A Manual of the Operations of Surgery
by Joseph Bell · English · Gutenberg #24564 · 610,716 chars · public domain (US)
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Title: A Manual of the Operations of Surgery
Author: Joseph Bell
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A MANUAL OF THE OPERATIONS OF SURGERY
For the Use of Senior Students, House Surgeons, and
Junior Practitioners.
Illustrated.
by
JOSEPH BELL, F.R.C.S. EDIN.
Lecturer on Clinical Surgery, Surgeon to the Royal Infirmary and to
the Eye Infirmary, and Late Demonstrator of Anatomy
in the University of Edinburgh.
FIFTH EDITION, REVISED AND ENLARGED.
Edinburgh: Maclachlan & Stewart,
Booksellers to the University.
London: Simpkin, Marshall, & Co.
1883.
TO THE MEMORY OF
JAMES SYME, ESQ., F.R.C.S. AND F.R.S.E.
SURGEON TO THE QUEEN IN SCOTLAND
PROFESSOR OF CLINICAL SURGERY
IN THE UNIVERSITY OF EDINBURGH
ETC. ETC.
THIS BOOK IS DEDICATED
BY HIS OLD HOUSE-SURGEON AND ASSISTANT
THE AUTHOR.
PREFACE TO FIFTH EDITION.
To retain the small size of the work and to keep it up to date have been
the Author's aim in the Fifth Edition.
20 MELVILLE STREET, EDINBURGH,
_August 1883._
PREFACE TO THE FIRST EDITION.
Having been asked, year after year, by the members of my Class for
Operative Surgery, to recommend to them some Manual of Surgical
Operations which might at once guide them in their choice of operations,
and give minute details as to the mode of performance, I have been
gradually led to undertake the production of this little work.
My aim has been to describe as simply as possible those operations which
are most likely to prove useful, and especially those which, from their
nature, admit of being practised on the dead body.
In accordance with this plan, neither historical completeness of detail,
nor much variety in the methods of performing any given operation, is to
be expected. Hence, also, many omissions which would be unpardonable in
the briefest system of Surgery are unavoidable. For example, excision of
tumours and operations for necrosis are hardly mentioned, because for
these no special instructions can well be given; for, while general
principles may guide us to _what_ should be done, the special
circumstances of each case must dictate _how_ it is to be done.
In such a work as this, to attempt originality would be undesirable and
intrusive; a judicious selection, a faithful compilation, are all that
can be expected.
That the selection of operations may sometimes show "Northern
Proclivities" is possible; and this is perhaps not unnatural to a
scholar and teacher in the Edinburgh School.
An earnest endeavour has been used to make the references correct and
copious: for any mistakes or omissions the author would crave
indulgence.
The four plates which precede the letterpress were drawn on wood (from
original photographs) by Mr. D.W. Williamson, Melbourne Place, and the
lines of incision for the various operations were added by the author.
The rough woodcuts scattered through the work were drawn on wood by the
author, and for their roughness he, not his engraver, is responsible. He
also hopes that the references in the letterpress will be accepted as
sufficient acknowledgment of the true ownership, in those few instances
in which the idea of the diagram has been borrowed.
It has been thought unnecessary to introduce woodcuts of surgical
instruments, as the illustrated catalogues lately published by Weiss,
Maw, and others, are sufficiently accurate.
In excuse of the frequent baldness and brevity of the style, the author
must point to the size and price of the work. Its composition would have
been easier had its dimensions been greater.
Though intended chiefly to guide the studies, on the dead subject, of
students and junior practitioners, the author ventures to hope that the
Manual may be useful to those who, in the public services, in the
colonies, or in lonely country districts, find themselves constrained to
attempt the performance of operations which, in the towns, usually fall
to the lot of a few Hospital Surgeons.
JOSEPH BELL.
5 CASTLE TERRACE, EDINBURGH,
_July 1866._
CONTENTS.
CHAPTER I.
LIGATURE OF ARTERIES.
PAGE
Ligature of Arteries--General Maxims--Ligature of
Aorta--Iliacs--Gluteal--Femoral--Popliteal--Innominate--Carotids--
Lingual--Subclavian--Brachial, etc., 1-45
CHAPTER II.
AMPUTATIONS.
Eras of Amputation--Flap and Circular compared--Special Amputation of
Arm and Leg, 46-107
CHAPTER III.
EXCISION OF JOINTS.
Brief Historical Sketch--Comparison of Excisions with
Amputations--Special Excisions of the six larger Joints--Excisions of
smaller Joints and Bones, 108-146
CHAPTER IV.
OPERATIONS ON CRANIUM AND SCALP.
Trephining--Excision of Wens, 147-150
CHAPTER V.
OPERATIONS ON THE EYE AND ITS APPENDAGES.
Entropium and Ectropium--Trichiasis--Tarsal Tumours--On Lachrymal
Organs--Mr. Bowman's Operation--Pterygium--Strabismus, convergent
and divergent--Paracentesis of the Anterior Chamber--Operations
for Cataract by Displacement, Solution, and Extraction--Various
methods of Extraction--Operations for Artificial
Pupil--Iridesis--Corelysis--Iridectomy--Excision of Staphyloma--Excision
of Eyeball, 151-174
CHAPTER VI.
OPERATIONS ON THE NOSE AND LIPS.
Rhinoplastic Operations from Cheek, Forehead, and elsewhere--Removal of
Nasal Polypi--Excision of Cancers of Lips--Cheiloplastic
Operations--Operations for Harelip, 175-187
CHAPTER VII.
OPERATIONS ON THE JAWS.
Excision of Upper Jaw--Of Lower Jaw, 188-195
CHAPTER VIII.
OPERATIONS ON MOUTH AND THROAT.
For Salivary Fistula--Excision of Tongue, complete and partial--Fissures
of the Palate, soft and hard--Excision of Tonsils, 196-205
CHAPTER IX.
OPERATIONS ON AIR PASSAGES.
Larynx and
Trachea--Tracheotomy--Tubes--Laryngotomy--OEsophagotomy--[see
Addendum, p. 302], 206-217
CHAPTER X.
OPERATIONS ON THORAX.
PAGE
Excision of Mamma--Paracentesis Thoracis, 218-221
CHAPTER XI.
OPERATIONS ON ABDOMEN.
Paracentesis Abdominis--Gastrotomy--Ovariotomy--Operation for
Strangulated Hernia--Inguinal--Femoral--Umbilical--Operations for the
Radical Cure of Hernia, 222-255
CHAPTER XII.
OPERATIONS ON PELVIS.
Lithotomy--Varieties--Lithotrity--Operations for Stricture--Puncture of
the Bladder--Phymosis--Amputation of
Penis--Hydrocele--Hæmatocele--Castration--Operation for
Fistula--Fissure--Polypi of Rectum--Piles, 256-295
CHAPTER XIII.
TENOTOMY.
On Tenotomy for Wry Neck and Club Foot, 296-298
CHAPTER XIV.
OPERATIONS ON NERVES.
Nerve-stretching--Nerve-cutting--Nerve suture, 299-301
ADDENDUM to Chapter IX., 302
INDEX, 303-311
LIST OF ILLUSTRATIONS.
FIG. PAGE
I. Amputations of Fingers, 50
II. Diagram of Finger showing Articulations, 50
III. Dubrueil's Amputation at Wrist (front view), 57
IV. " " (dorsal view), 57
V. Amputations of Toes, 69
VI. Excision of Wrist-joint--Lister's, 126
VII. Operations for Ectropium and Entropium, 151
VIII. Operation for Trichiasis--Streatfeild's, 151
IX. Operation for Epiphora--Bowman's, 155
X. Greenslade's Instrument for above, 156
XI. Operations for Squint, 157
XII. Linear Extraction of Cataract, 162
XIII. Flap Extraction of Cataract, 162
XIV. Operation of Corelysis--Streatfeild's, 171
XV. Operation for Staphyloma--Critchett's, 172
XVI. Result of above, 172
XVII. Rhinoplastic Operation from Cheek, 176
XVIII. " " Forehead, 177
XIX. Operation on Lip, V-shaped incision, 181
XX. Operation on Lip, by scissors, 181
XXI. Operation for a new Lip, incisions, 182
XXII. Operation for New Lip sewed up, 182
XXIII. Diagram of Partial Fissure (Harelip), 184
XXIV. Nelaton's Operation for ditto, 184
XXV. Operation for Double Harelip, 185
XXVI. Diagram of Double Harelip, 186
XXVII. Excision of Upper and Lower Jaws, 189
XXVIII. Operation for Salivary Fistula, 196
XXIX. Operation for Fissure in Soft Palate, 201
XXX. Operation for Fissure in Hard Palate, 203
XXXI. Diagram illustrating Operations on Air Passages, 207
XXXII. Diagram illustrating Operations for Hernia, 241
XXXIII. Diagram of an Artificial Anus, 253
XXXIV. Diagram of Section of Prostate, 257
XXXV. Diagram of Membranous portion of Urethra, 259
XXXVI. Diagram illustrating Puncture of Bladder, 284
XXXVII. Diagram of Operation for Phymosis, 286
XXXVIII. Diagram of Amputation of Penis, 287
[Illustration]
PLATE I.
1. Ligature of Aorta--Sir A. Cooper's incision.
2. Ligature of Aorta--South and Murray's incision.
3. Ligature of Common Iliac.
4. Ligature of External Iliac--Sir A. Cooper's.
5. Ligature of Femoral in Scarpa's triangle.
6. Ligature of Femoral below Sartorius.[1]
7. Ligature of Innominate.
8. Ligature of third part of Left Subclavian.
9. Ligature of Axillary in its first part.
10. Ligature of Axillary in its third part.
11. Ligature of Brachial.
12. Amputation of Arm by double flaps.
13. Amputation at Shoulder-joint (1st method), showing portion of skin
left uncut till the conclusion of the disarticulation.
14. Amputation at Ankle-joint by internal flap--Mackenzie's.
15-16. Amputation of Leg just above the Ankle-joint.
17-18. Amputation below Knee--modified circular.
19. Amputation through Condyles of Femur--Syme, and Pl. III. 5.
20. Amputation at lower third of Thigh--Syme, and Pl. III. 6.
A. Excision of Head of Humerus.
B. Excision of Knee-joint; semilunar incision.
FOOTNOTES:
[1] This line is placed too low down; it should be in the middle third
of the thigh.
[Illustration]
PLATE II.
1. Amputation at lower third of Fore-arm--Teale's.
2-2. Amputation at Shoulder-joint by large postero-external flap--2d
method.
3-3. Amputation at Shoulder-joint by triangular flap from deltoid--3d
method.
4-5. Amputation through Tarsus--Chopart's.
6-7. Amputation at Knee-joint.
8. Amputation by Single Flap--Carden's, and Pl. IV. 16.
9-10. Amputation of Thigh--Teale's.
A. Excision of Hip-joint.
B-B. Excision of Ankle-joint--Hancock's incisions.
[Illustration]
PLATE III.
1. Ligature of Popliteal.
2. Amputation at Elbow-joint--posterior flap.
3. Amputation at Shoulder-joint--posterior incision of first method, and
Pl. I. 13.
4. Amputation at Ankle-joint--Mackenzie's, and Pl. I. 14.
5. Amputation through Condyles of Femur--Syme, and Pl. I. 19.
6. Amputation at lower third of Thigh--Syme, and Pl. I. 20.
7. Amputation at Knee--posterior incision.
8. Amputation of Thigh--Spence's, and at Pl. IV. 18.
9. Amputation at Hip-joint, and Pl. IV. 20.
A. Excision of Shoulder-joint--deltoid flap.
B. Excision of Shoulder-joint by posterior incision.
C. Excision of Elbow-joint--H-shaped incision.
D. Excision of Elbow-joint--linear incision.
E. Excision of Hip-joint--Gross's.
F. Excision of Os Calcis.
G. Excision of Scapula.
[Illustration]
PLATE IV.
1. Ligature of Carotid.
2. Ligature of Subclavian (3d stage)--Skey's incision.
3. Amputation at Wrist-joint--dorsal incision.
4. Amputation at Wrist-joint--palmar incision.
5. Amputation at Fore-arm--dorsal incision.
6. Amputation at Fore-arm--palmar incision.
7. Amputation at Elbow-joint--Anterior flap, and Pl. III. 3.
8. Amputation at Arm--Teale's method.
9. Amputation at Shoulder-joint--1st method, and Pl. III. 3.
10-11. Amputation of Metatarsus--Hey's.
12-13. Amputation at Ankle--Syme's.
14-15. Amputation of Leg--posterior flap--Lee's.
16. Amputation at Knee-joint--Carden's, and Pl. II. 8.
17. Amputation of Thigh--B. Bell's.
18. Amputation of Thigh--Spence's, and Pl. III. 8.
19. Amputation of Thigh in middle third.
20-20. Amputation at Hip-joint, and Pl. III. 9.
A. Excision of Wrist--radial incision.
B. Excision of Wrist--ulnar incision.
CHAPTER I.
LIGATURE OF ARTERIES.
LIGATURE OF ARTERIES.--In a work of this nature there is no room for any
discussion of the principles which should guide us in the selection of
cases, or of the pathology of aneurism, or the local effects of the
ligature on the vessels. One or two fundamental axioms may be given in a
few words:--
1. In selecting the spot for the application of the ligature, avoid as
far as possible bifurcations, or the neighbourhood of large collateral
branches.
2. A free incision should be made through the skin and subjacent
textures, till the sheath of the artery is reached and fairly exposed.
3. The sheath must be opened and the artery cleaned with a sharp knife
till the white external coat is clearly seen. The portion cleaned
should, however, be as small as possible, consistent with thorough
exposure, so that the ligature may be passed round the vessel without
force.
4. As the artery should never be raised from its bed, it is generally
advisable to pass the needle only so far as just to permit the eye to be
seen past the vessel. The ligature should then be seized by a pair of
forceps and gently pulled through, the needle being cautiously
withdrawn. When catgut is used, it is better to pass the unarmed needle
till the eye is visible, then thread and withdraw it, thus pulling the
catgut through.
5. As a rule, the needle should be passed from the side of the vessel at
which the chief dangers exist. This will generally be in the side at
which the vein is.
6. The ligature should be single, and consist of strong well-waxed silk,
and should always be drawn as tight as possible, so as to divide the
internal and middle coats of the vessel. In cases where the wound is to
be treated with antiseptic precautions and an attempt at immediate union
made, the ligature may be of strong catgut properly prepared, and both
ends of it may be cut off.
7. Before the ligature is tightened, it is well to feel that pressure
between the ligature and the finger arrests the pulsation of the tumour.
LIGATURE OF THE AORTA.--It has been found necessary in a few rare cases
to place a ligature on the abdominal aorta; no case has as yet survived
the operation beyond a very few days, but they have in their progress
sufficiently proved that the circulation can be carried on, and gangrene
does not necessarily result even after such a decided interference with
vascular supply.
_Operation._--The ligature may be applied in one of two ways, the choice
being influenced by the nature of the disease for which it is done.
1. A straight incision (Plate I. fig. 1) in the linea alba, just
avoiding the umbilicus by a curve, and dividing the peritoneum, allows
the intestines to be pushed aside, and the aorta exposed still covered
by the peritoneum, as it lies in front of the lumbar vertebræ. The
peritoneum must again be divided very cautiously at the point selected,
and the aortic plexus of nerves carefully dissected off, in order that
they may not be interfered with by the ligature. The ligature should
then be passed round, tied, cut short, and the wound accurately sewed
up.
2. Without wounding the peritoneum.
A curved incision (Plate I. fig. 2), with its convexity backwards, from
the projecting end of the tenth rib to a point a little in front of the
anterior superior spinous process of the ilium. At first through the
skin and fascia only, this incision must be continued through the
muscles of the abdominal wall, one by one, till the transversalis fascia
is exposed, which must then be scraped through very cautiously, so as
not to injure the peritoneum, which is to be detached from the fascia
covering the psoas and iliacus muscles, and must be held inwards and out
of the way by bent copper spatulæ. The common iliac will then be felt
pulsating, and on it the finger may easily be guided up until the aorta
is reached.
The really difficult part of the operation now begins: to isolate the
vessel from the spine behind, the inferior cava on the right side, and
the plexus of nerves in the cellular tissue all round. The cleaning of
the vessel must be done in great measure by the finger-nail, and much
dexterity will be required to pass the ligature without unnecessarily
raising the vessel from its bed, especially as the vessel itself may
very possibly be diseased, and the aneurism of the iliac trunk for which
the operation is required will displace and confuse the parts, and may
have set up adhesive inflammation.
_Results._--Operation has been performed at least ten times. By the
first method by Sir Astley Cooper and Mr. James; by the second by Drs.
Murray and Monteiro, M'Guire, Heron Watson, and Stokes, and Mr. South,
and Czerny of Heidelberg. All the cases proved fatal; Dr. Monteiro's
survived for ten days, and eventually perished from hæmorrhage; the rest
all died at shorter intervals.
LIGATURE OF COMMON ILIAC.--_Anatomical Note._--This short thick trunk
varies slightly in its relations on the two sides of the body. As the
aorta bifurcates on the left side of the body of the fourth lumbar
vertebra, the common iliac of the right side would have a longer course
to pursue than that on the left, if both ended at corresponding points.
However, this is not always the case, as has been pointed out by Mr.
Adams of Dublin, as the right common iliac often bifurcates sooner than
the left does. With this slight difference, the position of the two
vessels is precisely similar, each extending along the brim of the
pelvis from the bifurcation of the aorta towards the sacro-iliac
synchondrosis for about two inches. Sometimes the division takes place a
little higher, even at the junction of the last lumbar vertebra and the
sacrum. This variation depends chiefly on the length of the artery,
which, as Quain has shown, varies from one inch and a half to more than
three inches.
The anterior surface of both arteries is covered by the peritoneum, and
each is crossed by the ureter just as it bifurcates into its branches.
The artery of the right side is in close contact behind with its
corresponding vein, which at its upper part projects to the outside, and
below to the inner side. The artery of the left side is less involved
with its vein, which lies below it, and to the inside. The right is in
contact with a coil of ileum, the left with the colon. The inferior
mesenteric artery crosses the left one, while to the outside of both,
and behind them, lie the sympathetic and obdurator nerves.
There are no named branches from the common iliac.
_Operation._--The chief difficulties to be encountered are--1. The close
proximity of the peritoneum, and specially the risk there is that it has
become adherent to the sac of the aneurism; 2. The depth of the parts,
and tendency of the intestines to roll into the wound; 3. Specially on
the right side, the proximity of the great veins. With these exceptions
the passing of the ligature is not so difficult as in some situations,
the lax cellular tissue in which the vessel lies generally yielding much
more easily than the tough sheath which elsewhere, as in the femoral,
requires accurate dissection.
_Incision._--(Plate I. fig. 3.)--From a point about half an inch above
the centre of Poupart's ligament, a crescentic incision should be made,
at first extending upwards and outwards, so as to pass about one inch
inside of the anterior superior spine of the ilium, and then prolonged
upwards and inwards, as far as may be rendered necessary by the size of
the aneurism or the depth of parts. It must extend through skin and
superficial fascia, exposing the tendon of the external oblique, which
must then be slit up to the full extent visible. The spermatic cord may
then be easily exposed under the edge of the internal oblique, and the
forefinger of the left hand inserted on the cord, and thus beneath the
internal oblique and transversalis muscles, the peritoneum being quite
safe below.
On the finger these muscles may be safely divided to the full extent of
the external incision. The deep circumflex iliac artery if possible
should not be divided, but may bleed smartly and require a ligature.
The peritoneum must then be very cautiously raised from the tumour, and
supported, along with the intestines, by copper spatulæ. The surgeon
will rarely succeed in obtaining anything like a satisfactory view of
the vessel, but can expose it for the ligature by the aid of his
finger-nail. An ordinary aneurism-needle will generally suffice for the
conveyance of the ligature.
The difficulties may occasionally be much increased by special
circumstances, such as great stoutness of the patient, and consequent
thickness of the abdominal wall; or large size of the aneurism, which
may cause alterations in the relation of parts and adhesion of the
peritoneum. The ureter generally gives no trouble, as in pressing back
the peritoneum it is adherent to it, and is removed along with it
towards the middle line.
_Results._--Are not by any means satisfactory.
Out of twenty-two cases in which the common iliac has been tied for
aneurism, eight recovered and fourteen died; while out of thirteen cases
where it required ligature for hæmorrhage after amputation, rupture of
aneurism, etc., only one recovered.
LIGATURE OF INTERNAL ILIAC.--Little need be added to the account just
given of the operation for ligature of the common iliac, as precisely
the same incisions are required. The operator having reached the
bifurcation of the vessel, must, instead of tracing it upwards,
endeavour to trace it downwards, and the same time inwards, into the
basin of the pelvis. To do this his finger must cross the external iliac
artery, which will pulsate under the joint of the ungual phalanx, while
the pulp of the finger is touching the internal iliac,--the external
iliac vein, which occupies the angle formed by the bifurcation of the
artery, lying between these two points. The ligature should be applied
within three-quarters of an inch from the bifurcation.
_Anatomical Note._--This short thick trunk extends backwards and inwards
(Ellis); downwards and backwards (Harrison), in front of the sacro-iliac
synchondrosis, as far as the upper extremity of the great sacro-sciatic
notch, a distance varying in the adult from one and a half to two inches
in length. It forms a curve with its concavity forwards, and at its
termination divides into, rather than gives off, its two or three
principal branches. Its corresponding vein is in close contact behind,
as also the lumbo-sacral nerve, the obdurator nerve to its outer side.
The peritoneum covers it anteriorly, and it is crossed just at its
commencement by the ureter. On the left side it is covered anteriorly by
the rectum. Of its anatomical relations, that of the external iliac vein
is perhaps the most important, as it is apt to interfere with the
passing of the needle.
_Results._--This vessel has been tied for aneurism of one or other of
its branches, or for wound, about seventeen times.[2] Of these seven
recovered; in ten the operation proved fatal, in most of them from
secondary hæmorrhage. In one case the hæmorrhage occurred within twelve
hours after the operation. The circulation of the parts supplied after
the ligature is carried on mainly by the lumbar and lateral sacral
branches, which become much developed even before the operation, in
cases of aneurism.
LIGATURE OF EXTERNAL ILIAC.--_Anatomical Note._--This artery extends
from the bifurcation of the common iliac to the centre of Poupart's
ligament, where it leaves the abdomen, passing under the ligament, and
becomes the common femoral. Its upper extremity is thus not always
constant, varying in position from the sacro-lumbar fibro-cartilage to
the upper end of the sacro-iliac synchondrosis, or even a little lower
down. Thus, though the position of the lower end is at a fixed point,
the artery varies in length. In an adult male of moderate stature it is
from three and a half to four inches in length. On the surface of the
abdomen the position of this vessel would be indicated by a line drawn
from about an inch on either side of the umbilicus to the middle of the
space between the symphysis pubis and the crest of the ilium. Its
relations to neighbouring parts are as follows:--The peritoneum lies _in
front_ of it, separated from it only by a subperitoneal layer of loose
fascia, in which the artery and vein lie, which varies much in
consistence and amount, and which occasionally gives a good deal of
trouble in the operation of ligature. Near its origin it is sometimes
crossed by the ureter, and near its termination the genito-crural nerve
lies on it. The spermatic vessels cross it, and occasionally a quantity
of subperitoneal fat marks its course. _Externally._--The fascia-iliaca
and some fibres of the psoas muscle separate it from the anterior
crural nerve, which lies outside of the vessel, and at a somewhat deeper
level, hidden amid the fibres of psoas and iliacus. _Internally._--The
external iliac vein lies on the same plane, and to the inner side of the
artery, at Poupart's ligament, on both sides of the body. As we trace it
upwards we find that on the left side it lies internal to the artery in
its whole course, while on the right side it becomes posterior to the
artery as it approaches the bifurcation of the common iliac. Lastly,
just before the vessel reaches Poupart, the circumflex iliac vein
crosses it from within outwards.
_Branches._--The two large branches to the wall of the abdomen, the
epigastric and the circumflex iliac, rise a few lines above Poupart's
ligament. Their position is unfortunately apt to vary upwards, to the
extent of an inch and a half or even two inches, and they are important,
as, besides being liable to be cut during the operation, their position
very materially modifies the prognosis, as, if too high up, they
interfere with the proper formation of the coagulum.
_Operation._--Various plans of incision through the skin have been
recommended by various operators, the chief difference being with regard
to the part of the artery aimed at; the plan known as that of Mr.
Abernethy, with various modifications, being intended to expose the
artery pretty high up, and enable the surgeon to reach it from above;
while the method going by the name of Sir Astley Cooper's exposes the
lower part of the artery, and enables the surgeon to reach it from
below. Though the latter is in some respects easier, the former method
is generally to be preferred, being further from the seat of disease,
and especially more out of the way of the epigastric and circumflex
arteries.
The higher operation (ABERNETHY'S modified).--An incision must be made
through the skin about four inches in length, but longer in proportion
to the amount of subcutaneous fat, and the depth of the pelvis,
extending from a point one inch to the inside of the anterior superior
spine of the ilium, to a point half an inch above the middle line of
Poupart's ligament. It must be slightly curved, with its convexity
looking outwards and downwards.[3]
The subcutaneous cellular tissue and the tendon of the external oblique
may then be divided freely in the same line. Then at some one point or
other (generally easiest below), the internal oblique and transversalis
muscles must be cautiously scraped through with the aid of the forceps,
till the transversalis fascia is reached; they may then be freely
divided by a probe-pointed bistoury (guarded by the finger pushed up
below the muscles) to the required extent. The muscles being held aside
by flat copper spatulæ, the fascia transversalis must be carefully
scratched through near the crest of the ilium, and thus the operator
will be enabled to push the peritoneum inwards, and by the forefinger
will easily recognise the pulsation of the artery lying on the soft brim
of the pelvis.
A branch of the circumflex iliac artery will very likely be cut in
dissecting through the muscles, and must be secured, as also any
branches of the epigastric which may be divided in the incisions through
the abdominal wall (_ut supra_, p. 5).
The operator should then, by pressing the peritoneum and its contents
gently inwards, endeavour to see the vessel; if, from the depth of the
pelvis, this cannot be done, the sense of touch will be in most cases
sufficient to enable him to isolate the artery by the point of his
finger-nail, or by the blunt aneurism-needle, from the vein. The
ligature should be passed from the inner side to avoid including the
vein, and thus there will be less chance of wounding the peritoneum
from the convexity of the needle being applied to it. If possible, the
genito-crural nerve should not be included in the ligature, but probably
such an accident would do no great harm.
It is of much more consequence to avoid injuring the peritoneum. This is
sometimes very difficult, from the adhesions which are set up between
the peritoneum, the artery, and especially the aneurism, as the result
of pressure and inflammation. The accident of wounding the peritoneum
has happened to Keate, Tait, Post, and others, and in some cases with
perfect impunity. However, the peritoneum should be displaced as little
as possible from its cellular connections, as such displacement
increases the risk of diffuse inflammation of that membrane; and the
vessel itself should be raised and disturbed as little as possible, lest
destruction of the vasa vasorum cause ulceration of the weak coats and
secondary hæmorrhage.
The operation from below (Plate I. fig. 4), SIR ASTLEY COOPER'S, is thus
described by Mr. Hodgson:[4]--"A semilunar incision is made through the
integuments in the direction of the fibres of the aponeurosis of the
external oblique muscle. One extremity of the incision will be situated
near the spine of the ilium; the other will terminate a little above the
inner margin of the abdominal ring. The aponeurosis of the external
oblique muscles will be exposed, and is to be divided throughout the
extent, and in the direction of the external wound. The flap which is
thus formed being raised, the spermatic cord will be seen passing under
the margin of the internal oblique and transverse muscles. The opening
in the fascia which lines the transverse muscle through which the
spermatic cord passes, is situated in the mid space between the anterior
superior spine of the ilium and the symphysis pubis. The epigastric
artery runs precisely along the inner margin of this opening, beneath
which the external iliac artery is situated. If the finger therefore be
passed under the spermatic cord through this opening in the fascia, it
will come in immediate contact with the artery which lies on the outside
of the external iliac vein. The artery and vein are connected by dense
cellular tissue, which must be separated to allow of the ligature being
passed round the former."
In comparing the two methods of operating, we find that while the latter
is in some respects easier, and the vessel in it lies more superficial,
it has certain disadvantages which more than counterbalance its
advantages. Thus, first, the epigastric artery is very likely to be
wounded. It may be said, Well, if so, the ends can be tied; but this
tying is sometimes very difficult; and, as shown in Dupuytren's case of
this accident, involves considerable interference with the peritoneum,
and a possibly fatal peritonitis. Besides this, by cutting the
epigastric you destroy an important agent which would have carried on
the anastomosing circulation, and thus greatly increase the risk of
gangrene. By this method, also, the artery is exposed too near to the
seat of disease; and if found to be enlarged and involved in the
aneurism, considerable difficulty may be experienced in reaching the
upper part of the vessel. Again, ligature of the lower third or half of
the vessel, which this method implies, is dangerous from the occasional
high origin of the circumflex or epigastric, or both, rendering the
formation of a clot much more difficult, and secondary hæmorrhage much
more likely.
The circumflex iliac vein must also be remembered, as it crosses the
artery from within outwards in the lower end of it, just before it goes
under Poupart's ligament.
However, the method may occasionally vary with the individual case. In
every case of ligature of the great vessels of the abdomen, the bowels
should be carefully evacuated before the operation, and the bladder
emptied. A properly managed position, with the shoulders raised and the
knees semiflexed, will greatly facilitate the gaining access to the
vessel.
In sewing up the wounds in the abdominal walls, advantage will be gained
by putting in a certain number of stitches so deeply as to include the
whole thickness of the muscles, and in the intervals between these deep
ones to insert others less deeply, so as accurately to approximate the
edges of the skin. This will both facilitate union and also render the
occurrence of hernia less probable. This latter accident did occur in a
case, otherwise successful, in which Mr. Kirby tied the external iliac.
Both external iliacs have been tied in the same patient with success, on
at least two occasions, once by Arendt, with an interval of only eight
days between the operations; and a second time by Tait, at an interval
of rather more than eleven months.
This operation is in the great majority of cases performed for femoral
aneurism, and naturally secondary hæmorrhage is a too frequent result.
Wounds of these great vessels generally result in so rapid death from
hæmorrhage as to give no time for surgical interference. One case,
however, is recorded,[5] in which the external iliac was cut in a lad of
seventeen by an accidental stab, and in which Drs. Layraud and Durand,
who were almost instantly on the spot, succeeded in stopping the
bleeding by compresses, till Velpeau arrived, who tied the vessel above
with perfect success.
Of the first twenty-two cases collected by Hodgson, fifteen recovered--a
mortality of 31.81 per cent.; and of 153 in Norris's collection,
including Cutter's cases, forty-seven died--a mortality of only 32.5 per
cent.,--a very satisfactory result, considering the size of the vessel
and the importance of its relations.
LIGATURE OF GLUTEAL.--This vessel, though one of the branches of the
internal iliac, approaches the surface so nearly as to be occasionally
wounded. It is also, though very rarely, the subject of spontaneous
aneurism. The principle of treatment and the operation to be selected in
any given case, depends upon its origin, whether traumatic or
spontaneous. For if traumatic, the wound must almost necessarily be
accessible from the outside; the neighbouring part of the artery is
probably healthy, and hence the case can be treated by the old
operation, slitting up the tumour, and tying the vessel above and below
the wound. When the aneurism is spontaneous, there is no guide to tell
us where the aneurism may have first originated; it may be that it is
high up in the pelvis, and that the visible tumour is only its expansion
in the direction of least resistance, or the coats of the vessel may be
extensively diseased. The only chance is ligature of the internal iliac.
1. The old operation, or ligature of the gluteal artery in the hip.
_Anatomical Note._--The gluteal is the largest branch of the internal
iliac, and leaves the pelvis by the great sacro-sciatic notch just at
the upper edge of the pyriformis muscle. After a very short course, it
divides into superficial and deep branches opposite the posterior margin
of the glutens minimus, between it and the pyriformis muscles.
Very precise rules have been given to enable the operator to hit on the
exact spot where the artery leaves the pelvis. These, though perhaps
interesting anatomically, are quite useless in a surgical point of view,
for the only reasons which could possibly induce a surgeon to cut down
upon the gluteal in the living body, are the existence either of a wound
of the vessel or an aneurism. In the first the flow of blood, in the
second the tumour, would give sufficient guidance.
In cases of traumatic aneurism the operation should be something like
the following:--A free incision should be made into the tumour, dividing
it in its long direction; the contents should be rapidly scooped out,
and a finger placed on the bleeding point, just at the upper corner of
the sciatic notch. This will at once stop the hæmorrhage till the vessel
can be secured. This sounds easy enough, and has been done several times
with success. Thus, John Bell, by an incision two feet long, as he tells
us in his hyperbolical language, was enabled to tie the vessel in the
case of the leech-gatherer who had punctured the artery by a pair of
long scissors. Carmichael of Dublin used a smaller incision, removed one
or two pounds of clots, and tied the vessel, in a case of wound by a
penknife.[6]
Now, though both of these cases were eventually successful, both
patients lost during the operation a very large quantity of blood; John
Bell's especially could not be removed from the operating-table for a
considerable time after the operation. The period at which the great
loss of blood took place was the interval after the incision was made,
and before the artery was exposed to view, _i.e._ the interval in which
the surgeon was busy dislodging the clots from the cellular membrane,
the sac of the false aneurism. The procedure devised by Mr. Syme to
obviate this difficulty, and which was put in practice by him in several
very trying cases, is best given in his own terse description of an
operation in a case of traumatic gluteal aneurism:--
"The patient having been rendered unconscious, and placed on his right
side, I thrust a bistoury into the tumour, over the situation of the
gluteal artery, and introduced my finger so as to prevent the blood from
flowing, except by occasional gushes, which showed what would have been
the effect of neglecting this precaution, while I searched for the
vessel. Finding it impossible to accomplish the object in this way, I
enlarged the wound by degrees sufficiently for the introduction of my
fingers in succession, until the whole hand was admitted into the
cavity, of which the orifice was still so small as to embrace the wrist
with a tightness that prevented any continuous hæmorrhage. Being now
able to explore the state of matters satisfactorily, I found that there
was a large mass of dense fibrinous coagulum firmly impacted into the
sciatic notch; and, not without using considerable force, succeeded in
disengaging the whole of this obstacle to reaching the artery, which
would have proved very serious if it had been allowed to exist after the
sac was laid open. The compact mass, which was afterwards found to be
not less than a pound in weight, having been thus detached, so that it
moved freely in the fluid contents of the sac, and the gentleman who
assisted me being prepared for the next step of the process, I ran my
knife rapidly through the whole extent of the tumour, turned out all
that was within it, and had the bleeding orifice instantly under
subjection by the pressure of a finger. Nothing then remained but to
pass a double thread under the vessel, and tie it on both sides of the
aperture."
The bleeding in this case was thus rendered comparatively trifling, and
the patient made a speedy and complete recovery. He returned home within
six weeks after the operation.[7]
2. In one case, at least, the gluteal artery has been tied with success
(for traumatic aneurism) just where it leaves the pelvis, without the
tumour being opened. This was in the practice of Professor Campbell of
Montreal. The operation was a very difficult one, and while possible
only in cases seen very early, and where the tumour is very small, does
not appear to have any advantage over the old method.
Cases of spontaneous aneurism of the gluteal artery should be treated by
ligature of the internal iliac. Steven's and Syme's cases of ligature
of the internal iliac were of this nature.
Manuals of operative surgery occasionally devote pages to the
description of special operations for the ligature of such arteries as
the sciatic, epigastric, circumflex ilii, and pudic. They do not require
ligature, except in cases of wound either of the vessels themselves or
their branches; and, according to the modern principles of surgery in
such cases, the ligature should be applied to the bleeding point, rather
than to the vessel at a distance above it.
LIGATURE OF FEMORAL.--Under this head we practically mean cases of
ligature of the superficial femoral, for the common femoral, or (as
called by some anatomists) the femoral, before the profunda is given
off, very rarely requires to be tied. If it is wounded, of course the
bleeding point must be sought, and the artery tied above and below it,
but if an aneurism on the superficial femoral renders ligature of that
trunk impossible, experience teaches that ligature of the external iliac
gives better results than ligature of the common femoral. Erichsen
asserts that out of twelve cases in which the common femoral has been
tied, only three have succeeded, the others dying from secondary
hæmorrhage. The experience of the Dublin surgeons, Porter, Smyly, and
Macnamara, has been more satisfactory, as in eight cases of this
operation six were successful.[8] A ninth case was unsuccessful. Reasons
to explain the danger are not far to seek, for the numerous small
muscular branches, along with the superficial epigastric, circumflex,
and pudic trunks, reduce the chances of a good coagulum in the common
femoral to a minimum, even without taking into consideration the
shortness of the trunk before the great profunda femoris is given off.
For the common femoral artery is only from one to two inches in length,
and if there are some rare cases in which it is a little later in its
bifurcation, there are others in which it divides nearer to Poupart's
ligament.
The superficial femoral is the name given to the main trunk between the
origin of the profunda, and the point at which, passing through the
tendon of the adductor magnus, it receives the name of popliteal. During
this long course it gives off no branch large enough or regular enough
to receive a name, except one, the anastomotica magna, which rises in
Hunter's canal, close to the end of the vessel, so in that respect it is
peculiarly suitable for the application of a ligature. Again, in the
upper part of its course, it is superficial, being covered only by skin
and fascia. A short notice of its most important anatomical relations is
necessary.
For the first two inches or two inches and a half of its separate
existence, the superficial femoral lies in Scarpa's triangle, covered,
as we said, only by skin and fascia. This triangle is formed by the
sartorius and adductor longus muscles which meet at its apex, and by
Poupart's ligament, which defines its base. The artery lies almost
exactly in the centre of the space, and at the apex is covered by the
sartorius muscle. The spot where it goes under the sartorius is the one
selected for the application of the ligature. The femoral vein lies to
the inner side of the femoral artery in this triangle, but their mutual
relations vary with the portion of the limb; for, on the level of
Poupart's ligament, the artery and vein lie side by side on the same
plane, but in different compartments of their sheath; as the artery
dives below the sartorius, the vein is still on the inside, but on a
plane slightly posterior; while, by the time they reach Hunter's canal,
the vein has got completely behind the artery. The separate compartments
of the sheath in which the vessels lie are much less marked as the
vessels go down the limb, the septum between the artery and the vein
being in most cases very ill marked, even at the level where the
ligature is applied. The anterior crural nerve, which on the level of
Poupart's ligament lay outside of the artery and on a plane somewhat
posterior, has divided into numerous branches before it reaches the
point of ligature. One of its branches requires to be mentioned, and may
sometimes be noticed and avoided during the operation, namely the
internal saphenous nerve, which, first lying external to the artery,
crosses it in front, reaching its inner side just before it enters
Hunter's canal, where it leaves the vessel accompanying the anastomotica
magna branch.
OPERATION OF LIGATURE OF THE FEMORAL--SCARPA'S SPACE.--The patient being
placed on his back, and being brought very thoroughly under chloroform,
the knee of the affected limb should be bent at an angle of about 120°,
and supported on a pillow. Having previously ascertained the angle of
junction of the sartorius and adductor, the surgeon should make an
incision (Plate I. fig. 5) just over the pulsations of the vessel, in
the middle line of the space, having its lower end quite over the
sartorius muscle, and its upper one, at a distance from two and a half
to three and a half inches, varying according to the amount of fat and
muscle. The saphena vein can generally be recognised, and is almost
always safe out of the way of this incision at its inner side.
The first incision should divide the skin, superficial fascia, and fat,
quite down to the fascia lata. The edges of the wound being held apart,
the fascia should be carefully divided, and the sartorius exposed; its
fibres can generally be easily enough recognised by their oblique
direction; once recognised, the fascia should be dissected from it till
its inner edge be gained, the corner of which should then be turned so
that it may be held outwards by an assistant with a blunt hook. The
sheath of the vessels is now exposed, and after having thoroughly
satisfied himself of the position of the artery by the pulsation, the
surgeon should carefully raise a portion of the sheath with the
dissecting forceps, and open it freely enough to allow the coats of the
artery to be distinctly seen. If the parts are deep, as in a fat or
muscular patient, great advantage will be gained by seizing one edge of
the sheath by a pair of spring forceps, and committing it to the care of
an assistant, while the operator holds the other in his dissecting
forceps; there is thus no fear of losing the orifice of the sheath,
which without this precaution may easily happen, from the parts being
confused with blood, or the position altered by movements of the
patient. Now comes the stage of the operation on which, more than on
anything else, success or failure depends. A _small_ portion of the
vessel must be cleaned for the reception of the ligature, and it must be
_thoroughly_ cleaned, so that the needle may be passed round it without
bruising of the coats, or rupture of an unnecessary number of the vasa
vasorum by rough attempts to force a passage for it. Hence all
compromises, such as blunted instruments, silver knives, and the like,
are dangerous, for in trying to avoid the Scylla of wounding the artery,
they fall into the Charybdis, on the one hand, of isolating too much of
the vessel and causing gangrene from want of vascular supply, or, on the
other, expose the vein to the danger of injury by the aneurism-needle in
their attempts to force it round an uncleaned vessel.
The needle should in most cases be passed from the inner side, care
being taken to avoid including the vein which is on the inner side and
behind the vessel; the internal saphenous nerve, if seen, should be
avoided. The needle must not be passed quite round the vessel raising it
up, still less must the vessel be held up on the needle, as used to be
done, as if the surgeon was surprised at his own success, but the needle
should be passed just far enough to expose the end of the ligature,
which must be seized by forceps and cautiously drawn through. It must
then be tied very firmly and secured with a reef knot.
The edges of the wound must be brought into accurate apposition, and
secured by one or two stitches. If antiseptics are used, drainage should
be provided for.
From the very fact that ligature of the superficial femoral is a
remarkably successful operation in causing consolidation of the aneurism
and a rapid cure, there is also a corresponding danger that the limb be
not sufficiently supplied with blood at first. The limb may very
possibly become cold, and remain so for some hours at least after the
operation. To avoid this as far as possible, it should be wrapped in
cotton wadding, and very great care should be taken that it be not
over-stimulated by hot applications, friction, or the like, any of which
measures might very likely excite reaction, which would result in
gangrene.
Complete rest of the limb and of the whole body must be enjoined; the
food must be nourishing and in moderate quantity. The chief danger is
from gangrene of the limb, which is especially apt to result when the
vein is wounded, or even too much handled during the operation.
When properly performed, and in suitable cases, the operation is very
successful. Mr. Syme tied this artery for aneurism thirty-seven times,
and of these every one recovered. The statistics of Norris and Porta,
who collected all the cases in which ligature of the femoral had been
employed for _any_ cause, show a mortality of somewhat less than one in
four. Rabe's table up to 1869 with the additional cases collected by Mr.
Barwell to 1880 gives 297 cases with 53 deaths.[9] Mr. Hutchinson's
table, again, of fifty cases collected from the records of Metropolitan
Hospitals, shows the very startling result of sixteen deaths out of the
fifty cases, or a mortality, in round numbers, of one-third.
Certain anomalies have been observed in the distribution of the femoral
vessels, of some importance as affecting the possibility of applying,
and the result of, ligature; such as--1. A high division of the branches
which afterwards become posterior tibial and peroneal. 2. A double
superficial femoral, both branches of which may unite and form the
popliteal, as in Sir Charles Bell's well-known case. 3. Absence of the
artery altogether, as in Manec's case, where the popliteal was a
continuation of an immensely enlarged sciatic.
In such a case the absence of pulsation in front, and the presence of
increased pulsation behind the limb, ought to prevent any fruitless
attempt at search.
LIGATURE OF THE SUPERFICIAL FEMORAL BELOW THE SARTORIUS MUSCLE.--This
operation, though once common in France, and though the one recommended
by Hunter himself, is now comparatively little used in this country; and
rightly so; for while it has no advantage over the upper position, it is
at once nearer the seat of disease, and the vessel is more deeply buried
under muscles, and has a more distinct fibrous sheath, which requires
division.
It is, however, by no means a difficult operation, and is thus
performed:--
The limb being laid as before on the outside, and slightly bent, the
skin shaved and the pulsation of the artery detected, an incision (Plate
I. fig. 6) must be made from the lower edge of the sartorius muscle just
as it crosses the vessel, along the course of the vessel, avoiding if
possible the internal saphena vein.
The sartorius when exposed must be drawn inwards. The fibrous canal
filling the interspace between the abductor magnus and vastus internus
is then recognised, and must be fairly opened; the artery is now seen
lying in it, and over the vein which is posterior to it, but projects
slightly on its outer side; the internal saphenous nerve is lying on the
artery. The needle is best passed from without inwards so as to avoid
the vein. The anastomotica magna is sometimes a large trunk, and has
been mistaken for the femoral in this situation, and tied instead of it.
LIGATURE OF THE POPLITEAL.--This operation is now hardly ever performed
for aneurism, ligature of the superficial femoral having quite
superseded it, and it is very rarely required for wounds, from the
manner in which the vessel is protected by its position.
Before the invention of the Hunterian principle of ligature at a
distance, the old operation for popliteal aneurism consisted in cutting
into the space, clearing out the contents of the aneurismal sac, and
tying both ends of the vessel; from the depth of parts and the close
connection of the popliteal vein, this operation was very rarely
successful, and is now quite given up. If the vessel is wounded the
bleeding point is the object to be aimed at, and is generally sufficient
guide.
In cases of hæmorrhage for suppuration of an aneurismal sac, it might
possibly be advisable, and there are certain cases of rupture of the
artery, without the existence of an external wound, in which attempts
have been made to save the limb by tying the vessel.[10] From the
complexity of the parts, the numerous tendons, veins, and nerves crowded
together in a narrow hollow, and chiefly from the great depth at which
the artery lies, any attempt at ligature is very difficult. It is least
so at the lower angle of the space, where, between the heads of the
gastrocnemius, the vessel comes more to the surface, but is still
overlapped by muscle.
_Operation._--The patient lying on his face, a straight incision (Plate
III. fig. 1), at least four inches in length, should be made over the
artery, and thus nearer the inner than the outer hamstring; a strong
fibrous aponeurosis will require division after the skin and superficial
fascia are cut through, the limb is then to be flexed, and the tendons
drawn aside with strong retractors; fat and lymphatic glands must next
be dissected through, and then the vein and artery, lying on a sort of
sheath of condensed cellular tissue, are seen, the vein lying above the
artery and obscuring it. The vein must be drawn to the outside, and the
thread passed round the artery, which lies close to the bone, on the
ligamentum posticum of Winslowe.
It is a very difficult subject to decide what operations should be
described in a work of this character, on the vessels of the leg and
foot. A very large number of distinct methods of operations on the
various parts of the three chief arteries of the leg have been described
by surgeons and anatomists, but specially by the latter.
The fact is, however, that these complicated procedures are rarely
required, for aneurisms of the arteries of the leg and foot are almost
unknown, while in cases of wound of the vessel, or rupture resulting in
traumatic aneurism, the proper treatment is not to tie the vessel higher
up, but by dilating the wound and clearing out the clots, if required,
to secure the bleeding point, and tie the vessel above and below.
Again, a wound of the sole of the foot often gives rise to very severe
and persistent hæmorrhage, while the fasciæ and complicated tendons
render ligature of the vessel at the spot very difficult; yet ligature
of either the anterior or posterior tibial would probably be
insufficient; and to tie both these vessels, with possibly the peroneal
and interosseous as well, would be a much more severe and dangerous
procedure than ligature of the superficial femoral; while probably
careful plugging of the wound, combined with flexion of the knee, will
be found to stop the hæmorrhage sooner than either of the more
formidable methods.
A competent knowledge of the anatomy of the part, and of the ordinary
methods of checking hæmorrhage, such as ligatures, graduated compresses,
and styptics, aided by position, specially flexion of the knee after Mr.
Ernest Hart's method, will suffice to enable the surgeon to check any
hæmorrhage of the foot or leg, without it being necessary to burden the
memory with the three positions in which to tie the peroneal, or the
various methods, more or less bloody and tedious, by which the posterior
tibial in its upper third may be secured.
NOTE.--While, as a matter of surgical principle to guide our
practice on the living, I still hold very strongly the opinions
here expressed against special operations for ligature of the
arteries of the leg, and allow the sentences to stand as in the
first edition of this work, I insert in a note a brief description
of the more important ones, in deference to the advice of friends
and the urgent request of pupils, as these operations are used by
Examining Boards as tests of the operative dexterity of
candidates:--
1. ANTERIOR TIBIAL ARTERY IN LOWER HALF OF LEG.--_Anatomical
Note._--This vessel is related on its tibial side to the tibialis
anticus, and on its fibular, to the extensor longus digitorum
above, and the extensor pollicis below. The anterior tibial nerve
lies first on its outer side, then crosses the artery, and
eventually reaches its inner side near the foot. _Operation._--An
incision, at least three inches long, parallel with the outer edge
of the tibia, and about three-quarters of an inch from it, exposes
the deep fascia. This being divided, the outer edge of the tibialis
anticus must be found, and will be the guide to the artery, which,
surrounded by its venæ comites, lies very deeply between the
muscles.
2. Posterior Tibial.--_A._ In middle third of leg. Here the artery
is separated from the inner border of the tibia, by the flexor
longus digitorum, and is covered by the soleus. _Operation._--An
incision at least four inches long, along the inner margin of the
tibia, exposes the edge of the gastroenemius; then divide the
tendinous attachment, then expose the soleus, and divide its
attachment also; the deep fascia will then be seen; slit it up, and
the vessel will be found about an inch internal to the edge of the
bone. The nerve is there just crossing it.
Guthrie's, or the direct operation, has the very high authority of
the late Professor Spence in its favour. An incision through skin
and fascia in the middle of the back of the leg allows the two
heads of the gastrocnemius to be separated to the same extent. The
soleus is then to be scraped through in same direction, and its
deep aponeurotic surface carefully slit up. The artery and vein are
then easily seen.
B. In lower third of leg.--This is an easier and more scientific
operation, as it does not involve the division of great tendons. An
incision midway between the internal malleolus and the tendo
Achillis, parallel with both, will expose the very deep and strong
fascia in which the tendons lie. The artery, with its venæ comites,
occupies a central position, having the tendons of the tibialis
posticus and flexor communis in front between it and the internal
malleolus, and the posterior tibial nerve behind it, while the
flexor longus pollicis lies still nearer the tendo Achillis.
TABLE illustrating anastomotic circulation after ligature of
arteries of lower limb.
1. AORTA.--Epigastric and mammary of both sides. Hæmorrhoidal and
spermatic, with branches of pudic both deep and superficial.
2. COMMON ILIAC.--Internal iliac and branches, with those of the
other side, along with the following:--
3. EXTERNAL ILIAC.--Internal mammary and deep epigastric.
Iliolumbar and lumbar branches of aorta, with deep circumflex ilii.
Pudic from internal iliac, with superficial pudic of common
femoral.
Gluteal, sciatic, and obturator, with the circumflex and
perforating branches or deep femoral.
4. FEMORAL.--External circumflex, with external articular of
popliteal.
Perforating, with branches of gluteal and sciatic.
Profunda branches with anastomotica and articular branches.
Obturator and internal circumflex with anastomotica and superior
internal articular.
NOTE.--The importance of the articular branches of the popliteal
explain the danger of gangrene after a sudden rupture or increase
in size of a popliteal aneurism.
LIGATURE OF THE INNOMINATE.--The performance of this extremely
dangerous, in fact almost hopeless operation, is by no means so
difficult as might be expected.
The patient lying down with the shoulders raised and head thrown well
back, the sternal attachment of the right sterno-mastoid must be very
freely exposed. This may be done by an incision (Plate I. fig. 7) along
its anterior edge from the upper edge of the sternum, as far as may be
necessary; another about the same length along the upper edge of the
clavicle, will meet the former at an acute angle, and will include a
triangular flap of skin, which must be carefully dissected up. The
sternal, and probably a portion of the clavicular attachment of the
right sterno-mastoid, must then be cautiously divided. This being done,
the sterno-hyoid and sterno-thyroid muscles require division immediately
above their sternal attachments.
A dense process of cervical fascia (just becoming thoracic) now covers
the vessel, binding it on the right side to the right innominate vein,
and on the left maintaining the relation of the innominate artery to the
trachea. The inferior thyroid veins lie on this fascia, and must be
drawn aside, not cut. The fascia is then to be scraped through very
cautiously, exposing the root of the right carotid, which, being traced
downwards, will lead to the innominate. The following parts lie in close
relation to the vessel at the point of ligature, and must be
avoided:--1. The left innominate vein crosses the artery in front from
left to right, and must be drawn down. 2. The right innominate vein and
right pneumogastric are in close contact with the artery on the right
side; to avoid them the aneurism-needle must be entered on the outside
(right of the vessel). 3. The apex of the right pleura and the trachea
are in close contact behind, requiring the point of the needle to be
kept close to the artery in bringing the thread round.
It might have been expected that the sudden arrest of so large a
proportion of the vascular supply of the body, so very near the heart,
would cause serious, or even fatal symptoms; this, however, is not the
case, no serious inconvenience of this sort being experienced; yet
hitherto every case has proved fatal, either from secondary hæmorrhage
or inflammation of lungs and pleura.
In fifteen well-authenticated, and in three more doubtful cases, the
ligature has been applied; all of these died at periods varying from
twelve hours (as in Hutin's case), to forty-two days as in Thomson's,
and sixty-seven days (Graefe's).[11]
A successful case of ligature of the innominate along with the right
carotid and (after secondary hæmorrhage) the right vertebral, in a
mulatto aged thirty-two, for a subclavian aneurism, has been put on
record by Dr. Smyth of New Orleans, in the _American Journal of Medical
Science_ for July 1866.
And here we may also note that Mr. Heath has lately treated a case of
innominate aneurism by simultaneous ligature of the third part of the
subclavian and the carotid. Both ligatures separated on the eighteenth
day, and the tumour was much smaller some months afterwards.[12]
Mr. R. Barwell has reported several most interesting cases in which
simultaneous ligature of carotid and subclavian have proved of marked
benefit in aortic as well as in innominate aneurisms.[13]
In four cases the operation was attempted, but the operators had to
desist before the application of the ligature, in consequence of the
diseased state of the arterial coats. Of these, three died, and one
(Professor Porter's of Dublin) case recovered, the patient leaving the
hospital with the aneurism nearly consolidated.
Dr. Peixotto of Portugal applied a precautionary ligature to the
innominate in a case where secondary hæmorrhage occurred from the
carotid. The ligature was not tightened beyond what was necessary merely
to cause flattening of the vessel. The patient made a good recovery.
Professor George Porter of Dublin records an interesting case of
subclavian aneurism, in which, after failing to close the axillary
artery by acupressure, he applied L'Estrange's compressor to the
innominate itself for three days, with temporary benefit. The patient
eventually died of hæmorrhage.[14]
For a very full and interesting account of ligatures of vessels in root
of neck we may refer to vol. iii. of the 1883 edition of _Holmes'
Surgery_, pp. 119-122.
LIGATURE OF COMMON CAROTID.--Though the anatomical relations of the
right and left carotid are different at their origin, they so precisely
resemble each other in the whole of that part of their course which is
at all amenable to surgical treatment, that one description will suffice
for both, and the necessary anatomy will be brought out quite
sufficiently in the description of each operation.
From its giving off no collateral branches, the common carotid artery
may be tied at any part of its course.
It has been tied successfully at the distance of only three-quarters,
or, in one case by Porter, hardly to be imitated, one-eighth of an inch
from the innominate, and up to an equal distance from its bifurcation.
In choosing the part of the vessel for operation, the operator must be
guided by the position of the aneurism, if on the vessel itself, but if
the aneurism be distant, as in scalp or orbit, he need have regard to
position simply as facilitating the operation.
The easiest position in which to apply the ligature is just above the
omohyoid muscle, the vessel being there superficial.
LIGATURE ABOVE OMOHYOID.--Using the anterior border of the
sterno-mastoid as a guide, but leaving it gradually above to a little
nearer the mesial line, an incision (Plate IV. fig. 1), varying in
length according to the depth of fat and cellular tissue in the neck,
but with its central point opposite the upper border of the cricoid
cartilage, must be made through skin, platysma, and superficial fascia.
While making the incision the head should be held back, and the face
slightly turned to the opposite side; the parts being now relaxed by
position, the edges of the wound must be held apart by blunt hooks or
copper spatulæ, and the deep fascia carefully divided over the vessel,
which will be recognised by the pulsation. It may be noted here that
even in thin subjects the sterno-mastoid edge _invariably_ overlaps the
vessel, though in many anatomical diagrams it would appear to be in part
subcutaneous.
The descendens noni may possibly be seen, but this is by no means
invariably the case, crossing the sheath of the vessel very gradually
from without inwards in its progress down the neck. It must be carefully
displaced outwards.
The sheath of the vessel is then to be cautiously opened to the extent
of about half an inch. The internal jugular vein, possibly much
distended, may overlap the artery on its outer side, and will require to
be pressed, emptied, and held out of the way. A small portion of the
artery being thoroughly separated from the sheath, the aneurism-needle
must be passed from without inwards to avoid the vein, and keep as close
to the artery as possible to avoid the vagus.
The tendon of the omohyoid muscle, or, in muscular subjects, a portion
of its anterior fleshy belly, may be seen crossing the vessel from
above downwards and outwards at the lower angle of the wound.
An enlarged lymphatic gland has occasionally given much trouble, by
being mistaken for the vessel and cleaned, while the ligature has even
been placed on a carefully isolated fasciculus of muscular fibres.
LIGATURE OF CAROTID BELOW THE OMOHYOID.--An incision in precisely the
same direction as the former, but at a slightly lower level, is
required, but the dissection is rather more difficult. The edge of the
sterno-mastoid when exposed must be drawn outwards; the sterno-hyoid and
thyroid inwards; the omohyoid upwards; the sheath opened, and the
descendens noni or its branches drawn to the tracheal side. The jugular
vein and vagus are both at the outer side, and must be avoided, while
the inferior thyroid artery and sympathetic nerve both lie behind the
vessel, and may be included in the ligature if care be not taken.
VARIETIES.--_Sedillot's Operation._--To secure the artery still
lower in the neck: An incision two and a half inches long, from the
inner end of the clavicle obliquely upwards and outwards in the
interval between the sternal and clavicular attachments of the
sterno-mastoid; this divides the superficial textures; the two
portions of muscle must then be drawn apart. The internal jugular
vein lies in the interval, and must be drawn to the outside before
the artery can be seen at all, and it is this that makes this
operation very difficult and dangerous, especially on the left
side, where the vein is close to the artery, and probably even
crossing it from left to right. The thoracic duct is behind.
_Malgaigne's modification of the above_ is an improvement: to
expose the external attachment of the muscle, to cut it through and
turn it to the outside, as in the operation for ligature of the
innominate, then to divide or pull inwards sterno-hyoid and
sterno-thyroid, thus exposing the sheath. The needle must be passed
from without inwards.
_Results._--Pilz has collected 600 cases, of which 43.16 per cent. died.
The united tables of Norris and Wood give 188 cases, with a mortality of
sixty, or nearly one in three. These tables include cases in which the
vessel was tied for wounds, and as a preparatory step in the operation
of removal of tumours of the jaw, etc. Later statistics give a very much
lessened mortality, due chiefly to the use of animal ligatures.
Of thirty-one cases in which it was tied for pulsating tumours of the
orbit, only two died from the operation.[15] Rivington's statistics to a
later date give forty-six cases on forty-four patients with six deaths.
Both carotids have been tied in the same patient twenty-five times, at
intervals of less than a year; and it is a very remarkable fact that
only five of these fifty ligatures proved fatal,--two in which both were
tied on the same day, and three in which the operation was performed to
arrest hæmorrhage from malignant disease of the face and jaws--from
gunshot wound,--and from syphilitic ulceration.
The external carotid, and also most of its principal branches, have been
tied for aneurisms, wounds, goitres, enlargement of the tongue, vascular
tumours on occiput and other lesions; also as a first stage in the
operation of extirpation of the upper jaw, for the purpose of preventing
hæmorrhage. However, such operations are rare, and will probably become
rarer still, and it is hardly necessary to describe the operations on
each _seriatim_.
Aneurism of the external carotid or branches are rare; if idiopathic,
ligature of the common carotid will be found at once easier, not more
dangerous, and more effectual than ligature of the branch; if traumatic,
the aneurism itself should be attacked, and the bleeding point secured
by a double ligature. Wounds are common enough, but if accessible at
all, the injured vessel should be tied at the bleeding point; if
inaccessible (and under this head we may include wounds of the internal
carotid), the common carotid must be tied.
No one would think of trying the superior thyroids for goitre, unless
they were so manifestly enlarged, tortuous, and pulsating, as to render
the operation so simple (from their superficial position) as to require
no special directions; besides this, the cases in which it has been
already done have given very little encouragement to repeat it.
As cases may occur in which any diminution of the cerebral supply is
contra-indicated, and thus the more difficult ligature of the external
carotid may be preferred to the more simple operation on the common
trunk, and as the lingual may require ligature near its root, in
consequence of obstinate hæmorrhage from the tongue, short directions
are given for the performance of both these operations.
1. LIGATURE OF EXTERNAL CAROTID.--Head in same position as for the
common carotid. A straight incision parallel with the anterior edge of
sterno-mastoid, but about half an inch in front of it, must begin almost
at angle of jaw, and extend downwards nearly to the level of the thyroid
cartilage. Cautiously divide skin, platysma, and fascia; the lower end
of the parotid must be pulled upwards, and the veins, which are
numerous, cautiously separated. The anterior border of the
sterno-mastoid must be pulled backwards, and the digastric and
stylo-hyoid forwards and inwards. The superior laryngeal nerve which
lies behind the vessel must be avoided.
2. LIGATURE OF LINGUAL.--To secure this vessel either before it becomes
concealed by the hyo-glossus, or after it is under the muscle, a curved
incision is necessary, following the line of the hyoid bone, and
especially of its greater cornu, but a line or two above its upper
border. After the skin and platysma are divided, the posterior belly of
the digastric must be recognised, which again will guide to the
posterior edge of the hyo-glossus. The edge of the sub-maxillary gland
may very probably require to be raised out of the way. The artery can
then be secured, either before it dips under the hyo-glossus muscle, or
after it has done so, by the division of a few of its fibres on a
director. Care is needed to avoid injury of the hypo-glossal nerve,
which lies above the muscle.
The internal carotid artery occasionally, but very rarely, is the
subject of aneurism. It may, like any other artery, be wounded,
especially from the fauces. The treatment of either of these lesions is
ligature of the common carotid itself, in preference to ligature of the
internal carotid. Guthrie's operation for securing the bleeding internal
carotid at the injured spot, by dividing and turning up the ramus of the
lower jaw, has never been performed in the living body, and is so
difficult, dangerous, and unnecessary, as not to merit description.
LIGATURE OF SUBCLAVIAN.--_Note._--In consequence of the difference in
the origin, and variety in the anatomical relations of the right and
left subclavian arteries, in so far at least as their first stage is
concerned, it is necessary to give a very brief separate account of
each.
_Right Subclavian._--The innominate artery divides into the right
subclavian and right carotid exactly behind the sterno-clavicular
articulation. The right subclavian extends from this point in an arched
form across the neck, between the scalene muscles, over the apex of the
pleura, till, passing under cover of the clavicle, it changes its name
to axillary at the lower end of the first rib. For convenience of
description, the artery is divided into three parts, which have very
various anatomical relations, and differ from each other much in their
amenability to surgical treatment by ligature. The anterior scalenus
muscle defines the three parts, the first extending to the inner border
of the muscle, the second being concealed by the muscle, and the third
reaching from its outer border to the lower border of the first rib.
_Branches of the Subclavian._--While the deep relations of pleura,
veins, and nerves can be noticed under the head of each operation in
detail, one anatomical point must never be forgotten as influencing very
much the success of all surgical interference with the subclavian
arteries--_i.e._ the branches given off. To give any chance of success
in the application of a ligature to such a large vessel, so near the
heart, a large portion of artery free from branches is required, that
the clot may be long, firm, and undisturbed. The first part of the
subclavian gives off the vertebral, thyroid axis, and internal mammary;
the second, the superior intercostal; while the third part has in most
cases no branch whatever. In these anatomical differences we find the
reason for the almost invariable fatality resulting on any interference
with the first and second parts, and the comparative safety of ligature
of the third part, without requiring to account for the difference on
other grounds, such as depth of part, importance of nervous relations,
or nearer proximity to the heart.
The second and third parts of both arteries are so similar to each
other, that a separate account is not required for the two sides.
LIGATURE OF RIGHT SUBCLAVIAN.--_First Part._--_Operation._--An incision
just at upper edge of sternum and right clavicle, extending from inner
edge of _left_ sterno-mastoid transversely to outer border of right
sterno-mastoid through skin, platysma, and exposing sterno-mastoid, to
be joined at an angle by a second incision, which, two, three, or even
four inches long, must extend along inner border of right
sterno-mastoid. Flap to be raised upwards and outwards. The sternal
attachment of the sterno-mastoid must then be cautiously divided, as
also part or the whole of its clavicular attachment, according as room
is required. The sterno-hyoid and thyroid muscles will then require
similar division. The internal jugular will then be seen very
prominent,[16] and will require to be drawn inwards or outwards,
according to circumstances. The carotid and right subclavian arteries
will then be felt lying close together crossed by the pneumogastric and
recurrent nerves, the latter turning behind the subclavian. The nerves
must be drawn inwards; the cardiac filaments of the sympathetic will
then be observed, and drawn outwards. The subclavian vein lies below,
concealed by the clavicle, and will probably not be seen during the
operation. The needle should be passed round the artery from below
upwards, care being taken not to injure the pleura, which lies beneath
and behind the artery.
_Results._--Twelve cases, all of which died; ten of hæmorrhage, one of
pleurisy and pericarditis, and one from pyæmia. Attempted in one case by
Mr. Butcher, but the artery was too much diseased to bear a ligature.
The patient died on the fourth day.
LIGATURE OF LEFT SUBCLAVIAN.--_First Part._--This operation, which has
been described by some as impossible, has, I believe, been only once
performed on the living body. _Operation._--Incisions as for the
preceding operation, except being on the opposite side. After the skin,
platysma, and muscles have been divided, as already described, the deep
cervical fascia requires division close to the inner edge of the
scalenus anticus. The artery lies excessively deep, and great difficulty
is experienced in avoiding injury to the pleura and the thoracic duct.
_Results._--Once performed by Dr. Rodgers of New York; death from
hæmorrhage on fifteenth day.
_Anatomical Note._--The course of the left subclavian in its first stage
is much straighter, as its origin is much deeper, than on the right
side. The pneumogastric, phrenic, and cardiac nerves lie parallel to its
course; the oesophagus and thoracic duct lie behind it, and to its inner
side.
LIGATURE OF SUBCLAVIAN.--_Second Part._--This very rare operation hardly
requires a separate description, as the incisions necessary for ligature
of the artery in its third part will, with very slight modifications, be
sufficient for the purpose.
It has, however, special elements of danger in it, involved in the
unavoidable division, of part at least, or probably the whole, of the
scalenus anticus. The phrenic nerve, from its position on that muscle,
requires special care to avoid dividing it, and in most cases the
internal jugular vein is also in the way. The branches of the thyroid
axis, which cross the neck, are quite in the line of the incision. The
lowest cord of the brachial plexus lies immediately behind the artery,
between it and the middle scalenus. The pleura lies just below it. The
subclavian vein is generally quite safe, running in front of the
scalenus anticus, and at a lower level.
The presence of the superior intercostal branch adds greatly to the
danger of ligature of the vessel in this position, from its interfering
with a proper clot.
_Results._--Dupuytren[17] performed it successfully for a traumatic
axillary aneurism. Auchincloss[18] did it for a large true aneurism, but
the patient died sixty-eight and a half hours after the operation.
Liston cut through the outer portion of the scalenus with success for an
idiopathic aneurism. Thirteen have been collected by Wyeth with four
recoveries and nine deaths.
LIGATURE OF SUBCLAVIAN.--_Third Part._--For this comparatively common
operation, various methods of procedure have been suggested and
employed.
In the dead body, where the axilla is free from swelling, and in thin
patients, the artery in this third stage is tolerably superficial, and
can be secured with ease. But in very muscular men, with short necks and
well curved clavicles, and specially when the axilla is filled up with
an aneurism, and the shoulder cannot be depressed, the operation becomes
very difficult.
_Operation of Ramsden, Liston, and Syme._--_Position._--The patient
lying on his back with his shoulders supported by pillows, and his head
lying back, and drawn to the opposite side; the shoulder of the affected
side must be depressed as much as possible.
_Incisions._--(Plate I. fig. 8.)--One through skin, superficial fascia,
and platysma, along the upper edge of the clavicle, for at least three
inches from the anterior edge of the trapezius to the posterior border
of the sterno-mastoid, and in muscular subjects freely overlapping the
edges of both muscles. Another two inches in length along posterior
border of sterno-mastoid meets the first at an angle. On reflecting the
chief flap thus made upwards and backwards, the external jugular will be
seen, and, if possible, must be drawn to a side; if not, it must be
divided, and both ends tied. The lower edge of the posterior belly of
the omohyoid must then be sought; this leads at once to the posterior or
outer margin of the scalenus anticus. The connection of the deep fascia
to that muscle must then be very carefully scraped through, and by
tracing the muscle to its insertion to the first rib, the artery is at
once reached, lying behind the insertion. The pulsation of the vessel
between the forefinger and the first rib will prove a great assistance;
yet care is required, lest one of the branches of the brachial plexus be
secured instead of the artery. The lowest cord lies very close to the
vessel. The subclavian vein is not likely to give much trouble, from
its being on a lower level, and (unless very much dilated) nearly
concealed by the clavicle. The suprascapular artery is also hidden, but
the transverse cervical crosses the very line of incision, and may give
trouble, being occasionally much enlarged, so much so as even for a time
to have been mistaken for the subclavian itself. If possible, both these
branches should be saved, as being important means of carrying on the
anastomosis for the future support of the limb.
An absorbent gland is occasionally in the way, and has even been
mistaken for the vessel and carefully cleaned. Such may be removed
without scruple.
Care must be taken not to injure the pleura, which lies immediately
behind and below the vessel at the seat of ligature. Various
instrumental devices have been invented for passing the ligature. The
simplest seems still to be best, a common aneurism-needle with a
considerable curve.
_Other methods of operating._--A single curved incision above the
clavicle, with its concavity upwards, of about three or four inches
long, with its inner end rather higher than the outer (Green,
Fergusson).
A linear transverse incision in the same situation (Velpeau).
A single linear incision perpendicular to the clavicle (Roux).
An arched incision (Plate IV. fig. 2) with its convexity outwards,
and its base on the posterior edge of the sterno-mastoid, from
three inches above the clavicle to the clavicular attachment of the
muscle (Skey).
_Results._--Dr. Wyeth's Tables in 1877 give 251 cases with 134 or 53 per
cent. of deaths.
The late Mr. Furner of Brighton reported a most interesting case,
in which he tied both subclavian arteries at an interval of two
years in the same patient, for axillary aneurisms, with success.
LIGATURE OF AXILLARY.--_Anatomical Note._--This vessel, the next stage
in the continuation of the subclavian downwards, may be defined
surgically as extending from the clavicle to the lower border of the
teres major. From the depth of the vessel at its upper part, the
numerous nerves, and the close proximity of the vein, the surgeon has
carefully to study the anatomical relations. It, like the subclavian, is
commonly divided into three stages, and, also like the subclavian, these
stages are defined by the relations of the artery to a muscle, the
pectoralis minor. Surgically we may draw a very close parallel between
the two vessels, for we find that in the axillary, as in the subclavian,
the first stage is very deep, and very rarely amenable to ligature; the
second, still deeper and more rarely attempted, as in both the operation
involves division of a deep muscle; while the third stage in each is the
one most frequently chosen by the surgeon.
_First Stage._--Between the lower edge of the first rib and upper border
of the pectoralis minor the vessel is deeply seated, contained in that
process of deep fascia called the costo-coracoid membrane, and covered
above by skin, platysma, and the clavicular portion of the pectoralis
major. It lies on the first intercostal muscle and the upper digitation
of the serratus magnus, while the cords of the brachial plexus are on
its acromial side, and the axillary vein in close contact with it on its
thoracic side, and frequently overlapping the artery.
_Operation._--The great desideratum is free access. An incision (Plate
I. fig. 9), semilunar in shape, with its convexity downwards, must
extend from half an inch outside of the sterno-clavicular articulation
to very near the coracoid process, stopping just before it arrives at
the edge of the deltoid, in order to avoid injury of the cephalic vein.
It must include skin, fascia, and platysma, and the flap must be thrown
upwards. The clavicular portion of the pectoralis major must then be
divided right across its fibres, which will retract. The arm must then
be brought close to the side to relax the pectoralis minor, which must
be drawn aside. The artery will then be felt pulsating, but hidden by
the costo-coracoid membrane, which acts as its sheath. This must be
carefully scratched through, the nerves pulled outwards, the vein
avoided and pulled downwards and inwards, and the thread passed round
from within outwards. (Manec, Hodgson, and, with slight modification in
the incision through the skin, Chamberlaine.)
Ligature has been performed in this position by separating the
pectoralis and deltoid muscles, without dividing the muscular
fibres (Roux, Desault).
To attempt to gain access between the clavicular and sternal
portions of pectoralis major, as has been proposed by some, is
almost impracticable in the living body, from the position of the
vein, to which, rather than to the artery, this incision leads.
LIGATURE OF AXILLARY, _in its second stage_, is not an advisable
operation, when it is merely intended to throw a ligature round the
artery for an aneurism lower down.
It has been performed at least twice by Delpech, but it is a rude
procedure; in his cases, after the muscle was cut, a dive with the
finger was made to collect the whole mass of vessels and nerves, and
bring them to the surface near the collar-bone; in this position it is
said the artery was easily isolated and tied.
In Mr. Syme's operation of cutting into large axillary aneurisms, and
tying both ends of the vessel, the pectoralis minor may, indeed
generally has, to be divided, and must take its chance without any
special notice or precaution, in the sweeping, free incisions required.
LIGATURE OF AXILLARY _in its third stage_.--This is an operation very
much more common, more easy of accomplishment, and safer in its results
than either of the preceding; the artery in this stage being more
superficial, in fact almost subcutaneous.
_Operation._--The arm being extended and supinated, an incision (Plate
I. fig. 10) two and a half or three inches long, must be made in the
base of the axilla over the artery, involving at first skin and
superficial fascia only; the deep fascia is then exposed and must be
carefully scraped through, avoiding injury of the basilic vein, if (as
sometimes occurs) it has not yet dipped through the fascia. The vessel
can now be felt; the median nerve which lies over the artery, or
slightly to its outer side, must be drawn outwards, and the axillary
vein, which lies at the thoracic side, but often overlaps the vessel,
must be carefully drawn inwards. The ligature must then be passed from
within outwards.
When the patient is very fat or muscular, the coraco-brachialis muscle
may be required as a guide to the vessel; but in general its superficial
position renders any guide quite unnecessary, even in the dead body.
_Anatomical Note._--While in each stage the axillary artery gives off
branches, those arising from the third stage are by far the most
important, especially the subscapular, which leaves it at the edge of
the muscle of the same name. To avoid these the ligature should be
applied as low down on the vessel as possible, and, in point of fact,
the operation called ligature of the third stage of the axillary is,
anatomically speaking, really ligature of the brachial high up, and
where there is room at all, there will be the less chance of secondary
hæmorrhage, the greater the distance is between the ligature and the
great subscapular branch.
_Mr. Syme's Operation for Axillary Aneurism._--Description of the
operation in his own words:--
"Chloroform being administered, I made an incision along the outer edge
of the sterno-mastoid muscle, through the platysma myoides and fascia of
the neck, so as to allow a finger to be pushed down to the situation
where the subclavian artery issues from under the scalenus anticus and
lies upon the first rib. I then opened the tumour, when a tremendous
gush of blood showed that the artery was not effectually compressed;
but while I plugged the aperture with my hand, Mr. Lister, who assisted
me, by a slight movement of his finger, which had been thrust deeply
under the upper edge of the tumour, and through the clots contained in
it, at length succeeded in getting command of the vessel. I then laid
the cavity freely open, and with both hands scooped out nearly seven
pounds of coagulated blood, as was ascertained by measurement. The
axillary artery appeared to have been torn across, and as the lower
orifice still bled freely, I tied it in the first instance. I next cut
through the lessor pectoral muscle close up to the clavicle, and holding
the upper end of the vessel between my finger and thumb, passed an
aneurism-needle, so as to apply a ligature about half an inch above the
orifice."[19]
In a similar operation lately performed by the author for traumatic
aneurism, the result of a stab, very little blood was lost, though no
incision was made above the clavicle. The patient made a good
recovery.[20]
LIGATURE OF BRACHIAL.--To arrest hæmorrhage from a wound of the artery
itself, no special directions are required, except to enlarge the wound,
and secure the vessel above and below the bleeding point. There are,
however, rare cases in which for bleeding in the palm (after all other
means have failed), or for aneurism lower down the arm, a ligature may
be necessary.
_Operation._--The biceps muscle, at its inner edge, is the best guide to
the position of the incision, or if it be obscured by fat or oedema, a
line extending from the axilla, just over the head of the humerus to the
middle of the bend of the elbow will define its course. An incision
(Plate I., fig. 11) three inches in length, about the middle of the arm
(when you have the choice of position), through skin and superficial
fascia, will expose the deep fascia, and probably the basilic vein.
Drawing the latter aside, cautiously divide the deep fascia. The artery
is then exposed, but in close relation to various nerves; of these the
ones most likely to come in the way are--1. The median, which lies in
front of, but a little to the outside of the artery, though in some rare
cases it lies behind it; 2. The internal cutaneous; 3. The ulnar, both
of which ought to be rather to the inside of the artery. Two brachial
veins accompany and wind round the vessel, occasionally interlacing.
Pulsation will, in the living body, usually suffice to distinguish the
artery from the other textures, and the ligature may be passed from
whichever side is most convenient.
_Note._--The relation of the median nerve to the vessel varies
according to the part of the arm--thus, as low as the insertion of
the coraco-brachialis it is to the outer side, as has been
described, it then crosses the vessel obliquely, and two inches
above the elbow it is on the inner side of the artery. Again, the
operator must never forget the possibility of there being a high
division of the artery. This occurs, Mr. Quain has shown, perhaps
once in every ten or eleven cases, and may necessitate ligature of
both trunks.
In those cases (once much more frequent than at present) where an
aneurism has formed after a wound of the brachial at the bend of the arm
in venesection, the aneurism may be either circumscribed or diffuse.
If circumscribed, it is advised by some surgeons, specially by the late
Professor Colles of Dublin, that the brachial should be tied immediately
above the tumour. In most cases of circumscribed, and in all such cases
of diffuse aneurism, the preferable operation is boldly to lay open the
tumour, turn out all the clots, seek for the wound in the artery, and
tie the vessel above and below. A tourniquet above, or, better still, a
trustworthy assistant, prevents all fear of hæmorrhage, and such a
radical operation exposes the limb to far less chance of gangrene than
do any attempts at removing or lessening the tumour by pressure (as
recommended by Cusack, Tyrrell, Harrison), and is much more certain
than a mere ligature above.[21]
LIGATURE OF VESSELS IN FORE-ARM.--Here, as also we found is the case in
the leg, it is almost useless to go on giving exact directions as to the
method of throwing a ligature round the vessels in all possible
situations.
For below the elbow spontaneous aneurism is almost unknown, and even
traumatic aneurisms are extremely rare. It is therefore for hæmorrhage
only that the vessels are likely to require ligature, and it is a rule
in surgery that to enlarge the wound and to apply a ligature above and
below the bleeding point is better practice than to apply a ligature at
a distance.
In the case of wounds of the palmar arch, it is extremely difficult, and
very apt to injure the future usefulness of the hand, thus to seek for
the bleeding point under the palmar fascia, and for _these_, ligatures
of radial and ulnar have occasionally been practised. However, as even
this has proved ineffectual, and the interosseous has proved sufficient
to continue the bleeding, ligature of the brachial at once is preferable
to ligature of so many branches in the fore-arm.
The use of graduated compresses, carefully applied, combined with
flexion of the elbow over a bandage, will generally prove sufficient to
check such hæmorrhage from the palm, without having recourse to either
of the above more severe measures.
_Note._--As in the lower limb at page 24, and for the same reasons,
I here insert a brief account of the methods of tying the ulnar and
radial arteries.
1. LIGATURE OF ULNAR.--Only admissible in the lower half of its
course. _Operation._--Use the tendon of the flexor carpi ulnaris as
a guide, and make an incision along its radial edge, at least two
inches in length; expose the deep fascia of the arm and then
cautiously divide it; then bending the hand, the flexor carpi
ulnaris is relaxed, and the artery is found lying pretty deeply
between it and the flexor sublimis digitorum. The ulnar nerve lies
at its ulnar side, and the venæ comites accompany the artery. In a
tolerably muscular arm, the incision will have to be about an inch
inside of the ulnar border of the limb.
2. RADIAL.--This artery lies more superficial than the preceding,
and may be tied at any part of its course.
_A._ Operation in upper part of fore-arm. Here the artery lies in
the interval between the supinator longus and the pronator radii
teres. In a muscular arm, the edge of the former muscle is the best
guide; in a fat one, the incision may be made in a line extending
from the centre of the bend of the arm to the inner edge of the
styloid process of the radius. The deep fascia must be exposed and
opened, and the muscles relaxed and held aside. The radial nerve
lies on the radial side of the vessel.
_B._ Operation in lower half of arm. Here the vessel is more
superficial, lying in the groove between the flexor carpi radialis
and supinator longus. An incision two inches in length, and
parallel with these tendons, easily exposes the artery. The nerve
is still on its radial side.
_C._ Operation at first metacarpal. The artery may be tied easily
enough in the triangular space bounded by the extensors of the
thumb, on the dorsum of the proximal end of the first metacarpal
bone. Skey[22] recommends a transverse,--Stephen Smith[23] and
others, a longitudinal incision. The author had lately to secure
the radial in its lower third, the superficialis volæ, and the
radial again in the triangular space, in a case where division of
the artery by a transverse cut had caused a large aneurism to form
close above the annular ligament.
TABLE illustrating anastomotic circulation after ligature of
arteries of neck and upper limb.
1. Common carotid.
(_a_) Across middle line: thyroids, linguals, facials, occipitals;
also terminal branches of external carotids; also internal carotids
by circle of Willis.
(_b_) Of same side: occipital with vertebral; superior thyroid with
inferior thyroid, etc.
2. Subclavian, 3d part.
Suprascapular with dorsal branches of subscapular; posterior
scapular with costal and muscular branches of subscapular. Thoracic
anastomosis between internal mammary and intercostals, with
branches of axillary.
3. Axillary and brachial. Anastomosis varies with the position of
the ligature, but is very free between the various muscular
branches of these vessels.
FOOTNOTES:
[2] Erichsen, _Surgery_. Sixth edition, vol. ii. p. 121.
[3] The line 3 in Plate I. shows the direction required. It
will not be necessary to carry the incision so far up for the external
as for the common iliac.
[4] _On the Arteries and Veins_, p. 421.
[5] _Cyclopædia of Practical Surgery_, vol. i. p. 277.
[6] John Bell's _Prin. of Surg._, vol. i. 421; _Dublin Jour._,
vol. iv. 321.
[7] _Observations in Clinical Surgery_, Syme, pp. 171-3.
[8] _Brit. Med. Jour._ 1867, Oct. 5.
[9] _International Encyclopædia of Surgery_, vol. iii. p. 466.
[10] Poland, _Guy's Hosp. Report_, ser. iii. vol. vi.
[11] Mr. W. Thomson's most interesting paper on this subject is
full of information down to the latest date.
[12] _Lancet_, Jan. 5, 1867.
[13] _Lancet_, May 1879.
[14] _Dublin Quarterly Journal_, Nov. 1867.
[15] W. Zehender--Monatsbl. für Augenheilkunde. 1868.
[16] Butcher, _Op. and Cons. Surgery_, p. 861.
[17] _Leçons Orales_, iv. 530.
[18] _Ed. Med. and Surg. Journ._ vol. xlv.
[19] _Observations in Clinical Surgery_, pp. 148, 149.
[20] _Edin. Med. Journal_, March 1879.
[21] See case of recurrence, Fergusson's _Practical Surgery_
1st ed. p. 222.
[22] _Operative Surgery_, p. 279.
[23] _Surgical Operations_, p. 50.
CHAPTER II.
AMPUTATIONS.
In ordinary surgical language the name Amputation is applied to all
cases of removal of limbs, or portions of limbs, by the knife, though in
strict accuracy it should be restricted to those cases in which a limb
is removed _in the continuity of a bone_, its removal _at a joint_ being
called a Disarticulation.
The briefest outline of a history of amputation would fill a work much
larger than the present. I may be allowed in a few sentences to attempt
to show the principle on which such a sketch should be written, in
describing the three great eras of progress in improvement of the
methods of amputating.[24]
I. Prior to the invention, or at least prior to the general
introduction, of the ligature and the tourniquet, the great barrier to
all improvement in operating was the impossibility of checking
hæmorrhage during an operation, and after its conclusion. Many surgeons
would not amputate at all, others only through gangrenous parts; others
more bold, only at the confines of parts in which gangrene had been
artificially induced by tight ligatures.
With the exception of Celsus, who in one place recommends a flap to be
dissected up, and the bone thus divided at a higher level, all were in
too great a hurry to get the operation completed to think of flaps. Cut
through all the parts at the same level with a red-hot knife, if you
will, like Fabricius Hildanus; by a single blow with a chisel and
mallet, like Scultetus; or by a crushing guillotine, like Purmannus: or
by two butchers' chopping-knives fixed in heavy blocks of wood, one
fixed, the other falling in a grove, like Botal; and then try to check
the bleeding by tying a pig's bladder over the face of the stump, like
Hans de Gersdorf; or tying it up in the inside of a hen newly killed; or
by plunging it at once into boiling pitch.
We are the less surprised to read of Celsus's description of a flap
operation, when we remember that it is almost certain that Celsus _was_
acquainted with the ligature as a means of checking hæmorrhage.[25]
II. A new era was ushered in when, about 1560, Ambrose Paré invented, or
re-introduced, the ligature as a means of arresting hæmorrhage, but not
for more than a century after this did the full benefit of his discovery
begin to be felt, when the tourniquet was introduced by Morel at
Besançon in 1674, and James Young of Plymouth in 1678, and improved by
Petit in 1708-10.
_Now_ surgeons had time to look about them during an amputation, and to
try to get a good covering for the bone, so that the stump might heal
more rapidly and bear pressure better. Great improvements were rapidly
made, and any history of these improvements would need to trace two
great parallel lines, one the circular method, the other the flap
operation.
1. The old method in which the limb was lopped off by one sweep, all the
tissues being divided at the same level, might be called the true
circular. This, however, was soon improved--
_A._ By Cheselden and Petit, who invented the double circular incision,
in which first the skin and fat were cut and retracted, and then the
muscle and bone were divided as high as exposed.
_B._ By Louis, who improved this by making the first incision include
the muscles also, the bone alone being divided at the higher level.
_C._ By Mynors of Birmingham, who dissected the skin back like the
sleeve of a coat, and thus gained more covering.
_D._ Then comes the great improvement of Alanson, who first cut through
skin and fat, and allowing them to retract, next exposed the bone still
further up by cutting the muscles obliquely so as to leave the cut end
of the bone in the apex of a conical cavity.
_E._ An easier mode, fulfilling the same indications, is found in the
triple incision of Benjamin Bell of Edinburgh, who in 1792 taught that
first the skin and fat should be divided and retracted, next the
muscles, and lastly the bone.
_F._ A slight improvement on _E_, made by Hey of Leeds, who advised that
the posterior muscles of the limb should be divided at a lower level
than the anterior, to compensate for their greater range of contraction.
2. In the progress of the flap operation fewer stages can be defined.
Made by cutting from within outwards, after transfixion of the limb, the
flaps varied in shape, size, position, and numbers, from the single
posterior one of Verduyn of Amsterdam, to the two equal lateral ones of
Vermale, and the equal anterior and posterior ones of the Edinburgh
school.
Then came the battle of the schools: flap or circular.
_Flap._--Speedy, easy, and less painful; apt to retract, and that
unequally.
_Circular._--Leaving a smaller wound, but more slow in performance, and
apt to leave a central adherent cicatrix.
3. The last era in amputation began after the introduction of
anæsthetics. Now speed in amputation is no object, and the surgeon has
full time to shape and carve his flaps into the curves most suited for
accurate apposition, and suitable relation of the cicatrix to the bone.
It has also been brought clearly out that different methods of operating
are suitable for different positions, and also that even in the same
operation it is possible to unite the advantages of both the flap and
the circular method.
In the modified circular, which is best suited for amputation below the
knee, in the long anterior flaps of Teale, Spence, and Carden, we have
illustrations of the manner in which the advantages of both the flap and
circular methods have been secured, without the disadvantages of either.
The long anterior flap, not like Teale's to fold upon itself, but like
Spence's and Carden's to hang over and shield the end of the bones, and
the face of a transversely-cut short posterior flap, seems to be now the
typical method for successful amputations. There may be exceptions, as
when the anterior skin is more injured than the posterior, or where an
anterior flap would demand too great sacrifice of length of limb, but as
a rule it will be found the best method for the patient.
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.
[Illustration: FIG. I.]
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.
[Illustration: 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.
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:[26]--"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.)
[Illustration: FIG. III.[27]]
[Illustration: FIG. IV.[27]]
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.[28]
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."[29]
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,[30] 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 Gross[31]
and Ashhurst,[32] 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.
AMPUTATION AT THE SHOULDER-JOINT.--This operation, like that at the hip
joint, can, from the nature of the joint to be covered, and the abundant
soft parts in the normal state of the tissues, be performed on the dead
in very various ways, by single, double, or triple flaps, by transfixion
or dissection, rapidly or slowly. Hence manuals of operative surgery
might collect at least twenty different methods, most of which have some
recommendation, and all of which are practicable enough.
When, however, we reflect that in the living body, in cases where
amputation at the shoulder-joint is required at all, the severity of the
accident, or the urgency of the disease, will, in general, leave no room
for selection, we shall see how utterly valueless is any knowledge of
mere methods of operating, and of how much greater importance it is that
we should be simply thoroughly familiar with the anatomy of the joint.
For example, an accident which necessitates amputation so high up has,
in all probability, opened into the joint and destroyed the soft parts
on at least one aspect; in such a case the flaps must be cut from the
uninjured soft parts only. If an aneurism has rendered amputation
through it and through the joint a last resource, the flap must be
gained chiefly at least from the outside; a malignant tumour of the
humerus will almost certainly prevent any transfixion, and require flaps
to be made by dissection, wherever the skin is least likely to be
involved. Again, some of the most vaunted and most rapid operations
almost require for their success the integrity of the humerus, which has
to make itself useful as a lever in disarticulation, while in most cases
of accident we are amputating for compound injury of the humerus, almost
certainly implying fracture with comminution.
From its proximity to the trunk, hæmorrhage is one of the chief dangers
to be apprehended during this operation, especially from the axillary
artery. As far as possible to obviate this danger, most plans of
operating are based on the principle that the vessels and nerves should
be the last tissues to be cut; in some they are not divided till after
disarticulation.
While a good assistant, to make pressure on the subclavian above the
clavicle, is a most advisable precaution, too much must not be trusted
to this pressure above, as the struggles of the patient and the
spasmodic movements of the limb, which are so apt to occur under the
stimulus of the knife, are apt to render futile the best efforts at
compression.
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
assistant, 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 circumflex, 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 assistants 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 assistant, 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 hæmorrhage 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 assistant 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 circumflex 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 assistant, and taking care to keep the edge of the knife close to
the bone, the trunk of the posterior circumflex is protected. In regard
to the axillary vessels, they can either be compressed by an assistant
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 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 means the 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. (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.
[Illustration: 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 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 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 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 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 constituted 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,
Guérin, 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:--
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 to the
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 sacrificing the 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 AMPUTATION has 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 the _exact_ plan
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 as they
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 much to 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's _Surgery_, the incision is figured
passing obliquely _forwards_. 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,
and _must_ divide dozens of them; the slit we make is parallel with
their course, and _may_ not 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:--
Amputation of hip, 85 per cent. died.
" thigh, 64 "
" knee, 55 "
" leg, 26 "
Amputation of ankle-joint, 13 per cent. died.
" shoulder, 39 "
" arm, 21 "
" fore-arm, 16 "
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 of _Observations 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 plantar aspect 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. It leaves 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 the other
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 gave
the 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 in _Holmes'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.
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 AMPUTATION _of 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 the _posterior edge_ of the fibula to the
_posterior edge_ of the tibia, or _vice 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 KNEE _at 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 tibia need 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 the _face_ of the stump, but by putting the limb
into a well-padded case with soft rounded 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, the _whole_ tibia
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 it fills 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.
The statistics seem to be favourable: out of 55 cases, Continental,
American, and English, 21 died, a mortality of 38 per cent., while
in a table of 1055 cases of amputation of the thigh, 464 died,
being a mortality of 44 per cent. In some of the American cases the
articulating extremity of the femur seems to have been removed, as
in the following operation:--
AMPUTATION THROUGH THE CONDYLES OF THE FEMUR.--In the _London and
Edinburgh Journal of Medical Science_ for 1845, Mr. Syme advocated a
method of amputation through the condyles of the femur as specially
suitable in case of diseased knee-joint. Amputation at this spot has
certain advantages:--1. The shaft of the bone being untouched, there is
no injury of the medullary cavity, and hence no fear of inflammation of
its lining membrane. 2. There is less risk of exfoliation, the
cancellated texture of the epiphysis not being liable to it. 3. Being
close to the joint, the muscles are cut through where they are
tendinous, thus very much diminishing the risk of retraction and
consequent protrusion of the bone. 4. A large broad surface of bone is
left to bear the weight of the body, and one which, like the ankle-joint
stump, will round off and afford a comfortable pad over which the skin
of the flap will freely play.
One objection used to be urged against this mode of operating, the fear
lest the thickened, brawny, and often ulcerated textures in the
neighbourhood of a diseased knee-joint, would not make a good covering.
This, however, is no longer a bugbear, as we see in cases of resection,
where the diseased joint alone is taken away, how very soon all swelling
and disease departs, once its cause is removed.
Mr. Syme's original operation was briefly as follows:--With an ordinary
amputating-knife make a lunated incision (Plate I. fig. 19) from one
condyle to the other, across the front of the joint, on a level with the
middle of the patella, divide the tissues down to the bones, and then
draw the flap upwards, then cut the quadriceps extensor immediately
above the patella. The point of the blade should then be pushed in at
one end of the wound, thrust behind the femur, and made to appear at the
other end; it should then be carried downwards (Plate III. fig. 5), so
as to make a flap from the calf of the leg, about six or eight inches in
length, in proportion to the thickness of the limb; the flap should then
be slightly retracted, and the knife carried round the bone a little
above the condyles to clear a way for the saw, which should be applied
so as to leave the section as horizontal as possible.
This method is now hardly ever used, as the following seems a much
better one:--
GRITTI'S[44] AMPUTATION.--In this two flaps are formed--an anterior long
one rectangular and a posterior short one. The condyles of the femur are
divided through their base, and the lower surface of patella is removed
by a small saw, and then the surfaces of bone approximated.
STOKES'S[45] MODIFICATION OF GRITTI'S AMPUTATION.--In this
"supracondyloid" amputation, the femur is sawn just above the condyles,
without going into the medullary canal. The anterior flap is oval, twice
as long as posterior, and the patella is brought up after denudation
against end of femur.
CARDEN'S AMPUTATION AT THE CONDYLES OF THE FEMUR.[46]--The operation
consists in reflecting a rounded or semi-oval flap of skin and fat from
the front of the knee-joint, dividing everything else straight down to
the bone, and sawing the bone slightly above the plane of the muscles,
thus forming a flat-faced stump, with a bonnet of integument to fall
over it.
The operator standing on the right side of the limb, seizes it between
his left forefinger and thumb at the spot selected for the base of the
flap, and enters (Plate II. fig. 8) the point of the knife close to his
finger, bringing it round through skin and fat below the patella to the
spot pressed by his thumb; then turning the edge downwards at a right
angle with the line of the limb, he passes it through to the spot where
it first entered, cutting outwards through everything behind the bone
(Plate IV. fig. 16). The flap is then reflected, and the remainder of
the soft parts divided straight down to the bone; the muscles are then
slightly cleared upwards, and I saw it applied.
I have ventured to make a slight change in the method of performing this
most excellent operation, for having found the posterior flap, as cut in
the method above described, rather scanty in the earlier cases in which
I have had occasion to perform it, after dissecting back the anterior
flap and cutting into the knee-joint, I shape a slightly convex
posterior flap of skin only, at least one and a half inches in length
in adult, and allow it to retract before dividing the muscles by a
circular cut to the bone, and have had every reason to be satisfied with
the change.
AMPUTATION OF THE THIGH.--Amputation of the thigh has been the favourite
battle-ground where flap and circular, antero-posterior and lateral,
long and short flaps, double, triple, and conical incisions, have
striven with each other; so were I to attempt to describe one quarter of
the various methods employed, I should need to rewrite the history of
Amputation.
It will suffice merely to describe the _best_ modes of amputating the
thigh through its lower, middle, and upper thirds respectively, and at
the hip-joint.
In one word, it may be stated that, with the exception of those
amputations performed through the lower third of the bone, the flap
method is to be preferred, and the flaps should in almost every case be
made by transfixion.
In the lower third, however, the flap method, though exceedingly easy,
and capable of very rapid performance, has certain defects; the chief of
these being the tendency which the muscular flaps (the necessary result
of transfixion) have to cause undue retraction, and hence protrusion of
the bone. This is seen specially in the hamstrings, which from the great
distance of their origin, and the purely longitudinal direction of their
fibres, retract to a very great extent, much more than the anterior
muscles can do from the pennate direction of their fibres, and the
manner in which they are mutually bound down to each other and to the
bone.
Even in this one position, the lower third of the thigh, the methods
that may be needed are various, and require separate notice;--for
operations here are extremely frequent from the frequency of strumous
disease of the knee-joint in our variable climate, and from the fact
that compound fractures or dislocations of the knee-joint so very often
necessitate amputation.
In cases where the skin over the patella is uninjured and available, the
operation by long anterior flap (either by Teale's method, or by Mr.
Spence's modification of it, which curiously is almost exactly similar
to the amputation of Benjamin Bell by a single flap) is suitable enough.
But, I believe, preferable to either of these is the operation of Mr.
Carden, already described. In cases where the knee-joint is injured, and
the skin over the patella unavailable, and yet where it is not necessary
to go higher up the limb, the modified circular amputation of Mr. Syme
will be found very suitable.
As it is in this lower third of the thigh that a very large proportion
of the cases requiring a long anterior flap is to be found, it affords
the best opportunity for comparing in their detail the three almost
similar plans of B. Bell, Teale, and Spence--after which Mr. Syme's
modified circular may be described.
BENJAMIN BELL'S FLAP OPERATION ABOVE THE KNEE (reported in his own
words, slightly abbreviated).--"When this operation is to be performed
above the knee, it may be done either with one or two flaps, but it will
commonly succeed best with one. The flap answers best on the fore part
of the thigh, for here there is a sufficiency of the parts for covering
the bones, and the matter passes more freely off than when the flap is
formed behind.... The extreme point of the flap should reach to the end
of the limb, unless the teguments are in any part diseased, in which
case it must terminate where the disease begins, and its base should be
where the bone is to be sawn. This will determine the length of the
flap, and we should be directed with respect to the breadth of it by the
circumference of the limb, for the diameter of a circle being somewhat
less than a third of its circumference, although a limb may not be
exactly circular, yet by attention to this we may ascertain with
sufficient exactness the size of a flap for covering a stump (Plate IV.
fig. 17). Thus a flap of four inches and a quarter in length will reach
completely across a stump whose circumference is twelve inches; but as
some allowance must be made for the quantity of skin and muscles that
may be saved on the opposite side of the limb, by cutting them in the
manner
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