Elements of Surgery

by Robert Liston

When healing by the first intention has failed, fomentation and poultices are generally the most grateful and beneficial applications for a day or two. Afterwards, when suppuration has been fairly established, and the stump begins to be flabby and œdematous, simple dressing and uniform support by bandaging are required, sometimes along with compresses on particular points to prevent lodgement of matter.

Sometimes the secondary hemorrhage is not an arterial and rapid flow, but a slow and continued oozing from a cavity, ulcerated, dark, and angry, round the end of the bone; this seems to arise from diseased action in the cancellated tissue of the bone. Removal of the coagula, stuffing the cavity with dry lint, and the application and continuance of firm pressure, generally suffice for its arrestment.

Hitherto, these general observations on amputation have regarded the operation by flaps only; the circular method has not been mentioned. The reason is, that the circular amputation has been, it is hoped, in a great measure abandoned in this country. And its inferiority to the method by flaps is so obvious, and so generally acknowledged, that detail of the different steps of the operation is, I conceive, here altogether unnecessary. It is more tedious in performance, more painful to the patient, does not afford so good a covering for the end of the bone, and consequently not so convenient and useful a support for an artificial limb, and the cure of the wound is protracted. The stump is almost always conical, the end of the bone is, ultimately at least, covered only by integument, and from even very slight pressure this is apt to ulcerate; exfoliation of the bone follows to a greater or less extent, or unhealthy nicer of the soft parts continues, along with caries of the bone, and partial death of its surface; and at length it becomes necessary either to perform a second amputation or to curtail the length of the bone. It may sometimes succeed tolerably well when there is but one bone: when there are two, it is altogether inadmissible. In very muscular limbs, when amputation is demanded on account of destruction of the bones and joints, with laceration of the soft parts, as when the patient is not required to have pressure made on the stump, it suits well to make the flaps of integument only, and to cut the muscles short, as will be noticed more fully afterwards. The advocates for the circular amputation, my excellent friend Sir George Ballingall, and others wish it to be believed, (and this is their main argument,) that the exposed surface of the flaps is much greater than that in their favourite method. Some of the philosophers of the Modern Athens have been appealed to, and have measured, it is said, the area of the one and the other, and given their verdict in favour of the round about incision. The accompanying drawings from nature, and the corresponding diagrams, speak pretty plainly in favour of the other method. In the first there is a cone formed by the cut skin and muscles, with a corresponding hollow and ragged cavity; and the second set shows two smooth, nearly triangular surfaces, which the said philosophers may measure and report upon at their leisure.

Various accidents and diseases require removal, either primary or secondary, of the fingers, or of parts of them. Amputation is most easily accomplished at the articulations, and ought therefore always to be performed at these points, when the circumstances of the case permit. The last phalanx may require removal either on account of severe injury, or from incurable disease, as onychia maligna, necrosis, caries, &c. The operation is one by single flap, and may be conducted in one of two ways. The doomed phalanx is grasped, on its anterior and posterior aspects, by the fore and middle fingers of the left hand; and the articulation is flexed almost to the full extent, in order that incision into it may be facilitated. A straight, narrow, and sharp-pointed bistoury is carried in a semicircular sweep over the back part of the joint, so as to divide the integuments, and open completely the articulating cavity. The remaining ligamentous investments of the joint are divided by one or more additional touches of the knife, so as to loosen the base of the phalanx. The fingers of the left hand are then changed from the fore and back parts of the phalanx to its sides, the edge of the knife is passed behind the base of the bone, and the surgeon, by carrying the blade forwards and downwards, forms a flap of sufficient dimensions to cover the wound, and removes the offending part. There is seldom any trouble from hemorrhage; no ligatures are required. The flap is turned up so as to form a cushion over the exposed surface of the middle phalanx, and is retained so by the adhesive composition formerly mentioned, or by one or two turns of a linen bandage. The other method of operation is the reverse of the preceding. The joint is extended, the bistoury is made to transfix close to the joint and at its anterior part, and by then carrying it downwards and forwards, as before, a similar flap is formed; this is retracted by an assistant, and with one sweep of the knife the articulation is divided from before backwards. By either method the flap is the same. By similar procedure the amputation at the middle articulation is performed.

It is sometimes an object to save as much as possible of the proximal phalanx, when amputation is rendered necessary by disease of the middle articulation, or of the distal extremity of the bone. In such cases, two semicircular flaps are made by cutting from without, either on the lateral, or on the thenal and anconal aspect, and the bone is divided either by a small saw or by the cutting pliers. The flaps are retained in apposition, and the bleeding arrested by bandaging.

Amputation at the proximal articulation is also performed by double flap. In the previous operations an assistant steadies and supports the hand; in this he has likewise to bend the rest of the fingers, and to separate as widely as possible those neighbouring to the one about to be removed. The operator seats himself before the patient, grasps the finger so as to manage its movements with the left hand, and holding the knife perpendicularly, with its point upwards, lays it over the knuckle, and carries it obliquely upwards so as to open that side of the articulation. He then pushes the finger towards the opposite side, and with the point of the knife completes the loosening of the articulation; for this the blade of the instrument should never be employed, otherwise the integument will be cross-cut and mangled. After separation of the base of the phalanx by the point, the blade is passed behind, and carrying it downwards and outwards, a flap is formed similar to the first—both proportioned to the size of the wound which they are to cover, and the bone which they are to protect. The fingers may also be removed by the oval method, as described and delineated in the Practical Surgery. The flaps are retained in contact by bringing the neighbouring fingers towards each other. This also suffices, in general, to suppress the bleeding, but sometimes one or both digital arteries require ligature. At first, cold cloths are probably the best applications, with the view of stopping the oozing, and warding off inflammatory action. Vascular excitement is very apt to follow this amputation, when performed for disease of the finger, as after neglected or severe whitlow; the soft parts in which the incisions are made are generally infiltrated and condensed, and prone to inflammation. The surface around is red, tense, and shining, on the second or third day; the back of the hand, the palm, and perhaps the forearm, are then involved in inflammation of the surface, and infiltration of the cellular tissue; and in all probability, free incisions, followed by poultice and fomentation, will be necessary to restore the parts to quietude. Such consequences are to be guarded against as much as possible, by attention to the system, and by avoiding all irritating dressing.

The phalanges of the thumb are removed in the same manner as those of the fingers. Amputation of the metacarpal bone is accomplished thus. The thumb is grasped by the fingers of the left hand, and so managed. The bistoury, held in the same manner as for amputation at the proximal articulation of the finger, is placed with its point on the web betwixt the thumb and forefinger, and carried in one sweep rapidly upwards in a slightly oblique direction, till it is stopped by the os trapezium. The point is used to effect disarticulation, the member being at the same time pushed steadily outwards; the blade is then placed behind the base, carried downwards close to the side of the bone, and is not to be brought out till sufficiently low down for forming a flap to cover the whole wound. The flaps may be formed otherwise, and much more handsomely, by transfixion of the ball of the thumb, as shown in the Practical Surgery, p. 360. After arresting the hemorrhage, the flap is laid smoothly down, and retained in its proper position by bandage or slips of the adhesive plaster. The metacarpal bone of the little finger is removed by the same method of incision as for the thumb.

In amputation of the fingers, the incisions sometimes require to extend beyond the proximal articulation, on account of disease having involved that part; in other words, it may be necessary to remove more or less of the metacarpal bone along with the finger. The method of incision will vary according to the extent to which the bone is diseased. When the operation is required for disease of merely the distal extremity, the incisions are made in the same form as for amputation of the joint, only they are on each side sufficiently high to be beyond diseased bone. They may either be made from below upwards in the usual way, or be commenced at their highest point on the dorsum of the metacarpal bone. After the soft parts have been separated from the bone, by a few touches of the knife after formation of the principal incisions, removal is completed either by the cutting pliers or the metacarpal bow-saw—the former I have found the more convenient instrument. It is applied perpendicularly, and should always have its smooth surface in contact with the part to be retained, otherwise the cut part will be rough and irregular. Section is completed more rapidly than by the saw, and, by attention to the above precaution, the stump is equally smooth, if not more so. The wound is brought and retained in contact by approximation of the fingers. But in taking away any considerable portion of the metacarpal bone, it is of importance to preserve the palm uninjured. With this view, the knife is entered over the centre of the bone on its dorsal aspect, above the diseased part, and carried straight downwards till near the articulation, when it is made to diverge for the formation of lateral flaps; the integuments in the track of the longitudinal wound are then dissected backwards, so as to expose the bone completely, and the bistoury is passed round the bone throughout its whole extent, the edge being kept close to it,—in order that the soft parts may be separated, and that without unnecessary width of wound or implication of the palmar arches and branches proceeding from them. Then the bone is clipped at the proper point by the cutting pliers; or the section of the bone may be performed before separation of the soft parts from its under surface, as, by raising the cut end, this part of the operation may be facilitated. Here the metacarpal saw is inapplicable.