Part 82

Hitherto, these general observations on amputation have regarded the operation by flaps only; the circular method has not been mentioned. The reason is, that the circular amputation has been, it is hoped, in a great measure abandoned in this country. And its inferiority to the method by flaps is so obvious, and so generally acknowledged, that detail of the different steps of the operation is, I conceive, here altogether unnecessary. It is more tedious in performance, more painful to the patient, does not afford so good a covering for the end of the bone, and consequently not so convenient and useful a support for an artificial limb, and the cure of the wound is protracted. The stump is almost always conical, the end of the bone is, ultimately at least, covered only by integument, and from even very slight pressure this is apt to ulcerate; exfoliation of the bone follows to a greater or less extent, or unhealthy nicer of the soft parts continues, along with caries of the bone, and partial death of its surface; and at length it becomes necessary either to perform a second amputation or to curtail the length of the bone. It may sometimes succeed tolerably well when there is but one bone: when there are two, it is altogether inadmissible. In very muscular limbs, when amputation is demanded on account of destruction of the bones and joints, with laceration of the soft parts, as when the patient is not required to have pressure made on the stump, it suits well to make the flaps of integument only, and to cut the muscles short, as will be noticed more fully afterwards. The advocates for the circular amputation, my excellent friend Sir George Ballingall, and others wish it to be believed, (and this is their main argument,) that the exposed surface of the flaps is much greater than that in their favourite method. Some of the philosophers of the Modern Athens have been appealed to, and have measured, it is said, the area of the one and the other, and given their verdict in favour of the round about incision. The accompanying drawings from nature, and the corresponding diagrams, speak pretty plainly in favour of the other method. In the first there is a cone formed by the cut skin and muscles, with a corresponding hollow and ragged cavity; and the second set shows two smooth, nearly triangular surfaces, which the said philosophers may measure and report upon at their leisure.

Various accidents and diseases require removal, either primary or secondary, of the _fingers_, or of parts of them. Amputation is most easily accomplished at the articulations, and ought therefore always to be performed at these points, when the circumstances of the case permit. The last phalanx may require removal either on account of severe injury, or from incurable disease, as onychia maligna, necrosis, caries, &c. The operation is one by single flap, and may be conducted in one of two ways. The doomed phalanx is grasped, on its anterior and posterior aspects, by the fore and middle fingers of the left hand; and the articulation is flexed almost to the full extent, in order that incision into it may be facilitated. A straight, narrow, and sharp-pointed bistoury is carried in a semicircular sweep over the back part of the joint, so as to divide the integuments, and open completely the articulating cavity. The remaining ligamentous investments of the joint are divided by one or more additional touches of the knife, so as to loosen the base of the phalanx. The fingers of the left hand are then changed from the fore and back parts of the phalanx to its sides, the edge of the knife is passed behind the base of the bone, and the surgeon, by carrying the blade forwards and downwards, forms a flap of sufficient dimensions to cover the wound, and removes the offending part. There is seldom any trouble from hemorrhage; no ligatures are required. The flap is turned up so as to form a cushion over the exposed surface of the middle phalanx, and is retained so by the adhesive composition formerly mentioned, or by one or two turns of a linen bandage. The other method of operation is the reverse of the preceding. The joint is extended, the bistoury is made to transfix close to the joint and at its anterior part, and by then carrying it downwards and forwards, as before, a similar flap is formed; this is retracted by an assistant, and with one sweep of the knife the articulation is divided from before backwards. By either method the flap is the same. By similar procedure the amputation at the middle articulation is performed.

It is sometimes an object to save as much as possible of the proximal phalanx, when amputation is rendered necessary by disease of the middle articulation, or of the distal extremity of the bone. In such cases, two semicircular flaps are made by cutting from without, either on the lateral, or on the thenal and anconal aspect, and the bone is divided either by a small saw or by the cutting pliers. The flaps are retained in apposition, and the bleeding arrested by bandaging.

Amputation at the proximal articulation is also performed by double flap. In the previous operations an assistant steadies and supports the hand; in this he has likewise to bend the rest of the fingers, and to separate as widely as possible those neighbouring to the one about to be removed. The operator seats himself before the patient, grasps the finger so as to manage its movements with the left hand, and holding the knife perpendicularly, with its point upwards, lays it over the knuckle, and carries it obliquely upwards so as to open that side of the articulation. He then pushes the finger towards the opposite side, and with the point of the knife completes the loosening of the articulation; for this the blade of the instrument should never be employed, otherwise the integument will be cross-cut and mangled. After separation of the base of the phalanx by the point, the blade is passed behind, and carrying it downwards and outwards, a flap is formed similar to the first—both proportioned to the size of the wound which they are to cover, and the bone which they are to protect. The fingers may also be removed by the oval method, as described and delineated in the _Practical Surgery_. The flaps are retained in contact by bringing the neighbouring fingers towards each other. This also suffices, in general, to suppress the bleeding, but sometimes one or both digital arteries require ligature. At first, cold cloths are probably the best applications, with the view of stopping the oozing, and warding off inflammatory action. Vascular excitement is very apt to follow this amputation, when performed for disease of the finger, as after neglected or severe whitlow; the soft parts in which the incisions are made are generally infiltrated and condensed, and prone to inflammation. The surface around is red, tense, and shining, on the second or third day; the back of the hand, the palm, and perhaps the forearm, are then involved in inflammation of the surface, and infiltration of the cellular tissue; and in all probability, free incisions, followed by poultice and fomentation, will be necessary to restore the parts to quietude. Such consequences are to be guarded against as much as possible, by attention to the system, and by avoiding all irritating dressing.

The phalanges of the thumb are removed in the same manner as those of the fingers. Amputation of the metacarpal bone is accomplished thus. The thumb is grasped by the fingers of the left hand, and so managed. The bistoury, held in the same manner as for amputation at the proximal articulation of the finger, is placed with its point on the web betwixt the thumb and forefinger, and carried in one sweep rapidly upwards in a slightly oblique direction, till it is stopped by the os trapezium. The point is used to effect disarticulation, the member being at the same time pushed steadily outwards; the blade is then placed behind the base, carried downwards close to the side of the bone, and is not to be brought out till sufficiently low down for forming a flap to cover the whole wound. The flaps may be formed otherwise, and much more handsomely, by transfixion of the ball of the thumb, as shown in the _Practical Surgery_, p. 360. After arresting the hemorrhage, the flap is laid smoothly down, and retained in its proper position by bandage or slips of the adhesive plaster. The metacarpal bone of the little finger is removed by the same method of incision as for the thumb.

In amputation of the fingers, the incisions sometimes require to extend beyond the proximal articulation, on account of disease having involved that part; in other words, it may be necessary to remove more or less of the metacarpal bone along with the finger. The method of incision will vary according to the extent to which the bone is diseased. When the operation is required for disease of merely the distal extremity, the incisions are made in the same form as for amputation of the joint, only they are on each side sufficiently high to be beyond diseased bone. They may either be made from below upwards in the usual way, or be commenced at their highest point on the dorsum of the metacarpal bone. After the soft parts have been separated from the bone, by a few touches of the knife after formation of the principal incisions, removal is completed either by the cutting pliers or the metacarpal bow-saw—the former I have found the more convenient instrument. It is applied perpendicularly, and should always have its smooth surface in contact with the part to be retained, otherwise the cut part will be rough and irregular. Section is completed more rapidly than by the saw, and, by attention to the above precaution, the stump is equally smooth, if not more so. The wound is brought and retained in contact by approximation of the fingers. But in taking away any considerable portion of the metacarpal bone, it is of importance to preserve the palm uninjured. With this view, the knife is entered over the centre of the bone on its dorsal aspect, above the diseased part, and carried straight downwards till near the articulation, when it is made to diverge for the formation of lateral flaps; the integuments in the track of the longitudinal wound are then dissected backwards, so as to expose the bone completely, and the bistoury is passed round the bone throughout its whole extent, the edge being kept close to it,—in order that the soft parts may be separated, and that without unnecessary width of wound or implication of the palmar arches and branches proceeding from them. Then the bone is clipped at the proper point by the cutting pliers; or the section of the bone may be performed before separation of the soft parts from its under surface, as, by raising the cut end, this part of the operation may be facilitated. Here the metacarpal saw is inapplicable.

Before quitting this part of the amputations, it may be observed, that no good can result from taking away a metacarpal bone and leaving a finger, or from removing a proximal phalanx and leaving the distal. The parts so left can be of no use, they have no support, and the muscles cannot act upon them: they must prove an incumbrance, and as such will either form the subject of a second amputation, or remain a proof of the unsuccessful result of the first.

Amputation in the _forearm_, may be necessary at various points, on account of accident or disease, but should never be resorted to, in either case, so long as part of the hand can be saved. The preservation of even a small portion of this useful member, even of one finger or a part of one, is of great importance to the patient. When, however, this is hopeless, all must be removed; and, if the wrist be sound, amputation may be performed at that joint. Hitherto, no mention has been made of the temporary suppression of bleeding, for in the amputations detailed there is scarcely ever any necessity for adopting such measures; but in those of the forearm and arm, a steady assistant must be placed ready to compress the humeral artery as soon as the incisions are commenced; in the case of the forearm, the pressure is made on the lower portion of the artery; in the arm, the point of pressure will necessarily depend on the point of removal. The patient may be either seated or recumbent. One assistant compresses, another steadies the limb in the supine position. The surgeon holds the hand in his left, standing on the inside of the right limb, and on the outside of the left. Suppose the right wrist is to be operated on,—the end of the ulna is felt for, and at that point the knife is entered, and drawn across the wrist on its dorsal aspect in a semilunar direction, the convexity of the curve of course pointing towards the fingers. The joint is opened by retracting and dissecting back the flap so formed; the knife is then passed behind the scaphoid and lunar bones, which are exposed and turned out by division of the ligaments, and by rapid and gentle sawing motion downwards and forwards, a flap of sufficient size is then formed on the palmar aspect. The dorsum of the hand may be so diseased or injured as not to afford sufficiency of sound parts for a posterior flap; in such circumstances the anterior must be made proportionally large, that it may alone cover the ends of the bones. After suppression of the bleeding, the flaps are approximated by one or two points of suture; these are afterwards removed, and their place supplied by the adhesive plaster.

Amputation, at any point between the wrist and elbow-joints, requires, in all, the same method of incision, but the nearer to the elbow the better is the stump; at the wrist the flaps are composed principally of integuments and tendons, and the cushion so formed for the bones is very inferior to one of muscle. Compression is made and the limb steadied as before; the surgeon with his left hand grasps the wrist, and places the forearm in the middle state between pronation and supination. In the right forearm, the knife, held perpendicularly, is entered over the centre of the radius, and its point, after reaching the bone, is inclined inwards so as to pass round it; transfixion is then made, the knife passing close to the palmar surface of the bones, and emerging at a point opposite to its entrance; and then by rapid motion downwards and inwards, a proper flap is formed. The instrument is again introduced over the radius, at a little distance from the upper part of the first wound, and passed on the opposite side of the bones, emerging also in the first incision and at a similar point; another flap is made. These are retracted, the knife is swept round the bones, and passed freely between them, to divide the remaining muscular substance, and after this has been completed, the saw is applied. During the sawing it is well to preserve the limb in the same position as during the incisions, and to apply the instrument perpendicularly; thus both bones will be divided at once, and the risk of splintering diminished. In transfixion, great care is required that the point of the knife pass across, not between, the bones, and with this view a slight change of position is useful; during the transfixion for the inner flap, the surgeon, as soon as he feels the knife rounding the radius, rotates the forearm gently inwards, and in transfixing for the outer flap similar rotation is made outwards. In this situation, and others where the soft parts are less thick in one aspect than the other, it is by much a preferable plan to make a flap first, by cutting from without inwards, as already described in regard to the wrist, and then to transfix for the formation of the second flap. This is delineated in the _Practical Surgery_, p. 367. Sometimes slight difficulty is experienced in tying the interosseal artery. The flaps are brought together, and treated in the way already mentioned.

In all amputations of the upper extremity, it is of importance, and indeed a rule scarcely to be departed from, to leave as much of the limb as possible; for here the longer the stump, the more useful is it to the patient. In accordance with this maxim, amputation at the elbow-joint may be required, when either disease or injury extends too high for amputation in the forearm, but not too high for the formation of an anterior flap over the joint. The limb is steadied in the supine position, compression being made near the middle of the humeral artery; the knife is passed horizontally across the condyles close to the bone, and brought downwards and forwards to a sufficient extent for the production of a flap, which is alone to form the protecting cushion. The joint is then cut through, the knife is passed down till obstructed by the olecranon, and with one sweep a semicircular incision of the posterior integument is made. All soft parts in this line are divided, and then the saw is applied to the olecranon process. This amputation is easy, rapid, and beautiful in execution; and, when the flap is sufficiently large,—as it always may be, for there is no want of soft parts in front,—the stump is well formed and useful. The flap is laid down, and attached by suture to the integument posteriorly; in due time the adhesive dressing is applied. The circumstance of a secreting surface forming the stump does not seem detrimental, either here, or in the wrist-joint. The synovial fluid soon ceases to distil, and union is not interrupted by it. There is no necessity for scarification, or scraping the cartilage, with the view of hastening cessation of secretion and granulation of the surface.

Amputation of the _arm_ is performed by the formation of lateral flaps, at any point below the insertion of the deltoid muscle. Compression is made on the upper part of the humeral, or on the axillary artery. The limb is held well separated from the side; and care should be taken that, when so raised, its height be convenient to the operator. The knife is entered perpendicularly to the shaft of the bone, passed fairly down to it, and then inclined along its side; the operator now grasps the limb below the line of incision with the left hand, and pulls the muscles towards him—it is supposed that the right arm is being amputated, the surgeon standing on the inside, and an assistant supporting the forearm—and then completes transfixion, inclining the handle of the knife towards himself, in order that its point may pass round the bone and emerge at as distant a point in the circumference of the limb as possible. By a rapid sawing motion, downwards and inwards to the proper extent, the inner flap is formed; and by attention to the grasping of the muscles and the inclination of the knife, its base is so large as to admit of the more easy performance of accurate transfixion for the outer—that is, the instrument is more easily brought through the same incision. The assistant seizes the extremity of the inner flap as soon as formed, and retracts it, but only to a slight extent; it is simply held out of the way. If it be pulled backwards, as in retraction during sawing, the formation of the second will be much impeded. The knife is again entered about half an inch below the commencement of the first incision, and by inclining the handle the point is brought round the bone, and made to appear on the opposite side also in the first incision; this is facilitated by pulling the soft parts outwards with the left hand. Then the outer flap is completed. The knife is swept rapidly round the bone, so as to expose it completely at the upper part, the assistant at the same time retracting the flaps fully. The saw is applied, the arteries tied, the flaps approximated, and the operation completed.

In performing the second transfixion, the reason why the knife is entered lower than in the first, is, that cross-cutting of the corners of the wound is thereby avoided. For a long time I was surprised and annoyed to find many stumps present an unseemly cross-cutting of the integument at the upper parts, particularly after approximation of the flaps, although the incisions seemed to have been made smoothly and accurately. It is occasioned by the sawing process for making the second flap, and when this is commenced at the same height as for the first, irregularity of incision at the upper part is unavoidable. The precaution, however, of making the second transfixion considerably lower than the first I have found quite effectual. The disparity between the bases of the flaps is readily and quickly remedied, after their formation, by a sweep of the knife upwards on the lower side.

Irritable and painful stumps are more frequently met with after the amputations of the arm and forearm than any other. The occurrence, however, is less common than formerly, and this may be fairly attributed to the improvements in the operation—to the method by flaps having superseded the circular, and nothing but the arteries being surrounded in ligature. Still the affection is occasionally met with, and there can be none more painful and troublesome. Generally, no obvious cause can be found for the attack of this malady; but in some of the cases there would seem to be a constitutional and innate tendency, as it were, towards this irritability of the cut and bulbous extremities of the nerves—as in the following case:—A gentleman, aged 53, underwent amputation of the thumb, in consequence of laceration of the hand. Amputation was very soon afterwards performed at the middle of the forearm, on account of hemorrhage and infiltration of the hand, after fruitless attempts to secure the arteries. After cicatrisation of the wound, he complained of great pain in the stump, and in the situation where the tourniquet had been applied. Amputation of the arm was then performed, but the stump was not well made. The pain returned, and he applied to me, with the view of again submitting to amputation. It was performed nearer to the shoulder-joint, and in order to guard against recurrence of the disease, the nerves were laid hold of, pulled outwards, and cut across as high as possible. The patient was relieved of many of his sufferings, and continued tolerably comfortable for nearly two years; again, however, the painful symptoms have returned, though in a slighter degree. On examining the removed stump, all the nerves, particularly the musculo-spiral, were found greatly enlarged in their extremities, and intimately adherent to the cicatrix and the ligamentous covering of the rounded extremity of the humerus. More desperate operations have even been performed to free patients from irritable stump. The lower limb has been hacked off bit by bit, even to the coxo-femoral articulation, without much, if any, relief. Such operations are hardly warrantable.