Elements of Surgery

by Robert Liston

Before quitting this part of the amputations, it may be observed, that no good can result from taking away a metacarpal bone and leaving a finger, or from removing a proximal phalanx and leaving the distal. The parts so left can be of no use, they have no support, and the muscles cannot act upon them: they must prove an incumbrance, and as such will either form the subject of a second amputation, or remain a proof of the unsuccessful result of the first.

Amputation in the forearm, may be necessary at various points, on account of accident or disease, but should never be resorted to, in either case, so long as part of the hand can be saved. The preservation of even a small portion of this useful member, even of one finger or a part of one, is of great importance to the patient. When, however, this is hopeless, all must be removed; and, if the wrist be sound, amputation may be performed at that joint. Hitherto, no mention has been made of the temporary suppression of bleeding, for in the amputations detailed there is scarcely ever any necessity for adopting such measures; but in those of the forearm and arm, a steady assistant must be placed ready to compress the humeral artery as soon as the incisions are commenced; in the case of the forearm, the pressure is made on the lower portion of the artery; in the arm, the point of pressure will necessarily depend on the point of removal. The patient may be either seated or recumbent. One assistant compresses, another steadies the limb in the supine position. The surgeon holds the hand in his left, standing on the inside of the right limb, and on the outside of the left. Suppose the right wrist is to be operated on,—the end of the ulna is felt for, and at that point the knife is entered, and drawn across the wrist on its dorsal aspect in a semilunar direction, the convexity of the curve of course pointing towards the fingers. The joint is opened by retracting and dissecting back the flap so formed; the knife is then passed behind the scaphoid and lunar bones, which are exposed and turned out by division of the ligaments, and by rapid and gentle sawing motion downwards and forwards, a flap of sufficient size is then formed on the palmar aspect. The dorsum of the hand may be so diseased or injured as not to afford sufficiency of sound parts for a posterior flap; in such circumstances the anterior must be made proportionally large, that it may alone cover the ends of the bones. After suppression of the bleeding, the flaps are approximated by one or two points of suture; these are afterwards removed, and their place supplied by the adhesive plaster.

Amputation, at any point between the wrist and elbow-joints, requires, in all, the same method of incision, but the nearer to the elbow the better is the stump; at the wrist the flaps are composed principally of integuments and tendons, and the cushion so formed for the bones is very inferior to one of muscle. Compression is made and the limb steadied as before; the surgeon with his left hand grasps the wrist, and places the forearm in the middle state between pronation and supination. In the right forearm, the knife, held perpendicularly, is entered over the centre of the radius, and its point, after reaching the bone, is inclined inwards so as to pass round it; transfixion is then made, the knife passing close to the palmar surface of the bones, and emerging at a point opposite to its entrance; and then by rapid motion downwards and inwards, a proper flap is formed. The instrument is again introduced over the radius, at a little distance from the upper part of the first wound, and passed on the opposite side of the bones, emerging also in the first incision and at a similar point; another flap is made. These are retracted, the knife is swept round the bones, and passed freely between them, to divide the remaining muscular substance, and after this has been completed, the saw is applied. During the sawing it is well to preserve the limb in the same position as during the incisions, and to apply the instrument perpendicularly; thus both bones will be divided at once, and the risk of splintering diminished. In transfixion, great care is required that the point of the knife pass across, not between, the bones, and with this view a slight change of position is useful; during the transfixion for the inner flap, the surgeon, as soon as he feels the knife rounding the radius, rotates the forearm gently inwards, and in transfixing for the outer flap similar rotation is made outwards. In this situation, and others where the soft parts are less thick in one aspect than the other, it is by much a preferable plan to make a flap first, by cutting from without inwards, as already described in regard to the wrist, and then to transfix for the formation of the second flap. This is delineated in the Practical Surgery, p. 367. Sometimes slight difficulty is experienced in tying the interosseal artery. The flaps are brought together, and treated in the way already mentioned.

In all amputations of the upper extremity, it is of importance, and indeed a rule scarcely to be departed from, to leave as much of the limb as possible; for here the longer the stump, the more useful is it to the patient. In accordance with this maxim, amputation at the elbow-joint may be required, when either disease or injury extends too high for amputation in the forearm, but not too high for the formation of an anterior flap over the joint. The limb is steadied in the supine position, compression being made near the middle of the humeral artery; the knife is passed horizontally across the condyles close to the bone, and brought downwards and forwards to a sufficient extent for the production of a flap, which is alone to form the protecting cushion. The joint is then cut through, the knife is passed down till obstructed by the olecranon, and with one sweep a semicircular incision of the posterior integument is made. All soft parts in this line are divided, and then the saw is applied to the olecranon process. This amputation is easy, rapid, and beautiful in execution; and, when the flap is sufficiently large,—as it always may be, for there is no want of soft parts in front,—the stump is well formed and useful. The flap is laid down, and attached by suture to the integument posteriorly; in due time the adhesive dressing is applied. The circumstance of a secreting surface forming the stump does not seem detrimental, either here, or in the wrist-joint. The synovial fluid soon ceases to distil, and union is not interrupted by it. There is no necessity for scarification, or scraping the cartilage, with the view of hastening cessation of secretion and granulation of the surface.

Amputation of the arm is performed by the formation of lateral flaps, at any point below the insertion of the deltoid muscle. Compression is made on the upper part of the humeral, or on the axillary artery. The limb is held well separated from the side; and care should be taken that, when so raised, its height be convenient to the operator. The knife is entered perpendicularly to the shaft of the bone, passed fairly down to it, and then inclined along its side; the operator now grasps the limb below the line of incision with the left hand, and pulls the muscles towards him—it is supposed that the right arm is being amputated, the surgeon standing on the inside, and an assistant supporting the forearm—and then completes transfixion, inclining the handle of the knife towards himself, in order that its point may pass round the bone and emerge at as distant a point in the circumference of the limb as possible. By a rapid sawing motion, downwards and inwards to the proper extent, the inner flap is formed; and by attention to the grasping of the muscles and the inclination of the knife, its base is so large as to admit of the more easy performance of accurate transfixion for the outer—that is, the instrument is more easily brought through the same incision. The assistant seizes the extremity of the inner flap as soon as formed, and retracts it, but only to a slight extent; it is simply held out of the way. If it be pulled backwards, as in retraction during sawing, the formation of the second will be much impeded. The knife is again entered about half an inch below the commencement of the first incision, and by inclining the handle the point is brought round the bone, and made to appear on the opposite side also in the first incision; this is facilitated by pulling the soft parts outwards with the left hand. Then the outer flap is completed. The knife is swept rapidly round the bone, so as to expose it completely at the upper part, the assistant at the same time retracting the flaps fully. The saw is applied, the arteries tied, the flaps approximated, and the operation completed.

In performing the second transfixion, the reason why the knife is entered lower than in the first, is, that cross-cutting of the corners of the wound is thereby avoided. For a long time I was surprised and annoyed to find many stumps present an unseemly cross-cutting of the integument at the upper parts, particularly after approximation of the flaps, although the incisions seemed to have been made smoothly and accurately. It is occasioned by the sawing process for making the second flap, and when this is commenced at the same height as for the first, irregularity of incision at the upper part is unavoidable. The precaution, however, of making the second transfixion considerably lower than the first I have found quite effectual. The disparity between the bases of the flaps is readily and quickly remedied, after their formation, by a sweep of the knife upwards on the lower side.

Irritable and painful stumps are more frequently met with after the amputations of the arm and forearm than any other. The occurrence, however, is less common than formerly, and this may be fairly attributed to the improvements in the operation—to the method by flaps having superseded the circular, and nothing but the arteries being surrounded in ligature. Still the affection is occasionally met with, and there can be none more painful and troublesome. Generally, no obvious cause can be found for the attack of this malady; but in some of the cases there would seem to be a constitutional and innate tendency, as it were, towards this irritability of the cut and bulbous extremities of the nerves—as in the following case:—A gentleman, aged 53, underwent amputation of the thumb, in consequence of laceration of the hand. Amputation was very soon afterwards performed at the middle of the forearm, on account of hemorrhage and infiltration of the hand, after fruitless attempts to secure the arteries. After cicatrisation of the wound, he complained of great pain in the stump, and in the situation where the tourniquet had been applied. Amputation of the arm was then performed, but the stump was not well made. The pain returned, and he applied to me, with the view of again submitting to amputation. It was performed nearer to the shoulder-joint, and in order to guard against recurrence of the disease, the nerves were laid hold of, pulled outwards, and cut across as high as possible. The patient was relieved of many of his sufferings, and continued tolerably comfortable for nearly two years; again, however, the painful symptoms have returned, though in a slighter degree. On examining the removed stump, all the nerves, particularly the musculo-spiral, were found greatly enlarged in their extremities, and intimately adherent to the cicatrix and the ligamentous covering of the rounded extremity of the humerus. More desperate operations have even been performed to free patients from irritable stump. The lower limb has been hacked off bit by bit, even to the coxo-femoral articulation, without much, if any, relief. Such operations are hardly warrantable.

Amputation at the shoulder-joint is more frequently required for accident than for disease. It has always been the custom to trust for suppression of bleeding, during this operation, to the hands of an assistant; and when the method has been found effectual in the case of the large axillary artery, why should it be objected to, on the score of inefficiency, in the minor amputations? particularly when it is evident, putting efficiency out of the question, that it is preferable to compression by the tourniquet, or any other circular apparatus;—more quickly applied and relaxed; less painful, less formidable; always ready, and independent of the instrument-maker. The compression is made above the clavicle, so as to secure the subclavian, where it passes over the first rib. The thumb of a steady assistant is placed deeply into the cavity of the lower triangular space of the neck, immediately above the first large sinuosity of the clavicle. The pressure thus made is quite effectual; but as it requires to be firm and uniform, and as there is always a risk of the thumb giving way from exhaustion, it is better to interpose some mechanical contrivance when the assistant is either diffident or inexperienced. The best apparatus for this purpose is a common door-key. A bit of lint or cloth is wrapped round the handle, and this part is then pressed down on the vessel. As in other amputations, the pressure is not commenced till the knife is about to enter.

The flaps may be double, on the outer and inner aspects, or one may be made sufficiently large to cover the whole wound. The patient is seated on a chair, and secured by a person placed behind. The arm is raised a little from the side, and supported by an assistant. Two oblique incisions are made, commencing high on each side of the shoulder, and converging gradually till they meet near the insertion of the deltoid. The triangular flap, so marked out, is dissected rapidly upwards, close to the bone, and kept raised by an assistant. The person supporting the arm then uses it as a lever, carrying it downwards and backwards; the joint, thus made more palpable, is cut into by a semicircular sweep of the knife across it; the head of the bone is now dislocated, and the rest of the capsule and fibrous tissue exterior to it divided; the blade of the knife is insinuated behind the head of the bone, and carried rapidly through the remaining soft parts. In no amputation can I conceive any necessity for suspending the incisions, in order to secure vessels, provided the pressure is well applied, and the knife used dexterously. Here very little blood should be lost. The vessels divided in the formation of the flap are small, and the axillary is not cut till the incisions are nearly completed; as soon as the limb has dropped, the surgeon places his finger on the mouth of the artery, and then applies his ligature as quickly as possible; the pressure may now be removed, and the minor vessels secured leisurely. The flap covers the wound completely, and is easily retained.

Or two flaps may be made by transfixion. In operating thus on the right limb, the surgeon, standing in front of the patient, enters the knife a little below the point of the acromion, passes it across the outer aspect of the joint, and by inclination of the handle outwards, makes its point to appear on the inside of the outer margin of the axilla; by carrying it downwards and outwards to a sufficient extent, the outer flap is formed. This is immediately elevated by an assistant, and then the arm is pushed upwards, and across the chest, so as to render the joint more accessible; the ligaments are cut, the bone disarticulated, the knife passed beyond its head, and placed with the edge parallel to the shaft of the humerus, and the arm restored to its former position; the inner flap is then made by carrying the instrument downwards and inwards. In the left limb, the knife is entered on the inside of the outer border of the axilla, and brought out below and in front of the extremity of the acromion, reversing the order of the former incisions; after the outer flap has been so formed, the joint is cut across, the knife passed beyond the head of the bone, and the inner flap made as before.