amputations of the arm and forearm than any other. The occurrence,
however, is less common than formerly, and this may be fairly
attributed to the improvements in the operation—to the method by
flaps having superseded the circular, and nothing but the arteries
being surrounded in ligature. Still the affection is occasionally met
with, and there can be none more painful and troublesome. Generally,
no obvious cause can be found for the attack of this malady; but in
some of the cases there would seem to be a constitutional and innate
tendency, as it were, towards this irritability of the cut and bulbous
extremities of the nerves—as in the following case:—A gentleman, aged
53, underwent amputation of the thumb, in consequence of laceration of
the hand. Amputation was very soon afterwards performed at the middle
of the forearm, on account of hemorrhage and infiltration of the hand,
after fruitless attempts to secure the arteries. After cicatrisation
of the wound, he complained of great pain in the stump, and in the
situation where the tourniquet had been applied. Amputation of the arm
was then performed, but the stump was not well made. The pain returned,
and he applied to me, with the view of again submitting to amputation.
It was performed nearer to the shoulder-joint, and in order to guard
against recurrence of the disease, the nerves were laid hold of, pulled
outwards, and cut across as high as possible. The patient was relieved
of many of his sufferings, and continued tolerably comfortable for
nearly two years; again, however, the painful symptoms have returned,
though in a slighter degree. On examining the removed stump, all the
nerves, particularly the musculo-spiral, were found greatly enlarged
in their extremities, and intimately adherent to the cicatrix and the
ligamentous covering of the rounded extremity of the humerus. More
desperate operations have even been performed to free patients from
irritable stump. The lower limb has been hacked off bit by bit, even
to the coxo-femoral articulation, without much, if any, relief. Such
operations are hardly warrantable.
Amputation at the _shoulder-joint_ is more frequently required for
accident than for disease. It has always been the custom to trust for
suppression of bleeding, during this operation, to the hands of an
assistant; and when the method has been found effectual in the case of
the large axillary artery, why should it be objected to, on the score
of inefficiency, in the minor amputations? particularly when it is
evident, putting efficiency out of the question, that it is preferable
to compression by the tourniquet, or any other circular apparatus;—more
quickly applied and relaxed; less painful, less formidable; always
ready, and independent of the instrument-maker. The compression is made
above the clavicle, so as to secure the subclavian, where it passes
over the first rib. The thumb of a steady assistant is placed deeply
into the cavity of the lower triangular space of the neck, immediately
above the first large sinuosity of the clavicle. The pressure thus made
is quite effectual; but as it requires to be firm and uniform, and as
there is always a risk of the thumb giving way from exhaustion, it is
better to interpose some mechanical contrivance when the assistant is
either diffident or inexperienced. The best apparatus for this purpose
is a common door-key. A bit of lint or cloth is wrapped round the
handle, and this part is then pressed down on the vessel. As in other
amputations, the pressure is not commenced till the knife is about to
enter.
The flaps may be double, on the outer and inner aspects, or one may be
made sufficiently large to cover the whole wound. The patient is seated
on a chair, and secured by a person placed behind. The arm is raised
a little from the side, and supported by an assistant. Two oblique
incisions are made, commencing high on each side of the shoulder, and
converging gradually till they meet near the insertion of the deltoid.
The triangular flap, so marked out, is dissected rapidly upwards, close
to the bone, and kept raised by an assistant. The person supporting the
arm then uses it as a lever, carrying it downwards and backwards; the
joint, thus made more palpable, is cut into by a semicircular sweep
of the knife across it; the head of the bone is now dislocated, and
the rest of the capsule and fibrous tissue exterior to it divided;
the blade of the knife is insinuated behind the head of the bone, and
carried rapidly through the remaining soft parts. In no amputation can
I conceive any necessity for suspending the incisions, in order to
secure vessels, provided the pressure is well applied, and the knife
used dexterously. Here very little blood should be lost. The vessels
divided in the formation of the flap are small, and the axillary is not
cut till the incisions are nearly completed; as soon as the limb has
dropped, the surgeon places his finger on the mouth of the artery, and
then applies his ligature as quickly as possible; the pressure may now
be removed, and the minor vessels secured leisurely. The flap covers
the wound completely, and is easily retained.
Or two flaps may be made by transfixion. In operating thus on the right
limb, the surgeon, standing in front of the patient, enters the knife
a little below the point of the acromion, passes it across the outer
aspect of the joint, and by inclination of the handle outwards, makes
its point to appear on the inside of the outer margin of the axilla; by
carrying it downwards and outwards to a sufficient extent, the outer
flap is formed. This is immediately elevated by an assistant, and then
the arm is pushed upwards, and across the chest, so as to render the
joint more accessible; the ligaments are cut, the bone disarticulated,
the knife passed beyond its head, and placed with the edge parallel to
the shaft of the humerus, and the arm restored to its former position;
the inner flap is then made by carrying the instrument downwards and
inwards. In the left limb, the knife is entered on the inside of the
outer border of the axilla, and brought out below and in front of the
extremity of the acromion, reversing the order of the former incisions;
after the outer flap has been so formed, the joint is cut across, the
knife passed beyond the head of the bone, and the inner flap made as
before.
Accidental injury, as already stated, is the most frequent cause for
amputation at this part, and this will always influence the method
of incision. There is nothing peculiar in the after-treatment of the
stump. But it ought always to be remembered, that the operation is one
of great severity; that a large part of the body has been suddenly
removed; that, consequently, there is risk of the mere shock being
dangerous, and of an untoward constitutional condition supervening—and,
therefore, the after-attendance should be zealous and careful.
[Illustration]
The phalanges of the _toes_ are removed in the same way as those of
the fingers. This latter operation may be required on account of bad
onychia, large exostosis or injury. This and the other must also
be removed on account of diseased bone, such as here represented
with affection of the interposed joint. The osseous shell formed
by the enlargement of the original tissue encasing a segmentum is
well represented. In the amputation at the proximal joint, it is to
be recollected that the extremity of the metatarsal bone lies more
removed from the web of integument betwixt the toes than the metacarpal
bone does from that of the fingers. The incision upwards, therefore,
requires to be deeper; but in other respects the operations are
precisely the same.
In amputating at the proximal articulation of the great toe, there is
often a difficulty in obtaining a sufficient covering for the wound, on
account of the presence of the sesamoid bones, and the general bulging
of the heads of the bones. The knife is entered on the dorsum of the
metatarsal bone, about half an inch above the joint, and then inclined
to each side, marking out lateral flaps of considerable length;
these are then reflected,—in making the outer, the instrument being
dextrously passed round the sesamoid bone,—and the disarticulation
completed.
In removing the great toe, along with the metatarsal bone, the bistoury
is entered over the articulation of the metatarsal bone with the
tarsus, and carried straight downwards, along the centre of the dorsum
of the bone, till near its extremity; it is then inclined to each
side, in the manner described for amputation of the metacarpal bones.
The integuments are dissected off on each side of the longitudinal
incision, and the knife run up along the inside of the bone, till
stopped by the tarsus. The surgeon now presses the toe outwards, so as
to assist the disarticulation; and after this has been completed, the
bistoury is carried downwards, close to the outside of the bone, and
not brought out till past the lower articulation. The external flap
thus formed is then laid accurately down, so as to cover the wound, and
retained. The preferable mode of making the flap, so as to expose the
metatarsal bone for division or disarticulation, is well illustrated
in the _Practical Surgery_, p. 375. The entire bone must be removed
in such cases as that here sketched. In cases in which the shaft is
comparatively sound, and the disease is principally seated in the
articulation with its distant extremity, the shaft may be divided with
the cutting forceps at a point sufficiently removed from the disease.
The operations on the other metatarsal bones are the same as those on
the metacarpal. They may be removed, either entirely or in part, along
with the corresponding phalanges, by operative procedure similar to
that practised on the hand.
[Illustration]
Sometimes disease of the _foot_ is not so extensive as to require
or justify removal of the whole organ; the metatarsal bones are not
involved throughout their whole extent. The same remark applies to
injury by accident. In such circumstances, amputation is performed at
the articulation of the metatarsal bones with the tarsus. The operator
first ascertains the exact site of these joints, and then transfixes
the foot at that point, passing the knife close along the plantar
aspect of the bones; carrying the instrument downwards, a sufficient
flap is formed to cover the stump, or a semicircular flap may be made
and reflected by cutting from without inwards. The integuments on the
dorsum are then divided in the line of articulation, the joints divided
successively, and the parts removed. The flap is raised, adjusted,
and retained. In dividing the articulations, it is to be recollected,
that the base of the second metatarsal bone, reckoning from that of
the great toe, is lodged considerably higher than the others; and,
therefore, the knife must be inclined upwards at that point, or
else the use of the saw is requisite. The stump thus formed proves
exceedingly useful: the subsequent lameness is not great; the heel and
tarsus compose a very efficient support for the weight of the body, and
the flexion is unimpaired; by attention, too, the deformity may be in a
great measure concealed. In short, the surgeon who amputates above the
ankle, for disease or injury not extending to the articulation of the
metatarsus with the tarsus, is guilty of a serious error.
The disease may reach higher than is compatible with the preceding
operation, and yet it may be possible to save the heel. In such cases
amputation is performed in the articulations of the os calcis with the
os cuboides, and of the astragalus with the os naviculare. The plan of
the incisions is the same as that for the operation at the bases of the
metatarsal bones.
No amputation is more frequently performed than that of the _leg_.
Operation near the ankle is inadmissible; sufficiency of soft parts,
for the protection of the stump, cannot be procured lower than
the calf. Incision is completely limited to two points, either
immediately below the tuberosity of the tibia, or in the bellies of
the gastrocnemii. The former is the situation to be preferred in
hospital practice, and amongst the lower orders generally; the latter
is suitable to the better classes of society, that is, to those who
can afford to purchase an expensive artificial support. The amputation
below the tibial tuberosity being the most frequently required,
will, with propriety, be described first. Suppose the right leg is
to suffer:—The operator places himself on its inner side, according
to the general rule formerly inculcated, and grasps the lower part
of the limb with his left hand, an assistant supporting the foot at
a proper height, and controlling motion. The knife is entered over
the fibula, on its outer aspect, and carried upwards along that bone
for an inch and a half, or two inches; it is then brought across the
limb in a semilunar direction, the convexity of this incision pointing
towards the foot, and after reaching the inner and lower part of the
tibia transfixion is performed, the instrument being pushed along
the posterior surface of the bones, and made to emerge at the upper
part of the fibular incision. By then carrying the knife downwards,
a posterior and larger flap is formed sufficient to cover the stump.
All this is effected by uninterrupted sweeps of the knife, that is,
without ever removing the point or edge from the track of incision.
The integuments on the fore part are then dissected upwards a little,
by a few touches of the knife, so as to form a small semilunar flap;
at this part of the operation there is no necessity for laying down
the knife and using a bistoury. The muscles in the interosseous space
are then completely divided, and the knife swept round the bones to
detach the soft parts still uncut. The saw is applied, either in a
horizontal or perpendicular direction; I prefer the latter for reasons
already assigned. The vessels are secured, and there are generally but
three—the popliteal, and two sural. I now generally aim at cutting
the vessel before it divides, and seldom fail in doing so. There is
then possibly the popliteal only requiring ligature, and there is less
chance of secondary hemorrhage. This has occurred, so as to prove
fatal at a considerable period after the operation, in consequence of
the posterior tibia being cut close to its origin, and no clot having
formed in it. Before adjusting the flap, it is well to assist nature
in rounding off the end of the tibia, and thereby prevent danger to
the integument; with this view the sharp anterior ridge of the bone
is cut away and rounded off by means of the pliers. This must be done
sparingly if at all, and with great caution. The nipped surface is
liable to exfoliation, or the medullary web is apt to be injured, and
this is inevitably followed by more or less death of bone. To some the
fibular incision may appear unnecessary; but I have long practised
it from conviction of its advantage. It is an excellent mark for
transfixion, and assists greatly in preventing entanglement of the
knife betwixt the two bones; besides the soft parts in this situation
must be divided at one or other step of the operation, and hence the
procedure cannot be objected to on the ground of causing unnecessary
wound. In operating on the left limb, there is not the same danger in
transfixion, and consequently so long a preliminary incision on the
inside is not requisite; in other respects the steps of the operation
are the same as for removal of the right. In muscular subjects two
semilunar flaps had better be made, one from the anterior aspect of the
limb, the other from the posterior, the muscles being cut short in the
ham, and the incision made to reach the popliteal artery.
It has been proposed to excise the head of the fibula after formation
of the flap, instead of sawing it across at a corresponding point
with the tibia. At one time I put this modification into extensive
practice, with the effect of improving the appearance of the stump
very considerably; but in several cases, untoward consequences took
place. Discharge of synovia occurred on the second day, followed
by very profuse suppuration, which proved of long continuance, and
very exhausting; in more than one case, the joint became anchylosed,
rendering the stump very inefficient as a means of support, in
consequence of being fixed at an inconvenient angle; and one patient
sank, exhausted by the profusion of the discharge. I then found, from
repeated examination of the parts on the dead subject, that it was
very difficult, nay impossible, to excise the head of the bone without
dividing the capsular ligament, and wounding the synovial pouch, or
opening a bursal cavity, beneath the popliteus muscle, communicating
with that of the knee-joint. It is scarcely necessary to add, I have
since wholly abandoned this method of operation.
It has been already observed that high amputation of the leg is
preferable amongst the working classes. The limb is of much greater
use to the patient than were the stump longer; he is able to follow
his occupation with greater ease and security, and at less expense,
by resting on the knee, than by using the artificial limb applied to
the middle of the leg. The wealthier patient, however, can afford a
more expensive support, and a less efficient, though more handsome
continuation of the limb suffices. In such circumstances, amputation
is performed at the middle of the leg; after cicatrisation, the artist
supplies an artificial support resembling the natural limb; and thus
the motion of the knee is preserved. The same directions apply to this
operation as to that immediately below the knee.
In amputation of the thigh, the same method of incision is followed
as in amputation of the arm. But, according to the point of removal,
the direction of the flaps varies. If in operating high in the limb
the flaps be made laterally, there will be imminent risk of the bone
protruding through the upper part of the wound; for the patient
uniformly raises the stump towards his abdomen. No antagonist muscular
power is left to oppose the action of the muscles inserted into the
trochanter minor, and the elevation of the stump is involuntary: it
always occurs to a remarkable extent in young persons. On this account,
anterior and posterior flaps are here far preferable to the lateral;
for then the more the stump is raised, the better is the end of the
bone covered—the anterior flap folds over it. Transfixion is therefore
made horizontally; and the posterior flap should be a little longer
than the anterior. But in the lower part of the limb, lateral flaps
are not only not liable to the same objection, but preferable to the
anterior and posterior. In the neighbourhood of the knee-joint, the
soft parts consist almost entirely of ligamentous tissue on the fore
and back part, and proper cushions can be obtained only from the sides.
Transfixion is therefore made perpendicularly. Thus the bone will be
well covered by parts likely soon to adhere; and there is no risk of
protrusion, for muscles are left to counteract the elevators, and there
is sufficient lever in the limb whereby to control its motions. And
it may be here mentioned, that after all amputations, when startings
of the muscles are not only painful, but disturb the position of the
stump, the limb should be bound down by a broad band, passed across it
a short way above the wound, and fastened firmly at each end to the bed
or pillow; at the same time anodynes are to be administered. I have
long since come to the conclusion that the femur in amputation should
not be sawn lower than its middle; the method by anterior and posterior
flap is therefore the only one applicable.
Amputation at the _hip-joint_ is deservedly ranked amongst the most
formidable operations in surgery. It ought, therefore, never to be
performed but as a last and necessitous resource for the salvation
of life. At the same time, when necessity for it is obvious and
acknowledged, and no other means can be of any avail, hesitation and
delay should never take place; otherwise the last and only chance of
saving the patient will pass away, and the operation, when at length
performed, will but hasten his exit from this world,—and besides
inflict an injury to science, by intimidating practitioners, and
affording subject of reproach and ridicule to the thoughtless and
uninformed part of the public. I prefer the formation of anterior
and posterior flaps,—as follows:—The patient is placed recumbent on
a firm table, his nates resting on, or rather projecting a little
over, the front edge. The sound limb is separated from the one to be
removed, and held aside by an assistant. Or it is secured to the foot
of the table by a towel, the necessity for an additional assistant
being thus done away with, and more freedom in his movements afforded
to the operator. Indeed, in all amputations of the lower extremity,
this is the preferable method of fixing the sound limb. The other
limb is supported by an experienced and intelligent assistant, who
understands, and is able to perform, the movements to facilitate the
different steps of the operation. The compression is intrusted also to
an experienced and steady assistant, who, standing by the patient’s
side, presses firmly with one or both thumbs on the femoral artery,
where it passes over the pubes; and in this more than in any other
operation should the pressure be delayed till the instant of incision,
for otherwise the blood lost in the limb will be immense. Transfixion,
by a knife proportioned in size to the dimensions of the limb, is made
horizontally, the instrument being passed in a somewhat semicircular
direction, so as to include as much of the soft parts as possible; an
anterior flap is made by cutting downwards. During the passage of the
knife across the joint, the assistant rotates the limb a little, so as
to facilitate the bringing of the instrument out with its point well
inwards; in the left limb the rotation will be inwards, in the right
outwards. After formation of the flap, the assistant abducts forcibly,
and presses downwards; the joint is opened, the round ligament cut,
the capsule divided, and the blade of the knife placed behind the
head of the bone and the large trochanter; the posterior flap is then
made rapidly. After transfixion for the superior flap, and when the
sawing motion downwards has advanced but a little way, the compressing
assistant shifts one of his hands into the incision, immediately behind
the back of the knife, and so obtains a firm grasp of the femoral
artery previously to its division. He retains this hold, at the same
time retracting the flap, during the rest of the operation. As soon as
the limb has been separated, the surgeon secures the vessels on the
posterior flap, partly by his fingers, partly by compression with a
large sponge, and ligatures are applied as quickly as possible. The
femoral is secured last; for, as long as the assistant retains his
hold, hemorrhage from it is not to be dreaded. Thus, when both surgeon
and assistants are quick and cool, the operation may be completed
with the loss of much less blood than might be expected. I have had
occasion more than once to perform this operation, and thus speak from
experience. In cases of accidental injury requiring this operation, the
lever use of the limb must frequently be wanting; and in such cases,
too, the parts may be so injured as not to afford flaps anteriorly and
posteriorly. In these circumstances, the surgeon must be guided by
experience and judgment in adopting the mode of procedure which appears
most applicable; in ordinary cases the operation above detailed appears
the preferable.