Amputations are performed for (a) the results of injury, (b) the results of disease, and (c) removal of deformity or mutilation, or the possible results of congenital defects. While generally they are measures of necessity, made such by traumatism or by actively advancing disease, there are occasional instances where an individual decides that an artificial limb will be more useful or that he will be freed from an intolerable annoyance by the sacrifice. The principal diseases which may require such mutilation are the exceedingly acute, e. g., osteomyelitis, the slower destructive forms of ulcer, tuberculosis or of sepsis, the gangrene caused by vascular or diabetic conditions, or the slow involvement of tumors, usually malignant, but sometimes benign.
When a serious and mutilating injury has been received, if there have been complete crushing of a limb or avulsion, of course no doubt exists as to the necessity. Amputation is not now made for compound fractures nearly as often as in former times, for if only the vascular supply be good much may be done by resection of bone ends, wiring, or other expedients; and the attempt should always be made to save a limb unless it appear that even should the effort succeed the limb itself would be too useless to justify the attempt. With the possibilities of modern asepsis, and with immediate attention to the injury, the question of what should be done with an injured limb is largely a question of its blood supply. Extensive contusions with lacerations do not of themselves necessitate amputation, neither does injury to the skin unless it be most extensive.
It is unfortunate when vacillation or any misguided effort at conservatism call for great delay. While this may sometimes be advantageous, at other times the favorable moment has passed before permission to amputate may be obtained. Should delay seem advisable the surgeon should use his best endeavor to effect suitable antisepsis, to provide physiological rest, and to preserve the circulation, all of which require a thorough antiseptic technique, which will include the removal of blood clot, of fragments, and of all tissue which evidently cannot live, and suitable splinting or its equivalent, and of everything that can be done by local warmth and general stimulation to maintain the vigor of the circulation. When once infection has occurred, and especially been allowed to spread, the possibility of recovery inheres only in immediate amputation.
Such mutilations as necessitate immediate amputation are usually accompanied by profound degrees of shock, as well as perhaps by other complicating injuries, whose existence may change the whole complexion of the case. For example, with a patient suffering from probably fatal fracture of the skull one would hardly seriously discuss the matter of immediate amputation of a foot; nevertheless he should take such care of the local lower injury as to permit operation to be done under still favorable circumstances should the head condition justify it. Wide discretion is therefore called for in all these cases. Furthermore the condition of lowered blood pressure or shock may be so extreme that the operator is compelled to delay, for at least a certain time, in order that by the employment of those measures already considered in the chapter on this subject the circulation may be sufficiently restored to make it adequate for the purpose, remembering that scarcely anything predisposes to infection more than such lowered vitality. While resorting to general stimulation, hypodermoclysis, or infusion, with or without adrenalin, the use of such antiseptics should not be omitted, as the local condition may require in order to combat what otherwise may be actively occurring.
Amputations are sometimes referred to as typical, when done according to long-established methods, or atypical, when the entire procedure is planned to fit the necessities of the case. Amputation at a joint is usually spoken of as disarticulation. Amputations, again, are classified as (a) immediate, i. e., before complete reaction from shock or within the first few hours; (b) primary, when done after reaction has occurred, but before visible occurrence of inflammatory changes, (c) intermediate, as done when suppuration is threatening, but before its actual occurrence; (d) secondary, i. e., after the occurrence of suppuration.
The control of hemorrhage is one of the most conspicuous and necessary features of any amputation method. Below the shoulder and at the hip this may be effected by the old-fashioned tourniquet, or the modern elastic bandage, which may or may not be combined with the more complete bloodless method with which Esmarch’s name will always be connected. The pure rubber gum bandage, I believe, was introduced by Martin, of Boston, but the method of its use for bloodless operations upon the extremities is to be credited to Esmarch. The surgeon may avail himself of this method in all suitable cases, but should never resort to it in septic or malignant disease. It includes the application of a Martin elastic bandage from the tip of the extremity to the necessary height, by turns which shall make gentle and equable pressure, gradually forcing the blood from the compressed tissues and out of the limb, and up to a height where another elastic, or, at all events, suitable constricting band is placed with a sufficient degree of tightness to completely shut off access of blood. To so apply a bandage in septic and malignant cases would be to coax septic and malignant material into the veins, and would evince the worst possible judgment. A sufficiently strong rubber tubing forms an effective tourniquet, which, however, should be applied over a folded towel, or in some manner so that it does not too deeply constrict and compress the soft tissues of the limb. Instead of tying a knot it may be secured with an ordinary clamp forceps.
The tourniquet should never be applied over the leg or forearm, for it can here make no impression upon the interosseous vessels. Its application should be begun by pressure upon the vascular, i. e., the adductor side of the limb, so that venous choking may be avoided. After it is once in place the limb should not be completely flexed nor extended, lest the tissues firmly enclosed by the constriction be more or less spontaneously torn; nor should the tourniquet be too long left in place, as injury to the vessels is the possible result.
The bloodless method of Esmarch is furthermore subject to the following disadvantages. It is sometimes followed by serious and permanent paralysis of the limb, the result of prolonged or excessive constriction and compression of the motor nerve trunks. Similar results (in the arms) follow the use of crutches as well as of pressure of the side of the operating table when the limbs are allowed to hang over it. Again after removal of the bandage there is sometimes most pronounced capillary oozing due to vasomotor paresis. This may be controlled by the stimulation of hot irrigation or applications, and by more or less massage of the limb. The dangers of forcing undesirable material into the circulation have been mentioned, in addition to which should be recorded the increased absorption of toxic substances.
When there is good reason for not using the elastic bandage, save as a tourniquet, much of the desired effect may be obtained by holding the limb for a few minutes in a vertical position, so that its contained blood is drained out of it by gravity, after which the tourniquet may be applied as before.
The cocainization of nerve trunks, as they are exposed and divided, is one of the new measures for the prevention of shock for which we are largely indebted to Crile. It has proved to be a most valuable expedient which should not be neglected. (See [Chapter XVIII].)