The operator should trust rather to making the incisions in such a manner that the great vessel be not divided till the hand of an a.s.sistant, or in default of a suitable one, his own left hand, is able to follow the knife and grasp the flap.

The bleeding from the circ.u.mflex, subscapular, and posterior scapular arteries can easily be arrested by a dossil of lint till the great vessel is tied, and they can be secured.

In cases where proper a.s.sistants cannot be had, temporary closure of the axillary vessel could easily be made by carrying a strong silver wire or silk ligature completely round the vessel by a curved needle before the incisions are commenced, and by tying this firmly over a pad of lint.

Pressure on the artery above the clavicle is best made by the thumb of a strong a.s.sistant, who endeavours to compress it against the first rib; where the parts are deep and muscular, the padded handle of the tourniquet, or of a large door-key, will do as the agent of pressure.

A brief notice of three of the best methods of operating will be quite sufficient to show what should be aimed at in shoulder-joint amputations:--

#1.# In cases where the surgeon can choose his flaps, the following method will be found the most satisfactory, as resulting in the smallest possible wound, in having less risk of haemorrhage during the operation than any other method, and in providing excellent flaps.

It is Larrey's method slightly modified.

_Operation._--With a moderate-sized amputating knife an incision of about two inches in length, extending through all the tissues down to the bone, should be made from the edge of the acromion process to a point about one inch below the top of the humerus; from this latter point a curved incision, enclosing a semilunar flap, should be made on each side of the limb to the anterior and posterior folds of the axilla respectively (Plate IV. fig. 9, and Plate III. fig. 3). These flaps should then be dissected back, including the muscles and exposing the joint. When thoroughly exposed, the joint must then be opened from above, and the bone separated. One small portion of skin lying above the artery, vein, and nerves still remains to be divided (Plate I. fig. 13).

This may be done by an oblique cut from within outwards, in such a direction as to form part of the anterior or internal incision, and with the precaution of having an a.s.sistant to command the vessels before they are divided. The resulting wound is almost perfectly ovoid, the flaps come together with great ease in a straight vertical line, which admits of easy and thorough drainage. Union is generally rapid. Larrey's success by this method was very remarkable: ninety out of a hundred cases in military practice were saved, notwithstanding the well-known risks of such operations.

#2.# As good as the former, and nearly as universally applicable, is the method devised by Professor Spence, and practised by him in nearly every case:--"With a broad strong bistoury I cut down upon the inner aspect of the head of the humerus, immediately external to the coracoid process, and carry the incision down through the clavicular fibres of the deltoid and pectoralis major muscles till I reach the humeral attachment of the latter muscle, which I divide. I then with a gentle curve carry my incision across and fairly through the lower fibres of the deltoid towards, but not through, the posterior border of the axilla. Unless the textures be much torn, I next mark out the line of the lower part of the inner section by carrying an incision through the _skin and fat only_, from the point where my straight incision terminated, across the inside of the arm to meet the incision at the outer part. This insures accuracy in the line of union, but is not essential. If the fibres of the deltoid have been thoroughly divided in the line of incision, the flap so marked out, along with the posterior circ.u.mflex trunk, which enters its deep surface, can be easily separated from the bone and joint, and drawn upwards and backwards so as to expose the head and tuberosities, by the point of the finger without further use of the knife. The tendinous insertions of the capsular muscles, the long head of the biceps, and the capsule, are next divided by cutting directly upon the tuberosities and head of the bone; and the broad subscapular tendon especially, being very fully exposed by the incision, can be much more easily and completely divided than in the double-flap method. By keeping the large posterior flap out of the way by a broad copper spatula or the fingers of an a.s.sistant, and taking care to keep the edge of the knife close to the bone, the trunk of the posterior circ.u.mflex is protected. In regard to the axillary vessels, they can either be compressed by an a.s.sistant before completing the division of the soft parts on the axillary aspect, or to avoid all risk, the axillary artery may be exposed, tied, and divided between two ligatures so as to allow it to retract before dividing the other textures."[33]

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, with the right he pa.s.ses an amputating knife, seven or eight inches in length, from a point a little nearer the clavicle than the middle s.p.a.ce 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 a.s.sistant then holds it upwards, while the surgeon, or (if the arm is very muscular) another a.s.sistant, 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 pa.s.sed behind the head of the bone, which is dislocated forwards, and a suitable flap of the tissues in front cut from within outwards. The a.s.sistant 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 pa.s.sing 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, pa.s.ses the knife behind the head of the bone, and cuts out without attempting to save any flaps below, in a transverse direction. By this means the artery is still almost the last structure to be divided, and can be secured by a ready a.s.sistant. 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 haemorrhage as far as possible, and to leave abundance of skin. In operations on the scapula, it should be freely exposed by large enough incisions. (See _Excisions_.)

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 operation _ever_ admissible, 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.

[Ill.u.s.tration: 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 the _dorsalis pedis_ artery 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 them _inwards_, 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 far _outwards_ as possible by an a.s.sistant, 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 that remains 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 anaesthetics, 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 p.r.i.c.king 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 tissues are 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 const.i.tuted the sole of the 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 method_ has, 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, Guerin, and others approve 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:--