Part 14
121. Mr. Luke performs the operation by two flaps on the same principle as in the thigh. There is a close resemblance in the manner of amputating the arm by the double-flap operation to that adopted for the amputation of the thigh. The first flap is made posteriorly to the bone, by transfixing the limb, for which purpose the knife is entered at the mid-point between the anterior and posterior surfaces, carried transversely across the limb, and made to cut toward the posterior surface, in an oblique direction, until all the soft structures are divided. It is necessary, in entering the knife, to bear in mind that the bone lies opposite to the mid-point, and that, in carrying the knife across the limb, it would strike against the surface of the bone, unless means were adopted for its prevention. This is easily done by grasping the structures which are to form the posterior flap between the fingers and thumb of the left hand, and by drawing them backward during the time the knife is entering at the mid-point and being carried across the limb. Having formed the posterior flap, the anterior one is formed as in amputation of the thigh, by cutting inward from the surface toward the bone with a sweep, which will make this flap equal in length to the posterior. The operation is completed by dividing the remaining soft parts by means of a cut carried circularly around the bone, and by sawing the bone in the line of division. The after-treatment is the same as in the thigh.
122. _Excision of the elbow-joint._--An incised wound of moderate extent into the elbow-joint, cutting off with it a part of the condyle of the humerus, or the head of the radius, or a part of the ulna, demands the removal of the injured piece of bone only. The forearm should be bent, and the antiphlogistic treatment fully carried out. A ball fracturing the olecranon, or other portion of a single bone, although opening into the joint, does not immediately require any operation.
If a ball should lodge in the lower part of the humerus, or in either of its condyles, it should be removed as quickly as possible by the trephine, or other appropriate instrument.
When the articulating ends of the humerus, radius, and ulna are wholly or in part injured by a musket-ball, it was formerly the custom to amputate the arm in such instances of great mischief--an operation which should be superseded by that of excision of the joint, by which the forearm will be saved, and considerable use of it retained.
To perform this operation, a straight, strong-pointed knife is to be pushed into the joint behind, immediately above but close to the olecranon process, and exactly at its inner edge, to avoid the ulnar nerve, which lies between it and the inner condyle, to which it may be considered to be affixed. The incision thus begun is to be carried outwardly to the external part of the humerus, dividing the insertion of the triceps. At each end of this transverse cut an incision is to be made upward and downward for about two inches each way, the three resembling the letter =H=. The flaps thus made being turned up and down, the olecranon should be sawn across, together with the great sigmoid cavity and the coronoid process of the ulna, the insertion of the brachialis internus having been previously separated from the coronoid process. Before this is done, the ulnar nerve should be separated with its attachments from the inner condyle, and turned aside to avoid injury. The joint being now fully exposed, the head of the radius may be sawn off or cut through with the strong spring scissors if possible, above the tubercle into which the biceps tendon is inserted. The extremity of the humerus should next be pushed through the wound, and the broken end sawn off, a spatula or other thin solid substance being placed underneath it, to prevent the brachial artery or median nerve being injured. Any hemorrhage which there may be having ceased, the forearm is to be bent, the bones are to be placed in apposition, and the incisions approximated by sutures and sticking-plaster, duly supported by compress and bandage, so that union may take place if possible, particularly of the transverse wound first made. The arm should be supported by a sling, and dressed early, as the shot-hole or holes must remain open and discharging. Some motion of the new joint to be formed may be expected under gentle passive movements; but as a stiff joint cannot always be avoided, the arm should be kept bent.
123. _Amputation of the elbow-joint_ has been recommended, but not frequently performed. It may be done in any way by which good covering can be obtained, and it has been supposed that the long stump thus made is more useful if the olecranon process be sawn across, and left with the triceps attached to it, than if it be removed. When the parts are sound, a flap may be made in front by introducing a straight, double-edged knife over the outer condyle, and carrying it across and through the soft parts over the opposite or inner condyle, when by cutting downward and outward a flap is to be formed of from three to four fingers’ breadth in length. A shorter flap is to be made behind, when both are to be raised, and the bleeding vessels previously secured, the external lateral ligament being divided. The radius is to be separated from the humerus, when the olecranon may be sawn across, or, if the arm be bent, separated from the humerus without difficulty. The flaps are to be brought together and retained in the usual manner.
124. _Amputation of the forearm_ is seldom required after wounds from musket-balls. The bones can be readily got at, and large pieces removed with ease. The arteries can be cut down upon and secured without difficulty, except at the upper part, and even there with some little sacrifice of muscular parts, which are not to be spared. The fascia may be divided freely in every direction, and as mortification from defect of nourishment rarely takes place in the fingers, as it does in the toes, when the great arteries of the limb have been injured, every effort should be made to save a forearm, however badly it may at first appear to be injured.
The flap operation is to be preferred to the circular, particularly when done a little above the wrist; to which operation Baron Larrey and the surgeons of France particularly objected during the late war. Having done it most successfully since 1806, however, it is recommended as preferable to any other, even when the injury admits of its being done neat the carpus. When the nature of the injury does not admit of two equal flaps being formed, it must be done by two unequal ones, or even by one, it being important for the fixing of an artificial hand or other help to have a long stump.
The arm being placed and held firmly in the intermediate position between pronation and supination, with the thumb uppermost, so that the radius and ulna are in one line, a sharp-pointed straight knife is to be entered close to the inner edge of the radius, and brought out below at the inner edge of the ulna. It is then to be carried forward for half an inch, and made to cut its way out with a gentle inclination, so as to form a semicircular flap. Re-entered at the same point as before, a similar flap is to be made on the outside, the position of the bones being a little altered to admit of its easy execution. The two flaps are to be turned back; the tendon of the supinator radii longus, and all other tendinous, muscular, or interosseous fibers, not cut through, are then to be divided, and the linen retractor run between the bones, which are to be sawn across at the same time. All pressure being taken off, the tendons and the vessels, if long, are to be cut short, and the arteries to be tied, after which the flaps are to be brought together by sutures, and retained by sticking-plaster, compress, and bandage.
125. When the operation is to be performed above the middle of the arm, it may be done by the _circular_ incision.
The arm being placed with the thumb uppermost, an assistant should retract the integuments as much as possible, while the operator makes a circular incision through them. They are then to be drawn up for nearly an inch. The muscles on the inside of the arm should be divided by one slanting cut to the bones; then those on the outside. The bones are to be cleared by cutting through any muscular fibers attached to them, when the interosseal ligament should be divided, and the linen retractor passed between the bones, which may be sawn through at the same time without difficulty. The stump is to be dressed in the usual manner. The operation may be done by cutting through the integuments and muscles at once in an oblique manner, until the flaps thus formed shall be sufficiently large to make a thick cushion over the ends of the bones.
126. _Amputation at the wrist_, or the joint of the radius and ulna with the first row of the bones of the carpus, has been recommended by some surgeons as preferable to amputation above the ends of the radius and ulna. The hand being placed midway between pronation and supination, the soft parts are to be divided by a circular incision beginning from half an inch to an inch below the ends of the radius and ulna. The integuments being turned up without the tendons, they are to be divided, and the joint is to be opened into before the spinous process of the radius; and, while the hand is pressed down, the knife should divide all the soft parts, and separate the carpus from the radius and ulna. The wound is to be closed by sutures in the usual manner. When a circular incision cannot be made, in consequence of the nature of the injury, and this operation is still preferred, a covering for the bones must be obtained wherever it can be procured, by one or more flaps.
127. _In all injuries of the hand_, the value of a thumb and a finger, or of two fingers, or even of one, should be borne in mind, and no part should be removed that can be saved, and appears likely to be of use. When cannon-shot, large splinters of shells, or grape-shot have struck the hand, amputation will often be necessary; but the foregoing precept should never be forgotten.
A musket-ball fairly passing through the hand generally fractures two metacarpal bones, although a small ball may pass between them without breaking either. The wounds should be enlarged, and the broken ends of the bone sawn off, or the splinters removed, and the points of bone smoothed off, the tendons to be carefully preserved, and vigorous antiphlogistic measures adopted. The tendency to tetanus or trismus will be best obviated by such measures, the incisions, when necessary, being made in the direction of the bones and tendons. Any hemorrhage which can ensue will be readily commanded by ligature, by torsion of the vessel, or by a small graduated compress and bandage, when those are inapplicable. Injuries by musket-balls to the metacarpal bones rarely take place without implicating one or more flexor or extensor tendons, and the consequence is that the fingers to which they belong are often bent inward toward the palm, constituting a defect less inconvenient, however, than if the finger remained straight and immovable.
128. When one or more fingers are destroyed, and the metacarpal bones injured, they are to be sawn or cut off, but not removed at the carpus, although an opening into the joint of the carpus will generally do well, if skin can be saved to cover it. In all cases of amputation of one or more fingers, the metacarpal bones, if injured, should be left as long as possible, and particularly that of the index finger, when the thumb remains. In all cases it is better, if possible, to leave the heads of the metacarpal bones in their places, rather than open into the joint of the carpus, if it can be avoided. If the articulating heads must come out, a strong, thin scalpel is to be pushed in between the bones, the ligaments cut through above, below, and at the sides, and care should be taken, in removing one or two of these bones, not to dislocate the others, and the joint should be covered by a flap or flaps made for the purpose, the sides of the remaining fingers being covered in a similar manner. This succeeds admirably, when the two outer bones and fingers only are taken away.
129. _The phalanges_ of the fingers may be removed by making a flap from the upper or under part, or from both, or from the sides. The square flap from the upper part of the finger is preferable, when the joint with the metacarpal bone is to be operated upon, the commencing points of the flap being united by a transverse incision on the under part of the joint. It should be recollected, that in all these excisions the larger end of bone belongs to that which is not removed, as may be shown by bending the finger; and that the ligamentous attachment between the metacarpal bones, connecting a middle one to its fellows on each side, should be cut through, when the joint will be easily dislocated. Attention should be paid to the division of the lateral ligaments, in the removal of any of the bones of the fingers.
Professor B. Langenbeck has operated in some instances, and he says successfully, without the loss of the finger, by sawing off, in his first case, the articulating ends of the first phalanx and of the metacarpal bone of the forefinger, in consequence of an injury from a rotating piece of machinery; in another, the ends of the first and second phalanges of the middle finger after a severe laceration; and in a third case, by sawing off the end of the second phalanx, and removing the whole of the bone of the third of the forefinger from the soft parts, leaving the nail; the man recovering with a shortened but useful finger. In all these cases the flexor and extensor tendons were from the first uninjured.
M. Langenbeck has also removed the metacarpal bone of the thumb in the following manner: “An incision is to be made along the whole length of the bone toward the palmar aspect, thus avoiding the tendons. Then free both articulating extremities, separate the soft parts from the body of the bone, which is to be drawn outward by a strong pair of forceps, with two bent points or teeth at each extremity. To prevent the shortening or drawing inward of the thumb, it is to be kept straight and duly extended by a splint and other apparatus.” He recommends, with Flourens, the preservation of as much as possible of the periosteum, and uses for its detachment a small curved knife with a square end. Separating the periosteum from the bone is more easily directed than done. Professor Quekett, at my request, made some trials on the humerus to ascertain the point, and found that the periosteum could not be separated from the cartilaginous covering of the head of the bone, in the manner proposed, although it could be done by scraping half an inch below the insertion of the capsular ligament, and a sufficient portion saved to cover the sawn end of the bone, in the manner recommended by M. Baudens.
LECTURE VII.
SECONDARY AMPUTATIONS, ETC.
130. _Secondary amputations_, or those performed after the lapse of six or more weeks from the receipt of an injury, when suppuration has been fully established, are not as successful in military as in civil hospitals, in which these operations are more commonly performed for incurable diseases than for injuries. When, however, they are done in them for injuries, they are not equally successful.
131. In military warfare these amputations are frequently done from necessity, not choice, after the first forty-eight hours; and especially after four or five days to the end of six weeks, in parts which have been lately, or are still affected by some of the accompaniments of inflammation, or are in a state of irritation. In these cases the cellular or areolar tissue has become firmer and more compact than usual; the muscles are not perfectly healthy; the blood-vessels are larger and more numerous, and ready to assume actions unusual to them in a state of health. Where the bones have been diseased, much bony matter may be deposited between the muscles, and in some cases the vessels even are surrounded by it. After a few hours’ remission, the constitutional symptoms often return, the wound sloughs, and secondary hemorrhage is not an infrequent consequence. The ligatures are a source of irritation, and prevent union, which, in fact, should not in such cases be attempted, and, if attempted, will as rarely succeed.
132. In these states of constitutional derangement, inflammation of the veins and sloughing of the stump are not uncommon, augmented by, if not dependent in some degree on, the state of the atmosphere, which in autumn, the season for many military movements, gives rise to endemic fevers, and even to dysenteries and cholera, which the soldier is often so unfortunate as to acquire in crowded hospitals. If the man should escape with life, a joint will frequently be lost which might have been saved, if the operation had been performed in the first instance below it. When the injury is in the thigh, this is a most important point for consideration.
133. If the sufferer should escape these dangers, there remain the sudden and usually disastrous affections from depositions of matter in the viscera, alluded to in aphorisms 58, 59, 60, 61, and 62, which are by no means so common when the patient is in better health; the connection of these with inflammation of the veins deserves a more close investigation than has as yet been bestowed upon it by civil or by military surgeons since attention was first drawn to it by me in 1815.
134. In secondary amputations in parts which have partaken of the extensive irritation which accompanies the original injury, more of the soft parts must be preserved, although they cannot be said to be unsound. In other words, the bone must be cut shorter, or the stump will be conical and bad, particularly if sinuses containing pus are found to run up between the muscles, or between them and the bone itself--a state very likely to give rise subsequently to caries.
In sawing the bone, it may be again stated, the point of the saw should incline downward, and when two-thirds of the bone have been divided, it should be made to cut perpendicularly, whereby the _side_ next the operator is the last part divided; the hazard of splintering the bone at that moment will then be avoided, particularly if the limb to be removed be held with great steadiness.
135. In secondary amputations, twice, nay, three times the number of arteries will often bleed as in primary ones. In the thigh, the femoral artery should be drawn out with a tenaculum or spring forceps, and tied firmly with a single thread of dentists’ silk, one of the two ends being cut off close to the knot. The smaller the vessel, the smaller the thread required. Torsion or twisting the smaller vessels, so as to rupture their inner coats, answers very well in cases in which many small ones bleed. When a nerve is known to accompany an artery, it should be carefully separated from it.
136. If the bleeding should continue from above the ligature on the extremity of an artery, it is generally caused by some small branch given off from it, which has been cut so close to the trunk of the vessel as not to have been observed. In that case, the artery itself should be drawn out by the tenaculum or spring forceps until the bleeding point can be seen, and a ligature placed above it, when the piece below should be cut off with the first ligature applied. This inconvenience will be in general avoided by taking care to divide the principal artery at one stroke of the knife, and with it half an inch at least of the surrounding tissues, if the operation be done by the circular incision; if by flaps, the extent of the exposed arteries should be carefully examined, and the ligatures applied at the highest point of exposure, when all below should be removed.
137. When a tourniquet is used, and applied too close to the incised parts, it often prevents, even when loosened, the principal vessel from being found, from its having pressed on the ends of the muscles. If one be used, it should be removed as soon as possible after the principal artery has been secured. The repeated tightening and loosening of the tourniquet will cause more vessels to bleed in the end, and more blood to be lost, than if it had not been used; it ought not, therefore, to be resorted to when good assistance is procurable. In cases of this kind, in which the stump may not cease to ooze, the circulation being good, and sponging with cold water not effectual, the wound should not be finally closed for two, four, or more hours, until the oozing has ceased, and the parts can be freed from the coagulated blood, and brought together.
138. In cases in which union is not expected to take place, both ends of the ligature should be cut off; for union of the external parts is not to be desired in many instances of secondary amputation, particularly after serious injuries; the inflammation consequent on which has in some degree implicated the structures divided in the operation, rendering them less liable to take on the healthy action of adhesion. The soft parts should be simply approximated by two or more sutures, the edges of the wound having a piece of lint or fine linen between them. This precaution should be particularly attended to after a great battle, when it is perceived that from the air, the crowded state of the hospital, or the season of the year, the stumps, although they may appear to unite in the first instance externally, do not in reality do so internally.
139. It has been proposed to use ligatures made of cat-gut or other animal substances, which may be cut short, and left in the wound to be absorbed. This has taken place in some instances, while in others little abscesses have followed, allowing their discharge, and not expediting the cure, so that the practice has not prevailed; it is said that greater success has attended in America ligatures used in this way made of very fine shreds of the strong tendons of the large deer of that country. Ligatures should not be applied on large veins when they continue to bleed, if it can be avoided, although it has frequently been done without subsequent inconvenience. A little delay and moderate pressure will generally suffice to arrest the bleeding.
140. If the surgeon find, after completing the operation, that the bone cannot be sufficiently covered to make a good stump, a piece should be sawn off at once, and the error remedied, with little comparative inconvenience to what would occur afterward, if the bone be too long. No false shame should prevent its being done. If, however, the error have occurred, and the end of bone should become uncovered during the process of healing, it may be allowed to separate of itself, as it cannot be sawn off at this period without difficulty and much suffering; for an exposed surface will then remain, from which an exfoliation will take place before the stump can heal. In cases of great protrusion, an incision should be made down to the bone, which should be firmly held by strong forceps, or by a tube in which it will fit, when it is to be sawn off by the chain saw at a sound part, above that which has been exposed. The wound, in all cases, should be well supported by compress and bandage, to secure a good stump; whence the necessity for the bone being shorter than in those secondary amputations which are done at the period of election, and which will, on the contrary, often unite without difficulty. In primary operations, cold water is most applicable in the first instance; in secondary amputations, warmth by fomentations, rather than by even the lightest of poultices.
ON COMPOUND FRACTURES.