Hip hip

On 18^th January 1824 The Lancet reported an operation of extraordinary daring.  It had taken place two days earlier at Guy’s Hospital in London, and the surgeon was the celebrated Sir Astley Cooper. At the age of 55 he was at the height of his powers, recently elevated to a baronetcy and basking in the glory of a succession of surgical feats.

The procedure he undertook that day was new to him, and one that he would never perform again: amputating a leg through the hip joint. Today, almost 200 years on, this remains one of the most radical and challenging operations in orthopaedic surgery; and Cooper attempted it in an age before anaesthetics.  He was far from being the first to do so: the first documented attempt had taken place half a century earlier in France, and the great Napoleonic battlefield surgeon Baron Larrey was known to have performed the operation no fewer than seven times. His first six patients died; this was a formidable undertaking with dreadful accompanying risks. If blood loss didn’t kill the patient, infection probably would. It was only attempted if there was genuinely no alternative.

This formidable operation was performed here this morning, for the first time, by Sir Astley Cooper, in the presence of some of the surgeons and pupils belonging to these institutions. The number of those present, however, was not so great as on many other occasions; no previous notice of the operation having been given, owing to its having been determined on but a few minutes before its performance.

Major operations were generally advertised in advance so that students, other surgeons and journalists could watch. Large numbers might crowd the galleries, unwashed and dressed in their street clothes – producing an environment teeming with microbes, the ideal environment for postoperative infection.

The patient is a man about forty years of age, whose leg had been amputated some years ago, just above the knee, since which time the thigh bone has become diseased from the extremity of the stump, up to the trochanter major…

The trochanter major (labelled ‘greater trochanter’ above) is the large bulge at the top of the femur, on the other side of the bone from its head (the ‘ball’ of the ball-and-socket joint of the hip). The entire thigh bone was diseased and needed to be removed if he was to have any chance of survival.

…and this disease has had such effect on him of late, that he has been rapidly sinking under it; the thigh was of the middle size; on being asked this morning to submit to an operation, he readily consented. At half-past one the patient was brought into the operating theatre, and placed in the recumbent posture on the table.

Lying on his back, in other words. Cooper began by ‘securing’ (tying) the major blood vessel to the thigh, the femoral artery. Had he failed to do this the patient would have died from blood loss in a matter of minutes.

Sir Astley, standing to the outer side, with the limb in one hand and the catlin in the other, commenced the operation, by making an incision just below Poupart’s ligament, a little to the iliac side of the femoral artery.

A catlin was a double-bladed knife often used in amputations. The inguinal (or Poupart’s) ligament runs from the outer part of the pelvis to the pubic bone, its main function being to contain the soft tissues of the lower abdomen.

This [incision] was continued obliquely downwards and outwards to the back of the thigh, about one-third of the way down, from which point the knife was carried in the opposite direction, obliquely upwards and inwards to meet the first incision; by this means forming an elliptical curve, the cellular membrane was merely cut through at first, but the knife was again carried in the same direction as before, and thus the muscles were also separated; at this step of the operation it was necessary to apply another ligature on the inside of the limb.

It is quite difficult to picture this, but it seems that the technique favoured by Cooper was one which created a ‘flap’ of skin and muscle which could then be secured over the wound and thus create a viable stump.

Here the operator changed positions, and sat on a chair in front of the patient, and waited a short time to see whether there were any bleeding vessels; after the lapse of a few minutes the operation was continued, and very shortly completed, the head of the thigh-bone being removed from the acetabulum without any difficulty; two ligatures in addition to those already used were applied, making in the whole four; the integuments were brought together, and a suture applied to the upper portion; strips of adhesive plaster, and lastly a bandage, were put over the stump.

The appearance of the stump after such an operation was an important measure of its outcome. If the skin and muscle sutured over the wound healed smoothly, it would be much easier for the patient to use a prosthetic leg and thus achieve something like their previous quality of life. It if failed to unite properly they could be left severely disabled.

There were about 12 ounces of blood lost, but it had the appearance of being venous. The limb was removed in the space of twenty minutes, the securing the arteries and dressing occupied fifteen more; the whole was completed in thirty-five minutes.

Thirty-five minutes is extraordinarily little for an operation of this gravity. On the other hand, imagine enduring the removal of your thigh bone for half an hour without any sort of anaesthetic.

During the operation the man was extremely faint, but some wine being given him, and fresh air admitted, he recovered. The patient bore the operation with extraordinary fortitude, and after all was finished, he said to Sir Astley, “that it was the hardest day’s work he had ever gone through,” to which Sir Astley replied, “that it was almost the hardest he ever had.”

True English understatement.

Remarkably, the man survived – though Sir Astley later regretted operating as he did. Thirty years later The Lancet returned to the subject of amputation through the hip joint, and revealed the later course of the case:

For some time after the operation his health remained very bad, and he was twice tapped for abdominal dropsy, but at length he recovered.

Dropsy (now known as ascites) is swelling caused by fluid retention. Sir Astley acknowledged in comments to a colleague that with the benefit of experience he would not have performed such a radical procedure, preferring to leave the hip joint in place:

“I may venture perhaps to say that it is an operation that ought not to be performed if it be possible to saw through the bone at the trochanters without opening the capsular ligament.” 

Still, it’s surprising and impressive that his patient lived to tell the tale.