Such mutilations as necessitate immediate amputation are usually

accompanied by profound degrees of shock, as well as perhaps by other

complicating injuries, whose existence may change the whole complexion

of the case. For example, with a patient suffering from probably fatal

fracture of the skull one would hardly seriously discuss the matter of

immediate amputation of a foot; nevertheless he should take such care

of the local lower injury as to permit operation to be done under still

favorable circumstances should the head condition justify it. Wide

discretion is therefore called for in all these cases. Furthermore the

condition of lowered blood pressure or shock may be so extreme that the

operator is compelled to delay, for at least a certain time, in order

that by the employment of those measures already considered in the

chapter on this subject the circulation may be sufficiently restored to

make it adequate for the purpose, remembering that scarcely anything

predisposes to infection more than such lowered vitality. While

resorting to general stimulation, hypodermoclysis, or infusion, with or

without adrenalin, the use of such antiseptics should not be omitted,

as the local condition may require in order to combat what otherwise

may be actively occurring.

Amputations are sometimes referred to as _typical_, when done according

to long-established methods, or _atypical_, when the entire procedure

is planned to fit the necessities of the case. Amputation at a joint

is usually spoken of as _disarticulation_. Amputations, again, are

classified as (_a_) _immediate_, _i. e._, before complete reaction from

shock or within the first few hours; (_b_) _primary_, when done after

reaction has occurred, but before visible occurrence of inflammatory

changes, (_c_) _intermediate_, as done when suppuration is threatening,

but before its actual occurrence; (_d_) secondary, _i. e._, after the

occurrence of suppuration.

The _control of hemorrhage_ is one of the most conspicuous and

necessary features of any amputation method. Below the shoulder and at

the hip this may be effected by the old-fashioned _tourniquet_, or the

modern _elastic bandage_, which may or may not be combined with the

more complete _bloodless method_ with which Esmarch’s name will always

be connected. The pure rubber gum bandage, I believe, was introduced by

Martin, of Boston, but the method of its use for bloodless operations

upon the extremities is to be credited to Esmarch. The surgeon may

avail himself of this method in all suitable cases, but should

_never resort to it in septic or malignant disease_. It includes the

application of a Martin elastic bandage from the tip of the extremity

to the necessary height, by turns which shall make gentle and equable

pressure, gradually forcing the blood from the compressed tissues and

out of the limb, and up to a height where another elastic, or, at all

events, suitable constricting band is placed with a sufficient degree

of tightness to completely shut off access of blood. To so apply a

bandage in septic and malignant cases would be to coax septic and

malignant material into the veins, and would evince the worst possible

judgment. A sufficiently strong rubber tubing forms an effective

tourniquet, which, however, should be applied over a folded towel, or

in some manner so that it does not too deeply constrict and compress

the soft tissues of the limb. Instead of tying a knot it may be secured

with an ordinary clamp forceps.

The tourniquet should never be applied over the leg or forearm, for

it can here make no impression upon the interosseous vessels. Its

application should be begun by pressure upon the vascular, _i. e._,

the adductor side of the limb, so that venous choking may be avoided.

After it is once in place the limb should not be completely flexed nor

extended, lest the tissues firmly enclosed by the constriction be more

or less spontaneously torn; _nor should the tourniquet be too long left

in place_, as injury to the vessels is the possible result.

The bloodless method of Esmarch is furthermore subject to the

following disadvantages. It is sometimes followed by serious and

permanent paralysis of the limb, the result of prolonged or excessive

constriction and compression of the motor nerve trunks. Similar results

(in the arms) follow the use of crutches as well as of pressure of the

side of the operating table when the limbs are allowed to hang over it.

Again after removal of the bandage there is sometimes most pronounced

capillary oozing due to vasomotor paresis. This may be controlled by

the stimulation of hot irrigation or applications, and by more or less

massage of the limb. The dangers of forcing undesirable material into

the circulation have been mentioned, in addition to which should be

recorded the increased absorption of toxic substances.

When there is good reason for not using the elastic bandage, save as a

tourniquet, much of the desired effect may be obtained by holding the

limb for a few minutes in a vertical position, so that its contained

blood is drained out of it by gravity, after which the tourniquet may

be applied as before.

The cocainization of nerve trunks, as they are exposed and divided,

is one of the new measures for the prevention of shock for which we

are largely indebted to Crile. It has proved to be a most valuable

expedient which should not be neglected. (See Chapter XVIII.)

Under modern methods more is expected of an amputation stump than in

days gone by, and the first demand is that it shall be _useful_, to

which end it is necessary that it be both movable and that its end

be not too irritable, nor the scar too sensitive to stand at least a

certain amount of pressure. It is expected that suitable prosthetic

apparatus, _i. e._ artificial limbs, shall take the place of severed

lower extremities and of most arms or hands removed. The skill and the

mechanical ingenuity of the maker of artificial limbs have now reached

a point where most acceptable substitutes are thus provided, but for

them suitable stumps should be afforded by the surgeon, and there

should be coöperation from each direction. Thus it used to be held that

the bone end in every stump should be covered with periosteum, yet it

has been recently shown, especially by Hirsch, that such bone ends

are as acceptable, and perhaps more so, when stripped of rather than

covered with this membrane, the latter being sensitive, and there being

no advantage in the presence of such new bone as may be formed by its

preservation.

Many a good stump may be molded in various ways, but always provided

that the end of the bone be smoothly divided, and have no corners or

osteophytic outgrowths to make pressure upon the sensitive scar. For

this reason it should be manipulated as early as possible, and should

not be allowed to undergo the atrophy noticeable in stumps left after

old operations. If primary union be gained, so long as the cicatrix and

the nerve ends be kept out of the way, one may expect a stump which is

serviceable in every respect. The ideal method is that the skin and

the periosteum should retain their normal relationship, an ideal best

attained in the supracondyloid operation after Gritti’s method. Various

osteoplastic methods have been devised, first by Walther, in 1813,

and since him especially by Ollier, Pirogoff, Gritti, and Bier. The

latter would cover every bone end not merely with periosteum, but with

a bone flap so arranged that its lower surface is one normally covered

by periosteum. The introduction of the _x_-rays has permitted a more

thorough study of bone ends in stumps which are, on one hand, extremely

tender, or, on the other, extremely serviceable, and the osteoplastic

methods seem to conduce to the latter condition. Another matter of

great importance is to so _place the scar that it shall be neither

subject to pressure nor to traction_. If, therefore, the sawed surfaces

be covered with a periosteum which shall retain its normal relation to

its coverings, a minimum of disturbance in the scar is the result.

The value of early use of the stump and of accustoming it to pressure

is considerable, as atrophic stumps are tender, like other disused

parts, and there is, therefore, every reason for resorting to

prosthetic apparatus as early as possible. As Kocher puts it, the

following is the best procedure for the normal operation: “An oblique

incision, combined if necessary with a longitudinal one, in the form

of a racket or lanceolate incision through skin and fascia. After

retracting the elastic skin the muscles are divided obliquely down to

the bone. The periosteum is also to be divided obliquely. Periosteum

is then separated along with the superficial layer of the cortex of

the bone, by means of a sharp raspatory or chisel, or, when possible,

a flap of bone having a movable periosteal hinge is made by means of

the saw. Lastly, if only a thin shell of the cortex have been raised

up along with the periosteum, the end of the bone is simply rounded

off, while if a distinct flap of bone, by any osteoplastic method, have

been divided, the end of the bone must be sawed in a curved direction

so as to fit it. The periosteal or bony flap is sutured over the sawed

surface of the bone to its periosteum, and the stumps of the muscles

or tendons are sutured to each other, or to the surface of the bone

at a distance from the sawed surface. Finally the skin and fascia

are sutured; but in case where a periosteal flap or flap of bone and

periosteum cannot be obtained in normal relation to other soft parts it

is better to remove the periosteum entirely from the end of the stump,

to scrape out the medullary cavity, and to round off edges of the bone

as dentists do.”

While these methods give better results than those formerly in vogue,

they also consume more time; but the days of brilliancy and rapidity

in amputation are past, as time should be devoted to careful work,

except only in those cases where emergency demands the most rapid and

dexterous removal of a limb in the shortest possible time, and where

every other consideration is sacrificed to the principal interest of

preserving life.[75]

[75] The following is taken from the article of Professor Matas in

the third edition of “Surgery by American Authors.” It furnishes a

brief but admirable introduction to the general study of amputation

methods:

“From Hippocrates to the time of Celsus the surgeon simply followed

in the wake of Nature, never venturing to apply the knife for the

removal of a limb except within the limits of the mortified tissues;

and this seems to have prevailed for at least four hundred years.

Celsus, the prince of Roman physicians, who lived shortly after the

time of Christ, introduced the first innovation by cutting down to

the bone between the living and the dead tissues. It is probable,

according to the evidence furnished by his writings, that he was

aware of the value of the ligature and that he applied it to control

bleeding vessels. Archigenes, following closely after Celsus, was

the first to attempt prophylactic hemostasis by applying a cord or

band around the limb to control the hemorrhage during the amputation.

With the fall of the Roman empire and the advent of the long night of

the middle ages the Celsian method was lost in the general darkness

and the old Hippocratic doctrines survived, and were maintained by

the all-potent influence of Galen and his Arabian commentators. As

late as the middle of the seventeenth century the only hemostatic

was the actual cautery and boiling oil, though Guy de Chauliac had

revived the teaching of Archigenes by constricting the limb, on

a level with a joint, with a cord which was allowed to remain in

situ, to ensure not only hemostasis, but a certain mortification of

the stump. In cutting limbs huge chisels and mallets were used. At

this period Botalli invented his guillotine, consisting of a sharp,

heavy, axe, which, being allowed to fall from a height upon the

limb, severed it instantaneously at a single blow. The revived or

independent rediscovery of the ligature by Ambrose Paré in 1579, and

the discovery of the circulation of the blood by Harvey, in 1628,

led to the invention of Morel’s tourniquet (1674), more commonly

known as the Spanish windlass, and to the familiar instrument,

Pettit’s tourniquet, which (introduced in 1718) perfected the means

of securing prophylactic and direct hemostasis. From this time

onward the treatment of the stump began to receive more systematic

attention. Instead of merely chopping off a limb, the soft parts were

detached from the bone, so that this could be sawed off at a higher

level, in order to avoid the conical projection of the stump which

invariably resulted when the primitive methods were adopted. All the

methods of amputation that followed--and these were numerous--aimed

chiefly at celerity, to reduce the pain of the operation to a

minimum; hence the rapid, circular section of the soft parts or the

rapid transfixion methods which were so much popularized by the

brilliant work of Liston, Lisfranc, Desault, Dupuytren, Langenbeck,

and others. These finally yielded, in this modern period, to less

rapid but more conservative and perfected methods, which aim chiefly

at the preservation of useful tissue and at securing the very best

functional prosthetic stump for the patient. Such methods could only

be perfected after the advent of anesthesia and antisepsis.”

AMPUTATION METHODS.

With a view to simplifying this subject as much as possible the

following methods alone will be considered: (1) The _circular_ with its

modifications, the _oblique_, the _elliptical_, the _ovoid_, etc.; (2)

the _flap method_; (3) the _mixed or skin flap and deep circular_.

Choice of method sometimes leaves much, sometimes nothing, to the

tastes or wishes of the operator. It should be based solely on the

primary consideration of saving life and the secondary consideration of

furnishing the most useful possible stump. To obtain the latter it is

necessary that the bone be amply covered, except that its coverings be

not adherent, that there be a minimum of disturbance of blood supply,

that nerves be drawn down and divided as far from the stump end as

possible, in order that they may not be entangled in the scar, and that

the scar be so planned for and arranged that it shall be _at one side_,

at all events in such position that no pressure shall be made upon it,

and, if possible, also no tension by muscle action.

Elasticity of skin and contractility of the muscles vary much in

different individuals, and it is not always easy to estimate either of

them previous to their division. Consequently it is much better to make

cuffs or flaps too long at first rather than too short. The existence

of previous disease will always modify these local conditions, but, in

general, the rule is laid down that the external flaps should be longer

than the bone by from one-third to one-half the diameter of the limb.

1. =Circular Method.=--The simple circular method is the simplest

and easiest of all. It may be so performed as to furnish a solid

musculotegumentary division, or skin cuffs may be made, which being

turned up, permit a further circular division of the muscles and other

tissues directly down to the bone. The former is preferable when

possible. With an ordinarily long amputating knife the skin, down to

and including the superficial fascia, is divided by one clean circular

incision, made in one stroke; then by further circular cuts the muscles

are divided in sections, the outer group being allowed to retract and

expose the deeper layers, which are then divided at a higher plane. In

this way the periosteum is reached. If sufficient time be afforded it

may be circularly divided at the level of the last incision through

the muscles, and then separated with a strong elevator or, as done by

Kocher, with a chisel, in order that some portion of the exterior of

the bone be raised with it. In this way a cuff of periosteum, or enough

of it to cover the bone end, is detached upward, to the level where

the bone itself is finally divided. The bone division is done with the

ordinary amputating saw, or with the wire or chain saw.

The _skin-cuff_ (Manchette) method differs in that the exterior flap

is made wholly of skin, which is dissected as a cuff nearly up to the

level of bone section, at which point the muscles are divided directly

down to the bone. In this method the skin, fat, and superficial fascia

should be raised together, and at no points separated from each other.

Modification of the cuff method, by which it is more easy to evert the

circular flap, is made by one or two _vertical incisions_, by which the

cuff is split some distance on one or both sides, thus transforming the

cuff proper into two nearly square skin flaps. At other times the first

method may be similarly modified, in which case we have to deal with

two square flaps, including not only the skin, but all the tissues down

to the bone.

Neudörfer still further modified the circular method for certain

purposes by first making an incision along the outer or least vascular

part of the limb, carrying the knife directly down to the bone,

retracting the wound edges, and thus exposing the bone, which is then

divided with a chain or Gigli saw. After the bone is divided the soft

coverings are lifted to a sufficient distance below the saw line to

ensure ample covering, then divided as above. The method is a slow

one and is especially serviceable for amputation of the thigh, at its

middle, for diabetic or senile gangrene, where it is so desirable to

protect vascular supply from injury (Fig. 677).

The so-called _elliptical method_ is practically a circular incision

carried obliquely around the limb, the upper and lower ends of the

ellipse being indicated by previous small incisions at the proper

height. The skin and superficial fascia are retracted from the lower

portion of the ellipse by turning them up to the level of the highest

point, at which level the muscles are divided transversely by a plain

circular incision. A modification of this method is the so-called

_ovoid_ or _racket_, which is simply an oval division with a pointed

end, the margins of the flap being united in the long axis of the bone.

This method is frequently applied in amputation of the fingers. (See

Fig. 683.)

2. =Flap Methods.=--Flaps are either _cutaneous_ or _musculocutaneous_.

In every case the skin surface must be larger than the muscular. They

are objectionable in that the skin flap is apt to slough, although

least so about joints. The flap method is advantageous in that one

flap may usually be made much longer than the other, and the longer

one so doubled over at its end as to place the scar out of harm’s way.

In certain injuries where the skin is much more injured on one side

of the limb than on the other the operator is compelled to resort to

flaps, unless he divide the limb much higher than might otherwise be

demanded. Double flaps may be _anteroposterior_ or _lateral_. A double

flap practically results from a circular incision, carried through to

the bone, with lateral division on either side, while a double flap

with one long member may be similarly furnished by an oblique circular

incision with the lateral prolongations.

[Illustration: FIG. 677

Neudörfer’s method of amputation by primary division of the bone,

before shaping the flaps. Neudörfer used the chisel, but one may use

the Gigli saw with special advantage in performing this operation. The

method is applicable to any portion of the upper or lower extremity,

especially in the continuity of the long bones. (Matas.)]

Flaps may be formed by _transfixion_, for which purpose a long,

sharp, amputating knife is required. Inasmuch as it makes an oblique

and irregular division of the principal vessels, which are in

consequence more difficult to secure, and by which nutrition of flaps

is endangered, it is not to be commended, save perhaps in certain

amputations about the wrist. A better method of making the flap is

to divide the skin and fascia with an ordinary stout scalpel, and

then, permitting them to retract, to divide the muscles obliquely

toward the bone in such a way as to leave a flap wedge-shaped at its

base. The anteroposterior amputations of the foot, thigh, and arm are

better performed in this way, each flap being in length preferably

three-fourths the diameter of the limb. (Matas.) An extension of this

method furnishes the possibility for various subperiosteal amputations

to be described below.

The _osteoplastic methods_ of today furnish desirable operative

procedures. One of the earliest of the good ones was Teale’s method,

as applied to the leg, of double quadrangular flaps, the anterior

being much the longer. A minor degree of this work includes simply

the preservation of a cuff of periosteum, which is supposed to afford

protection to the marrow cavity and a smoothly rounded bone end,

without adhesions to the overlying soft parts; but much more complete

operations are afforded by Pirogoff’s amputation at the heel, and

by Wladimiroff and Mikulicz’s amputation of the foot (practically

an exsection of the heel), or by Gritti’s and the other methods of

supracondyloid knee amputation, with preservation of the patella. Bier

and other foreign and domestic surgeons have also devised methods of

reflecting or raising bone flaps from the continuity of bone shafts,

which, being still connected by periosteal bridges, are so turned and

fastened in place as to furnish a complete bone end over the stump

(Figs. 678 and 679).

The choice of method must depend, to a large extent, on the character

of the case. Some injuries will leave parts so exposed that a portion

of a limb can still be utilized if only flaps be cut in an atypical

way. One need never hesitate to resort to these, especially about the

hand and upper extremity, where it is so desirable to save every inch

of tissue. It is not necessary to preserve every possible inch of

tissue in the foot and leg, as the makers of artificial limbs can adapt

an artificial leg to any kind of a stump. The intent in making these

statements is that while it is best to follow conventional methods

under ordinary circumstances, there need be no hesitation in departing

from them when occasion demands it.

[Illustration: FIG. 678

Bier’s osteoplastic amputation of the leg (procedure advocated by Bier

in 1897 and 1899): _F_, long anterior flap reflected on the tibia;

_A_, cross-section of tibia; _B_, periosteal flap after excision of

intervening section of bone; _C_, osteoperiosteal flap; _D_, projecting

border of periosteum to be sutured to tibial periosteum.]

[Illustration: FIG. 679

Bier’s osteoplastic amputation of the leg, with osteoperiosteal flap in

position.]

It is essential in caring for every stump, after the actual amputation

has been performed, (1) that _bleeding_ be absolutely controlled; (2)

that _nerve ends_ be placed out of the way of cicatricial entanglement;

(3) that proper _drainage_ be provided; (4) that the soft parts be

so brought _together_ as to unite in the promptest and most perfect

fashion. The possibility of the latter will depend very much on the

occasion for the operation and the condition of the tissues. Operating

in the presence of previous disease, as when the parts are inflamed

or edematous, or as when one amputates at a point where more or less

sloughing and separation of tissues have already occurred, the surgeon

cannot look for such primary repair as furnishes an ideal termination,

nor should he endeavor to make such close suturing or approximation

as he would otherwise attempt. In fact, under these circumstances, it

is often desirable to leave the wound widely open, perhaps packing it

with yeast, in order to hasten sloughing and secure healthy granulating

surfaces, which may be then brought together by secondary suture or

by suitable strapping and bandaging. Nothing worse can happen than

imprisonment of the debris resulting from the sloughing process.

But an amputation wound made with faultless technique, and in tissues

previously healthy, may be closed with a minimum of drainage, or often

without any, providing it be so closed as to leave no dead spaces in

which blood clot may accumulate. This requires careful _suturing_, by

numerous buried sutures, of muscle to muscle, tendon to tendon or to

periosteum, and the like, the wound being gradually closed from its

depth, and finally so bandaged that equable pressure shall be made,

with comfortable support, but without undue pressure at any point. In

aseptic cases animal ligatures and sutures (chromic gut) will prove

reliable and efficient. In septic cases it would probably be better to

trust to (secondary) silk, especially if parts are to be long exposed,

so that it can be later removed. For the superficial wound silkworm

sutures answer admirably.

For _drainage_ a gauze packing for the worst cases, one or two tubes

for ordinary cases, and for those which scarcely need it strands of

catgut or of silkworm-gut, or two or three little rolls of oiled silk,

will be sufficient.

In this country Link and in Germany Credé have practised the method

of bringing parts together merely by equable pressure and bandaging.

This has been of late modified by the use of strips of sterile adhesive

plaster; and in certain instances, everything else favoring, it has

given good results. It might be advantageously adopted in cases where

it is feared that it may be necessary to reopen the wound, as it would

permit an easy method of so doing.

_Dressings_ should be copious and snugly applied, and the limb involved

should be _immobilized_. Thus after a leg amputation it is well to bind

the leg and thigh upon a suitably arranged splint, physiological rest,

which is so essential to success, being in this way attained. The same

is also true of the arm.

AMPUTATIONS OF THE UPPER EXTREMITY.

=Amputations of the Finger and Thumb.=--It is desirable in the upper

extremity to save every portion which can be preserved and still

made useful. This is particularly true of the fingers, where every

half-inch adds to their usefulness. When it is possible the palmar

surface should be saved and made to cover the stump end, as it is not

only more sensitive but denser and stands wear better. This is equally

true of disarticulations or of divisions between the joint ends of the

phalanges, which are best exposed by bending the finger, cutting the

dorsal flap in this position, then stretching it and cutting the palmar

flap (Fig. 680).

The vessels and nerves lying on the lateral aspect should be secured

against hemorrhage, and cocaine solution introduced if local anesthesia

is being practised. It is important also to remember the arrangement

of the common palmar synovial bursa, with the digital prolongations to

the thumb and the little finger, and that the three middle fingers are

ordinarily shut off from it. Nevertheless if tendons be divided near

the hand, and short finger stumps be made, it is easy to infect this

common palmar bursa through retraction of the tendon and the consequent

opening up of a tunnel directly into that cavity.

[Illustration: FIG. 680

Typical amputation of finger in continuity (through a phalanx); long

palmar and short dorsal flaps. (Farabeuf.)]

[Illustration: FIG. 681

Typical or preferred method of disarticulating a finger by long single

palmar flap. (Farabeuf.)]

Figs. 680 and 681 illustrate the best methods of amputating fingers

through a phalanx or at the joints, while Fig. 682 shows the best

method of closing the wound. In this way a serviceable finger-tip is

preserved which will stand every irritation to which it will probably

be subjected.

When the finger is to be _disarticulated from the hand_ a modified

oval flap is preferable, with its long flap on the radial side and the

scar on the dorsum rather than in the palm. The _thumb_ is perhaps

best separated at an articulation by a single palmar flap, without the

preservation of the sesamoids which belong to its short flexor. Fig.

683 illustrates the various flaps and methods preferable at the bases

of the different fingers.

When two or more fingers have to be removed the incision should be

planned to meet the indications. When the first three fingers have to

be removed, with or without that portion of the hand to which they are

attached, leaving only the thumb and little finger, I have repeatedly

followed to advantage the suggestion of Lauenstein, and through a small

incision properly placed have, with cutting forceps, divided the first

and fifth metacarpal bones at about their middle, and have then given

to each of the remaining digits a quarter of a revolution toward each

other, in such a way that when their tips are flexed there was better

prehensile power, the hand acting similarly to a more perfect claw. If

they are to be maintained in this position during healing they must

be suitably held upon the splint to which the entire hand and forearm

should be attached.

[Illustration: FIG. 682

Stump resulting from the procedure shown in Fig. 681.]

[Illustration: FIG. 683

Illustrating various finger amputation. (Farabeuf.)]

[Illustration: FIG. 684

Removal of index finger. (Erichsen.)]

[Illustration: FIG. 685

Removal of little finger. (Erichsen.)]

[Illustration: FIG. 686

Results of amputation above metacarpo-phalangeal articulation in

middle, index, and ring fingers. (Erichsen.)]

[Illustration: FIG. 687

Hand after removal of metacarpal bones and three fingers, leaving thumb

and little finger. (Erichsen.)]

When an entire finger is to be removed it is a question whether the

metacarpal belonging thereto should also be sacrificed for cosmetic

purposes. In general this is undesirable except in the case of the

fifth metacarpal with the little finger. This is easily exposed by

lateral incision along the ulnar border of the hand, sufficient to

disclose the bone and permit its disarticulation from the carpus. The

same is also true, in at least some instances, of the thumb, but it is

unwise to expose the carpal joints to the possibility of infection when

this can be avoided; moreover, the deep palmar arch crosses just in

front of the bases of the second to the fourth metacarpals, where it

must be carefully avoided. If, then, the metacarpal is to be sacrificed

this should be done rather from the dorsal side, while for cosmetic

purposes alone it is usually sufficient to disarticulate the finger

at its base and then simply remove the head end of the corresponding

metacarpal. Figs. 688 to 692 furnish illustrations of how the incisions

may be best planned to effect either of these purposes.

=Hand Amputations and Wrist Disarticulations.=--While it makes but

little difference whether the metacarpals be disarticulated from the

carpus or the latter from the radial end, it is advisable to adopt

whichever line of separation will best meet the indications. For a

removal of the _hand at or near the wrist_ two flaps usually afford

the most serviceable method, the palmar tissues being preserved, if

possible, in order that they may cover the stump. This operation is

usually done for injury, and it is more than likely that one will have

to plan his flap according to the tissues which still are serviceable.

[Illustration: FIG. 688

Outline of amputation of fingers, with their metacarpals. (Modified by

Matas from Mignon.)]

In the lower part of the _forearm_ the flap method furnishes a

serviceable stump. As the elbow is approached the circular or

elliptical methods are preferable, as illustrated in Fig. 690.

=The Elbow.=--With _elbow disarticulations_ caution should be observed

to have flaps of sufficient length. The joint is opened more readily

from its radial side. The integument of the back of the elbow region

lies closely upon the bone, is thin, and retracts but slightly.

Anteriorly there is more muscular covering and consequently a tendency

to retraction. Therefore the anterior flap should be made longer than

might otherwise seem to be required. Here the ideal scar will be behind

the end of the humerus, but it is difficult to obtain because of the

tendency to drag it around beneath the end of the bone. An elliptical

incision, directed obliquely downward and forward, is the easiest

method and furnishes the best stump. The lower end of the posterior

part of the flap should be at a distance below the articulation, at

least equal to the transverse diameter of the joint itself, _i. e._,

in an adult nearly one hand-breadth from the line of the joint to the

point of dissection. (Matas.) (Fig. 690.)

=The Arm.=--The _arm_ furnishes that nearly cylindrical outline best

adapted for circular amputations. Here, as at the elbow, the greatest

retraction is on the flexor side. With the arm should be saved all that

is possible even up to its upper extremity.

Remembering the greater tendency of the flexors to contraction the

truly circular method should be modified to a somewhat elliptical

incision, in order to compensate for this difficulty, while an external

liberating incision is often of assistance. Abrupt transverse division

of the muscle down to the bone should be made after the oblique

incision of the skin.

[Illustration: FIG. 689

Outline of amputation of two fingers simultaneously with their

metacarpals; also thumb with its metacarpal. (Modified from Mignon.)]

=Disarticulation at the Shoulder.=--Until accurate methods of blood

control were introduced this was an amputation viewed usually with

disfavor, in spite of the fact that compression of the axillary artery

in theory is easy. The older methods comprised this compression, either

above the clavicle, or by exposure of the vessel and its proximal

ligation, or by opening and separating the joint and then seizing the

vessels within the inner flap, and controlling them by digital pressure

until their division. Now with the use of Wyeth’s pins and the elastic

bandage, effectual control may be secured without resorting to any

of the former expedients. If the removal is to be a high amputation,

just below the neck of the humerus, the method shown in Fig. 691, of

application of the tourniquet and its control by a constricting strap,

may be adopted.

If the surgeon expect to disarticulate he should resort to the pins of

Wyeth (_i. e._, to the use of long mattress needles), which are passed

through from above downward, or from the axilla upward, one of them

being passed anteriorly and the other posteriorly, and brought out at

corresponding points on the upper aspect of the shoulder, where, their

points being protected by sterilized corks, they serve to prevent

sliding of the elastic bandage or tourniquet, which is now placed

proximally to them, and is thus held more securely than is possible in

any other way.

[Illustration: PLATE LVII

_1. Anterior oval or racquet incision for disarticulation of the

shoulder by attacking the joint through the delto-pectoral groove

(modified Spence’s operation)._

_2, 3. Circular amputation of lower and middle thirds of arm

transformed into double square, antero-posterior flap operation by

unilateral or bilateral vertical incisions._

_4, 5, 6, 7. Circular amputation at various levels of forearm,

including the disarticulation at elbow. In all of these, one or two

lateral liberating incisions, cut down to the bone, may be required,

on ulnar or radial side, or both, to permit easy retraction of solid

musculo-tegumentary antero posterior flaps._

_8, 9. Circular amputation at lower third of forearm; lateral

liberating incision should be added on ulnar side, or radial side, or

both, according to tonicity of limb._

_10. Long palmar projection of oval method in disarticulating hand._

Cutaneous Incisions in Amputations of the Upper Extremity (Ventral or

Flexor Side).]

[Illustration: PLATE LVIII

_1. Racquet incision (Larrey) intradeltoid for disarticulation at

shoulder._

_2. Solid circular with liberating incisions for upper third._

_3. Solid circular with liberating incisions for middle third._

_4. Circular amputation at lower third of humerus; incision slightly

favoring the flexor side, to compensate for greater retraction;

two lateral liberating incisions, to facilitate retraction of

musculo-cutaneous flaps from bone._

_5. Neudörfer’s racquet incision for disarticulation at elbow;

preferred in all cases in which a preliminary exploration of

the elbow, as in advanced tubercular cases, is attempted before

proceeding to disarticulate at elbow._

_6. Elliptical or oval incision with long projection on flexor side

to compensate for greater retraction of skin and muscles on flexor

(ventral side); the longer end of the oval may be advantageously

reversed, the long end on the exterior side, when the tissues on the

flexor side are injured. Usually, a slightly elliptical circular,

with two lateral liberating incisions, cut squarely to the bone with

all the soft parts, including the periosteum, is the preferred method

in this region._

_7. Antero-posterior flap incision for amputation at lower third of

forearm; tendinous region._

_8. Oval or elliptical incision in typical amputation of the hand

(radio-carpal disarticulation)._

Surface Tracings showing Some of the More Useful Lines of Skin Incision

in Amputations of the Upper Extremity (Dorsal or Extensor Surface).]

[Illustration: FIG. 690

Lines of amputation in lower third of forearm, of elbow, and lower

third of arm. (Modified from Mignon.)]

Circulation being thus controlled, a modified circular operation may

be made or a long external and superior flap cut, matching it with

another one dissected from the axillary aspect. In the former case the

circular incision is made on a level a little below the anatomical

axillary border. Then a cuff of skin being raised while the arm is held

in adduction, all the soft parts are divided to the bone and separated

from it. Now a liberating incision may be made from the anterior border

of the acromion to the coracoid process, then over to the deltoid

groove, and along it to the first circular incision. Through this all

the soft tissues surrounding the glenoid margin are separated, and then

the bone is enucleated by opening the capsular ligament, reserving

perhaps the detachment of the group of scapular tendons until the last.

If one have any fear as to the efficiency of his hemostatic precautions

he may secure the axillary vessels so soon as they are divided and

then proceed with the disarticulation as above. In some cases it may

be preferable to cut a wide flap from the deltoid region, preserving

that muscle or not as may be desired, and, after having thus exposed

the joint, make the disarticulation, separating the head of the bone

sufficiently to allow the passage of an amputating knife behind it

and down along the shaft to a distance sufficient to justify turning

it abruptly and toward the surface, and then cutting out the axillary

flap. The attempt should be to cut all the vessels at right angles

rather than obliquely.

Plates LVII and LVIII, prepared by Professor Matas, afford a synoptic

view of the more useful lines of skin incision in the principal

amputations of the arm and shoulder.

=Interscapularthoracic Amputations. Removal of the Entire Upper

Extremity.=--This includes removal not only of the arm, but of the

scapula and clavicle as well, or at least its outer portion. It is

not often required, and inasmuch as the circumstances which justify

it are seldom duplicated, a suitable method for each individual case

should be planned, rather than try to make one set of directions cover

them all. Much will depend upon whether sufficient skin can be saved

in order to cover the large defect thus made. In general, however,

an incision should first be made along the clavicle, exposing it and

dividing it near its middle. It is convenient to take out the middle

portion at this time, and in this way to afford ample room through

which a proximal ligation of the subclavian vessels may be made, they

being here carefully dissected out, secured by double ligation, and

divided. From the outer part of the above incision another is carried

downward and outward toward the deltoid groove and then beneath the

axilla to its posterior margin. The posterior flap is then furnished by

an incision continuous with the last one, which terminates below about

opposite the lower angle of the scapula, and is then continued upward

along the inner scapular border and over the shoulder until it reaches

the outer end of the incision first made. In this manner will be

furnished a sufficient covering. The balance of the operation consists

in the gradual separation of the entire mass from the outer wall of the

thorax. With a preliminary ligation of the subclavian vessels there

will be no hemorrhage which cannot be easily checked by pressure and

forceps.

The above, however, is only a general description, which may need to

be modified in most cases. If the amputation be done for injury all

the skin _which is still viable_ should be utilized, no matter how

shaped, while if done for disease the incisions may have to be modified

materially, taking more skin from one side and less from the other, in

order to avoid that involved in the disease process.

In the majority of cases the result is satisfactory, in spite of the

mutilation thus afforded.

[Illustration: FIG. 691

Esmarch’s elastic constrictor applied and held in place by a bandage

or a strap (Wyeth’s pins may also be used to hold the constrictor in

place) in high amputation of the arm. (S. Smith.)]

AMPUTATIONS OF THE LOWER EXTREMITY.

The most important physiological purposes of the foot are those of

support and locomotion, not mere tactile sensibility nor prehension.

Its purposes being different from those of the upper extremity, the

tenets previously held regarding the advantage of conservatism may be

changed to some degree, for a tender foot or leg-stump is sometimes

extremely annoying, even disabling, and it is in the end far better

to so plan an amputation of this extremity as to make the stump most

serviceable, without primary reference to its exact length. As in the

hand, foot-stumps should be covered with dense plantar (instead of

palmar) tissues, and the long flap should, therefore, be made from

the sole. When this is impossible it would be wiser to shorten the

stump. Moreover, as there will be constant friction upon the resulting

cicatrix, this should be placed in the most protected location, on the

dorsum of the foot.

The most important indication, then, in all foot amputations is to

_furnish a complete plantar flap and to place the scar on top of the

foot_.

=The Toes.=--Amputations of the _toes_ are, by virtue of their

shortness, nearly always disarticulations. The basal row of phalanges

should be preserved when possible, and even here the covering of the

stump should be as far as possible fashioned from the sole.

The _big toe_ may be removed by either internal or oval plantar flaps,

which should be long enough to cover the metatarsal head, otherwise the

latter must be decapitated. These same principles also apply to the

_little toe_. When all or most of the toes have to be severed it may as

well be done by a single dorsal incision, as seen in Fig. 692, which

will permit either their disarticulation or their removal along with

that of the ends of the metatarsals. These methods are shown in Figs.

692 and 693.

_Amputation of a toe with its metatarsal_ is best effected by a racket

incision. This may extend up to the posterior tarsal joint. Some have

recommended to enucleate the metatarsals subperiosteally, through

dorsal incisions, all the soft parts being scrupulously left behind.

With the first and fifth toes the scar should be so placed as to be

removed from the edge of the foot (Fig. 693).

_Partial amputations of the foot_ have been suggested and devised

in great numbers, and the subject has been greatly complicated by

the number of methods that were taught. Modern ideas of conservative

surgery have caused a complete departure from the anatomist’s standard,

and it has been shown that with aseptic technique there is no advantage

in disarticulating when it leaves irregular lines. As Matas says:

“As Agnew taught long ago in this country, and others elsewhere, the

skeleton of the foot must be considered a surgical unity, to be treated

by the knife and saw just as the femur and humerus would be, at the

exact point which will yield the longest and most useful stump to the

patient. What is essential in every case is the application of the

principle of plantar flaps--preservation and scar protection.”

Concerning the utility of many of these methods and the usefulness of

the resulting stumps we may learn more from the makers of artificial

limbs than from almost any other source. Thus, Truax, for instance,

who has had large experience as a mechanic, has given this advice,

as quoted by Matas: “Avoid amputation within three inches of the

ankle-joint; do not amputate between the metatarsal bones and the

junction of the lower and middle thirds of the tibia. At other points

save all you can, and you will in every case have done the best for

your patient.” Should one be rationally governed by this advice a large

number of amputation methods which cumber most text-books would be

discarded.

[Illustration: FIG. 692

1, simultaneous disarticulation of all the toes; 2, amputation of the

toes in their continuity. (Mignon.)]

[Illustration: FIG. 693

1, partial amputations of the third and fifth metatarsals; 2,

disarticulation of the first and fifth metatarsals. (Mignon and

Matas.)]

[Illustration: FIG. 694

Tracings of intratarsal amputations at various levels (outer side):

1, subastragaloid; 2, tibiotarsal; 3, tibiocalcaneal; the different

lengths of flaps shown in relation to skeleton.]

[Illustration: FIG. 695

Tracings of incisions in mediotarsal amputations and total amputation

of fifth toe. (Mignon and Matas.)]

For my own part I would advise to save all of a foot that can be saved,

providing a sufficiently long plantar or heel flap can be retained; but

if these are not available, then I would advise amputation, at least

three inches above the ankle.

I would advise, moreover, to discard the complicated rules and

technique of stilted methods and to use the saw whenever it can be

made useful, rather than to go farther back to a row of joints simply

because they are joints (Fig. 694).

Figs. 695 and 696 illustrate conservative modern methods, which are

perfectly available for most purposes, and from which departure need be

made only when peculiar circumstances obtain, which so complicate the

case that none of the ordinary rules would apply. A surgeon of judgment

and experience is competent to devise a flap for a given case, whether

it complies with standard methods or not. It seems to me, therefore,

worth while to describe only the so-called _mediotarsal disarticulation

of Chopart_, in which but the astragalus and calcis remain of the

proper bones of the foot. The joint line extends from just behind the

tuberosity of the scaphoid to the outer side of the body of the calcis,

where a tubercle can be usually felt. Across this line an incision is

carried obliquely over the dorsum of the foot. The plantar flap is the

long one, and the line of division is just behind the balls of the

toes. Two lateral incisions can be made to facilitate disarticulation

if desirable.

[Illustration: FIG. 696

1, disarticulation at the tarsometatarsal joint, showing length of

flaps; 2, disarticulation of the big toe in continuity. (Mignon.)]

This operation sometimes leaves the foot in a bad equinus position;

accordingly it is wise to make tenotomy of the tendo Achillis, as well

as to attach the dorsal or extensor tendons to the stump end. (See

Figs. 699 and 700.)

=Amputations of the Foot (Tibiotarsal).=--The former favorite method

of amputating the _foot proper_ was that of Syme, illustrated in Fig.

701. This preserved the plantar surface and tip of the heel, thus

forming a cutaneous hood, which was made to cover the lower ends of the

tibia and fibula, whose malleoli were usually removed close to their

terminations. The incision is made directly down to the bone, from

the apex of one malleolus across the sole and up to the other. Then

the foot is forced into extreme flexion and another incision carried

directly across the dorsum, by which the upper ends of the first are

joined. This permits opening the ankle-joint in front, after which the

lateral ligaments are divided and the astragalus dislocated forward.

The heel hood is next carefully separated from the calcis with the

knife, and it and all the parts retracted from the ends of the leg

bones, which are divided just above the articular surfaces, or the

latter may be left and the malleoli alone removed. Now the heel hood is

raised, made to cover the end of the leg, and united to the anterior

incision, drainage being made by a small opening on the outer side of

the tendo Achillis, as the plantar surface of the flap should not be

opened (Fig. 703).

[Illustration: FIG. 697

Lisfranc’s tarsometatarsal disarticulation. (Farabeuf.)]

[Illustration: FIG. 698

Stump after same.]

[Illustration: FIG. 699

Classical mediotarsal amputation (Chopart), showing length of plantar

flap. (Farabeuf.)]

[Illustration: FIG. 700

Stump after Chopart’s amputation. (Farabeuf.)]

[Illustration: FIG. 701

Syme’s tibiotarsal operation, showing part removed and lines of

section, before division of malleoli. (Farabeuf.)]

Fig. 702, the complement of Fig. 701, illustrates the appearance of

the stump after the completion of the disarticulation and before the

removal of the malleoli.

Pirogoff introduced a serviceable modification by obliquely dividing

the os calcis in front of the heel, turning up its sawed surfaces

without any dissection of the hood from the heel, and uniting its fresh

bone aspect with that made by removal of the articular ends of the leg

bones. This would seem to be preferable to Syme’s disarticulation,

affording a better walking stump. (See Figs. 704 and 705.)

A reverse of this operation was suggested by Mikulicz and Wladimiroff,

independently, and at about the same time, the heel being excised by an

incision across the sole and then behind the ankle, the calcis being

divided and its posterior end removed, while the articular surfaces

of the leg bones are also removed. The foot is then brought down so

that these surfaces can be brought in contact, it being expected that

after their reunion the individual will walk in the exaggerated equinus

position and upon the ends of the metatarsal bones. The operation is,

in effect, an exsection rather than an amputation, and is applicable to

but a very small number of cases, in which, however, it sometimes gives

excellent results. (See Fig. 707).

[Illustration: FIG. 702

Syme’s amputation after disarticulation of the foot at the ankle-joint.

The soft parts are being cleared from the malleoli preparatory to

sawing the malleoli and lower articular surface of tibia. (Farabeuf.)]

[Illustration: FIG. 703

_S_, line of incision for Syme’s operation; _P_, line of incision for

Pirogoff’s operation. (Erichsen.)]

=Amputations Of the Leg.=--Modern prosthetic methods have materially

changed the indications in amputating the leg. The pressure in

artificial limbs is not borne upon the end of the stump, but is rather

circumferential and borne by a conical socket. It is now, therefore,

an object to preserve as much of the limb as practicable, in order to

have better leverage or control of the artificial member. Consequently

the point of election is now the middle of the leg, unless the

amputation may be made even below this point. The objection to a short

leg stump is the inevitable flexion which the hamstring flexors will

produce; in such cases the pressure will be borne upon the knee, while

the appearance of the stump is by no means ideal. If, therefore, one is

forced to make a high amputation of the leg it would be far preferable

to make a good knee disarticulation, or, better still, a supracondyloid

amputation, with preservation of the patella, thus furnishing a stump

which affords perhaps the only exception to the general rule, _i. e._,

that weight cannot be borne upon the stump end.

[Illustration: FIG. 704

Skeleton of stump after Pirogoff’s osteoplastic amputation. The sawed

surface of the calcaneum in apposition with divided surface of tibia.

(Farabeuf.)]

[Illustration: FIG. 705

Stump after Pirogoff’s operation. The weight of the body must rest upon

the thick plantar skin of the heel and never on the thin skin of the

retrocalcaneal surface. (Farabeuf.)]

[Illustration: FIG. 706

Sections of bone in Pirogoff’s amputation and its modifications: 1,

oblique section of calcaneum to correspond with (1) oblique section of

tibia. (Gunther.) 2, curvilinear or concave section of calcaneum to

correspond with (2) convex section of tibia. (v. Bruns.) 3″, horizontal

section of calcaneum to correspond with (3) similar section of tibia.

(Pasquier Le Fort.) 3‴, vertical section of calcaneum to correspond

with (3) horizontal section of tibia. (Typical Pirogoff.) (Modified by

Matas from Mignon.)]

[Illustration: FIG. 707

Osteoplastic excision of foot. (Mikulicz.)]

Let us, then, consider but one or two amputations of the leg--that low

down or near the middle and that at the knee. Whatever the method it is

most desirable that the scar be kept off to the side, and especially

_away from the front of the shin_. This can be best accomplished by a

modified circular (Fig. 708) or a bilateral flap method (Fig. 711), or

by the oblique method with lateral incisions, which practically convert

it into an anteroposterior operation, while for certain instances the

method of Teale may be preferred, _i. e._, that with a long anterior

and short posterior flap, or its modification by which the flaps are

made more lateral, or the even long flap method of Bell.

[Illustration: FIG. 708

Modified circular amputation of upper third of leg. (Erichsen.)]

Whichever of these be selected, after division of the muscles and

exposure of the bone, it is usually helpful to retract the flaps,

whatever their shape, by a cloth retractor made of a piece of sterile

bandage torn into three strips, the middle of which should be inserted

between the bones of the leg, the interosseous membrane being divided

for this purpose; by this they are held more perfectly out of the

way during the act of dividing the bones. The anterior border of the

tibia, which is practically a sharp ridge, should be divided obliquely

(bevelled), either by a small oblique section before the transverse

division is made, or by effecting this later, in order that there shall

not remain a sharp point to project through the skin or be subject to

constant irritation. The tibia is usually divided transversely, with

the above exception. The fibula may be divided slightly obliquely. It

is customary, however, to make the division simultaneously, and to so

conduct the sawing process as to divide the fibula completely before

the last strokes of the saw cut through the tibia.

There is greater difficulty in the recognition and securing of vessels

in leg amputations than in any other, especially if they have been

divided obliquely. The principal vessels may be found from their known

anatomical location. They nevertheless sometimes tend to retract

and they must be followed up in order to properly secure them. The

accompanying nerve trunks should also be seized firmly, drawn down, and

divided two or three inches above the line of division of the other

tissues, in order that they may retract out of harm’s way. Every nerve

which can be recognized, even in the skin, should be thus treated.

Before closing the wound it is well, unless one is absolutely sure of

his work, to release the tourniquet and ascertain if any vessel which

would otherwise bleed be not yet secured. Oozing may be checked with

hot water, while muscle surfaces which leak too much blood may be

lightly enclosed within catgut sutures inserted with a curved needle.

Providing that these stumps have well-nourished flaps, and that no

sharp or angular bone ends interfere with subsequent comfort, and that

the scars be kept away from their lower surfaces, they serve their

purpose admirably.

Supposing, then, that amputation is to be about the middle, the first

incision, made with a stout scalpel, is begun at the anterior border

of the tibia and carried downward along it until it is turned abruptly

backward to the posterior aspect, and then upward until a point is

reached opposite that of commencement. The skin is dissected up for

perhaps an inch. Then the flap on the other side is cut after the

same fashion, after which, with a short or long knife, the muscles

are divided transversely or circularly down to the bone. Much will

depend now upon whether the desire is to resort to the more modern

osteoplastic methods or adhere to the old. In the latter case it is

well to separate the flaps for the necessary distance from the bone,

with or without the periosteum, dividing the bones after suitable

retraction, as above suggested. If preference be for an _osteoplastic

flap_ it is planned and made at this time, the bone being divided

at the same level as the muscles, and the amputation being thus

practically completed, after which the osteoplastic flap is arranged,

it being now necessary to carefully preserve the periosteal bridge

and to again divide the bone at the base of this periosteal flap,

this being the true end of the bone stump. In this case the fibula is

divided at a higher level.

It is perhaps less desirable to preserve periosteum in young children

than in adults, for if bone be permitted to grow too rapidly conical

stumps result, sometimes even with protrusion of bone ends. Ollier and

his pupil Mondan have shown that this so-called _atrophic elongation_

of bone is a consequence of abnormally rapid growth from the upper

epiphyseal direction, permitted by lack of pressure from below, and

that conical stumps will often happen in children in spite of every

precaution. Nevertheless it should not be encouraged, and for this

reason periosteum should not be preserved.

The _method of Teale_ was to cut a long anterior flap, raising the

coverings from the bone with the least possible disturbance, to divide

the bone at the high level, then to double the flap upon itself in such

a way as to bring the scar at a level one inch or more above the stump

end. Heine modified this slightly by raising the periosteum with the

rest of the anterior flap. In cases which permit such a long flap to be

formed from one aspect of the leg the method gives excellent results

(Fig. 709).

[Illustration: FIG. 709

Teale’s method of amputation.]

Bruns devised a method which is begun almost as an exsection, by an

oblique circular incision, with liberating lateral incisions, and

division of all the tissues over the inner border of the tibia and

the outer side of the fibula; after which, without disturbing skin

attachments in front, the periosteum is separated from the bones as

high as the liberating lateral incisions permit, and then the fibula

first and later the tibia divided. It is practically a subperiosteal

excision of the leg bones and affords a well-protected stump. In effect

it is an anteroposterior flap method.

[Illustration: FIG. 710

Stump after Stephen Smith’s amputation at knee.]

=The Knee.=--It was Brinton who, in 1872, suggested the preservation

of the semilunar cartilages in all knee disarticulations, as in this

way all the normal relations are preserved and retraction is prevented.

But the makers of prosthetic apparatus have urged to abandon all

true disarticulations, and to substitute for them the supracondyloid

method, which affords ideal stumps. Disarticulations are supposed to

produce less shock, less loss of blood, and less danger of sepsis from

opening up the bone-marrow, while muscle insertions are less disturbed

and the stump covering usually is mobile and not very sensitive. No

disarticulation should be thought of unless the joint involved be

free from disease and unless about it there be met sufficient healthy

integument to furnish a satisfactory flap.

For a true _disarticulation_ Stephen Smith’s bilateral method is now

almost universally adopted. Here the incision is begun one inch below

the tubercle of the tibia and is carried directly down to the bone,

downward and forward around the side of the leg, and then inward and

upward toward the middle of the popliteal space, the lateral flaps thus

made being nearly duplicates. The flaps thus cut out are completely

separated from the bone up to the joint level, where the ligaments

are divided, the joint being manipulated as may be necessary to best

expose them and facilitate division. In this operation the patella is

usually removed, the joint being opened by separating its ligament at

its insertion into this bone. One should remember that the internal

condyle is lower and longer than the external, and that the internal

flap should be perhaps made on this account a little the longer of the

two. Fig. 710 illustrates the stump resulting from this operation and

shows the cicatrix drawn up out of harm’s way and resting in the fossa

between the condyles. Fig. 711 illustrates the simple method by lateral

flaps.

[Illustration: FIG. 711

Amputation at knee by lateral flap. (Erichsen.)]

=Amputation of the Thigh.=--Under this head, rather than that of

amputation at the knee, should be described the _supracondyloid

amputations_ which give decidedly the best results of all, and which

are preferable to any others for the middle of the lower extremity.

Of these the best is that suggested by Gritti, which consists in not

only removing the condyles but sawing off the articular surface of

the patella, which is then drawn upward and applied to the end of the

femur, the division of the latter being made at a point above the

condyles, where the diameter of both bones will nearly correspond, this

latter perhaps being a suggestion of Stokes rather than of Gritti, who

did not divide the bone quite so high. (See Fig. 712.)

[Illustration: FIG. 712

Gritti’s osteoplastic supracondyloid knee amputation, patella utilized:

_a_, shaded parts are those brought in apposition; _b_, appearance of

Gritti stump after suture; _c_, correct apposition of patella to femur;

_d_, defective apposition. (Farabeuf.)]

Fig. 712 will best illustrate the intent of the method as well as its

performance. The incisions are planned much as in the Stephen Smith

disarticulation method, only they are placed higher, and the patellar

tendon is divided as low down as possible, or even separated from the

tibia, in order that it may be made of use in attaching the divided

patellar surface to the femoral end. The rest of the operation is

performed as by other methods, the attachment of the patella being

effected by tendon sutures, or, if necessary, by an ivory peg, or even

a metal tack or nail which may be left in place.

The beauty of this method is that the anterior surface of the patella

is preserved with its natural weight-bearing facilities and the bursa

between it and the skin, while the latter is undisturbed. On the end of

this stump as much weight can be steadily borne as when one ordinarily

kneels, and to it a most serviceable kind of artificial limb can be

attached, with which one may walk as though nothing had ever happened.

Another osteoplastic method, namely, that of Sabanejeff, is illustrated

in Figs. 713 and 714. In this instance the bone covering over the end

of the femur is taken from the upper end of the tibia, the patella

not being disturbed. It permits a lower division of the femur and the

formation of a stump which is of practically the same length as the

original thigh.

[Illustration: FIG. 713

Sabanejeff’s knee amputation. (Chalot.)]

[Illustration: FIG. 714

Stump made as in Fig. 713. (Chalot.)]

=Amputation of the Thigh above the Knee.=--For _removal of the thigh_

it is well to preserve as much of its length as possible, and yet not

at the expense of all other considerations. A thigh stump too short

is likely to be pulled awkwardly upward by the psoas muscle, and upon

such a stump it is difficult to secure an artificial limb tolerable

of control against such action of this muscle. On this account, then,

thigh stumps should be long. So far as the method is concerned the

circular, or some modification thereof, gives the best results in

the majority of instances. It may easily be modified into one of the

oblique methods, or liberating incisions may be used whenever they will

be of service. If it be absolutely necessary to make the amputation

high hemostasis can be secured by the same methods that are used in

hip-joint amputations. The dense and strong fascia lata, which lies

beneath the superficial fascia, should be divided at the same level

with the skin, since it serves admirably, when secured by a separate

set of sutures, to make a good covering for the ends of the muscles,

after these have been themselves carefully united by buried sutures.

The sciatic nerve should be especially sought, thoroughly stretched,

and divided high up. The vessels often evince a tendency to retract

within Hunter’s canal; it is not, however, difficult to separate the

vastus internus from the adductor longus, between which they lie, and

in this way gain access to them. Even for high work on the thigh one

may, if necessary, do as some have done at the hip, make a preliminary

ligation of the femoral artery. This may be especially serviceable as

an emergency measure, or in special cases of tumors which have attained

large size, are placed high up and call for somewhat atypical methods.

=The Hip-joint.=--Amputation here is essentially a _disarticulation_

and constitutes one of the usually formidable and serious operations

of major surgery. Although the joint itself is generally easily

reached there are many things to be considered in the performance of

this operation, of which the mere arthrotomy is by no means the most

important.

Preparations being all made, the first consideration is the _control

of hemorrhage_, for which several methods have been suggested,

but of which but two or three are in general use. Such procedures

as compression of the abdominal aorta, either with the hand or by

tourniquet, or of the common aorta through the rectum, with a lever, as

suggested by Davey, or with the hand, as suggested by Woodbury, or the

exposure of the common iliac, either within the peritoneum as practised

by McBurney, or externally, or exposing the common femoral above

Poupart’s ligament, are now adopted by very few surgeons. Langenbeck

used to be fond of preliminary ligation of the femoral where it is

most accessible in the groin, and this is probably the best of all of

these methods. But they have been all practically discarded since Wyeth

introduced the simple method of transfixing the limb with his pins (_i.

e._, long mattress needles or skewers made for the purpose), these

serving to hold in place an elastic cord or tourniquet (Fig. 715). This

has been found to be a great improvement on the suggestion of Senn, who

excised the femoral head and then compressed each half of the limb with

a separate elastic band.

[Illustration: FIG. 715

Wyeth’s bloodless method: pins inserted and tube applied.]

The directions for the use of Wyeth’s pins are simple. Here, as in

other cases, it may not be practicable to use the elastic bandage from

the lower end of the limb, but one may at least elevate the limb and

thus coax the blood out of it by gravity or by gentle manipulation.

While it is still in this position one of the long pins is introduced

just below the anterosuperior spine and a trifle to its inner side, and

made to emerge on a level with and about three inches from the point of

its entrance. The other needle is inserted just to the inner side of

the saphenous opening, and below the level of the crotch, and brought

out about one inch below the tuberosity of the ischium. Corks should

then be placed upon them so as to protect the needle points. Next a

piece of elastic tubing or band is placed around the limb above these

pins and tightened, each turn being made a little tighter, so as to

absolutely control the circulation. The effect of this is felt upon

practically every vessel in that part of the body, and if the method be

properly practised it affords absolute security.

The surgeon now has his choice of various methods of disarticulation,

either that by anteroposterior flaps or lateral flaps, or by the

circular, with the free liberating lateral incision; or he may devise

any method of his own which will best meet the indication in a given

case. Fig. 715 illustrates the employment of Wyeth’s pins and the

first circular incision made as for the circular method. Of these

all the latter seems preferable when circumstances permit. It should

be combined with a sufficient lateral incision, which should be made

to pass well over the great trochanter. The cuff raised through this

incision should extend down to the deep fascia and up to the level of

the lesser trochanter, at which level the deeper tissues are divided

transversely or by a circular cut.

It is well next to lay down the knife and secure the large vessels,

after which the deep muscles are separated from the upper end of the

shaft and the proximity of the joint, while the entire limb may be

still used as a lever in so stretching the joint capsule as to better

expose and divide it. So soon as the capsule has been opened, and the

entrance of air thus permitted, it will be easy to expose and divide

the teres ligament, after which the balance of the disarticulation is

easily effected. The large nerve trunks are now sought, retracted, and

divided high up, all visible vessels are secured firmly, after which

the elastic constriction may be gradually released and any vessels that

spurt may still be secured. There will nearly always be troublesome

oozing from the cut ends of the large muscles, and here, if hot water

prove insufficient to check it, with large curved needles and catgut

sutures the muscle ends may be secured by ligature _en masse_, before

they are brought together for the purpose of closing the stump.

Whatever the method selected as perfect a closure of the wound as

possible should be made, with ample provision for drainage. By careful

deep suturing, with tiers of buried sutures, it is possible to avoid

leaving dead spaces at any point except perhaps the acetabulum. Through

retaining sutures may also be used to advantage. It is most desirable

to so plan the incisions and the closure of the wound as to keep them,

so far as possible, away from the region of the perineum. Therefore the

longer the inner flap or inside of the stump the better. As conditions

which necessitate removal of the limb at the hip-joint are always

serious, and have each their own peculiarities, any method which will

best serve the purpose should be used.

Plates LIX and LX, designed by Prof. Matas, afford the best and

briefest epitome of the choicest amputation methods which can be

furnished.

THE STUMP.

An amputation having been effected, and the stump closed, there is

still occasion to consider how it may best be treated to fit it for its

future purposes. When entire chapters, or even small monographs, can be

written on the subject of “diseases of stumps” it would appear that the

consideration is not one of merely trifling import.

A _good stump_ has a regular outline, with a protected scar, and

should be firm, yet mobile, and without tender or sensitive surfaces.

It should constitute the lower end of a truncated cone, and needs to

be of sufficient length to permit leverage within the socket of the

artificial limb which will be fitted about it.

A stump failing in these characteristics is a _bad_ stump, the features

which especially tend to make it bad being undue conicity (Fig. 716)

or sensitiveness of surfaces, ulceration from friction, or, worse yet,

occurring without it, and neuralgia from inclusion of nerve ends, or

from bone ends which present osteophytic outgrowths and thus distort

and displace tissues (Fig. 717). Acute osteomyelitis occurs in stumps,

as do slower carious processes which may call for re-amputation,

perhaps even at a distance. The stump is for a long time more or

less tender and troublesome, and its owner may be a sufferer from

hyperesthesia or perverted sensations.

The possibility of the production of a conical stump in children as the

result of _atrophic elongation_ was mentioned early in this chapter.

While this cannot always be prevented it may sometimes be foreseen,

and one should be prepared at any time in such cases to circumcise the

bone, forcibly retract the tissues, and then divide the bone ends on a

higher level.

[Illustration: PLATE LIX

_1, 2. Circular for middle and upper thirds of thigh._

_3. Circular for lower third of thigh, showing tendency of circle

to incline downward on adductor side to compensate for greater

retraction._

_4. Incision for Gritti’s or Carden’s amputations at knee (single

anterior flap)._

_5, 6. Stephen Smith’s bilateral flaps (posterior racquet)._

_7. Antero-posterior flaps, cut solid to the bone, the soft parts

being elevated from the periosteum (Marc See, von Brun’s method).

This is the author’s preferred method for leg only, simplified by

making a simple circular with two lateral liberating incisions on

fibular and tibial sides._

_8, 9, 10. Circular with posterior racquet extension to form

bilateral flaps (Stephen Smith)._

_11. Guyon’s supra-malleolar amputation._

_12. Lines of Syme’s amputation._

_13. Inner aspect of Roux’s tibio-tarsal amputation; also

subastragaloid._

_14. Medio-tarsal amputation (inner aspect)._

_15. Tarso-metatarsal disarticulation (inner aspect)._

_16. Disarticulation of toe with its metatarsal._

_17. Disarticulation of big toe; in front of this lines for

amputating first or terminal phalanx by long plantar flap._

The Right Lower Limb, Internal Lateral View (Surface Incisions).]

[Illustration: PLATE LX

_1. Low circular with external incision (Furneaux Jordan) or at a

higher level (gluteo-femoral furrow) applicable to Wyeth’s method of

disarticulating hip._

_2. Circular incision with tendency to racquet posteriorly in middle

third amputations._

_3. Circular with posterior vertical incision in amputation of lower

third of thigh._

_4. Long anterior flap for supra-condyloid amputation of thigh._

_5. Racquet incision with long anterior flap for extreme upper third

of leg. Note long posterior tail, which facilitates upward retraction

of a solid musculo-cutaneous flap cut down to the periosteum,

resembling a bilateral flap operation (Stephen Smith). The same

incision cut a little higher is most serviceable in disarticulating

at the knee._

_6. Long-hooded anterior flap, with posterior racquet (Stephen Smith

and Bier’s osteoplastic)._

_7. Amputation by equal antero-posterior flap (Marc See, von Bruns)._

_8. Amputation by long anterior and short posterior flaps (Teale’s

principle)._

_9. Amputation of leg at extreme lower third, practically a circular

amputation converted into a solid antero-posterior flap by liberating

incisions on fibular and tibial sides._

_10. Guyon’s supra-malleolar amputation of leg._

_11. Medio-tarsal and intra-tarsal amputations (Chopart and its

derivatives)._

_12. Tarso-metatarsal amputation (Lisfranc and derivatives)._

Surface Outlines of Amputations Practised in the Lower Extremity.]

An exquisitely neuralgic stump is usually made so by the entanglement

of nerve ends and their subsequent enlargement into so-called

_amputation stump neuromas_ (which are histologically fibromas), from

pressure upon nerve terminals. Under these circumstances their excision

through incisions planned for the purpose, or the exsection of a

portion of the nerve trunk at a higher level, may be necessitated (Fig.

717).

[Illustration: FIG. 716

Extreme case of conical stump.]

[Illustration: FIG. 717

Neuromatous endings of nerves in a stump.]

[Illustration: FIG. 718

Ideal stump.]

[Illustration: FIG. 719

Bad stump, because posterior flap was cut too short, and there has been

great retraction of all soft tissues. (Farabeuf.)]

While patients may prefer disuse of a stump for as long a time as

possible the judicious surgeon will prepare it as rapidly as he may

for early application of the expected artificial limb. Inasmuch as leg

stumps allowed to hang downward become cyanotic and edematous it is

well to keep them bandaged, and the makers of artificial limbs prefer

to have the bandages kept wet. When the stump is healed, passive motion

of the remainder of the limb should be begun, in order that there

may be a minimum of stiffening of joints. If, then, such a stump be

bathed, massaged, moved, and then bandaged with comfortable snugness

with cold, wet bandages, over which oiled silk may be fastened, and if

this be done at least once each day, the stump will be prepared for the

artificial limb, on the average, in two to three months. One should

not wait for this expiration of time if it be thoroughly healed; or,

on the other hand, he may have to wait much longer under unfortunate

circumstances; but the above general principles of treatment and

general statements will be found to prevail. Figs. 718 and 719

illustrate the difference between good and bad stumps, while Plates

LIX and LX (reproduced from Matas) furnish the surface outlines for

selection of the various amputations of the lower limb.

CINEPLASTIC OR CINEMATIC AMPUTATIONS OF THE UPPER EXTREMITY.

The most pronounced and illustrative of recent methods is perhaps the

“cinematic” or “cineplastic” procedure of Vanghetti. This Italian

surgeon proposed a prosthetic method, in 1898, which is illustrated in

Figs. 720, 721 and 722. He has shown that tendon terminations may be

left exposed in stumps, under favorable conditions, and so utilized

as to serve remarkably useful purposes--though under exceptional

conditions. For a description of these methods the reader is referred

to his monograph. (G. Vanghetti, _Plastica e Protesi Cinematiche_,

Empoli, 1906.)

[Illustration: FIG. 720

FIG. 721

FIG. 722

Results of Vanghetti’s “cinematic” method, with preservation and

utilization of tendons.]

INDEX.

A

ABDOMEN, diseases of, diagnosis of, 768

distention of, in appendicitis, 856

drainage of, 776

general considerations and conditions of, 767

inflation of, 769

inspection of, 768

measurement of, 769

operation on, technique of, 773

palpation of, 768

bimanual, 769

wounds of, gunshot, 214, 232

Abdominal aorta, aneurysm of, 346

ligation of, 356

cavity, irrigation of, 775

diseases, diagnosis of, 768

incisions, closure of, 777

operations, after-treatment of, 777

embolism following, 784

hemorrhage after, 780

peritonitis following, 780

technique of, 773

thrombosis following, 784

viscera, general considerations and conditions of, 767

wall, abscess of, 783

actinomycosis of, 783

burns of, 783

carcinoma of, 784

contusions of, 781

cysts of, congenital, 783

endothelioma of, 784

epithelioma of, 784

erysipelas of, 783

fibroma of, 784

foreign bodies in, 783

gangrenous cellulitis of, 783

hematoma of, 781

injuries of, 781

lacerations of, 781

osteomyelitis of, 783

phlegmons of, 783

sarcoma of, 784

suppurative spondylitis of, 783

syphilis of, 783

tuberculosis of, 783

tumors of, 783

vascular, 784

wounds of, gunshot, 783

penetrating, 781

Abscess of abdomen, 783

atheromatous, 73, 339

bone, 419, 425

treatment of, 426

of brain, 567

prognosis of, 569

symptoms of, 568

treatment of, 573

of breast, 757

classification of, 58

acute, 58

cold, 58, 112

gravitation, 58

metastatic, 59

subacute, 58

subfacial, 59

subperiosteal, 59

cold, 112

peri-articular, treatment of, 399

collar-button, 319

definition of, 58

frontal, 569

of heart wall, 733

ischiorectal, 879, 1013

of liver, 911

symptoms of, 912

treatment of, 912

lumbar, 114

of lung, 734

of mesentery, 939

metastatic, 59, 91

occipital, 569

of pancreas, 949

parietal, 569

peri-appendicular, 860

perilaryngeal, 704

perineal, 1013

treatment of, 1013

perinephritic, 961

perirectal, 879

treatment of, 879

peritracheal, 704

perityphlitic, 860

of prostate, 994

psoas, 114

of rectum, 879

treatment of, 879

renal, 957

retropharyngeal, 114, 682

signs of, 60

of spleen, 941

subphrenic, 753

treatment of, 754

symptoms of, 60

temporosphenoidal, 569

of tonsils, 662

treatment of, 60

Abstraction of blood, 182

A. C. E. mixture, 198

Accommodation, defects of, 604

Acetabulum, migration of, 453

Acetonemia, 82

Acetonuria, 82

Acheilia, 638

Achondroplasia, 432

Acid intoxication from anesthetics, 203

Acinous carcinoma, 290

Acoustic nerve, neurofibroma of, 584

Acromegaly, 437

Acromial process, fracture of, 494

Actinomycis, 109

fungi, 55

Actinomycosis, 109

of abdominal wall, 783

of bone, 432

of breast, 759

definition of, 109

diagnosis of, 110

of face, 640

of intestines, 827

of kidneys, 964

of liver, 914

of lung, 732, 734

of mesentery, 939

of mouth, 657

organism of, 109

prognosis of, 110

pus in, 109

of skin, 308

of thorax, 729

of tongue, 659

treatment of, 110

Adenocarcinoma, 285

of bladder, 992

of pancreas, 953

Adenoids of pharynx, 679

treatment of, 680

Adenoma, 284

of bladder, 992

of breast, 760

of kidney, 969

congenital, 969

of liver, 914

of pancreas, 953

of rectum, 885

sebaceous, 285

cysts, 285

of thyroid, 712

Adenosarcoma, embryonal, 268

Adventitious bursæ, 263

Ainhum, 76

Air embolism, 38

of veins, 363

Aleppo boil, 309

Alimentary canal, infection through, 49

Allantoic cysts, 260

Alveolar sarcoma, 274

suppuration, 664

Alypin, 207

Amastia, 755

Amazia, 755

Amputations, 1023

of arm, 1032

atypical, 1023

control of hemorrhage in, 1024

of elbow, 1031

of finger, 1029

of foot, 1037, 1041

Bruns’ method, 1042

partial, 1034

Teale’s method, 1042

of forearm, 1031

of hand, 1031

of hip-joint, 1045

Davey’s method, 1045

McBurney’s method, 1045

Woodbury’s method, 1045

Wyeth’s method, 1045

interscapularthoracic, 1033

of knee, 1043

Gritti’s method, 1044

Sabanejeff’s method, 1044

Stephen Smith’s method, 1043

of leg, 1039

Bier’s osteoplastic, 1028

circular, 1041

Pirogoff’s method, 1040

of lower extremity, 1034

mediotarsal of Chopart, 1037

method of, 1026

circular, 1026

flap, 1027

osteoplastic, 1027

of penis, 1010

of shoulder, 1032

stump after, 1046

bad, 1046

good, 1046

neuromas, 1047

supracondyloid, 1043

of thigh, 1043

above knee, 1044

Gritti’s method, 1043

Stokes’ method, 1043

of thumb, 1029

tibiotarsal, 1037

of toes, 1034

typical, 1023

of upper extremity, 1029

cineplastic, 1048

entire, 1033

of wrist, 1031

Anastomosis of arteries, aneurysm by, 344

gastric, 816

of intestines, 842

Anastomotic varix, 364

Anel’s method of treating aneurysm, 347

Anemia, 30

pernicious, 30

primary, 30

secondary, 30

splenic, 31

Anesthesia and anesthetics, 192

A. C. E. mixture, 198

accidents from, 201

arrested respiration, 202

treatment of, 202

cardiac failure, 201

acid intoxication from, 203

administration of, 193

anesthol, 200

chloroform, 195

accidents from, 196

action of, 196

administration of, 197

death from, 196

choice of, 200

dangers of, 201

discovery of, 192

ether, 193

accidents due to, 194

action of, 194

narcosis by rectum, 195

petroleum, 199

sequels from administration of, 195

ethyl bromide, 198

chloride, 199

local use of, 199

intraspinal, 207

local, 205

alypin, 207

anesthesin, 207

beta-eucaine, 207

cocaine, 205

liquid air, 205

nervanin, 207

orthoform, 207

stovaine, 207

magnesium salts, 209

management of, 192

methylene bichloride, 198

morphine, 205

nitrous oxide gas, 200

scopolamine, 205

somnoform, 199

Anesthesin, 207

Aneurysmal bruit, 341

varix, 363

of abdominal aorta, 346

arteriovenous, 344

of axillary artery, 345

of carotid artery, 345

external, 345

internal, 345

cirsoid, 278, 339, 344

classification of, 342

diagnosis of, 345

diffuse, 339, 342

dissecting, 339, 342

false, 339, 343

of femoral artery, 346

fusiform, 339, 343

of heart, 732

hernial, 339

of iliac artery, 346

of innominate artery, 345

intracranial, 345

of liver, 914

of neck, 701

of orbit, 592

progress of, 341

pulsation of, 341

racemose, 344

rupture of, 341

sacculated, 339, 342

spontaneous, 339

of subclavian artery, 345

traumatic, 339, 343

treatment of, 346

by extirpation, 348

by introduction of wire, 348

by ligation, 347

Anel’s method, 347

Brasdor’s method, 347

Hunter’s method, 347

Wardrop’s method, 347

by open division, 347

by opening and suture, 348

true, 339

varicose, 339, 342, 363

Angina, Ludwig’s, 658, 703

Vincent’s, 703

Angiocholitis, desquamating, 919

Angioma, 277

arterial, 278

capillary, 277

cavernous, 277

of omentum, 935

of orbit, 592

plexiform, 278

of veins, 366

treatment of, 367

Angiosarcoma, 275

Angiotribe, control of hemorrhage by, 236

Ankle, dislocations of, 544

excision of, 414

Ankyloblepharon, 603

Ankyloglossum, 652

Ankylosis, 403

contractures, 403

of hip, 404

of jaw, 667

of knee, 404

treatment of, 405

true, 403

Annular thrombosis, 35

Anthrax, 106

bacillus of, 54

definition of, 106

incubation in, 107

postmortem appearances in, 107

prognosis of, 107

prophylaxis of, 108

symptoms of, 107

treatment of, 107

Antisepsis, 243

Antiseptic applications, 248

solutions, 248

Antiseptics, toxic, 175

Antitoxin treatment of tetanus, 101

Antrum of Highmore, operations on, 611

Anus, absence of, 873

artificial, 839

congenital defects of, 872

fissures of, 876

imperforate, 873

malformations of, 872

Aorta, abdominal, aneurysm of, 346

ligation of, 356

Aplasia cranii, 547

Aponeurotomy, 327

Apoplectic cysts, 952

Apoplexia neonatorum, 564

Apoplexies, compression, 560

Appendicitis, bacteriology of, 852

causes of, 854

chronic, operation for, 866

complications of, 855

diagnosis of, 857

from acute obstruction of bowel, 858

pancreatitis, 858

from cholecystitis, 857

from colitis, 857

from enterocolitis, 857

from floating kidney, 858

from gastric ulcers, 857

from intestinal ulcers, 857

from lead colic, 858

from mesenteric embolism, 858

thrombosis, 858

from peritonitis, 857

from psoas abscess, 859

from pyosalpinx, 858

from ruptured extra-uterine pregnancy, 858

from strangulated hernias, 858

McBurney’s point in, 855

recurrent, 854

operation for, 866

symptoms of, 859

acute, 855

abdominal distention, 856

bowels, 856

jaundice, 856

muscle spasm, 855

pain, 855

pulse, 856

temperature, 856

tenderness, 855

tumor, 856

vomiting, 856

treatment of, 861

non-operative, 862

operative, 862

indications for, 862

in typhoid fever, 859

Appendicostomy, 850

Appendicular colic, 853

Appendix, vermiform. _See_ Vermiform appendix.

Aprosopia, 638

Arlt’s operation for blepharoplasty, 602

Arm, amputation of, 1032

Arrow poisoning, 173

Arterial angioma, 278

Arteries, abdominal aorta, aneurysm of, 346

ligation of, 356

aneurysm of, 339

by anastomosis, 344

arteriovenous, 344

cirsoid, 339, 344

classification of, 342

diagnosis of, 345

diffuse, 339, 342

dissecting, 339, 342

false, 339, 342

fusiform, 339, 343

hernial, 339

progress of, 341

pulsation of, 341

racemose, 344

rupture of, 341

sacculated, 339, 342

spontaneous, 339

traumatic, 339, 343

treatment of, 346

true, 339

varicose, 339, 344

axillary, aneurysm of, 345

ligation of, 355

brachial, ligation of, 355

calcification of, 339

carotid, aneurysm of, 345

common, ligation of, 351

external, aneurysm of, 345

excision of, 352

ligation of, 352

injuries, 563

internal, aneurysm of, 345

ligation of, 352

circumflex, ligation of, 359

epigastric, ligation of, 359

facial, ligation of, 352

fatty degeneration of, 339

femoral, aneurysm of, 346

ligation of, 359

iliac, aneurysm of, 346

common, ligation of, 356

external, ligation of, 357

internal, ligation of, 357

innominate, aneurysm of, 345

ligation of, 350

ligation of, 350

gangrene from, 73

lingual, ligation of, 352

middle meningeal, injuries of, 563

occipital, ligation of, 352

popliteal, ligation of, 360

radial, ligation of, 356

subclavian, aneurysm of, 345

ligation of, 354

surgical diseases of, 337

temporal, ligation of, 35

thyroid, inferior, ligation of, 353

tibial, anterior, ligation of, 360

posterior, ligation of, 360

ulnar, ligation of, 356

vertebral, ligation of, 353

Arteriorrhaphy in treatment of aneurysm, 348

Arteriosclerosis, 339

Arteriotomy, 183

Arteriovenous aneurysm, 344, 564

Arteritis, 338

Arthrectomy, 400

Arthritis, 382

chronic, 386

treatment of, 386

deformans, 387

treatment of, 389

gonorrheal, 392

postgonorrheal, 152, 392

of jaw, 667

rheumatoid, 387

syphilitic, 385

tuberculous, 393

diagnosis of, 398

pathology of, 394

symptoms of, 397

treatment of, 398

Arthropathic joint disease, 394

Arthrotomy, 400

Artificial respiration, 204

Howard’s method, 204

Marshall Hall’s method, 204

in shock, 180

Sylvester’s method, 204

Ascites, chylous, 368

Ascitic tuberculous peritonitis, 791

Asepsis, 243

sterilization, 243

by boiling water, 244

of dressings, 247

by formalin, 244

fractional, 244

of hands, 245

by heat, 243

of instruments, 246

by mustard flour, 245

of sponges, 247

of suture materials, 247

Aseptic wound fever, 85. _See_ Surgical fever.

Aspergillus fungi, 56

Aspiration, paracentesis by, 184

Asthma, thymic, 163

Astomia, 638

Astragalectomy, 467

Astragalus, dislocation of, 544

Atheroma of arteries, 339

Atheromatous abscess, 73, 339

cysts of neck, 707

of skin, 310

ulcer, 339

Atresia of rectum, 872

Atrophic elongation of bones, 436

Atrophy of bone, 422

of brain, 578

definition of, 26

of muscles, 332

treatment of, 332

pathological, 26

physiological, 26

senile, 26

of skull, 547

of testicle, 1015

trophoneurotic, 27

of veins, 361

Auricle, rodent ulcer of, 606

Auricles, supernumerary, 605, 638

Auto-intoxication, 79

cause of, 79

ferments in, 79

intestinal putrefaction in, 81

osmotic pressure of blood in, 80

potassium salts in, 80

treatment of, general, 83

venesection in, 80

urea in, 80, 81

Axilla, syphilis of, 751

tuberculosis of, 751

Axillary artery, aneurysm of, 345

ligation of, 355

B

BACILLUS aërogenes capsulatus, 55

anthracis, 54

bubonic plague, 54

chancroid, 55

coli communis, 53

diphtheriæ, 54

lepræ, 54

mallei, 54

œdematis maligni, 54

pneumoniæ, 54

proteus, 53

pyocyaneus, 53

of Rauschbrand, 55

of rhinoscleroma, 54,

tetani, 54

of tuberculosis, 54

typhi abdominalis, 53

Bacteria of pus formation, 51

facultative pyogenic, 53

bacillus aërogenes capsulatus, 55

anthracis, 54

bubonic plague, 54

chancroid, 55

diphtheriæ, 54

lepræ, 54

mallei, 54

œdematis maligni, 54

proteus, 53

pneumoniæ, 54

of Rauschbrand, 55

of rhinoscleroma, 54

tetani, 54

tuberculosis, 54

typhi abdominalis, 53

obligate pyogenic, 52

bacillus, pyocyaneus, 53

coli communis, 53

colon bacillus, 53

diplococcus pneumoniæ, 53

micrococcus gonorrhϾ, 53

lanceolatus, 53

tetragenus, 53

staphylococcus pyogenes albus, 52

aureus, 52

epidermidis, 52

streptococcus erysipelatus, 52

pyogenes, 52

Bacterial determination of pus as an indication to treatment, 57

Balanitis, 149, 1005

Balanoposthitis, 149, 1005

Bandage, elastic, for control of hemorrhage, 234

Bandaging, 189

kinds of, 189, 190, 191

materials used in, 191

Banti’s disease, 31, 942

Barbadoes leg, 372

Barrel-shaped chest, 719

Barton’s head bandage, 191

Basedow’s disease, 713

Bassini’s operation for hernia, 902

Bastard clap, 148

Bed-sores, a cause of gangrene, 74

Bees, poisoning by, 172

Bell’s palsy, 640

Bellocq’s cannula, 681

Bennett’s fracture, 506

Beta-cocaine, 207

Beta-eucaine, 207

Bichat, fatty ball of, 641