree, as to require the stump to be fastened down to the mattress by a broad strap, and large opiates administered internally. Inflammatory fever oc casionally supervenes, and requires active treat ment, even in the emaciated constitution. As suppuration results in forty-eight hours, the wound should be dressed on the third day after the opera tion in summer, and fourth in winter, and not de ferred until the eighth, as recommended by some. The straps of adhesive plaster should be most care fully removed at both ends, and one substituted be fore another is detached, and the clean bandage rolled downwards to the end of the bone, before their reapplication. Unctuous dressings are to be applied. Warm water ought to be injected into the wound, if there are any cysts or abscesses, and should be gradually reduced to the ordinary cool temperature, at each daily dressing. The diet should be moderate, as long as there is any in creased action, and ought to be carefully augmen ted, but if the suppuration be profuse, it may then be nourishing. In amputation of so large a mem ber as that of the thigh, the patient should be kept in the horizontal position, for at least a fortnight, and even then be allowed very little exertion. If bleeding has occurred after the operation, and so filled the wound that its lips are opened, and the bone has been deprived of its periosteum during the operation, there will not only be protrusion of it, but death of the bone. If the latter be the case,
the protruded portion should at once he sawn off, and if the former, or simple protrusion, this step must be left to the discretion of the surgeon. We would recommend the same little operation to be at once adopted. After amputation, the patient should walk upon crutches for at least six months, before attempting to walk upon a wooden or cork leg, in order that the stump may be thoroughly consolidated and strong. Our limits will not per mit us to give a description of the individual am putations; for them the reader is referred to Lizars's Snatomieal Plates.
Incised wounds are made with a clean sharp in strument, although a very blunt one, by no means clean, when moved with velocity, may inflict a very cleanly incised wound. 'Whatever be the ex tent of such wounds, they are to be gently approx imated with adhesive straps, compress, and ban dage; but so prone is the scalp to inflammation, which generally assumes the erysipelatous type, that even the adhesive strap is occasionally inad missible. In such cases, either poultices alone or combined with the strap are to be applied. In every case, more or less internal excitement is to be dreaded, so that the patient should remain quiet, on moderate diet, and pay attention to his bowels, and if the feat degree of heaclach follows, venesec tion ought to be performed. In injuries of the head, blood-letting should be prescribed with as much freedom as a dose of salts.
In lacerated wounds, whatever may be their ex tent, and however insulated may be the scalp, the part, if possible, should be preserved. This plan was followed in the time of Celsus, but went into de suetude until Pare revived it, and again was laid aside until the day of La Moue, for in the Hotel Dieu the lacerated scalp was dissected off by Petit and others. Cases of prodigious portions of the scalp, which had been torn off and reunited, are to be found in the works of Pare, La Moue, Hill, Pott, J. Bell,- and Abernethy. In all cases of lacerated scalp, the whole hair of the head is to be shaved off, and the portion which is torn to be cleansed of blood and dirt, and carefully replaced, and retained in po sition by adhesive strops, gentle compression and bandage, or a handkerchief. The latter, when fold ed triangular, is named kerchef or couvrechef, when folded square and applied, is termed grand courrc chef Poultices, although condemned by some wri ters, will be round of much more service than cold lotions in those eases where inflammation of the scalp takes place. In lacerated wounds, there is always such a degree of injury done to the bone or its contents, that we must keep in view the most active autiphlogistic treatment. Wounds of the scalp are fully more dangerous than those of the brain, so that even after the wound is healed, the most rigid attention should be paid to diet and the bowels, and all exciting causes avoided for some time to come. Suppuration is very frequently con sequent on this injury, and the matter requires to be most freely evacuated. Occasionally portions of the scalp slough, and require removal, but never until the part has completely sphacelated.
The same treatment is to be adopted in contused wounds, accompanied with laceration of the scalp, or lacerated wounds attended with contusion. In the latter case, we must anticipate suppuration and sphacelation, and poultices are more necessary. Lacerated and contused wounds frequently lay the foundation of suppuration of the membranes of the brain, and even of the brain itself.
Punctured wounds of the integuments of the cra nium are subdivided by Pott and the majority of surgical writers, into those of the cutis, of the sub cutaneous cellular tissue, the tendon of the occipito frontalis, and the pericranium, and they have at tempted to assign symptoms characteristic of each, with an appropriate treatment, "opinion Cvidem merit nee des applications anatomiques," says De sault, " plutOt que de Pobservation de la nature." And with equal truth, says J. Bell, " the integu ments of the skull are essentially connected as a whole, having one continuous circulation, and hav ing their disease in common." In punctured wounds, therefore, there is commonly erysipelatous inflammation, with more or less affection of the brain and its membranes, accompanied with gene ral fever, in which the hepatic and gastric organs are affected. The treatment consists in general and local blood-letting, leeches being applied to the parts adjoining the wound, and the temporal artery, or external jugular vein should be opened ; foment ations and poultices afterwards to the scalp, brisk cathartics, warmth to the feet, blisters to the nape of the neck, low diet, and confinement to bed in a darkened chamber. If there be much tension around the wound, the expansive tendon of the occipito frontalis muscle should be divided transversely ; and it may be even advisable to take into consider ation the propriety of making several incisions in the erysipelatous scalp, as mentioned under erysipe las phlegmonodes. When suppuration follows punc tured wounds of the scalp, free incisions ought to be made to evacuate the matter, which, on some occa sions descends to the eye-lids, and even beneath the fascia of the temporal muscle clown to the mouth.