of the vessels has commenced, is easily arrested by exposure of the
surface, removal of all clots, for by these hemorrhage is encouraged,
and by including the open vessels in ligatures. For the accomplishment
of this, the period and mode of dressing, above recommended, afford
great facility, as has been already observed. Hemorrhage at a later
period is not common. It happens occasionally in consequence of the
stump having acquired an unhealthy condition, from sloughing,—or from
abscess, as when this occurs round ligatures which have been retained,
along with the slough of the vessel and cellular tissue, both ends
having been cut away. The matter formed during separation of the
ligature in the usual way, escapes readily along the protruding end,
but when there is merely a knot, the integuments have most probably
closed over, there is no direct outlet; the matter is confined,
and causes ulceration of the coats of the vessel as well as of the
surrounding tissues. In this kind of hemorrhage, it is needless
to attempt finding the bleeding point by tearing open the stump,
separating any adhesions that may have formed, causing much pain and
retardation of cure. And even though the bleeding vessel or vessels
could be found, they are not in a state to hold a ligature. The artery
is surrounded by sloughing cellular substance, its coats are tender,
and in no condition to assume a healthy action necessary for permanent
closure after deligation. If ligature is applied, the included
part quickly separates, and then the vessel is as open as before.
Astringents, and even the cautery, are useless. Ligature of the main
arterial trunk, above the origin of branches supplying the stump, so as
to weaken for a time the circulation, is found to be effectual. I have
had recourse to this in many cases, and uniformly with success. Some
years ago, several occurred in the Royal Infirmary, within a very short
time of one another; it was during rather an unhealthy season, and at
the time I was making trial of cutting off both ends of the ligatures.
They were all after removal of the lower limb; one patient died—the
amputation was high, through the trochanter minor, and the vessel tied
secondarily was the common iliac; this had the effect of completely
arresting the hemorrhage, but the previous loss of blood proved too
much for the system to recover from; transfusion was had recourse
to, and produced temporary benefit. The others, cases of amputation
below the knee, made most favourable recoveries after ligature of the
superficial femoral, and in more than one the stump healed very rapidly
after its readjustment. Indeed, it is not unfrequently found that when
the flaps are separated, from whatever cause, and replaced when the
granulations have appeared, there follows a rapid union and cure.
When healing by the first intention has failed, fomentation and
poultices are generally the most grateful and beneficial applications
for a day or two. Afterwards, when suppuration has been fairly
established, and the stump begins to be flabby and œdematous, simple
dressing and uniform support by bandaging are required, sometimes along
with compresses on particular points to prevent lodgement of matter.
Sometimes the secondary hemorrhage is not an arterial and rapid flow,
but a slow and continued oozing from a cavity, ulcerated, dark, and
angry, round the end of the bone; this seems to arise from diseased
action in the cancellated tissue of the bone. Removal of the coagula,
stuffing the cavity with dry lint, and the application and continuance
of firm pressure, generally suffice for its arrestment.
[Illustration]
Hitherto, these general observations on amputation have regarded the
operation by flaps only; the circular method has not been mentioned.
The reason is, that the circular amputation has been, it is hoped,
in a great measure abandoned in this country. And its inferiority to
the method by flaps is so obvious, and so generally acknowledged,
that detail of the different steps of the operation is, I conceive,
here altogether unnecessary. It is more tedious in performance, more
painful to the patient, does not afford so good a covering for the end
of the bone, and consequently not so convenient and useful a support
for an artificial limb, and the cure of the wound is protracted. The
stump is almost always conical, the end of the bone is, ultimately at
least, covered only by integument, and from even very slight pressure
this is apt to ulcerate; exfoliation of the bone follows to a greater
or less extent, or unhealthy nicer of the soft parts continues, along
with caries of the bone, and partial death of its surface; and at
length it becomes necessary either to perform a second amputation or
to curtail the length of the bone. It may sometimes succeed tolerably
well when there is but one bone: when there are two, it is altogether
inadmissible. In very muscular limbs, when amputation is demanded on
account of destruction of the bones and joints, with laceration of the
soft parts, as when the patient is not required to have pressure made
on the stump, it suits well to make the flaps of integument only, and
to cut the muscles short, as will be noticed more fully afterwards. The
advocates for the circular amputation, my excellent friend Sir George
Ballingall, and others wish it to be believed, (and this is their
main argument,) that the exposed surface of the flaps is much greater
than that in their favourite method. Some of the philosophers of the
Modern Athens have been appealed to, and have measured, it is said,
the area of the one and the other, and given their verdict in favour
of the round about incision. The accompanying drawings from nature,
and the corresponding diagrams, speak pretty plainly in favour of the
other method. In the first there is a cone formed by the cut skin
and muscles, with a corresponding hollow and ragged cavity; and the
second set shows two smooth, nearly triangular surfaces, which the said
philosophers may measure and report upon at their leisure.
[Illustration]
Various accidents and diseases require removal, either primary or
secondary, of the _fingers_, or of parts of them. Amputation is most
easily accomplished at the articulations, and ought therefore always
to be performed at these points, when the circumstances of the case
permit. The last phalanx may require removal either on account of
severe injury, or from incurable disease, as onychia maligna, necrosis,
caries, &c. The operation is one by single flap, and may be conducted
in one of two ways. The doomed phalanx is grasped, on its anterior and
posterior aspects, by the fore and middle fingers of the left hand;
and the articulation is flexed almost to the full extent, in order
that incision into it may be facilitated. A straight, narrow, and
sharp-pointed bistoury is carried in a semicircular sweep over the back
part of the joint, so as to divide the integuments, and open completely
the articulating cavity. The remaining ligamentous investments of the
joint are divided by one or more additional touches of the knife, so
as to loosen the base of the phalanx. The fingers of the left hand
are then changed from the fore and back parts of the phalanx to its
sides, the edge of the knife is passed behind the base of the bone,
and the surgeon, by carrying the blade forwards and downwards, forms
a flap of sufficient dimensions to cover the wound, and removes the
offending part. There is seldom any trouble from hemorrhage; no
ligatures are required. The flap is turned up so as to form a cushion
over the exposed surface of the middle phalanx, and is retained so by
the adhesive composition formerly mentioned, or by one or two turns
of a linen bandage. The other method of operation is the reverse of
the preceding. The joint is extended, the bistoury is made to transfix
close to the joint and at its anterior part, and by then carrying it
downwards and forwards, as before, a similar flap is formed; this
is retracted by an assistant, and with one sweep of the knife the
articulation is divided from before backwards. By either method the
flap is the same. By similar procedure the amputation at the middle
articulation is performed.
It is sometimes an object to save as much as possible of the proximal
phalanx, when amputation is rendered necessary by disease of the middle
articulation, or of the distal extremity of the bone. In such cases,
two semicircular flaps are made by cutting from without, either on the
lateral, or on the thenal and anconal aspect, and the bone is divided
either by a small saw or by the cutting pliers. The flaps are retained
in apposition, and the bleeding arrested by bandaging.
Amputation at the proximal articulation is also performed by double
flap. In the previous operations an assistant steadies and supports
the hand; in this he has likewise to bend the rest of the fingers,
and to separate as widely as possible those neighbouring to the one
about to be removed. The operator seats himself before the patient,
grasps the finger so as to manage its movements with the left hand,
and holding the knife perpendicularly, with its point upwards, lays
it over the knuckle, and carries it obliquely upwards so as to open
that side of the articulation. He then pushes the finger towards the
opposite side, and with the point of the knife completes the loosening
of the articulation; for this the blade of the instrument should never
be employed, otherwise the integument will be cross-cut and mangled.
After separation of the base of the phalanx by the point, the blade
is passed behind, and carrying it downwards and outwards, a flap is
formed similar to the first—both proportioned to the size of the wound
which they are to cover, and the bone which they are to protect. The
fingers may also be removed by the oval method, as described and
delineated in the _Practical Surgery_. The flaps are retained in
contact by bringing the neighbouring fingers towards each other. This
also suffices, in general, to suppress the bleeding, but sometimes one
or both digital arteries require ligature. At first, cold cloths are
probably the best applications, with the view of stopping the oozing,
and warding off inflammatory action. Vascular excitement is very apt
to follow this amputation, when performed for disease of the finger,
as after neglected or severe whitlow; the soft parts in which the
incisions are made are generally infiltrated and condensed, and prone
to inflammation. The surface around is red, tense, and shining, on
the second or third day; the back of the hand, the palm, and perhaps
the forearm, are then involved in inflammation of the surface, and
infiltration of the cellular tissue; and in all probability, free
incisions, followed by poultice and fomentation, will be necessary
to restore the parts to quietude. Such consequences are to be guarded
against as much as possible, by attention to the system, and by
avoiding all irritating dressing.
The phalanges of the thumb are removed in the same manner as those of
the fingers. Amputation of the metacarpal bone is accomplished thus.
The thumb is grasped by the fingers of the left hand, and so managed.
The bistoury, held in the same manner as for amputation at the proximal
articulation of the finger, is placed with its point on the web betwixt
the thumb and forefinger, and carried in one sweep rapidly upwards in
a slightly oblique direction, till it is stopped by the os trapezium.
The point is used to effect disarticulation, the member being at the
same time pushed steadily outwards; the blade is then placed behind
the base, carried downwards close to the side of the bone, and is not
to be brought out till sufficiently low down for forming a flap to
cover the whole wound. The flaps may be formed otherwise, and much more
handsomely, by transfixion of the ball of the thumb, as shown in the
_Practical Surgery_, p. 360. After arresting the hemorrhage, the flap
is laid smoothly down, and retained in its proper position by bandage
or slips of the adhesive plaster. The metacarpal bone of the little
finger is removed by the same method of incision as for the thumb.
In amputation of the fingers, the incisions sometimes require to extend
beyond the proximal articulation, on account of disease having involved
that part; in other words, it may be necessary to remove more or less
of the metacarpal bone along with the finger. The method of incision
will vary according to the extent to which the bone is diseased. When
the operation is required for disease of merely the distal extremity,
the incisions are made in the same form as for amputation of the joint,
only they are on each side sufficiently high to be beyond diseased
bone. They may either be made from below upwards in the usual way, or
be commenced at their highest point on the dorsum of the metacarpal
bone. After the soft parts have been separated from the bone, by a
few touches of the knife after formation of the principal incisions,
removal is completed either by the cutting pliers or the metacarpal
bow-saw—the former I have found the more convenient instrument. It is
applied perpendicularly, and should always have its smooth surface in
contact with the part to be retained, otherwise the cut part will be
rough and irregular. Section is completed more rapidly than by the
saw, and, by attention to the above precaution, the stump is equally
smooth, if not more so. The wound is brought and retained in contact
by approximation of the fingers. But in taking away any considerable
portion of the metacarpal bone, it is of importance to preserve the
palm uninjured. With this view, the knife is entered over the centre
of the bone on its dorsal aspect, above the diseased part, and carried
straight downwards till near the articulation, when it is made to
diverge for the formation of lateral flaps; the integuments in the
track of the longitudinal wound are then dissected backwards, so as to
expose the bone completely, and the bistoury is passed round the bone
throughout its whole extent, the edge being kept close to it,—in order
that the soft parts may be separated, and that without unnecessary
width of wound or implication of the palmar arches and branches
proceeding from them. Then the bone is clipped at the proper point by
the cutting pliers; or the section of the bone may be performed before
separation of the soft parts from its under surface, as, by raising
the cut end, this part of the operation may be facilitated. Here the
metacarpal saw is inapplicable.
Before quitting this part of the amputations, it may be observed, that
no good can result from taking away a metacarpal bone and leaving a
finger, or from removing a proximal phalanx and leaving the distal. The
parts so left can be of no use, they have no support, and the muscles
cannot act upon them: they must prove an incumbrance, and as such will
either form the subject of a second amputation, or remain a proof of
the unsuccessful result of the first.
Amputation in the _forearm_, may be necessary at various points, on
account of accident or disease, but should never be resorted to, in
either case, so long as part of the hand can be saved. The preservation
of even a small portion of this useful member, even of one finger or
a part of one, is of great importance to the patient. When, however,
this is hopeless, all must be removed; and, if the wrist be sound,
amputation may be performed at that joint. Hitherto, no mention
has been made of the temporary suppression of bleeding, for in the
amputations detailed there is scarcely ever any necessity for adopting
such measures; but in those of the forearm and arm, a steady assistant
must be placed ready to compress the humeral artery as soon as the
incisions are commenced; in the case of the forearm, the pressure is
made on the lower portion of the artery; in the arm, the point of
pressure will necessarily depend on the point of removal. The patient
may be either seated or recumbent. One assistant compresses, another
steadies the limb in the supine position. The surgeon holds the hand in
his left, standing on the inside of the right limb, and on the outside
of the left. Suppose the right wrist is to be operated on,—the end
of the ulna is felt for, and at that point the knife is entered, and
drawn across the wrist on its dorsal aspect in a semilunar direction,
the convexity of the curve of course pointing towards the fingers. The
joint is opened by retracting and dissecting back the flap so formed;
the knife is then passed behind the scaphoid and lunar bones, which
are exposed and turned out by division of the ligaments, and by rapid
and gentle sawing motion downwards and forwards, a flap of sufficient
size is then formed on the palmar aspect. The dorsum of the hand may
be so diseased or injured as not to afford sufficiency of sound parts
for a posterior flap; in such circumstances the anterior must be made
proportionally large, that it may alone cover the ends of the bones.
After suppression of the bleeding, the flaps are approximated by one
or two points of suture; these are afterwards removed, and their place
supplied by the adhesive plaster.
Amputation, at any point between the wrist and elbow-joints, requires,
in all, the same method of incision, but the nearer to the elbow the
better is the stump; at the wrist the flaps are composed principally
of integuments and tendons, and the cushion so formed for the bones
is very inferior to one of muscle. Compression is made and the limb
steadied as before; the surgeon with his left hand grasps the wrist,
and places the forearm in the middle state between pronation and
supination. In the right forearm, the knife, held perpendicularly, is
entered over the centre of the radius, and its point, after reaching
the bone, is inclined inwards so as to pass round it; transfixion is
then made, the knife passing close to the palmar surface of the bones,
and emerging at a point opposite to its entrance; and then by rapid
motion downwards and inwards, a proper flap is formed. The instrument
is again introduced over the radius, at a little distance from the
upper part of the first wound, and passed on the opposite side of the
bones, emerging also in the first incision and at a similar point;
another flap is made. These are retracted, the knife is swept round the
bones, and passed freely between them, to divide the remaining muscular
substance, and after this has been completed, the saw is applied.
During the sawing it is well to preserve the limb in the same position
as during the incisions, and to apply the instrument perpendicularly;
thus both bones will be divided at once, and the risk of splintering
diminished. In transfixion, great care is required that the point of
the knife pass across, not between, the bones, and with this view a
slight change of position is useful; during the transfixion for the
inner flap, the surgeon, as soon as he feels the knife rounding the
radius, rotates the forearm gently inwards, and in transfixing for
the outer flap similar rotation is made outwards. In this situation,
and others where the soft parts are less thick in one aspect than
the other, it is by much a preferable plan to make a flap first, by
cutting from without inwards, as already described in regard to the
wrist, and then to transfix for the formation of the second flap. This
is delineated in the _Practical Surgery_, p. 367. Sometimes slight
difficulty is experienced in tying the interosseal artery. The flaps
are brought together, and treated in the way already mentioned.
In all amputations of the upper extremity, it is of importance, and
indeed a rule scarcely to be departed from, to leave as much of the
limb as possible; for here the longer the stump, the more useful is
it to the patient. In accordance with this maxim, amputation at the
elbow-joint may be required, when either disease or injury extends too
high for amputation in the forearm, but not too high for the formation
of an anterior flap over the joint. The limb is steadied in the supine
position, compression being made near the middle of the humeral artery;
the knife is passed horizontally across the condyles close to the bone,
and brought downwards and forwards to a sufficient extent for the
production of a flap, which is alone to form the protecting cushion.
The joint is then cut through, the knife is passed down till obstructed
by the olecranon, and with one sweep a semicircular incision of the
posterior integument is made. All soft parts in this line are divided,
and then the saw is applied to the olecranon process. This amputation
is easy, rapid, and beautiful in execution; and, when the flap is
sufficiently large,—as it always may be, for there is no want of soft
parts in front,—the stump is well formed and useful. The flap is laid
down, and attached by suture to the integument posteriorly; in due
time the adhesive dressing is applied. The circumstance of a secreting
surface forming the stump does not seem detrimental, either here, or in
the wrist-joint. The synovial fluid soon ceases to distil, and union
is not interrupted by it. There is no necessity for scarification,
or scraping the cartilage, with the view of hastening cessation of
secretion and granulation of the surface.
Amputation of the _arm_ is performed by the formation of lateral flaps,
at any point below the insertion of the deltoid muscle. Compression
is made on the upper part of the humeral, or on the axillary artery.
The limb is held well separated from the side; and care should be
taken that, when so raised, its height be convenient to the operator.
The knife is entered perpendicularly to the shaft of the bone, passed
fairly down to it, and then inclined along its side; the operator now
grasps the limb below the line of incision with the left hand, and
pulls the muscles towards him—it is supposed that the right arm is
being amputated, the surgeon standing on the inside, and an assistant
supporting the forearm—and then completes transfixion, inclining the
handle of the knife towards himself, in order that its point may pass
round the bone and emerge at as distant a point in the circumference
of the limb as possible. By a rapid sawing motion, downwards and
inwards to the proper extent, the inner flap is formed; and by
attention to the grasping of the muscles and the inclination of the
knife, its base is so large as to admit of the more easy performance
of accurate transfixion for the outer—that is, the instrument is more
easily brought through the same incision. The assistant seizes the
extremity of the inner flap as soon as formed, and retracts it, but
only to a slight extent; it is simply held out of the way. If it be
pulled backwards, as in retraction during sawing, the formation of the
second will be much impeded. The knife is again entered about half an
inch below the commencement of the first incision, and by inclining
the handle the point is brought round the bone, and made to appear on
the opposite side also in the first incision; this is facilitated by
pulling the soft parts outwards with the left hand. Then the outer
flap is completed. The knife is swept rapidly round the bone, so as to
expose it completely at the upper part, the assistant at the same time
retracting the flaps fully. The saw is applied, the arteries tied, the
flaps approximated, and the operation completed.
In performing the second transfixion, the reason why the knife is
entered lower than in the first, is, that cross-cutting of the corners
of the wound is thereby avoided. For a long time I was surprised and
annoyed to find many stumps present an unseemly cross-cutting of the
integument at the upper parts, particularly after approximation of
the flaps, although the incisions seemed to have been made smoothly
and accurately. It is occasioned by the sawing process for making the
second flap, and when this is commenced at the same height as for the
first, irregularity of incision at the upper part is unavoidable. The
precaution, however, of making the second transfixion considerably
lower than the first I have found quite effectual. The disparity
between the bases of the flaps is readily and quickly remedied, after
their formation, by a sweep of the knife upwards on the lower side.