A Manual of the Operations of Surgery

Fig. i.

Amputation of the Upper Extremity.—The extreme importance of the human hand, its tactile sensibility, its grasping power, and the irreparable loss sustained by its removal, render the greatest caution necessary, lest we should remove a single digit or portion of one that might be saved. In cases of severe smashing injuries involving the fingers, it is the surgeon's bounden duty not recklessly to amputate the limb with neat flaps at the wrist-joint, but carefully to endeavour to save even a single finger from the wreck, though at the risk of a longer convalescence, or even of a profuse suppuration. While a toe or two, or a small longitudinal segment of the foot, may be comparatively useless, and a good artificial foot, with an ankle-joint stump, certainly preferable, a single finger, provided its motions are tolerably intact, will prove much more valuable to its possessor than the most ingeniously contrived artificial hand.

However, while in cases of extensive smash we endeavour to save anything we can, the case is very much altered when it is only one or two fingers that are injured. Here we find another principle brought into play, and our conservative surgery must be limited by the following consideration. In endeavouring to save a portion of the injured finger or fingers, will the saved portion interfere with the important movements of the uninjured ones? These two principles—1. Generally to save as much as we can; 2. Not to save anything which may be detrimental or in the way,—will guide us in describing the amputations of the upper extremity.

Fig. ii.

Amputation of a distal phalanx.—This small operation is not very often required. In cases of whitlow in which the distal phalanx alone has necrosed, removal of the necrosed bone by forceps is generally all that is necessary. In cases of injury, however, in which nail and distal phalanx are both reduced to pulp, it will hasten recovery much to remove the extremity. There is no choice as to flap, the nail preventing an anterior one, so a flap long enough to fold over must be cut from the pulp of the finger in either of two ways (Fig. i. 1):—1. Holding the fragment to be removed in the left hand, and bending the joint, the surgeon makes a transverse cut across the back of the finger, right into and through the joint, cutting a long palmar flap from within outwards as he withdraws the knife.

Note.—Some difficulty is often felt in making the dorsal incision so as exactly and at once to hit the joint; the most common mistake being, that the transverse incision is made too high, and the knife, instead of striking the joint, only saws fruitlessly at the neck of the bone above. To avoid this, the surgeon should take as a guide to the joint, not the well-marked and tempting-looking dorsal fold in the skin, but the palmar one, which exactly corresponds with the joint between the proximal and middle phalanges, and is only about a line above the distal articulation.—(Fig. ii.)

2. Making the long flap by transfixion, it may be held back by an assistant, and the joint cut into.

Amputation through the second phalanx.—If the distal phalanx be so much crushed that a flap cannot be obtained, two short semilunar lateral flaps may be dissected (Fig. i. 2) from the sides of the second phalanx, which may then be divided by the bone-pliers at the spot required.

In cases of injury which do not admit of either of the preceding operations, it is quite possible to amputate either at the first joint, or even through the proximal phalanx. Patients are sometimes anxious for such operations in preference to amputation of the whole finger. The surgeon should, however, never amputate through a finger higher up than the distal end of the second phalanx, unless absolutely compelled by the patient, for the resulting stump, being no longer commanded by the tendons, will prove merely an incumbrance, and may possibly require a secondary operation at no distant date for its removal.

This rule is applicable in cases in which a single finger is injured, and two or three complete ones are left; in cases where all the fingers have been mutilated every morsel should be left, and may be of use.

Amputation of a whole finger.—(Fig. i. 3)—This is an operation of great importance, from its frequency.

If the third or fourth digits require amputation, it should be performed as follows:—The vessels of the arm being commanded, an assistant holds the hand, separating the fingers at each side of the one to be removed. The surgeon holding the finger to be removed, enters the point of a long straight bistoury exactly (some authorities say half an inch) above the metacarpo-phalangeal joint, and cuts from the prominence of the knuckle right into the angle of the web, then, turning inwards there, cuts obliquely into the palm to a point nearly opposite the one at which he set out.

Note.—While most authorities agree with the direction in the text regarding the palmar termination of the incision, I believe, in most cases, it is not necessary to go so far, and that the incisions may fitly meet in the palm at a point midway between a point opposite to the knuckle, and the centre of the well-marked "sulcus of flexion."

He then repeats this incision on the other side, makes tense the ligaments, first at one side and then at the other, by drawing the finger to the opposite side, and cuts them. The tendons being cut, the finger is detached. The vessels being tied, one point of suture is put in on the dorsal aspect, and the fingers on each side tied together at their extremities, with a pad of lint between them.

Modification.—Lisfranc's method is too long in its minute description to give in detail. The principle is to make a semilunar flap at one side (the one opposite the operator's right hand), by cutting from without inwards, then to open the joint from this cut, and, still keeping the edge of the knife close to the head of the phalanx, cutting the other flap from within outwards. This can be very rapidly done, but the last flap is apt to be irregular and deficient, especially in those common cases, in which, after whitlow or the like, the tissues are hard and brawny, and the skin does not play freely.

It is quite unnecessary to remove the head of the metacarpal, either for the sake of appearance, or to render healing more rapid, and its removal weakens the arch of the hand; where the cartilage is eroded by disease, the cartilage-covered portion can be scooped off by a gouge or removed entire by pliers, without interfering with the broad end to which the transverse ligament of the palm is attached. If required either for injury or disease, the metacarpal head may be easily removed by a single straight incision from the knuckle upwards, as far as the point at which it may be deemed necessary to saw it through, or better still, divide it with the bone-pliers. This incision should be made as a first step in the first incision for amputation of the finger, and the finger should not be disarticulated, but kept on, to aid by its leverage in separating the metacarpal head.

Amputation of the index or little fingers.—This operation differs from the preceding only in this, that care must be taken to make a good large flap on the free side of each; making the incision, which begins at the knuckle (Fig. i. 4), enclose a well-rounded flap, and not allowing it to enter the palm till it reaches the level of the web between the fingers. The metacarpal heads may here be cut obliquely with the bone-pliers, to prevent undue projection.

Amputation of one or more metacarpals.—These operations may be rendered necessary by disease or injury. If the latter demands their performance, no rules can be given for incisions or flaps, they must just be obtained where and how they can best be got. If for disease, a single dorsal incision (Fig. i. 5) over the bone will allow it to be dissected out of the hand.

N.B.—In no case, except that of the thumb, should any attempt be made to save a finger while its metacarpal is removed. (See Excisions of Bones.)

Amputation of first and fifth metacarpals.—Various special operations have been devised for speedy and elegant removal of these bones. Their disadvantages, etc., are fully detailed under Amputations of the Foot.

The vascularity and consequent vitality of the tissues of the hand and arm sometimes afford very encouraging and satisfactory results in conservative operations.

The following is an instance of what may be accomplished in a young healthy subject.

A. A., æt. 18, ploughman, was harnessing a vicious horse, when it caught his right hand between its teeth, and gave a severe bite. On admission, I found the middle and ring fingers completely separated at the metacarpal joints, but each hanging on by a portion of skin, the middle by the skin on its radial side, the ring by that on its ulnar. The back and the palm were both stripped of skin up to the middle of the third and fourth metacarpal bones, which were exposed, but not fractured. As it was important for him to maintain the transverse arch of the hand intact, I determined to make an attempt to save the metacarpals, and finding that the skin on the radial side of the middle, and ulnar side of the ring fingers, was still warm, and apparently alive, I carefully dissected as long a flap as possible from each, and then folded them down, one at the front, the other at the back of the hand. The flaps survived, and the result was admirable, the patient being able in a very few weeks to guide the plough. The sensation in his new palm and back of the hand is very peculiar, they being still the fingers, so far as nervous supply is concerned.

In amputations involving the metacarpals for injury, it is always important to avoid entering the carpo-metacarpal joint, hence if it can be done it is best to saw through the bones at the required level, rather than disarticulate. This rule should be observed even in those cases in which the thumb alone can be saved, for notwithstanding the isolation of the joint between the first metacarpal and the trapezium, it is very important for the future use of this one digit that the motions both of the wrist and carpal joints should be preserved entire.

No exact rules can be given for the performance of these operations, as the size and positions of the flaps must be determined by the nature of the accident and the amount of skin left uninjured.

In the rare condition where the greater part of the metacarpus is destroyed, and yet carpal joints are uninjured, a most useful artificial band, preserving the movements of the wrist, may be fitted on; and as much as possible should be saved, but in cases of injury, where the carpus is opened and the hand irreparably destroyed, the question arises, Where ought amputation to be performed? To this we answer that there appears no conceivable advantage to be gained by leaving all or any of the carpal bones. If successful, it would result only in the retention of a flapping joint, unless from there being no tendons to act upon it, except the tendon of the flexor carpi ulnaris attached to the pisiform, and there are several risks it would run in the inflammation of all the carpal joints, and the almost certain spread of this inflammation to the bursa underneath the flexor tendons, beyond the annular ligament, and up the arm among the muscles.

Amputation at the Wrist-Joint.—This is an operation by no means frequent, and it has the advantages of preserving a long stump, and retaining the full movements of pronation and supination, in cases where the radio-ulnar joint is sound and uninjured, but in practice it is often found that fibrous adhesions limit to a great extent the motions of the two bones on each other, specially in those cases where the radio-ulnar joint has been diseased or injured.

Another advantage is the extreme ease with which disarticulation may be performed on emergency, no saw being required, and the ordinary bistoury of the pocket-case being quite sufficient for cutting the flaps.

Operation.—By double flap. An incision (Plate IV. fig. 3) on the dorsal surface, extending in a semilunar direction from one styloid process to the other, will define a flap of skin only, which must be raised; the joint must then be opened by a transverse incision, and a long semilunar flap of skin and fascia should be shaped (Plate IV. fig. 4) from the palm. Disarticulation is facilitated by the surgeon forcibly bending the wrist when he makes the transverse cut, and it will be found easier to shape the palmar flap from the outside by dissection, than to do it by transfixion after disarticulation, on account of the prominence of the pisiform on the inner side of the palm.

Fig. iii.26

Fig. iv.27

In the thin wasted wrists of the aged, or in any case where the skin is very lax, this amputation may be very easily performed by the circular method. While an assistant draws up the skin as much as possible, the surgeon makes an accurate circular incision through the skin, about an inch below the styloid processes, just grazing the thenar and hypothenar eminences. Another circular sweep just above the pisiform and unciform bones divides all the soft textures, after which the joint may be opened, and, if necessary, the styloid processes cut away with saw or pliers.

Amputation by a long single flap, either dorsal or palmar, may be rendered necessary by accident. The palmar one of the two is preferable; indeed, rather than trust for a covering to the thin skin of the back of the hand, with its numerous tendons, it is better to amputate an inch or two higher up through the fore arm.

The following amputation by external flap has been described (so far as I can discover, for the first time) by Dr. Dubrueil, in his work on operative Surgery:28—"Commencing just below the level of the articulation, while the hand is pronated, the surgeon makes a convex incision, beginning at the junction of the outer and middle thirds of the arm behind, reaching at its summit the middle of the dorsal surface of the first metacarpal, and terminating in front just below the palmar surface of the joint, again at the junction of the outer and middle thirds of the breadth of the arm. This flap being raised, the wrist is disarticulated, beginning at the radial side. A circular incision finishes the cutting of the skin." (Figs. iii. and iv.)

Amputation through the Fore-arm.—The method of operating must, in the fore-arm, depend a good deal upon the part of the arm where you require to amputate, the muscularity of the limb, and the condition of the skin and subcutaneous cellular tissue.

It must be remembered that a section of the fore-arm involves two bones, not, like the tibia and fibula, on a constant permanent relation in position to each other, but which rotate one upon another to an amount which varies with the part of the limb divided, and which rotation is a very important element in the future usefulness of the stump; again, that two sets of muscles occupy, one the back, the other the front of the limb, that these two are unequal in size, and that the outer sides or rather edges of each bone are subcutaneous; again, that these sets of muscles are comparatively fleshy in the upper two-thirds of the limb, and almost entirely tendinous in the lower third.

Remembering these points, we find that certain things require our attention, and certain difficulties are present in amputation of the fore-arm, from which amputation of the arm, with its single bone and copious muscular covering on all sides, is completely free.

Thus our flaps in the fore-arm must be antero-posterior; lateral flaps are an impossibility. Great care is requisite to cut them at all equal, from the inequality of the muscles on the two sides. In the lower third we cannot obtain available muscular flaps. Lastly, care must be taken lest, from the ever-varying relations of the two bones to each other in the varying positions of the limb, the surgeon mistake their position and pass his knife between them.

The next question that arises is, Where are we to operate? In cases where we have a choice, is there here, as in the leg, any "point of election"? No. As a rule in the fore-arm, the surgeon should endeavour to save as much as possible; especially when nearing the middle of the fore-arm, he should try to save the insertion of the pronator teres, so important in its function of pronating the radius.

Amputation in Lower Third of the Fore-arm.—By two flaps. These antero-posterior flaps must consist of skin only, as the tendons are only in the way, and thus should be made by dissection from without.29 Making the dorsal one first, the surgeon should enter his knife at the palmar edge of the bone that is further from him, and cut a semilunar flap of skin only, finishing the incision quite on the palmar edge of the inner bone. The two ends of this incision must then be united by a similar semilunar flap of skin on the palmar side. The two flaps having been dissected back, he then clears the bones by a circular incision through tendons and muscles, not forgetting to pass the knife between the bones, and retracting all the soft parts, saws through the bones, at least half or probably three-quarters of an inch higher up. It is generally easiest to saw through both bones at once.

Long Dorsal Flap.—Where it is possible from laxity of the soft parts and the wrist not being much destroyed, to get a long flap from the back of the arm after Mr. Teale's method, a very good stump will result. This rule is, "In tracing the long flap a longitudinal line is drawn over the radius, so as to leave the radial vessels for the short flap (Plate II. fig. 1). At a distance equal to half the circumference of the limb, another line parallel to the former is drawn along the ulna. These are then joined at their lower ends, across the dorsal aspect of the wrist or fore-arm, by a transverse line equal in length to half the circumference of the fore-arm. The short flap is marked by a transverse line on the palmar aspect, uniting the long ones at their upper fourth.

"The operator, in forming the long flap, makes the two longitudinal incisions merely through the integuments, but the transverse one is carried directly down to the bones. In dissecting the long flap from below upwards, the tissues of which it is composed must be separated close to the periosteum and interosseous membrane. The short flap is made by a transverse incision through all the structures down to the bones, care being taken to separate the parts upwards close to the periosteum and membrane." The stump must be placed in the prone position, "to allow the long dorsal flap to be the superior when the patient is recumbent, and thus fall over the ends of the bones."30

The principal objection to the long dorsal rectangular flap (which makes an excellent covering) is, that unless it can be obtained from over the wrist-joint it requires the bones to be sawn so very high up. This may be avoided, to some extent, by making it shorter and rounded off, as in Carden's Amputation, q.v.

Amputation in Upper Two-Thirds.—Where the fore-arm is very fat or fleshy, this amputation can be very easily performed by two equal antero-posterior flaps made by transfixion. In most cases, however, from the comparative leanness of the dorsal aspect of the limb, the following method will have the best result. The surgeon must, as in the former case, shape a rounded dorsal flap by dissection from without (Plate IV. fig. 5), embracing the whole breadth of the limb down to the palmar edge of both bones. Then at once he transfixes the two points of this dorsal flap, and cuts out an equal one from the anterior aspect of the limb (Plate IV. fig. 6). Dissecting up the dorsal flap he clears the bones at least half an inch above as before, and applies the saw.

N.B.—This operation should be performed even in cases where only an inch of radius can be retained, as the attachment of the biceps makes a very small stump of fore-arm wonderfully useful.

Amputation at Elbow-Joint.—In cases where it is found impossible to save any portion of the fore-arm, disarticulation at the elbow-joint may be easily performed. This operation was proposed and performed so long ago as the days of Ambrose Paré,31 was much approved by Dupuytren, Baudens, and Velpeau, had fallen into disuse for a time, but is now again recommended by some excellent surgeons, especially by Gross32 and Ashhurst,33 both of Philadelphia.

It is tolerably easy to perform, and does not involve any sawing of bones, but the flaps are apt to be cut too short, unless care be taken, from the manner in which the trochlea projects downwards beyond the line of the condyles, so that if the base of an ordinary-shaped flap be made on a level with the condyles, it will prove insufficient to cover the bone. It may be performed either by the circular method (Velpeau), oval (Baudens), or by a long anterior and short posterior flap (Textor and Dupuytren). Probably the best method is by a long anterior flap when it can be obtained, thus:—The arm being placed in a slightly flexed position, the surgeon transfixes in front of the joint, in a line extending from the level of the external condyle to a point one inch below the internal condyle (Plate IV. fig. 7); the tissue should be held well forward at the moment of transfixion. The flap should be at least two and a half inches deep at its apex, which must be rounded off. The two ends of this flap may then be united behind by a semilunar incision (Plate III. fig. 2), which will separate the radial attachments. The ulna must then be cleared, and the triceps divided at its insertion.

Modifications.—Dupuytren used to saw through the ulna, leaving the olecranon attached. Velpeau opposed this, but it is again recommended by Gross, who leaves the olecranon, and at the same time improves the shape of the stump by sawing off the "inner trochlea" on a level with the general surface.

Amputation of the Arm.—This amputation is best performed by double flap, and is the typical instance which exhibits all the advantages of two equal flaps made by transfixion, without any of the disadvantages of that method. These advantages are, easiness of performance, rapidity, excellent covering for the bone, with as little sacrifice of tissue as is possible, while the fact that the cicatrix is opposite the end of the bone is hardly a disadvantage in the arm (as it certainly is in the leg), as no weight has to be borne on it. When they can be obtained, anterior and posterior flaps are generally considered most satisfactory, but Mr. Spence prefers lateral ones, lest the line of union should be interfered with by the deltoid raising the bone. If the right arm has to be amputated, the operator standing at the inner side raises the anterior muscles with his left hand, and enters the knife just in front of the brachial vessels (Plate I. fig. 12); keeping as close as possible to the bone, he brings out the knife at a point exactly opposite, then with a brisk sawing motion, cuts a semicircular flap, taking care to bring out the knife more suddenly just at the end, in order to cut through the skin as perpendicularly to the arm as possible. The knife is again entered at the same point, carried behind the bone, and brought out at the same angle, and an exactly corresponding flap cut from the other side of the limb, the flaps are then retracted, the bone cleared by circular incision and sawn through as high up as it is exposed. In primary cases, where the muscles are firm and developed, the flaps should be cut a little concave.

Modifications and Varieties.—Teale's method may of course be used here as elsewhere. The internal line of incision (Plate IV. fig. 8) should be made just in front of the brachial vessels. This method requires the amputation to be performed higher up than would otherwise be necessary (from the length of the anterior flap), and this disadvantage is not counterbalanced by any special advantage in the posterior retraction of the cicatrix.

In feeble flabby arms, the true circular operation is very easily performed, and with good results. A circular sweep of the knife is made through the skin alone, which is drawn up by an assistant, while the surgeon separates it from the fascia; another circular cut through fascia and muscles exposes the bone, which must then be cleared and cut through at a still higher level.