Under modern methods more is expected of an amputation stump than in days gone by, and the first demand is that it shall be useful, to which end it is necessary that it be both movable and that its end be not too irritable, nor the scar too sensitive to stand at least a certain amount of pressure. It is expected that suitable prosthetic apparatus, i. e. artificial limbs, shall take the place of severed lower extremities and of most arms or hands removed. The skill and the mechanical ingenuity of the maker of artificial limbs have now reached a point where most acceptable substitutes are thus provided, but for them suitable stumps should be afforded by the surgeon, and there should be coöperation from each direction. Thus it used to be held that the bone end in every stump should be covered with periosteum, yet it has been recently shown, especially by Hirsch, that such bone ends are as acceptable, and perhaps more so, when stripped of rather than covered with this membrane, the latter being sensitive, and there being no advantage in the presence of such new bone as may be formed by its preservation.
Many a good stump may be molded in various ways, but always provided that the end of the bone be smoothly divided, and have no corners or osteophytic outgrowths to make pressure upon the sensitive scar. For this reason it should be manipulated as early as possible, and should not be allowed to undergo the atrophy noticeable in stumps left after old operations. If primary union be gained, so long as the cicatrix and the nerve ends be kept out of the way, one may expect a stump which is serviceable in every respect. The ideal method is that the skin and the periosteum should retain their normal relationship, an ideal best attained in the supracondyloid operation after Gritti’s method. Various osteoplastic methods have been devised, first by Walther, in 1813, and since him especially by Ollier, Pirogoff, Gritti, and Bier. The latter would cover every bone end not merely with periosteum, but with a bone flap so arranged that its lower surface is one normally covered by periosteum. The introduction of the x-rays has permitted a more thorough study of bone ends in stumps which are, on one hand, extremely tender, or, on the other, extremely serviceable, and the osteoplastic methods seem to conduce to the latter condition. Another matter of great importance is to so place the scar that it shall be neither subject to pressure nor to traction. If, therefore, the sawed surfaces be covered with a periosteum which shall retain its normal relation to its coverings, a minimum of disturbance in the scar is the result.
The value of early use of the stump and of accustoming it to pressure is considerable, as atrophic stumps are tender, like other disused parts, and there is, therefore, every reason for resorting to prosthetic apparatus as early as possible. As Kocher puts it, the following is the best procedure for the normal operation: “An oblique incision, combined if necessary with a longitudinal one, in the form of a racket or lanceolate incision through skin and fascia. After retracting the elastic skin the muscles are divided obliquely down to the bone. The periosteum is also to be divided obliquely. Periosteum is then separated along with the superficial layer of the cortex of the bone, by means of a sharp raspatory or chisel, or, when possible, a flap of bone having a movable periosteal hinge is made by means of the saw. Lastly, if only a thin shell of the cortex have been raised up along with the periosteum, the end of the bone is simply rounded off, while if a distinct flap of bone, by any osteoplastic method, have been divided, the end of the bone must be sawed in a curved direction so as to fit it. The periosteal or bony flap is sutured over the sawed surface of the bone to its periosteum, and the stumps of the muscles or tendons are sutured to each other, or to the surface of the bone at a distance from the sawed surface. Finally the skin and fascia are sutured; but in case where a periosteal flap or flap of bone and periosteum cannot be obtained in normal relation to other soft parts it is better to remove the periosteum entirely from the end of the stump, to scrape out the medullary cavity, and to round off edges of the bone as dentists do.”
While these methods give better results than those formerly in vogue, they also consume more time; but the days of brilliancy and rapidity in amputation are past, as time should be devoted to careful work, except only in those cases where emergency demands the most rapid and dexterous removal of a limb in the shortest possible time, and where every other consideration is sacrificed to the principal interest of preserving life.[75]
[75] The following is taken from the article of Professor Matas in the third edition of “Surgery by American Authors.” It furnishes a brief but admirable introduction to the general study of amputation methods:
“From Hippocrates to the time of Celsus the surgeon simply followed in the wake of Nature, never venturing to apply the knife for the removal of a limb except within the limits of the mortified tissues; and this seems to have prevailed for at least four hundred years. Celsus, the prince of Roman physicians, who lived shortly after the time of Christ, introduced the first innovation by cutting down to the bone between the living and the dead tissues. It is probable, according to the evidence furnished by his writings, that he was aware of the value of the ligature and that he applied it to control bleeding vessels. Archigenes, following closely after Celsus, was the first to attempt prophylactic hemostasis by applying a cord or band around the limb to control the hemorrhage during the amputation. With the fall of the Roman empire and the advent of the long night of the middle ages the Celsian method was lost in the general darkness and the old Hippocratic doctrines survived, and were maintained by the all-potent influence of Galen and his Arabian commentators. As late as the middle of the seventeenth century the only hemostatic was the actual cautery and boiling oil, though Guy de Chauliac had revived the teaching of Archigenes by constricting the limb, on a level with a joint, with a cord which was allowed to remain in situ, to ensure not only hemostasis, but a certain mortification of the stump. In cutting limbs huge chisels and mallets were used. At this period Botalli invented his guillotine, consisting of a sharp, heavy, axe, which, being allowed to fall from a height upon the limb, severed it instantaneously at a single blow. The revived or independent rediscovery of the ligature by Ambrose Paré in 1579, and the discovery of the circulation of the blood by Harvey, in 1628, led to the invention of Morel’s tourniquet (1674), more commonly known as the Spanish windlass, and to the familiar instrument, Pettit’s tourniquet, which (introduced in 1718) perfected the means of securing prophylactic and direct hemostasis. From this time onward the treatment of the stump began to receive more systematic attention. Instead of merely chopping off a limb, the soft parts were detached from the bone, so that this could be sawed off at a higher level, in order to avoid the conical projection of the stump which invariably resulted when the primitive methods were adopted. All the methods of amputation that followed—and these were numerous—aimed chiefly at celerity, to reduce the pain of the operation to a minimum; hence the rapid, circular section of the soft parts or the rapid transfixion methods which were so much popularized by the brilliant work of Liston, Lisfranc, Desault, Dupuytren, Langenbeck, and others. These finally yielded, in this modern period, to less rapid but more conservative and perfected methods, which aim chiefly at the preservation of useful tissue and at securing the very best functional prosthetic stump for the patient. Such methods could only be perfected after the advent of anesthesia and antisepsis.”
AMPUTATION METHODS.
With a view to simplifying this subject as much as possible the following methods alone will be considered: (1) The circular with its modifications, the oblique, the elliptical, the ovoid, etc.; (2) the flap method; (3) the mixed or skin flap and deep circular.
Choice of method sometimes leaves much, sometimes nothing, to the tastes or wishes of the operator. It should be based solely on the primary consideration of saving life and the secondary consideration of furnishing the most useful possible stump. To obtain the latter it is necessary that the bone be amply covered, except that its coverings be not adherent, that there be a minimum of disturbance of blood supply, that nerves be drawn down and divided as far from the stump end as possible, in order that they may not be entangled in the scar, and that the scar be so planned for and arranged that it shall be at one side, at all events in such position that no pressure shall be made upon it, and, if possible, also no tension by muscle action.
Elasticity of skin and contractility of the muscles vary much in different individuals, and it is not always easy to estimate either of them previous to their division. Consequently it is much better to make cuffs or flaps too long at first rather than too short. The existence of previous disease will always modify these local conditions, but, in general, the rule is laid down that the external flaps should be longer than the bone by from one-third to one-half the diameter of the limb.