Another, but not so good method of making an external flap, is the following:—(a.) For the right arm.—The patient lying well over on his left side, the surgeon stands to the inside of the arm to be removed. Seizing the deltoid in the left, withthe right he passes an amputating knife, seven or eight inches in length, from a point a little nearer the clavicle than the middle space between the acromion and coracoid processes; then, transfixing the base of the deltoid, and just grazing the posterior surface of the humerus, thrusts the knife downwards and backwards till it protrudes at the posterior margin of the axilla. When doing this, it is important that the arm be held outwards and backwards, and even upwards, as far as possible to relax the deltoid; without this it will be impossible to make the flap of the full size. The flap must then be cut of as full length as can be obtained, four or five inches at least. An assistant then holds it upwards, while the surgeon, or (if the arm is very muscular) another assistant, brings the arm forwards well across the patient's chest, thus exposing the posterior aspect of the joint. This may have very possibly been already opened during the transfixion; the attachments of muscles must now be divided, the knife passed behind the head of the bone, which is dislocated forwards, and a suitable flap of the tissues in front cut from within outwards. The assistant is to follow the knife with his finger and compress the vessels.(b.) If the left shoulder is to be amputated, the patient lying on his right side, the surgeon stands behind him, and raising the elbow of the limb to be removed from the side, and pulling it slightly backwards, enters the knife at the posterior fold of the axilla (Plate II.fig. 2), and passing the posterior aspect of the head of the humerus, endeavours to protrude it as near the acromion as possible; the flaps must be cut and the rest of the operation performed in the manner we have just described for the other arm.
Another, but not so good method of making an external flap, is the following:—(a.) For the right arm.—The patient lying well over on his left side, the surgeon stands to the inside of the arm to be removed. Seizing the deltoid in the left, withthe right he passes an amputating knife, seven or eight inches in length, from a point a little nearer the clavicle than the middle space between the acromion and coracoid processes; then, transfixing the base of the deltoid, and just grazing the posterior surface of the humerus, thrusts the knife downwards and backwards till it protrudes at the posterior margin of the axilla. When doing this, it is important that the arm be held outwards and backwards, and even upwards, as far as possible to relax the deltoid; without this it will be impossible to make the flap of the full size. The flap must then be cut of as full length as can be obtained, four or five inches at least. An assistant then holds it upwards, while the surgeon, or (if the arm is very muscular) another assistant, brings the arm forwards well across the patient's chest, thus exposing the posterior aspect of the joint. This may have very possibly been already opened during the transfixion; the attachments of muscles must now be divided, the knife passed behind the head of the bone, which is dislocated forwards, and a suitable flap of the tissues in front cut from within outwards. The assistant is to follow the knife with his finger and compress the vessels.
(b.) If the left shoulder is to be amputated, the patient lying on his right side, the surgeon stands behind him, and raising the elbow of the limb to be removed from the side, and pulling it slightly backwards, enters the knife at the posterior fold of the axilla (Plate II.fig. 2), and passing the posterior aspect of the head of the humerus, endeavours to protrude it as near the acromion as possible; the flaps must be cut and the rest of the operation performed in the manner we have just described for the other arm.
3.Where the destruction of tissue has been chiefly below the joint, a very good flap may be obtained from above, composed chiefly of the deltoid muscle, and the skin over it. This may be made by transfixion at its base, but is better obtained by dissection from without.
The surgeon cuts (Plate II.figs. 3, 3) in a semilunar direction (with the convexity downwards) from one side of the deltoid to the other, viz., from the root of the acromion to near the coracoid process; he then raises the large flap upwards and throws it back, opens the joint, disarticulates, passes the knife behind the head of the bone, and cuts out without attempting to save any flaps below, in a transverse direction. By this meansthe artery is still almost the last structure to be divided, and can be secured by a ready assistant. In cases where much injury has been done to the floor of the axilla and wall of chest, the deltoid flap must be made large in proportion, and triangular rather than semilunar in shape.
N.B.—The statistics of amputation at the shoulder-joint bring out some interesting facts: 1. That the primary amputations here are far more successful than secondary ones. Guthrie records nineteen cases of the former out of which only one died, while out of a similar number in which the amputation was secondary, fifteen died. In the Crimea, British surgeons had thirty-nine cases, with thirteen deaths; of thirty-three primary, nine died; and of six secondary, four were fatal.
S.W. Gross's[34]statistics confirm this: of one hundred and seventy-eight primary, forty-six died—25.8 per cent.; ninety-five secondary, sixty-one died—64.2 per cent.
Amputations above the Shoulder-Joint.—Under this head we may group the comparatively rare cases in which, from accident or disease, the removal of portions of the scapula and clavicle, or even the entire bones, is rendered necessary. That it is quite possible to survive such injuries has been frequently shown in cases of accident when the scapula along with the arm has been torn off, and yet the patient recovered.
Encouraged by such cases, Gaetani Bey of Cairo removed the whole of scapula and part of the clavicle in a case where he had amputated at the shoulder for smash. The patient recovered. Heron Watson has had a similar case. Dr. George M'Lellan amputated arm and scapula in a youth of seventeen for an enormous encephaloid tumour. Fifty-one such cases are now on record.
Syme amputated with success the arm along with the scapula and outer half of clavicle, in a case in which he had previously excised the head of the humerus for a tumour.[35]
Gilbert, Mussey, Rigaud, Fergusson, and others have performed similar operations, secondary to amputation at the shoulder-joint, for cases of caries and malignant tumour. It is impossible to give any exact directions for the incisions which must be planned for individual cases, with two chief aims, to avoid hæmorrhage as far as possible, and to leave abundance of skin. In operations on the scapula, it should be freely exposed by large enough incisions. (SeeExcisions.)
Amputations of Lower Extremity.—Commencing with the most distal, and gradually working our way upwards, we find that partial amputations of the toes are extremely rare. Only in the case of the great toe is such an operationeveradmissible, for the other toes are so short, and the stumps left by amputation are at once so useless from their shortness, and so detrimental from the manner in which they project upwards and rub against the shoe, that any injury requiring partial amputation of a lesser toe is treated by its complete removal.
Fig. V.Fig. v.
Amputation of Distal Phalanx of Great Toe.—This is comparatively rarely required now. It used to be thought necessary for the cure of those not uncommon cases of exostosis of the distal phalanx, but it is now found that most of these can be cured by simply clipping off the exostosis. When necessary, however, and when the choice of flaps is possible, the best plan is by a long flap from the plantar surface (Fig.v. 4), as in the similar operation on the thumb; laying the edge of the knife over the dorsal aspect of the joint, cutting through it, and turning the edge of the knife round close to the bone, so as to cut out a large flap from the ball of the toe.
Amputation of a Single Lesser Toe—second,third,or fourth.—This operation is on exactly the same principle as that described for the corresponding finger; but it must be remembered that the metatarso-phalangeal joint is more deeply situated in the soft parts than is the metacarpo-phalangeal; and thus the commencement of the elliptical incision which is to surround the base of the toe must be proportionally higher up (Fig.v. 1). On the other hand, as it is very important to avoid as much as possible any cicatrix in the sole of the foot, the plantar end of the incision need not be carried to a point exactly opposite the one from which it set out, but it will be sufficient if it reaches the groove between the toe and sole. A little more care may thus be required in dissecting out the head of the first phalanx, but this is quite repaid by the cicatrix in the sole being avoided. Early division of flexor tendons renders disarticulation easy.
Amputation of the First and Fifth Toes.—The incisions are conducted on the same principle as in the other operations, the operator being careful to preserve as much as possible (Fig.v. 2) of the hard useful pad of the inner and outer sides respectively.
Most surgeons are now agreed that in these toes it is best not to remove the head of the metatarsal bone with the toe. Cutting off the large cartilaginous head obliquely with a pair of bone-pliers may prevent an awkward unseemly projection, but it does diminish the strength of the transverse arch of the foot.
Amputation of one or more Toes with their Metatarsals.—It is not necessary to give very particular details regarding such operations, as the surgeon must be guided in the individual cases by the specialties of accident or disease.
One or two guiding principles are important:—
1. Having made up your mind at what point you are to cut the metatarsal, if the amputation be a partial one, or as to the exact position of the joint, if you intend to disarticulate, commence your dorsal incision (Fig.v. 3) at a point fully half an inch higher up than the selected spot, as free access is of the very last importance.
2. Whenever it is possible, cut the bone through its continuity rather than disarticulate. Specially is this important in the case of the metatarsal bone of the great toe, that the insertion of the tendon of the peroneus longus may be saved. If, however, the terminal branch of thedorsalis pedisartery be wounded, it may be necessary to disarticulate the first metatarsal to secure it rather than trust to compression to stop the bleeding.
3. In cutting through the first and fifth metatarsals, remember to apply the bone-pliers obliquely, not transversely, so as to avoid unseemly projection.
4. As far as possible avoid cutting into the sole at all.
The plantar cicatrix is almost a fatal objection to a plan of removing the first and fifth toes and their metatarsals which has much otherwise in rapidity and elegance to recommend it. In the great toe, for example, it is performed as follows:—Seizing the soft parts of the inner edge of the foot in his left hand, the surgeon draws theminwards, transfixes just at the tarso-metatarsal joint, and, keeping as close as possible to the inner edge of the metatarsal bone, cuts the flap as long as to the middle of the first phalanx; then the soft parts of the foot being drawn as faroutwardsas possible by an assistant, the surgeon enters his knife between the first and second toes, and succeeds in entering his former incision so as to separate the metatarsal bone without removing any skin. All thatremains is to open the tarso-metatarsal joint. It is a very neat-looking operation, leaves a very good covering for the parts, and is performed with extreme rapidity. This last is not so much required in these days of anæsthetics, and the cicatrix in the sole is a very formidable objection to it.
The simplest and shortest rule that can be given for the amputation of a toe, with the part or whole of its metatarsal, is to make one dorsal incision, commencing about a quarter of an inch above the spot at which you intend to divide the bone or to disarticulate, extending downwards in a straight line to the metatarso-phalangeal articulation, and then bifurcating so as to surround the base of the toe at the normal fold of the skin. The soft parts are then to be cleared from the metatarso-phalangeal joint, and the toe still being retained on the metatarsal bone, it should be carefully dissected up, avoiding any pricking of the soft parts below, till the joint is reached, or the spot at which the bone-pliers are to be applied is fully cleared.
Amputation of the anterior portion of the Foot at the Tarso-metatarsal Joint—Hey's Operation.—This operation, which is now comparatively rarely performed, has been invested with a halo of difficulty and complexity which is to a great extent unnecessary.
There is no doubt that the anatomical conformation of the joints involved, especially the manner in which the head of the second metatarsal (Fig.v.C) projects upwards into the tarsus, and is locked between the cuneiform bones, renders disarticulation in the healthy foot rather difficult; but it must be remembered that in cases where for accident we have to deal with previously healthy tissues, it is quite unnecessary to disarticulate, a better result being attained by simply sawing the foot across in the line of the articulation; and again, where we have to operate for disease, the tissuesare so matted, and the bones so soft, that complete removal of the metatarsus is much easier than it appears when practising on the dead subject.
Very various plans of incision have been proposed. Mr. Hey's original procedure has not been much improved upon. His short account of it has at once surgical value and historical interest:—
"I made a mark across the upper part of the foot, to point out as exactly as I could the place where the metatarsal bones were joined to those of the tarsus. About half an inch from this mark, nearer the toes, I made a transverse incision through the integuments and muscles covering the metatarsal bones (Plate IV.figs. 10, 11). From each extremity of this wound I made an incision (along the inner and outer side of the foot) to the toes. I removed all the toes at their junction with the metatarsal bones, and then separated the integuments and muscles forming the sole of the foot from the inferior part of the metatarsal bones, keeping the edge of my scalpel as near the bones as I could, that I might both expedite the operation and preserve as much muscular flesh in the flap as possible. I then separated with the scalpel the four smaller metatarsal bones at their junction with the tarsus, which was easily effected, as the joints lie in a straight line across the foot. The projecting part of the first cuneiform bone which supports the great toe I was obliged to divide with a saw. The arteries, which required a ligature, being tied, I applied the flap which had formed the sole of the foot to the integuments which remained on the upper part, and retained them in contact by sutures....
"The patient could walk with firmness and ease; she was in no danger of hurting the cicatrix by striking the place where the toes had been against any hard substance, for this part was covered with the strong integuments which had before constituted the sole ofthe foot. The cicatrix was situated upon the upper part of the foot, and had very little breadth, as the divided parts had been kept united after being brought into close contact."[36]
Lisfranc's methodhas, briefly, the following modifications.—Having fixed the position of the articulations of the first and fifth metatarsals with the tarsus, the operator unites them by a curved incision across the dorsum of the foot, with its convexity downwards. He then divides the dorsal ligaments over the articulations, opens the first from the inside, the fifth, fourth, and third from the outside, he then with a strong narrow-bladed knife divides the interosseous ligaments between the sides and end of the head of the second metatarsal and the cuneiforms, thus completing the disarticulation; bending the fore part of the foot downwards, he then keeps the edge of the knife close to the lower surface of the bones, separating the plantar ligaments, and cutting out a long plantar flap of skin and muscles.
In every case it must be remembered that the upper end of the fifth metatarsal projects far up along the outer edge of the foot. Allowance must be made for this projection in commencing the incision. A rule given by Mr. Syme to guide the disarticulation of the three outer metatarsals will often be of service; it is this: "Having once entered the joint of the fifth, the knife must be drawn along in a direction of a line drawn towards the distal end of the first metatarsal; for the fourth, the direction must be changed to the middle of the same bone; and to open the third it will be necessary to come across the dorsum of the foot as if intending to reach the proximal end."
To avoid the difficulties of disarticulation, Skey recommends cutting off the head of the second metatarsal with a pair of pliers. Baudens, Guérin, and othersapprove of sawing all the bones across in the line desired.
Most surgeons are now agreed that in this operation it is better to make both flaps by cutting from without, in preference to transfixion of the plantar one from within. In cases where, from injury and disease, the plantar flap is deficient in size, it may be necessary to make the dorsal flap longer. However, the long plantar is preferable both from its superior hardness, and also because from its length it permits the cicatrix to be well on the dorsum of the foot, and therefore less likely to be injured by the pressure of the boot in front.
Amputations through the Tarsus.—Various plans of amputating through the tarsus have been devised and described at great length. The most important of these is the operation of removal of the anterior portion of the foot, at the joints between the astragalus and scaphoid, and os calcis and cuboid, well known to the profession by the name of its first describer, Chopart.
It has been so completely superseded by the infinitely preferable amputation at the ankle-joint of Mr. Syme, as rarely, if ever, to be practised in this country. Indeed, amputation at the ankle-joint may be said to have taken the place of all these amputations through the tarsus; for though cases are occasionally met with in which the limitation of the disease or injury may render Chopart's possible, and though at first sight it appears to have an advantage in removing less of the body, still the following objections are nearly fatal to its chance of being selected:—1. In cases of injury, through leaving a long stump, and, at first sight, a useful one, experience shows that the tendo Achillis sooner or later (being unopposed by the extensors of the toes) draws up the heel so as to make the end of the stump point, and the cicatrix press on the ground,rendering it unable to bear any weight. 2. In cases of removal for disease of the tarsus, the bones left behind, though apparently sound at the time, are almost sure to become eventually diseased.
As it has an historical interest, and as this operation (defective as it is) had been the means of saving many legs prior to the invention of amputation at the ankle-joint, a brief description may be appended:—
Chopart's own manner of operation was briefly somewhat as follows:—
The tourniquet having been applied, the surgeon is to make a transverse incision through the skin which covers the instep, two inches from the ankle-joint. He is to divide the skin, and the extensor tendons, and the muscles in that situation, so as to expose the convexity of the tarsus. He is next to make on each side a small longitudinal incision, which is to begin below and a little in front of the malleolus, and is to end at one of the extremities of the first incision. After having formed in this way a flap of integuments, he is to let it be drawn upwards by the assistant who holds the leg. There is no occasion to dissect and reflect the flap, for the cellular substance connecting the skin with the subjacent aponeurosis is so loose, that it can easily be drawn up above the place where the joint of the calcaneum with the cuboides and that between the astragalus and scaphoides ought to be opened. The surgeon will penetrate the last the most easily, particularly by taking for his guide the eminence which indicates the attachment of the tibialis anticus muscle to the inside of the os naviculare. The joint of the os cuboides and os calcis lies pretty nearly in the same transverse line, but rather obliquely forwards. The ligaments having been cut, the foot falls back. The bistoury is then to be put down, and the straight knife used, with which a flap of the soft parts is to be formed under the tarsus and metatarsus, long enough to admit of being applied tothe naked bones, so as entirely to cover them. It is to be maintained in position with three or four straps of adhesive plaster, etc.[37]
Chopart's amputation, after an interval of comparative neglect, was introduced into this country by Mr. Syme in 1829. His method of performance is simpler and easier than Chopart's. He thus describes it:—"The blade of the knife employed should be about six inches long, and half an inch broad, sharp at the point and blunt on the back. The tourniquet ought to be applied immediately above the ankle, having compresses placed over the posterior and anterior tibial arteries. The surgeon should measure with his eye the middle distance between the malleolus externus and the head of the metatarsal bone of the little toe, which is the situation of the articulation between the os cuboides and os calcis. Placing his forefinger here, he ought to place his thumb on the other side of the foot directly opposite, which will show him where the os naviculare and astragalus are connected. An incision (Plate II.figs. 4 and 5) somewhat curved, with its convexity forward, is then to be made from one of these points to the other, when, instead of proceeding to disarticulate, the operator should transfix the sole of the foot from side to side at the extremities of the first incision, and carry the knife forwards so as to detach a sufficient flap, which must extend the whole length of the metatarsus to the balls of the toes. The disarticulation may finally be completed with great ease, as the shape of the articular surfaces concerned is very simple, and nearly transverse."[38]Regarding the method of disarticulating at the astragalo-calcaneal joint, and removing all the foot except the astragalus, no detail need be given. Malgaigne advises an internal flap, thus sacrificingthe valuable pad of the heel. Roux, Verneuil, and others endeavour to save the pad. This operation, however, has now fallen almost completely into disuse.
Subastragaloid Amputationhas been highly recommended. In it the flap is made as in Syme's, then anterior bones removed as in Chopart's, and os calcis grasped by lion forceps and twisted off, its attachment and the insertion of tendo Achillis being cautiously avoided. If flaps are scanty, head of astragulus may be cut off with a small saw.—Hancock and Ashurst.
Tripier's Amputation[39]is a modification of above, the skin incisions being made as in Chopart's amputation, and then the calcaneum is sawn through on a level with the sustentaculum tali on a plane at right angles to the axis of the leg.
Amputation at the Ankle-joint, or Syme's Amputation.—This operation is one of much interest and great practical importance. In our cold variable climate caries of the bones of the tarsus, and strumous disease of the ankle-joint, are very common and very intractable maladies, and for both of these, when far advanced, Syme's amputation is the only justifiable procedure. When properly done, according to theexactplan of its proposer, it removes the whole of the diseased parts and not an inch more, is an operation of very slight danger to life, and results almost invariably in a thoroughly useful comfortable stump. Much of its success depends on the manner in which it is performed, and as many surgical manuals are not sufficiently full, some positively in error regarding this point, and as very many modifications have been devised diminishing in value and applicability very much in proportion asthey diverge from the original description, I think it advisable to describe the operation minutely, and point out in detail the parts of it which seem absolutely essential to success.
Operation.—The foot being held at a right angle to the leg, the point of a straight bistoury, with a pretty strong blade, should be entered just below the centre of the external malleolus (Plate IV.figs. 12, 13), (1.) and then carried right across the integuments of the sole, in a straight line (or in the case of a prominent heel, slightly backwards), (2.) to a point at the same level on the opposite side. (3.) This incision should reach boldly through all the tissues down to the bone. Holding the heel in the fingers of his left hand, the operator then inserts his left thumb-nail into the incision, and pushes the flap downwards, as with the knife kept close to the bone, and cutting on it, he frees the flap from its attachments. The thumb-nail guards the knife from in any way scoring the flap. (4.) This process is continued till the tuberosity of the os calcis is fairly turned, and the tendo Achillis nearly reached. Shifting his left hand he then extends the foot, and joins the extremities of the first incision by a transverse one right across the instep. (5.) Thus he opens the joint between the astragalus and tibia, (6.) divides the lateral ligaments, disarticulates, and still keeping close to the bone, removes the foot by the division of the tendo Achillis.
The lower ends of the tibia and fibula are then to be isolated from the soft parts, and a thin slice, including both malleoli, to be removed. If the disease of the joint has affected the lower end of the bone, slice after slice may be removed, till a healthy surface of cancellated texture is obtained. The vessels are then secured.
Dressing of the Stump.—From its peculiar shape and position, the escape of any blood into the stump is muchto be deprecated, for as it cannot easily get out, on the one hand it gives pain, and may cause sloughing from its pressure, and on the other it is sure eventually to cause suppuration, and delay union. To avoid such results care must be taken to secure every vessel that can be seen; if there is any general oozing it is best merely to pass the sutures through the edges of the flaps, but not bring them together, thus leaving the stump open for some hours; then apply cold, and when the surfaces are fairly glazed over, remove any clots and bring the flaps together.[40]
Another plan introduced by Mr. Syme was to make a longitudinal slit in the flap, through which all the ligatures are to be drawn; these give a dependent drain to any pus that may be formed, and by their presence greatly expedite the healing of the wound. Again, in cases where from the amount of disease existing before the operation, and the gelatinous thickening of the flap and neighbouring parts, much suppuration may be looked for, probably it will be found best to keep the flaps quite apart for some days, by stuffing the wound with lint, and aiming only at secondary union by granulations.
A drainage tube passed through the breadth of the flap, and brought out at the angles, and retained for a few days, will do admirably.
Notes.—(1.) If commenced further forward, as in Pirogoff's modification, it will be found difficult to turn the corner of the heel; if further back, the nutrition of the flap is endangered.(2.) This is very important. In several well-known text-books, even in the last edition of Gross'sSurgery, the incision is figured passing obliquelyforwards. This is a fatal error, for besides making a flap far too long, it forces the operator to cut fairly into the hollow of the sole, quite off the prominence of the os calcis, and he finds that it is utterly impossible to free his flap without using great force, and inevitably scoring it in all directions. Sloughing is almost inevitably the result.(3.) The incision is to stop at least half-an-inch below the internal malleolus. Most surgical manuals, even when they profess to describe Mr. Syme's own method of operating, say that the incision should extend from malleolus to malleolus. If this is done, the flap becomes unsymmetrical, too long, and also the posterior tibial artery, on which much of the vascular supply of the flap depends, is cut. When the incision is properly made, the vessel is not cut till after its division into the plantar arteries.(4.) Scoring the flap. Some may ask, Why do you object to a little scoring, the tissues are thick enough, and besides, don't you advise a slit in the flap yourself? Yes. One look at an injected preparation will show that the vessels supplying this thick flap come to it from its inner surface, and are inevitably cut across in any scoring of it, and also, that scoring cuts across the vessels, andmustdivide dozens of them; the slit we make is parallel with their course, andmaynot divide one.(5.) Across the instep. Some authors recommend a semilunar anterior flap; this is quite unnecessary, increases bagging and delays union. It can be required only in cases where the heel flap has been destroyed or lessened by disease, or by operators in whose hands the heel flaps occasionally slough.(6.) It is not impossible that a careless operator may (by cutting a little too low) miss the joint and get into the hollow of the neck of the astragalus, where he may cut away for a long time without making much progress.
Notes.—(1.) If commenced further forward, as in Pirogoff's modification, it will be found difficult to turn the corner of the heel; if further back, the nutrition of the flap is endangered.
(2.) This is very important. In several well-known text-books, even in the last edition of Gross'sSurgery, the incision is figured passing obliquelyforwards. This is a fatal error, for besides making a flap far too long, it forces the operator to cut fairly into the hollow of the sole, quite off the prominence of the os calcis, and he finds that it is utterly impossible to free his flap without using great force, and inevitably scoring it in all directions. Sloughing is almost inevitably the result.
(3.) The incision is to stop at least half-an-inch below the internal malleolus. Most surgical manuals, even when they profess to describe Mr. Syme's own method of operating, say that the incision should extend from malleolus to malleolus. If this is done, the flap becomes unsymmetrical, too long, and also the posterior tibial artery, on which much of the vascular supply of the flap depends, is cut. When the incision is properly made, the vessel is not cut till after its division into the plantar arteries.
(4.) Scoring the flap. Some may ask, Why do you object to a little scoring, the tissues are thick enough, and besides, don't you advise a slit in the flap yourself? Yes. One look at an injected preparation will show that the vessels supplying this thick flap come to it from its inner surface, and are inevitably cut across in any scoring of it, and also, that scoring cuts across the vessels, andmustdivide dozens of them; the slit we make is parallel with their course, andmaynot divide one.
(5.) Across the instep. Some authors recommend a semilunar anterior flap; this is quite unnecessary, increases bagging and delays union. It can be required only in cases where the heel flap has been destroyed or lessened by disease, or by operators in whose hands the heel flaps occasionally slough.
(6.) It is not impossible that a careless operator may (by cutting a little too low) miss the joint and get into the hollow of the neck of the astragalus, where he may cut away for a long time without making much progress.
Advantages.—1. It is wonderfully free of danger to life. It is very hard to obtain exact statistical information, but my experience is that the mortality is certainly not more than about 10 per cent., a very remarkable result when compared with that of amputations through the leg, the operation which used to be required for those cases which now require only amputation at the ankle-joint.
In the Statistical Report by the Surgeon-General of the United States, 9705 cases of amputation resulted in death, the proportions being as follows:—
2. It is the most perfect stump that can be made, in fact the only one in the lower extremity which can bear pressure enough to support the weight of the body; all the others require the weight to be distributed over the general surface of the limb by means of apparatus. A good ankle-joint stump can bear the whole weight of the body, as when the patient hops on it without any artificial aid, or without even the interposition of a stocking between the stump and a stone floor. More than this, I have seen a patient who had both his feet amputated at the ankle-joint run without shoes or stockings on the stone passages, without even the aid of a stick, and with very great swiftness.
The reason of this may be found in the nature of the flap itself, originally intended to bear the weight of the body, there being no cicatrix at the part on which pressure is borne. I have noticed that perfection in walking on an ankle-joint stump has a certain relation to the freedom of movement which the pad has over the face of the bone. This ought to be pretty considerable. It is explained by the new attachments formed by the tendons, and is under the control of the patient, being elicited when he is told to move his toes.
It has been objected to this operation that the flap is apt to slough. When improperly performed, as when the flap is scored transversely in its separation, and especially when the flap is cut too long (as has been already noticed), this may occur; but that there is nothing whatever in the position or condition of the flap itself that at all necessitates its sloughing, is thoroughly proved by the following remarkable case, given by Mr. Syme in his volume ofObservations in Clinical Surgery. I quote it entire:—
"P.C., aged thirty-three, was admitted into the hospital on the 25th July 1860, in the following state:—He had been treated in the Manchester Infirmary for popliteal aneurism by pressure, so decidedly applied that it had caused an ulcer, of which the cicatrix remained; but without producing the effect desired. The femoral artery was then tied with success, in so far as the aneurism was concerned, but with the unpleasant sequel, some months afterwards, of mortification in the foot, which was thrown off, with the exception of the astragalus and os calcis with their integuments, a large raw surface being presented in front where the bone was bare. Although the patient was extremely weak, and the parts concerned might be supposed more than usually disposed to slough, I did not hesitate to perform the operation, with the speedy result of a most excellent stump and complete restoration to health."—Pp. 49, 50.
The modifications of Mr. Syme's original operation have been very various. It will be unnecessary even to name them all. One or two may require notice. Retaining Mr. Syme's incisions in their integrity, some operators prefer not to disarticulate the foot, but remove it by sawing through the tibia and fibula at once, while still in connection with the foot. That most excellent surgeon and first-rate operator, Dr. Johnston of Montrose, used to prefer this method.
In cases where the pad of the heel has been destroyed by disease or accident, so as to be partially or entirely unavailable for the flap, the late Dr. Richard Mackenzie[41]practised the following operation by internal flap:—With the foot and ankle projecting from the table with their internal aspect upwards, he entered the point of the knife (Plate I.fig. 14) in the mesial line of the posterior aspect of the ankle, on a level with the articulation, carried it down obliquely across the tendo Achillis towards the external border of the plantaraspect of the heel, along which it is continued in a semilunar direction. The incision is then curved across the sole of the foot, and terminates on the inner side of the tendon of the tibialis anticus, about an inch in front of the inner malleolus. The second incision (Plate III.fig. 4) is carried across the outer aspect of the ankle in a semilunar direction, between the extremities of the first incisions, the convexity of the incision downwards, and passing half an inch below the external malleolus.
Precisely the same principle might supply the flap from the outer side in cases where the internal flap as well as the heel was deficient, but probably the nutrition of the external flap would be more doubtful. Neither the one nor the other is nearly so good as the true heel flap, and they are both only very poor substitutes for it when it cannot be had.
The modification devised by Dr. Handyside does not seem to have any advantages over the original operation, and has not been adopted.
The modification invented by Professor Pirogoff involves a much more important principle than any of the preceding. Instead of dissecting the flap from the posterior projecting portion of the os calcis, and removing the tarsus entire, he sawed off the posterior portion of the os calcis obliquely, leaving it in contact with the pad of skin, which is retained. Immediately after making the cut which defines the posterior flap and divides the tissues down to the bone, he opens the joint in front, disarticulates, and then putting on a narrow saw immediately behind the astragalus and over the sustentaculum tali, he saws the os calcis obliquely downwards and forwards till he reaches the first incision; then removes the ends of the tibia and fibula and brings up the slice of os calcis into contact with them.
Advantages.—It is easy of performance, saving the dissection from the heel, which some find so hard. Itleaves a longer limb. It is said to bear pressure better, and there is certainly not so much chance of bagging of pus, and the mortality is exceedingly small, Hancock's collected cases giving only 8.6 per cent.; in cases of injury it is quite a warrantable operation.
Disadvantages.—It is contrary to sound principle in cases of disease, for it wilfully leaves a portion of the tarsus, in which disease is almost certain to return. It leaves too long a limb, for it is found that the shortening in Mr Syme's method is just sufficient to admit of a properly constructed spring being placed in the boot to make up for the loss of the elastic arch of the foot. It brings the firm pad of the heel too much forward, thus tending to lean the weight of the body on the softer tissues behind the heel. It takes much longer to unite and consolidate.
The author has now, in a large number of cases of Syme's amputation for disease, found advantage in leaving the periosteum in the heel flap,i.e.he cuts fairly into the os calcis when dividing the skin of heel, and then using a periosteum scraper instead of the knife, it is quite easy to remove the whole of the periosteum from the bone; this results in a large and more rounded pad of great strength and thickness.
In cases where from disease or injury it is impossible to obtain either a heel flap or a substitute lateral one, the question is, Where should amputation be performed?
It was for a long time the opinion of nearly all the best surgeons, and still is the opinion of many, that amputation of the leg should be performed at what was known as the "seat of election," just below the knee, even in cases where abundance of soft parts could be obtained for an amputation much lower down. The rule in surgery, to save as much of the body as possible in every amputation, was in the leg believed to be set aside by objections which militated strongly against all theother operations in the leg except the one performed just below the knee. Very briefly, these were somewhat as follows:—1. Just above the ankle you have large bones with nothing to cover them except skin and tendons. 2. Higher up in the calf you have plenty of muscle, but it is all on one side, and that the wrong one; it is very heavy, very difficult to dress and keep in position, and then when you have succeeded with it, the muscle wastes away and the stump is flabby. 3. And chiefly, as in all the amputations of the leg, the cicatrices are so much in the way, and the bones are so ill covered, that the patient can never rest his leg on the stump itself, but has either to rest his weight on his patella impinging on the top of a bottle-shaped leg, or just to stick out his stump behind him and kneel on the top of his wooden leg; therefore it is no use to have a stump longer than a few inches; in fact, the longer the stump is the more it is in the way. And more than this, many of the stumps made near the ankle, or through the calf, are not only useless, but positively painful. The skin becomes attached to the bones, the cicatrix never properly firms at all, the patient can hardly bear the pressure of a stocking, far less can he make use of the limb. For these reasons, secondary amputations below the knee are of very common occurrence.
Now, this idea has been much modified, and a few isolated cases in the past, and series of cases considerably more numerous in the present day, show that under certain conditions, and as a result of certain precautions in their performance, such operations are both warrantable and successful.
In the past, as we find in an erudite note in South's Chelius, Dionis, White, and Bromfield had each of them many successful cases of amputation just above the ankle, successful in so far that artificial limbs could be used which preserved the motion of the knee, and gavethe patient much more command of the limb than is possible with the short stump below the knee.
A still more important point to be remembered is, that amputation just above the ankle is a much less fatal amputation than that just below the knee (Lister inHolmes's Surgery, 3d ed. vol. iii. p. 716; Gross, 6th ed. vol. ii. p. 1113; Ben. Bell, 6th edit. vol. vii. p. 312).
There is little doubt, however, that the principle so much in vogue in the present day, of one long anterior or posterior flap, instead of two equal flaps, or of circular amputations, has done very much to make amputations at the ankle or through the calf justifiable and useful in bearing the weight of the body.
Amputation just above the Ankle.—Cases admitting of this operation must always be rare, for disease of the tarsus or ankle-joint hardly ever goes so far as to contra-indicate the performance of Mr. Syme's greatly preferable operation; and an accident which would require this operation from injury to the ankle would in most cases require an amputation a good deal higher up from the splintering of the tibia so apt to occur.
In a suitable case the plan of the operation should be as follows:—A long anterior flap slightly rounded at the end should be cut (Plate I.figs. 15, 16)—from the outside, not by transfixion,—and the anterior muscles dissected up along with it. It should be long enough to fall down over the face of the bones at the point of section, and easily cover the point of the posterior flap, which is to be made by cutting through all the tissues with one bold transverse stroke of the knife. This operation, which is the plan of Mr. Teale of Leeds very slightly modified, is equally applicable at any point of the leg, with this difference only, that the length of the anterior flap must always be carefully proportioned to the mass of the muscular flap behind it has to cover in.
This operation provides a skin covering, without any danger of the cicatrix being pressed on or becoming adherent.
The author has within the last few years operated nine times in this manner, in cases of accident in which the heel flaps had been completely destroyed; and seen a tenth case in which Mr. Syme did so. All ten cases recovered completely and rapidly, and walked on useful limbs, with the free movement of the knee-joint.
The author has within the last few years operated nine times in this manner, in cases of accident in which the heel flaps had been completely destroyed; and seen a tenth case in which Mr. Syme did so. All ten cases recovered completely and rapidly, and walked on useful limbs, with the free movement of the knee-joint.
Where from injury in a muscular patient a long anterior flap cannot be had, recourse should be had at once to the operation at the seat of election, rather than run the risk of pressure on the cicatrix by using a double flap operation, or trust that broken reed, the long posterior flap from the great muscles of the calf.
In June 1865, Mr. Henry Lee described a method of operating which he hoped would unite the benefits of Mr. Teale's method to the ease of performance of the old flap from the calf. I append a short account of his method. From its position, however, it has the great disadvantage of retaining the discharges, and by its weight straining the stitches and weighing down the cicatrix:—
Lee's Amputationof the Leg by a long rectangular flap from the Calf.—The operation described was performed according to Mr. Teale's method, as far as the external incisions were concerned, but the long flap was made from the back instead of from the front of the limb (Plate IV.figs. 14, 15). Two parallel incisions were made along the sides of the leg, these were met by a third transverse incision behind, which joined the lower extremities of the first two. These incisions, which formed the three sides of the square, extended through the skin and cellular tissue only. A fourth incision was made transversely through the skin in front of the leg so as to form a flap in this situation,one-fourth only of the length of the posterior flap. When the skin had somewhat retracted by its natural elasticity, an incision was made through the parts situated in front of the bones, which were reflected upwards to a level with the upper extremities of the first longitudinal incisions. The deeper structures at the back of the leg were then freely divided in the situation of the lower transverse incision. The conjoined gastrocnemius and soleus muscles were separated from the subjacent parts, and reflected as high as the anterior flap. The deeper layer of muscles, together with the large vessels and nerves, were divided as high as the incision would permit, and the bones sawn through in the usual way. The flaps were then adjusted in the manner recommended by Mr. Teale.[42]
The patients were able to bear the weight of the body on the end of the stump.
In cases of chronic disease, where the muscles are atrophied and condensed, the following posterior flap method may be used with advantage. It is approved of by Mr. Spence. An incision is made across the front of the leg from theposterior edgeof the fibula to theposterior edgeof the tibia, orvice versâ, according to the limb. The limb is then transfixed behind the bones from the same points, and a long and gently rounded posterior flap cut. The bones are then cleaned, and cut through at a little higher level.
Amputation immediately below the Kneeat the"true seat of election."—The principles on which this operation is founded are—1. That a muscular flap is not necessary, skin being perfectly sufficient; 2. That as the muscles retract they must be cut at a lower level than the bones, and as they retract unequally from their varying length, the cuts must be made with due reference to that inequality; 3. That no more of the tibianeed be retained than what is just sufficient to retain the attachment of the ligamentum patellæ, and to insure its vitality; 4. That the head of the fibula must be retained in every case, as in a certain proportion the tibio-fibular articulation communicates with the knee-joint.
Operation.—Two equal semilunar flaps of skin must be cut—from the outside, not by transfixion,—one anterior and external, the other posterior and internal, their extremities meeting at points about two inches below the tuberosity of the tibia on either side (Plate I.figs. 17, 18). These must be reflected up, and with them a further extent of skin, embracing the whole circumference of the limb, must be dissected up (as if pulling off the fingers of a glove), so as to expose the bone one inch below the tuberosity. The anterior muscles being very close to their origin, and consequently being able to retract very slightly, must be cut as high as exposed, and the posterior ones about the middle of their exposed surface.
The bones must then be sawn as high as exposed, with the following precautions:—1. In order to prevent splintering of the fibula, endeavour to saw it along with the tibia, so as to finish it first; 2. To prevent projection of a sharp prominence of the edge of the tibia, enter the saw obliquely a little higher up than where you intend to divide the bone, then withdraw it, and enter the saw again at right angles to the bone, and a line or two lower down. Some surgeons prefer to make this section afterwards with a finer saw or the bone-pliers.
This operation is very frequently required to remedy painful and unhealed stumps, the result of amputations lower down, specially those in which the long posterior flap from the muscles of the calf has been used. In the above amputation the patient will not be able to rest the weight of his body on thefaceof the stump, but by putting the limb into a well-padded case with softrounded edges, the weight might be borne partly on the sides of the stump, and partly on the lower edge of the patella; and the patient will be able to walk with great comfort, preserving the use of his knee-joint.
Amputation at the Knee-joint.—This "relic of ancient surgery," as Mr. Skey calls it, has been revived only of late years, and seems in certain cases to be a justifiable and successful operation.
Practised by Fabricius Hildanus and Guillemeau in the sixteenth and seventeenth centuries, it had fallen into disuse till revived by Hoin, Velpeau, and Baudens, on the Continent, Professor Nathan Smith in America, and Mr. Lane in London.
It is not possible that this operation can be at all frequent, since the cases in which it is applicable are comparatively rare; for, to be successful, the following conditions are essential:—1. That there be abundant skin in front of the knee-joint to make a long anterior flap; 2. That the patella and articular surface of the femur are healthy. These conditions at once exclude nearly every case of disease or accident. If the joint is diseased some amputation through the thigh must be attempted; if injured, and the front of the knee is safe, it may very likely be possible to amputate below the knee. Hence this operation may be useful in cases where, for malignant disease, thewholetibia requires removal, and yet the knee-joint is sound, or for gunshot injuries, in which the tibia is splintered but the soft tissues comparatively uninjured.
Operation.—A long anterior flap should be cut with a semilunar end (Plate II.figs. 6, 7), extending as far as the insertion of the ligamentum patellæ. This flap, including the patella, should be thrown up, the joint cut into, and a short posterior flap made by transfixion.
It is important to retain the patella, if possible, as itfills up the hollow between the condyles; it sometimes becomes anchylosed, but in other cases it remains freely mobile, and adds to the value of the stump.
Professor Pancoast has practised an amputation at the knee-joint by three flaps, performed entirely by the scalpel, which, he says, results in a good stump. One flap, the anterior one, is longest and semilunar in shape, its convexity passing three inches below the tuberosity of the tibia; the other two are much smaller, and postero-lateral.[43]
Advantages.—The bone is not cut into at all, there is a free drain for matter, no tendency to retraction of the flaps, and the weight of the body is borne on skin previously habituated to pressure.