Prosthesis

“ In the thin wasted wrists of the aged, or in any case where the skin is very lax, this amputation may be very easily performed by the circular method. While an assistant draws up the skin as much as possible, the surgeon makes an accurate circular incision through the skin, about an inch below the styloid processes, just grazing the thenar and hypothenar eminences. Another circular sweep just above the pisiform and unciform bones divides all the soft textures, after which the joint may be opened, and, if necessary, the styloid processes cut away with saw or pliers. ”

“ An assistant then holds it upwards, while the surgeon, or (if the arm is very muscular) another assistant, brings the arm forwards well across the patient's chest, thus exposing the posterior aspect of the joint. This may have very possibly been already opened during the transfixion; the attachments of muscles must now be divided, the knife passed behind the head of the bone, which is dislocated forwards, and a suitable flap of the tissues in front cut from within outwards. The assistant is to follow the knife with his finger and compress the vessels. ”

“ Syme, the fore-arm may be flexed, and the bones as easily displayed, cleaned, and removed, as in the operation for disease. In this operation, as there is less thickening of the skin and subjacent textures, and in consequence more risk of deficiency and even sloughing of the flaps made by the H-shaped incision, a single straight incision will serve the purpose admirably.
Partial incisions of the elbow-joint are, as a rule, less successful and more dangerous to life than complete ones, except in cases of excision for anchylosis. ”

“ Before the Ligature is drawn close with the Gripe-Stick, a little piece of Paste-board is to be put underneath, for fear of pinching the Skin. Thus the Leg being well fixt, the Surgeon placeth himself between both the Legs of the Patient, to make the Incision with a crooked Knife, turning it circularly to the Bone, and laying one Hand upon the Back of the Knife, which must have no Edge. Afterward the Periosteum is to be scrap'd with an Incision-Knife, and the Flesh with the Vessels that lie between the two Bones are to be cut. ”

“ The rule in surgery, to save as much of the body as possible in every amputation, was in the leg believed to be set aside by objections which militated strongly against all the{86} other operations in the leg except the one performed just below the knee. Very briefly, these were somewhat as follows:—1. Just above the ankle you have large bones with nothing to cover them except skin and tendons. 2. Higher up in the calf you have plenty of muscle, but it is all on one side, and that the wrong one ”

“ When the knife is held as directed there is not much danger of a slip except at the end of the incision when, the resistance being overcome, the knife goes through with a rush. To avoid this, pressure should always be slackened toward the end of the incision. The main incisions in the organs should be made with the brain-knife or short amputation knife, by a long, sweeping cut made from heel to toe of the knife-blade and beginning at the part of the organ farthest from the operator, drawing the blade through the organ toward the operator. ”

“ 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. ”

“ When, however, we reflect that in the living body, in cases where amputation at the shoulder-joint is required at all, the severity of the accident, or the urgency of the disease, will, in general, leave no room for selection, we shall see how utterly valueless is any knowledge of mere methods of operating, and of how much greater importance it is that we should be simply thoroughly familiar with the anatomy of the joint. ”

“ 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. ”

“ 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. ”

“ It is the joint that cannot be moved, not the muscle which has lost its power. I prefer, therefore, in doing this operation, in cases of some standing, to make a short crescentic flap by an incision across the anterior part of the shoulder, as in the operation of amputation, which, on being turned up, leaves the joint exposed. ”

“ Like amputation at the shoulder, amputation at the hip has given rise to very many various methods of performance. Under the heads of single flap, double flap, oval, circular, and mixed flap and circular, at least twenty distinct methods have been put on record, and, including modifications, there are thirty-seven or thirty-eight different surgeons who have each their own plan of operation. ”

“ For a leg hanging like a flail, or shortened by some inches, is not so good for purposes of locomotion as a wooden leg is, while an arm, even though powerless at the elbow, and perhaps much shortened, can be so strengthened and supported by slings and bandages as to give a most useful hand, the complex movements and uses of the fingers of which no mechanism can at all imitate. ”

“ The tongue, being confided to a special assistant, must be drawn well forwards. Various plans have been devised for keeping it in position, as stitching it to the point of the patient's nose; putting a ligature into its apex, and fastening it to the cheek by a piece of strapping, and transfixing its roots with a harelip needle, used to stitch up a central incision in the chin. ”

“ Treatment of Deformities resulting from Antecedent Diseases of the Knee.—Flexion is the commonest of these; when due to contracture of the soft parts, these are either stretched by degrees, the limb being encased in plaster after each sitting, or they are divided by open dissection in the popliteal space. If there is fibrous or osseous ankylosis, the choice lies between arthroplasty, the removal of a wedge of bone which includes the joint, or, in patients who are still growing, of a wedge from the femur above the level of the epiphysial cartilage. ”

“ Before I had taken many steps a young man in our class came up, took the pail from me, and in a soothing tone said, “Please let me—now the worst is over, Miss Arnold.” The tears started at his kindness. The other young men must have felt ashamed, for they soon rallied round the table, showing us how to make the first incisions, how to hold our scalpels and tissue forceps, in fact, giving us many useful hints. We had had the theory, but to make the actual incisions, to lift the skin and deftly dissect it from the tissues beneath—was different from what we had imagined. ”

“ The blades must be made fairly to grasp and contain the stone in their hollow, for if they only nibble at the end of an oval stone, extraction is impossible. Extraction should then be performed slowly, with alternate wrigglings of the forceps from side to side, so as gradually to dilate, not to tear, the prostate, and the operator must remember to pull in the axis of the pelvis, not against the os pubis or the promontory of the sacrum. ”

“ His method is now almost entirely used for covering large defects. The grafts can be applied over connective tissue, periosteum, bone, and even adipose tissue. The grafts consist of very thin strips of skin taken from the extensor surface of the arm or the anterior region of the thigh, after thorough antiseptic preparation. They should be taken from the patient in preference to those of other individuals or the new-dead or freshly amputated parts. ”

“ Being close to the joint, the muscles are cut through where they are tendinous, thus very much diminishing the risk of retraction and consequent protrusion of the bone. 4. A large broad surface of bone is left to bear the weight of the body, and one which, like the ankle-joint stump, will round off and{93} afford a comfortable pad over which the skin of the flap will freely play. ”

“ In dissecting the long flap from below upwards, the tissues of which it is composed must be separated close to the periosteum and interosseous membrane. The short flap is made by a transverse incision through all the structures down to the bones, care being taken to separate the parts upwards close to the periosteum and membrane." The stump must be placed in the prone position, "to allow the long dorsal flap to be the superior when the patient is recumbent, and thus fall over the ends of the bones." ”

“ When arthroplasty is impracticable, and a movable joint is desired--for example at the elbow--a considerable amount of bone, and it may be also of periosteum and capsular ligament, is resected to allow of the formation of a false joint. ”

“ After the incision we apply the instrument called hypospathister, and extend the division from the left temple to the middle incision, dividing all the intermediate substance along with the pericranium; then we push a spatula from the middle one to the rest, and applying the point of a sharp-pointed knife to the first division, so that its sharp side may be turned to the flesh within the skin, and the blunt one to the bone, we push it as far as the middle division, cutting through all the vessels which descend from the head to the eyes, but not comprehending the external skin. ”

“ In the course of many operations foreign substances are introduced into the tissues and intentionally left there, for example, suture and ligature materials, steel or aluminium plates, silver wire or ivory pegs used to secure the fixation of bones, or solid paraffin employed to correct deformities. Other substances, such as gauze, drainage tubes, or metal instruments, may be unintentionally left in a wound. ”

“ Great care is requisite to cut them at all equal, from the inequality of the muscles on the two sides. In the lower third we cannot obtain available muscular flaps. Lastly, care must be taken lest, from the ever-varying relations of the two bones to each other in the varying positions of the limb, the surgeon mistake their position and pass his knife between them. ”

“ Every practitioner seems to have his own notions on the subject, and to adopt such measures as whim, fancy, or caprice may dictate. Whatever apparatus be resorted to, the great caution to be observed, on the part of the surgeon, is, that the extension be made in a slow and gradual manner, that the skin be protected from friction and uneven pressure, and that the dressings be steadily retained during the night, as well as during the day, until several weeks after all deformity has disappeared. ”

“ The best incision is probably one which (Fig. xxvii. C) commences at the angle of the mouth opposite the healthy portion of jaw, extends down to the place at which the saw is to be applied and then along the base of the jaw past the middle line to the other point of section. The flap is to be thrown up and the bone cleared. The next point to be noticed is, that when, in clearing the bone behind, the muscles attached to the symphysis are divided, the tongue loses its support, and unless watched may tend to fall backwards, embarrassing respiration and even perhaps choking the patient. ”

“ But a man who has lost both legs and has been suitably equipped with artificial limbs can earn a fair wage, [158] whereas a man who has lost both arms is completely disabled so that he cannot even wash or dress himself. Among the amputation cases the difference is also considerable in the lower limb, between amputation through the leg and through the thigh, and even more in the upper limb, between an amputation retaining the movements of the elbow and one in which they are lost. There is, moreover, a great difference in the quality of stumps and the consequent utility of the artificial limb. ”

“ Having determined upon the method to be followed in securing the flap, the surgeon is advised to consider such apparatus as he may be able to procure to retain the parts, or to use his own ingenuity to construct one of plaster-of-Paris bandages to meet the requirements of the case at not only less expense, but with greater comfort to the patient. At best, any apparatus employed will do little to overcome the agony of the retained member, which must be held in position. ”

“ About this time he devised his apparatus for cleft palate, a jurymast for fractures of the maxilla and a clamp for the treatment of fractures of long bones (Annals of Surgery, May, 1898) . By the latter, a valuable apparatus, he is best known to the profession. ”

“ A socket, fitted to the stump and articulated with the last named at the elbow.
3. The terminal appliance, intended to replace as far as possible the amputated hand and, if possible, resembling it in appearance. In the case of the upper limb the advantages that wood possesses in giving strength and accuracy of fit do not apply, and the arm and the forearm pieces are made of leather, with lateral steels articulated at the elbow: this joint is active in the case of amputations of the forearm but purely passive in amputations of the arm. ”