Amputation

“ When it is evident, from the extent, violence, and nature of the injury, that there is danger of speedy mortification, or of extensive and severe inflammation and suppuration, amputation is to be instantly performed,—delay is inadmissible. ”

“ Amputations are always necessarily{114} nearer the centre than the corresponding excisions, and statistics show that the fatality of operations increases in exact proportion as they approach the centre.
A successful excision, especially in arm, saves a limb nearly perfect; an amputation at best is only the stump for a wooden one. ”

“ Broadly, it may be laid down that very extensive injury to the soft parts is the only indication for primary amputation beyond primary hæmorrhage, and it may be added that the condition is rare with wounds from small-calibre bullets. If a primary amputation is necessary the observations as to the transport of fractured thighs are equally applicable. ”

“ In severe injuries of the limbs, the surgeon must be guided by the state of the part, and of the constitution, by the circumstances in which he is placed, as to accommodation, and mode of transportation, &c., in deciding on the removal of the part by amputation,—or on making an attempt to save it, by trusting to, and assisting, the processes of nature. The question whether to amputate immediately, and on the spot, merely allowing the shock, if any exist, to pass away, or to delay till suppuration occur, is now scarcely a matter of dispute. ”

“ In amputation of the thigh, the same method of incision is followed as in amputation of the arm. But, according to the point of removal, the direction of the flaps varies. If in operating high in the limb the flaps be made laterally, there will be imminent risk of the bone protruding through the upper part of the wound; for the patient uniformly raises the stump towards his abdomen. No antagonist muscular power is left to oppose the action of the muscles inserted into the trochanter minor, and the elevation of the stump is involuntary: it always occurs to a remarkable extent in young persons. ”

“ Amputation in the sound parts cannot be recommended: for vitality is impaired throughout the system, and more particularly near and above the line of demarcation,49 where, though the structure seems entire, yet the incisions are made in parts really diseased, and which would almost certainly and speedily mortify. In fact, amputation above the line of separation, in whatever way performed, is seldom if ever productive of advantage in spontaneous gangrene. ”

“ In cases of traumatic gangrene of the chronic form, amputation is not only justifiable, but imperative; as also in those cases of severe fracture in which the patient is sinking under profuse discharge, with disunited bones. And the same absolute necessity for operation exists in many diseased joints, and in some diseased bones, when the patient’s safety would otherwise be endangered, or when, on mature consideration, it is evident that the member, if retained, must for ever be an encumbrance, and worse than useless. ”

“ In ordinary surgical language the name Amputation is applied to all cases of removal of limbs, or portions of limbs, by the knife, though in strict accuracy it should be restricted to those cases in which a limb is removed in the continuity of a bone, its removal at a joint being called a Disarticulation. ”

“ In a lacerated wound of the foot, if death occurs from tetanus, it may be claimed that death would not have occurred if the foot had been amputated, or, if the foot were amputated and death followed, it may be claimed that amputation was unnecessary and was the cause of death. The surgeon should, therefore, be able to give the best reasons for every step of treatment. ”

“ In the manner in which amputation is performed at present, not more than one person in twenty loses his life in consequence of the operation, even taking into the account all the cases in which it is practised in hospitals. In private practice, where many circumstances favour its success, it is computed that 95 persons out of 100 recover from it, when it is performed at a proper time, and in a proper manner. ”

“ When the charge impinges on one of the extremities at close range, we often have the opportunity of observing that the exit wound is larger, more ragged than that of entrance, and that its edges are everted; the extensive tearing and bruising of all the tissues, including the bones, and the marked tendency to early and progressive septic infection, render amputation compulsory in the majority of such cases. ”

“ 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 ”

“ At the post-mortem examination, the right shoulder and ankle joints were found to be filled with pus. The operation in this instance was performed three weeks after the injury. No case of amputation, nor of resection, at the hip-joint has returned from the Indian mutiny. M. Legouest, in a recent essay in the Memoirs of the Society of Surgery, at Paris, maintains that amputation at the hip-joint should be reserved for cases of fracture with injury to the great vessels, and that where the vessels have escaped, resection should invariably be performed. ”

“ But I only remember three—I have always testified that—with all the things that have happened in the meantime and all the patients I have taken care of. It was not that Fischer or I overlooked an amputation, and it is certainly not true that an amputation can save the life of the patient in all cases of gangrene. As I remember the case histories, the most serious patient had a large abscess on the hip. Probably the corresponding glands had been affected. The infection on the calf and the abscess on the hip—what can I amputate? One can amputate when the infection is limited to the calf. ”

“ Until the last three or four hundred years, amputation of a limb was very rarely performed, except when, from injury or disease, its extremity had begun to mortify; and then, few surgeons ventured to make incisions in the sound portion, but limited themselves to an operation through the tissues which had already lost their vitality. This timidity was due to the fact that they were unacquainted with any effectual means of stopping the bleeding from the larger arteries divided by the knife. ”

“ In the first class of patients immediate amputation may be had recourse to with safety and advantage. In the second, the patient must be reassured, and stimulated both by external and internal means; in short, reaction must be brought about, and then let the surgeon operate. If he amputate before this, his patient will most probably die on the table, or very soon after his removal from it; reaction will never take place, and sinking of the vital powers be accelerated by the ill judged interference. ”

“ The amputation should be performed in the dead parts, just below the line of separation, in the most cautious and gentle manner possible, the mortified parts which remain being allowed to separate by the efforts of nature. ”

“ This case does not quite meet my proposition as to the effect of chloroform when the thigh has been carried off nearer the hip-joint, with rupture of the principal artery; cases which have hitherto been usually lost, whether amputation is performed or not.
50. While some persons, under the loss of a thigh high up, are reduced to a state of syncope, or nearly approaching to it, which renders them almost or even entirely speechless, others are said to suffer extreme pain, and earnestly entreat assistance, under which circumstances amputation should be performed forthwith. ”

“ But it is obvious that none of these expedients can be employed, and that these bleedings can neither be checked at the moment, nor permanently stopped, without such a knowledge of the course of the trunks and branches of vessels, as can be acquired only by the study of anatomy.
The success of amputation is closely connected with the knowledge of the means of stopping hemorrhage. Not to amputate, is often to abandon the patient to a certain and miserable death. And all that the surgeon formerly did, was to watch the progress of that death: he had no power to stop or even to retard it. ”

“ Patients are sometimes anxious for such operations in preference to amputation of the whole finger. The surgeon should, however, never amputate through a finger higher up than the distal end of the second phalanx, unless absolutely compelled by the patient, for the resulting stump, being no longer commanded by the tendons, will prove merely an incumbrance, and may possibly require a secondary operation at no distant date for its removal. ”

“ Amputation of the Penis.—This exceedingly simple operation is performed by a single stroke of an amputating knife, drawn along from heel to point, while the penis is stretched in the operator's left hand. As there is more risk of redundancy than of deficiency of the skin, no attempt is made to save it. Numerous vessels in the corpora cavernosa require ligature. Amputation of the penis may be done bloodlessly by the thermo-cautery even close to its root. Transfix the root of corpora cavernosa by a needle ”

“ Bone-setters ought carefully to examine whether the bone be not shattered or broken into several pieces. In this case it will sometimes be necessary to have the limb immediately taken off, otherwise a gangrene or mortification may ensue. The horror which attends the very idea of an amputation often occasions its being delayed in such cases till too late. ”

“ When from some cause or other amputation has not been performed, and the mortification has stopped below the knee, it is recommended to amputate above the knee after a line of separation has formed between the dead and the living parts. ”

“ If the injury accompanying the luxation be so extensive, as to destroy the principal blood-vessels, and leave no hope of saving the limb, amputation becomes then the only resource, and the case assumes a resemblance to those where the limbs are shattered by cannon balls: the success then depends very much on the strength or weakness of the patient. ”

“ Stripping of large areas of skin is not in itself a reason for removing a limb, as much can be done by skin grafting, but when it is associated with other lesions it favours amputation. In considering these points, it must be borne in mind that the damage to the deeper tissues is always more extensive than appears on the surface, and that in many cases it is only possible to estimate the real extent of the injury by administering an anæsthetic and exploring the wound. ”

“ That the patella and articular surface of the femur are healthy. These conditions at once exclude nearly every case of disease or accident. If the joint is diseased some amputation through the thigh must be attempted; if injured, and the front of the knee is safe, it may very likely be possible to amputate below the knee. Hence this operation may be useful in cases where, for malignant disease, the whole tibia requires removal, and yet the knee-joint is sound, or for gunshot injuries, in which the tibia is splintered but the soft tissues comparatively uninjured. ”

“ Remembering these points, we find that certain things require our attention, and certain difficulties are present in amputation of the fore-arm, from which amputation of the arm, with its single bone and copious muscular covering on all sides, is completely free. ”

“ After the amputation, of a foot or a finger, it has frequently happened, that an injury being offered to the stump of the amputated limb, whether from cold air, too great pressure, or other accidents, the patient has complained, of a sensation of pain in the foot or finger, that was cut off. ”

“ The Leg is usually cut off at the Ham; the Thigh as near as can be to the Knee; and the Arm as near as is possible to the Wrist: But an Amputation is never made in a Joynt, except in the Fingers and Toes.
In order to cut off a Leg, the Patient is to be set on the side of his Bed, or in a Chair, and supported by divers Assistants; one of 'em being employ'd to hold the Leg at the bottom, and another to draw the Skin upward above the Knee, to the end that the Flesh may cover the Bone again after the Operation. ”

“ The splinters of bone are to be removed, the ball and extraneous [113] substances are, if possible, to be taken out; and if the bones, tendons, and blood-vessels are so much injured as to render the attempt to preserve them useless, amputation is to be performed. If the preservation of the limb be thought practicable—and it generally will be so in wounds from musket-balls—the attempt must be made under the most rigid antiphlogistic treatment, the local application of leeches and cold water from the first, with free openings for the subsequent discharge. ”

“ This operation is very frequently required to remedy painful and unhealed stumps, the result of amputations lower down, specially those in which the long posterior flap from the muscles of the calf has been used. In the above amputation the patient will not be able to rest the weight of his body on the face of the stump, but by putting the limb into a well-padded case with soft{91} rounded edges, the weight might be borne partly on the sides of the stump, and partly on the lower edge of the patella; and the patient will be able to walk with great comfort, preserving the use of his knee-joint. ”