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.
Fig. i.
Amputation of the Upper Extremity.—The extreme importance of the human hand, its tactile sensibility, its grasping power, and the irreparable loss sustained by its removal, render the greatest caution necessary, lest we should remove a single digit or portion of one that might be saved. In cases of severe smashing injuries involving the fingers, it is the surgeon's bounden duty not recklessly to amputate the limb with neat flaps at the wrist-joint, but carefully to endeavour to save even a single finger from the wreck, though at the risk of a longer convalescence, or even of a profuse suppuration. While a toe or two, or a small longitudinal segment of the foot, may be comparatively useless, and a good artificial foot, with an ankle-joint stump, certainly preferable, a single finger, provided its motions are tolerably intact, will prove much more valuable to its possessor than the most ingeniously contrived artificial hand.
However, while in cases of extensive smash we endeavour to save anything we can, the case is very much altered when it is only one or two fingers that are injured. Here we find another principle brought into play, and our conservative surgery must be limited by the following consideration. In endeavouring to save a portion of the injured finger or fingers, will the saved portion interfere with the important movements of the uninjured ones? These two principles—1. Generally to save as much as we can; 2. Not to save anything which may be detrimental or in the way,—will guide us in describing the amputations of the upper extremity.
Fig. ii.
Amputation of a distal phalanx.—This small operation is not very often required. In cases of whitlow in which the distal phalanx alone has necrosed, removal of the necrosed bone by forceps is generally all that is necessary. In cases of injury, however, in which nail and distal phalanx are both reduced to pulp, it will hasten recovery much to remove the extremity. There is no choice as to flap, the nail preventing an anterior one, so a flap long enough to fold over must be cut from the pulp of the finger in either of two ways (Fig. i. 1):—1. Holding the fragment to be removed in the left hand, and bending the joint, the surgeon makes a transverse cut across the back of the finger, right into and through the joint, cutting a long palmar flap from within outwards as he withdraws the knife.