Chapter II: Amputations (2)

"The patient could walk with firmness and ease; she was in no danger of hurting the cicatrix by striking the place where the toes had been against any hard substance, for this part was covered with the strong integuments which had before constituted the sole of the foot. The cicatrix was situated upon the upper part of the foot, and had very little breadth, as the divided parts had been kept united after being brought into close contact."[36]

_Lisfranc's method_ has, briefly, the following modifications.--Having fixed the position of the articulations of the first and fifth metatarsals with the tarsus, the operator unites them by a curved incision across the dorsum of the foot, with its convexity downwards. He then divides the dorsal ligaments over the articulations, opens the first from the inside, the fifth, fourth, and third from the outside, he then with a strong narrow-bladed knife divides the interosseous ligaments between the sides and end of the head of the second metatarsal and the cuneiforms, thus completing the disarticulation; bending the fore part of the foot downwards, he then keeps the edge of the knife close to the lower surface of the bones, separating the plantar ligaments, and cutting out a long plantar flap of skin and muscles.

In every case it must be remembered that the upper end of the fifth metatarsal projects far up along the outer edge of the foot. Allowance must be made for this projection in commencing the incision. A rule given by Mr. Syme to guide the disarticulation of the three outer metatarsals will often be of service; it is this: "Having once entered the joint of the fifth, the knife must be drawn along in a direction of a line drawn towards the distal end of the first metatarsal; for the fourth, the direction must be changed to the middle of the same bone; and to open the third it will be necessary to come across the dorsum of the foot as if intending to reach the proximal end."

To avoid the difficulties of disarticulation, Skey recommends cutting off the head of the second metatarsal with a pair of pliers. Baudens, Guérin, and others approve of sawing all the bones across in the line desired.

Most surgeons are now agreed that in this operation it is better to make both flaps by cutting from without, in preference to transfixion of the plantar one from within. In cases where, from injury and disease, the plantar flap is deficient in size, it may be necessary to make the dorsal flap longer. However, the long plantar is preferable both from its superior hardness, and also because from its length it permits the cicatrix to be well on the dorsum of the foot, and therefore less likely to be injured by the pressure of the boot in front.

AMPUTATIONS THROUGH THE TARSUS.--Various plans of amputating through the tarsus have been devised and described at great length. The most important of these is the operation of removal of the anterior portion of the foot, at the joints between the astragalus and scaphoid, and os calcis and cuboid, well known to the profession by the name of its first describer, Chopart.

It has been so completely superseded by the infinitely preferable amputation at the ankle-joint of Mr. Syme, as rarely, if ever, to be practised in this country. Indeed, amputation at the ankle-joint may be said to have taken the place of all these amputations through the tarsus; for though cases are occasionally met with in which the limitation of the disease or injury may render Chopart's possible, and though at first sight it appears to have an advantage in removing less of the body, still the following objections are nearly fatal to its chance of being selected:--1. In cases of injury, through leaving a long stump, and, at first sight, a useful one, experience shows that the tendo Achillis sooner or later (being unopposed by the extensors of the toes) draws up the heel so as to make the end of the stump point, and the cicatrix press on the ground, rendering it unable to bear any weight. 2. In cases of removal for disease of the tarsus, the bones left behind, though apparently sound at the time, are almost sure to become eventually diseased.

As it has an historical interest, and as this operation (defective as it is) had been the means of saving many legs prior to the invention of amputation at the ankle-joint, a brief description may be appended:--

Chopart's own manner of operation was briefly somewhat as follows:--

The tourniquet having been applied, the surgeon is to make a transverse incision through the skin which covers the instep, two inches from the ankle-joint. He is to divide the skin, and the extensor tendons, and the muscles in that situation, so as to expose the convexity of the tarsus. He is next to make on each side a small longitudinal incision, which is to begin below and a little in front of the malleolus, and is to end at one of the extremities of the first incision. After having formed in this way a flap of integuments, he is to let it be drawn upwards by the assistant who holds the leg. There is no occasion to dissect and reflect the flap, for the cellular substance connecting the skin with the subjacent aponeurosis is so loose, that it can easily be drawn up above the place where the joint of the calcaneum with the cuboides and that between the astragalus and scaphoides ought to be opened. The surgeon will penetrate the last the most easily, particularly by taking for his guide the eminence which indicates the attachment of the tibialis anticus muscle to the inside of the os naviculare. The joint of the os cuboides and os calcis lies pretty nearly in the same transverse line, but rather obliquely forwards. The ligaments having been cut, the foot falls back. The bistoury is then to be put down, and the straight knife used, with which a flap of the soft parts is to be formed under the tarsus and metatarsus, long enough to admit of being applied to the naked bones, so as entirely to cover them. It is to be maintained in position with three or four straps of adhesive plaster, etc.[37]

Chopart's amputation, after an interval of comparative neglect, was introduced into this country by Mr. Syme in 1829. His method of performance is simpler and easier than Chopart's. He thus describes it:--"The blade of the knife employed should be about six inches long, and half an inch broad, sharp at the point and blunt on the back. The tourniquet ought to be applied immediately above the ankle, having compresses placed over the posterior and anterior tibial arteries. The surgeon should measure with his eye the middle distance between the malleolus externus and the head of the metatarsal bone of the little toe, which is the situation of the articulation between the os cuboides and os calcis. Placing his forefinger here, he ought to place his thumb on the other side of the foot directly opposite, which will show him where the os naviculare and astragalus are connected. An incision (Plate II. figs. 4 and 5) somewhat curved, with its convexity forward, is then to be made from one of these points to the other, when, instead of proceeding to disarticulate, the operator should transfix the sole of the foot from side to side at the extremities of the first incision, and carry the knife forwards so as to detach a sufficient flap, which must extend the whole length of the metatarsus to the balls of the toes. The disarticulation may finally be completed with great ease, as the shape of the articular surfaces concerned is very simple, and nearly transverse."[38] Regarding the method of disarticulating at the astragalo-calcaneal joint, and removing all the foot except the astragalus, no detail need be given. Malgaigne advises an internal flap, thus sacrificing the valuable pad of the heel. Roux, Verneuil, and others endeavour to save the pad. This operation, however, has now fallen almost completely into disuse.

SUBASTRAGALOID AMPUTATION has been highly recommended. In it the flap is made as in Syme's, then anterior bones removed as in Chopart's, and os calcis grasped by lion forceps and twisted off, its attachment and the insertion of tendo Achillis being cautiously avoided. If flaps are scanty, head of astragulus may be cut off with a small saw.--Hancock and Ashurst.

TRIPIER'S AMPUTATION[39] is a modification of above, the skin incisions being made as in Chopart's amputation, and then the calcaneum is sawn through on a level with the sustentaculum tali on a plane at right angles to the axis of the leg.

AMPUTATION AT THE ANKLE-JOINT, OR SYME'S AMPUTATION.--This operation is one of much interest and great practical importance. In our cold variable climate caries of the bones of the tarsus, and strumous disease of the ankle-joint, are very common and very intractable maladies, and for both of these, when far advanced, Syme's amputation is the only justifiable procedure. When properly done, according to the _exact_ plan of its proposer, it removes the whole of the diseased parts and not an inch more, is an operation of very slight danger to life, and results almost invariably in a thoroughly useful comfortable stump. Much of its success depends on the manner in which it is performed, and as many surgical manuals are not sufficiently full, some positively in error regarding this point, and as very many modifications have been devised diminishing in value and applicability very much in proportion as they diverge from the original description, I think it advisable to describe the operation minutely, and point out in detail the parts of it which seem absolutely essential to success.

_Operation._--The foot being held at a right angle to the leg, the point of a straight bistoury, with a pretty strong blade, should be entered just below the centre of the external malleolus (Plate IV. figs. 12, 13), (1.) and then carried right across the integuments of the sole, in a straight line (or in the case of a prominent heel, slightly backwards), (2.) to a point at the same level on the opposite side. (3.) This incision should reach boldly through all the tissues down to the bone. Holding the heel in the fingers of his left hand, the operator then inserts his left thumb-nail into the incision, and pushes the flap downwards, as with the knife kept close to the bone, and cutting on it, he frees the flap from its attachments. The thumb-nail guards the knife from in any way scoring the flap. (4.) This process is continued till the tuberosity of the os calcis is fairly turned, and the tendo Achillis nearly reached. Shifting his left hand he then extends the foot, and joins the extremities of the first incision by a transverse one right across the instep. (5.) Thus he opens the joint between the astragalus and tibia, (6.) divides the lateral ligaments, disarticulates, and still keeping close to the bone, removes the foot by the division of the tendo Achillis.

The lower ends of the tibia and fibula are then to be isolated from the soft parts, and a thin slice, including both malleoli, to be removed. If the disease of the joint has affected the lower end of the bone, slice after slice may be removed, till a healthy surface of cancellated texture is obtained. The vessels are then secured.

_Dressing of the Stump._--From its peculiar shape and position, the escape of any blood into the stump is much to be deprecated, for as it cannot easily get out, on the one hand it gives pain, and may cause sloughing from its pressure, and on the other it is sure eventually to cause suppuration, and delay union. To avoid such results care must be taken to secure every vessel that can be seen; if there is any general oozing it is best merely to pass the sutures through the edges of the flaps, but not bring them together, thus leaving the stump open for some hours; then apply cold, and when the surfaces are fairly glazed over, remove any clots and bring the flaps together.[40]

Another plan introduced by Mr. Syme was to make a longitudinal slit in the flap, through which all the ligatures are to be drawn; these give a dependent drain to any pus that may be formed, and by their presence greatly expedite the healing of the wound. Again, in cases where from the amount of disease existing before the operation, and the gelatinous thickening of the flap and neighbouring parts, much suppuration may be looked for, probably it will be found best to keep the flaps quite apart for some days, by stuffing the wound with lint, and aiming only at secondary union by granulations.

A drainage tube passed through the breadth of the flap, and brought out at the angles, and retained for a few days, will do admirably.

_Notes._--(1.) If commenced further forward, as in Pirogoff's
modification, it will be found difficult to turn the corner of the
heel; if further back, the nutrition of the flap is endangered.

(2.) This is very important. In several well-known text-books, even
in the last edition of Gross's _Surgery_, the incision is figured
passing obliquely _forwards_. This is a fatal error, for besides
making a flap far too long, it forces the operator to cut fairly
into the hollow of the sole, quite off the prominence of the os
calcis, and he finds that it is utterly impossible to free his flap
without using great force, and inevitably scoring it in all
directions. Sloughing is almost inevitably the result.

(3.) The incision is to stop at least half-an-inch below the
internal malleolus. Most surgical manuals, even when they profess
to describe Mr. Syme's own method of operating, say that the
incision should extend from malleolus to malleolus. If this is
done, the flap becomes unsymmetrical, too long, and also the
posterior tibial artery, on which much of the vascular supply of
the flap depends, is cut. When the incision is properly made, the
vessel is not cut till after its division into the plantar
arteries.

(4.) Scoring the flap. Some may ask, Why do you object to a little
scoring, the tissues are thick enough, and besides, don't you
advise a slit in the flap yourself? Yes. One look at an injected
preparation will show that the vessels supplying this thick flap
come to it from its inner surface, and are inevitably cut across in
any scoring of it, and also, that scoring cuts across the vessels,
and _must_ divide dozens of them; the slit we make is parallel with
their course, and _may_ not divide one.

(5.) Across the instep. Some authors recommend a semilunar anterior
flap; this is quite unnecessary, increases bagging and delays
union. It can be required only in cases where the heel flap has
been destroyed or lessened by disease, or by operators in whose
hands the heel flaps occasionally slough.

(6.) It is not impossible that a careless operator may (by cutting
a little too low) miss the joint and get into the hollow of the
neck of the astragalus, where he may cut away for a long time
without making much progress.

_Advantages._--1. It is wonderfully free of danger to life. It is very hard to obtain exact statistical information, but my experience is that the mortality is certainly not more than about 10 per cent., a very remarkable result when compared with that of amputations through the leg, the operation which used to be required for those cases which now require only amputation at the ankle-joint.

In the Statistical Report by the Surgeon-General of the United States, 9705 cases of amputation resulted in death, the proportions being as follows:--

Amputation of hip, 85 per cent. died.
" thigh, 64 "
" knee, 55 "
" leg, 26 "
Amputation of ankle-joint, 13 per cent. died.
" shoulder, 39 "
" arm, 21 "
" fore-arm, 16 "

2. It is the most perfect stump that can be made, in fact the only one in the lower extremity which can bear pressure enough to support the weight of the body; all the others require the weight to be distributed over the general surface of the limb by means of apparatus. A good ankle-joint stump can bear the whole weight of the body, as when the patient hops on it without any artificial aid, or without even the interposition of a stocking between the stump and a stone floor. More than this, I have seen a patient who had both his feet amputated at the ankle-joint run without shoes or stockings on the stone passages, without even the aid of a stick, and with very great swiftness.

The reason of this may be found in the nature of the flap itself, originally intended to bear the weight of the body, there being no cicatrix at the part on which pressure is borne. I have noticed that perfection in walking on an ankle-joint stump has a certain relation to the freedom of movement which the pad has over the face of the bone. This ought to be pretty considerable. It is explained by the new attachments formed by the tendons, and is under the control of the patient, being elicited when he is told to move his toes.

It has been objected to this operation that the flap is apt to slough. When improperly performed, as when the flap is scored transversely in its separation, and especially when the flap is cut too long (as has been already noticed), this may occur; but that there is nothing whatever in the position or condition of the flap itself that at all necessitates its sloughing, is thoroughly proved by the following remarkable case, given by Mr. Syme in his volume of _Observations in Clinical Surgery_. I quote it entire:--

"P.C., aged thirty-three, was admitted into the hospital on the 25th July 1860, in the following state:--He had been treated in the Manchester Infirmary for popliteal aneurism by pressure, so decidedly applied that it had caused an ulcer, of which the cicatrix remained; but without producing the effect desired. The femoral artery was then tied with success, in so far as the aneurism was concerned, but with the unpleasant sequel, some months afterwards, of mortification in the foot, which was thrown off, with the exception of the astragalus and os calcis with their integuments, a large raw surface being presented in front where the bone was bare. Although the patient was extremely weak, and the parts concerned might be supposed more than usually disposed to slough, I did not hesitate to perform the operation, with the speedy result of a most excellent stump and complete restoration to health."--Pp. 49, 50.

The modifications of Mr. Syme's original operation have been very various. It will be unnecessary even to name them all. One or two may require notice. Retaining Mr. Syme's incisions in their integrity, some operators prefer not to disarticulate the foot, but remove it by sawing through the tibia and fibula at once, while still in connection with the foot. That most excellent surgeon and first-rate operator, Dr. Johnston of Montrose, used to prefer this method.

In cases where the pad of the heel has been destroyed by disease or accident, so as to be partially or entirely unavailable for the flap, the late Dr. Richard Mackenzie[41] practised the following operation by internal flap:--With the foot and ankle projecting from the table with their internal aspect upwards, he entered the point of the knife (Plate I. fig. 14) in the mesial line of the posterior aspect of the ankle, on a level with the articulation, carried it down obliquely across the tendo Achillis towards the external border of the plantar aspect of the heel, along which it is continued in a semilunar direction. The incision is then curved across the sole of the foot, and terminates on the inner side of the tendon of the tibialis anticus, about an inch in front of the inner malleolus. The second incision (Plate III. fig. 4) is carried across the outer aspect of the ankle in a semilunar direction, between the extremities of the first incisions, the convexity of the incision downwards, and passing half an inch below the external malleolus.

Precisely the same principle might supply the flap from the outer side in cases where the internal flap as well as the heel was deficient, but probably the nutrition of the external flap would be more doubtful. Neither the one nor the other is nearly so good as the true heel flap, and they are both only very poor substitutes for it when it cannot be had.

The modification devised by Dr. Handyside does not seem to have any advantages over the original operation, and has not been adopted.

The modification invented by Professor Pirogoff involves a much more important principle than any of the preceding. Instead of dissecting the flap from the posterior projecting portion of the os calcis, and removing the tarsus entire, he sawed off the posterior portion of the os calcis obliquely, leaving it in contact with the pad of skin, which is retained. Immediately after making the cut which defines the posterior flap and divides the tissues down to the bone, he opens the joint in front, disarticulates, and then putting on a narrow saw immediately behind the astragalus and over the sustentaculum tali, he saws the os calcis obliquely downwards and forwards till he reaches the first incision; then removes the ends of the tibia and fibula and brings up the slice of os calcis into contact with them.

_Advantages._--It is easy of performance, saving the dissection from the heel, which some find so hard. It leaves a longer limb. It is said to bear pressure better, and there is certainly not so much chance of bagging of pus, and the mortality is exceedingly small, Hancock's collected cases giving only 8.6 per cent.; in cases of injury it is quite a warrantable operation.

_Disadvantages._--It is contrary to sound principle in cases of disease, for it wilfully leaves a portion of the tarsus, in which disease is almost certain to return. It leaves too long a limb, for it is found that the shortening in Mr Syme's method is just sufficient to admit of a properly constructed spring being placed in the boot to make up for the loss of the elastic arch of the foot. It brings the firm pad of the heel too much forward, thus tending to lean the weight of the body on the softer tissues behind the heel. It takes much longer to unite and consolidate.

The author has now, in a large number of cases of Syme's amputation for disease, found advantage in leaving the periosteum in the heel flap, _i.e._ he cuts fairly into the os calcis when dividing the skin of heel, and then using a periosteum scraper instead of the knife, it is quite easy to remove the whole of the periosteum from the bone; this results in a large and more rounded pad of great strength and thickness.

In cases where from disease or injury it is impossible to obtain either a heel flap or a substitute lateral one, the question is, Where should amputation be performed?

It was for a long time the opinion of nearly all the best surgeons, and still is the opinion of many, that amputation of the leg should be performed at what was known as the "seat of election," just below the knee, even in cases where abundance of soft parts could be obtained for an amputation much lower down. 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 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; it is very heavy, very difficult to dress and keep in position, and then when you have succeeded with it, the muscle wastes away and the stump is flabby. 3. And chiefly, as in all the amputations of the leg, the cicatrices are so much in the way, and the bones are so ill covered, that the patient can never rest his leg on the stump itself, but has either to rest his weight on his patella impinging on the top of a bottle-shaped leg, or just to stick out his stump behind him and kneel on the top of his wooden leg; therefore it is no use to have a stump longer than a few inches; in fact, the longer the stump is the more it is in the way. And more than this, many of the stumps made near the ankle, or through the calf, are not only useless, but positively painful. The skin becomes attached to the bones, the cicatrix never properly firms at all, the patient can hardly bear the pressure of a stocking, far less can he make use of the limb. For these reasons, secondary amputations below the knee are of very common occurrence.

Now, this idea has been much modified, and a few isolated cases in the past, and series of cases considerably more numerous in the present day, show that under certain conditions, and as a result of certain precautions in their performance, such operations are both warrantable and successful.

In the past, as we find in an erudite note in South's Chelius, Dionis, White, and Bromfield had each of them many successful cases of amputation just above the ankle, successful in so far that artificial limbs could be used which preserved the motion of the knee, and gave the patient much more command of the limb than is possible with the short stump below the knee.

A still more important point to be remembered is, that amputation just above the ankle is a much less fatal amputation than that just below the knee (Lister in _Holmes's Surgery_, 3d ed. vol. iii. p. 716; Gross, 6th ed. vol. ii. p. 1113; Ben. Bell, 6th edit. vol. vii. p. 312).

There is little doubt, however, that the principle so much in vogue in the present day, of one long anterior or posterior flap, instead of two equal flaps, or of circular amputations, has done very much to make amputations at the ankle or through the calf justifiable and useful in bearing the weight of the body.

AMPUTATION JUST ABOVE THE ANKLE.--Cases admitting of this operation must always be rare, for disease of the tarsus or ankle-joint hardly ever goes so far as to contra-indicate the performance of Mr. Syme's greatly preferable operation; and an accident which would require this operation from injury to the ankle would in most cases require an amputation a good deal higher up from the splintering of the tibia so apt to occur.

In a suitable case the plan of the operation should be as follows:--A long anterior flap slightly rounded at the end should be cut (Plate I. figs. 15, 16)--from the outside, not by transfixion,--and the anterior muscles dissected up along with it. It should be long enough to fall down over the face of the bones at the point of section, and easily cover the point of the posterior flap, which is to be made by cutting through all the tissues with one bold transverse stroke of the knife. This operation, which is the plan of Mr. Teale of Leeds very slightly modified, is equally applicable at any point of the leg, with this difference only, that the length of the anterior flap must always be carefully proportioned to the mass of the muscular flap behind it has to cover in.

This operation provides a skin covering, without any danger of the cicatrix being pressed on or becoming adherent.

The author has within the last few years operated nine times in
this manner, in cases of accident in which the heel flaps had been
completely destroyed; and seen a tenth case in which Mr. Syme did
so. All ten cases recovered completely and rapidly, and walked on
useful limbs, with the free movement of the knee-joint.

Where from injury in a muscular patient a long anterior flap cannot be had, recourse should be had at once to the operation at the seat of election, rather than run the risk of pressure on the cicatrix by using a double flap operation, or trust that broken reed, the long posterior flap from the great muscles of the calf.

In June 1865, Mr. Henry Lee described a method of operating which he hoped would unite the benefits of Mr. Teale's method to the ease of performance of the old flap from the calf. I append a short account of his method. From its position, however, it has the great disadvantage of retaining the discharges, and by its weight straining the stitches and weighing down the cicatrix:--

LEE'S AMPUTATION _of the Leg by a long rectangular flap from the Calf_.--The operation described was performed according to Mr. Teale's method, as far as the external incisions were concerned, but the long flap was made from the back instead of from the front of the limb (Plate IV. figs. 14, 15). Two parallel incisions were made along the sides of the leg, these were met by a third transverse incision behind, which joined the lower extremities of the first two. These incisions, which formed the three sides of the square, extended through the skin and cellular tissue only. A fourth incision was made transversely through the skin in front of the leg so as to form a flap in this situation, one-fourth only of the length of the posterior flap. When the skin had somewhat retracted by its natural elasticity, an incision was made through the parts situated in front of the bones, which were reflected upwards to a level with the upper extremities of the first longitudinal incisions. The deeper structures at the back of the leg were then freely divided in the situation of the lower transverse incision. The conjoined gastrocnemius and soleus muscles were separated from the subjacent parts, and reflected as high as the anterior flap. The deeper layer of muscles, together with the large vessels and nerves, were divided as high as the incision would permit, and the bones sawn through in the usual way. The flaps were then adjusted in the manner recommended by Mr. Teale.[42]

The patients were able to bear the weight of the body on the end of the stump.

In cases of chronic disease, where the muscles are atrophied and condensed, the following posterior flap method may be used with advantage. It is approved of by Mr. Spence. An incision is made across the front of the leg from the _posterior edge_ of the fibula to the _posterior edge_ of the tibia, or _vice versâ_, according to the limb. The limb is then transfixed behind the bones from the same points, and a long and gently rounded posterior flap cut. The bones are then cleaned, and cut through at a little higher level.

AMPUTATION IMMEDIATELY BELOW THE KNEE _at the_ "_true seat of election_."--The principles on which this operation is founded are--1. That a muscular flap is not necessary, skin being perfectly sufficient; 2. That as the muscles retract they must be cut at a lower level than the bones, and as they retract unequally from their varying length, the cuts must be made with due reference to that inequality; 3. That no more of the tibia need be retained than what is just sufficient to retain the attachment of the ligamentum patellæ, and to insure its vitality; 4. That the head of the fibula must be retained in every case, as in a certain proportion the tibio-fibular articulation communicates with the knee-joint.

_Operation._--Two equal semilunar flaps of skin must be cut--from the outside, not by transfixion,--one anterior and external, the other posterior and internal, their extremities meeting at points about two inches below the tuberosity of the tibia on either side (Plate I. figs. 17, 18). These must be reflected up, and with them a further extent of skin, embracing the whole circumference of the limb, must be dissected up (as if pulling off the fingers of a glove), so as to expose the bone one inch below the tuberosity. The anterior muscles being very close to their origin, and consequently being able to retract very slightly, must be cut as high as exposed, and the posterior ones about the middle of their exposed surface.

The bones must then be sawn as high as exposed, with the following precautions:--1. In order to prevent splintering of the fibula, endeavour to saw it along with the tibia, so as to finish it first; 2. To prevent projection of a sharp prominence of the edge of the tibia, enter the saw obliquely a little higher up than where you intend to divide the bone, then withdraw it, and enter the saw again at right angles to the bone, and a line or two lower down. Some surgeons prefer to make this section afterwards with a finer saw or the bone-pliers.

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 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.

AMPUTATION AT THE KNEE-JOINT.--This "relic of ancient surgery," as Mr. Skey calls it, has been revived only of late years, and seems in certain cases to be a justifiable and successful operation.

Practised by Fabricius Hildanus and Guillemeau in the sixteenth and seventeenth centuries, it had fallen into disuse till revived by Hoin, Velpeau, and Baudens, on the Continent, Professor Nathan Smith in America, and Mr. Lane in London.

It is not possible that this operation can be at all frequent, since the cases in which it is applicable are comparatively rare; for, to be successful, the following conditions are essential:--1. That there be abundant skin in front of the knee-joint to make a long anterior flap; 2. 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.

_Operation._--A long anterior flap should be cut with a semilunar end (Plate II. figs. 6, 7), extending as far as the insertion of the ligamentum patellæ. This flap, including the patella, should be thrown up, the joint cut into, and a short posterior flap made by transfixion.

It is important to retain the patella, if possible, as it fills up the hollow between the condyles; it sometimes becomes anchylosed, but in other cases it remains freely mobile, and adds to the value of the stump.

Professor Pancoast has practised an amputation at the knee-joint by three flaps, performed entirely by the scalpel, which, he says, results in a good stump. One flap, the anterior one, is longest and semilunar in shape, its convexity passing three inches below the tuberosity of the tibia; the other two are much smaller, and postero-lateral.[43]

_Advantages._--The bone is not cut into at all, there is a free drain for matter, no tendency to retraction of the flaps, and the weight of the body is borne on skin previously habituated to pressure.

The statistics seem to be favourable: out of 55 cases, Continental,
American, and English, 21 died, a mortality of 38 per cent., while
in a table of 1055 cases of amputation of the thigh, 464 died,
being a mortality of 44 per cent. In some of the American cases the
articulating extremity of the femur seems to have been removed, as
in the following operation:--

AMPUTATION THROUGH THE CONDYLES OF THE FEMUR.--In the _London and Edinburgh Journal of Medical Science_ for 1845, Mr. Syme advocated a method of amputation through the condyles of the femur as specially suitable in case of diseased knee-joint. Amputation at this spot has certain advantages:--1. The shaft of the bone being untouched, there is no injury of the medullary cavity, and hence no fear of inflammation of its lining membrane. 2. There is less risk of exfoliation, the cancellated texture of the epiphysis not being liable to it. 3. 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 afford a comfortable pad over which the skin of the flap will freely play.

One objection used to be urged against this mode of operating, the fear lest the thickened, brawny, and often ulcerated textures in the neighbourhood of a diseased knee-joint, would not make a good covering. This, however, is no longer a bugbear, as we see in cases of resection, where the diseased joint alone is taken away, how very soon all swelling and disease departs, once its cause is removed.

Mr. Syme's original operation was briefly as follows:--With an ordinary amputating-knife make a lunated incision (Plate I. fig. 19) from one condyle to the other, across the front of the joint, on a level with the middle of the patella, divide the tissues down to the bones, and then draw the flap upwards, then cut the quadriceps extensor immediately above the patella. The point of the blade should then be pushed in at one end of the wound, thrust behind the femur, and made to appear at the other end; it should then be carried downwards (Plate III. fig. 5), so as to make a flap from the calf of the leg, about six or eight inches in length, in proportion to the thickness of the limb; the flap should then be slightly retracted, and the knife carried round the bone a little above the condyles to clear a way for the saw, which should be applied so as to leave the section as horizontal as possible.

This method is now hardly ever used, as the following seems a much better one:--

GRITTI'S[44] AMPUTATION.--In this two flaps are formed--an anterior long one rectangular and a posterior short one. The condyles of the femur are divided through their base, and the lower surface of patella is removed by a small saw, and then the surfaces of bone approximated.

STOKES'S[45] MODIFICATION OF GRITTI'S AMPUTATION.--In this "supracondyloid" amputation, the femur is sawn just above the condyles, without going into the medullary canal. The anterior flap is oval, twice as long as posterior, and the patella is brought up after denudation against end of femur.

CARDEN'S AMPUTATION AT THE CONDYLES OF THE FEMUR.[46]--The operation consists in reflecting a rounded or semi-oval flap of skin and fat from the front of the knee-joint, dividing everything else straight down to the bone, and sawing the bone slightly above the plane of the muscles, thus forming a flat-faced stump, with a bonnet of integument to fall over it.

The operator standing on the right side of the limb, seizes it between his left forefinger and thumb at the spot selected for the base of the flap, and enters (Plate II. fig. 8) the point of the knife close to his finger, bringing it round through skin and fat below the patella to the spot pressed by his thumb; then turning the edge downwards at a right angle with the line of the limb, he passes it through to the spot where it first entered, cutting outwards through everything behind the bone (Plate IV. fig. 16). The flap is then reflected, and the remainder of the soft parts divided straight down to the bone; the muscles are then slightly cleared upwards, and I saw it applied.

I have ventured to make a slight change in the method of performing this most excellent operation, for having found the posterior flap, as cut in the method above described, rather scanty in the earlier cases in which I have had occasion to perform it, after dissecting back the anterior flap and cutting into the knee-joint, I shape a slightly convex posterior flap of skin only, at least one and a half inches in length in adult, and allow it to retract before dividing the muscles by a circular cut to the bone, and have had every reason to be satisfied with the change.

AMPUTATION OF THE THIGH.--Amputation of the thigh has been the favourite battle-ground where flap and circular, antero-posterior and lateral, long and short flaps, double, triple, and conical incisions, have striven with each other; so were I to attempt to describe one quarter of the various methods employed, I should need to rewrite the history of Amputation.

It will suffice merely to describe the _best_ modes of amputating the thigh through its lower, middle, and upper thirds respectively, and at the hip-joint.

In one word, it may be stated that, with the exception of those amputations performed through the lower third of the bone, the flap method is to be preferred, and the flaps should in almost every case be made by transfixion.

In the lower third, however, the flap method, though exceedingly easy, and capable of very rapid performance, has certain defects; the chief of these being the tendency which the muscular flaps (the necessary result of transfixion) have to cause undue retraction, and hence protrusion of the bone. This is seen specially in the hamstrings, which from the great distance of their origin, and the purely longitudinal direction of their fibres, retract to a very great extent, much more than the anterior muscles can do from the pennate direction of their fibres, and the manner in which they are mutually bound down to each other and to the bone.

Even in this one position, the lower third of the thigh, the methods that may be needed are various, and require separate notice;--for operations here are extremely frequent from the frequency of strumous disease of the knee-joint in our variable climate, and from the fact that compound fractures or dislocations of the knee-joint so very often necessitate amputation.

In cases where the skin over the patella is uninjured and available, the operation by long anterior flap (either by Teale's method, or by Mr. Spence's modification of it, which curiously is almost exactly similar to the amputation of Benjamin Bell by a single flap) is suitable enough. But, I believe, preferable to either of these is the operation of Mr. Carden, already described. In cases where the knee-joint is injured, and the skin over the patella unavailable, and yet where it is not necessary to go higher up the limb, the modified circular amputation of Mr. Syme will be found very suitable.

As it is in this lower third of the thigh that a very large proportion of the cases requiring a long anterior flap is to be found, it affords the best opportunity for comparing in their detail the three almost similar plans of B. Bell, Teale, and Spence--after which Mr. Syme's modified circular may be described.

BENJAMIN BELL'S FLAP OPERATION ABOVE THE KNEE (reported in his own words, slightly abbreviated).--"When this operation is to be performed above the knee, it may be done either with one or two flaps, but it will commonly succeed best with one. The flap answers best on the fore part of the thigh, for here there is a sufficiency of the parts for covering the bones, and the matter passes more freely off than when the flap is formed behind.... The extreme point of the flap should reach to the end of the limb, unless the teguments are in any part diseased, in which case it must terminate where the disease begins, and its base should be where the bone is to be sawn. This will determine the length of the flap, and we should be directed with respect to the breadth of it by the circumference of the limb, for the diameter of a circle being somewhat less than a third of its circumference, although a limb may not be exactly circular, yet by attention to this we may ascertain with sufficient exactness the size of a flap for covering a stump (Plate IV. fig. 17). Thus a flap of four inches and a quarter in length will reach completely across a stump whose circumference is twelve inches; but as some allowance must be made for the quantity of skin and muscles that may be saved on the opposite side of the limb, by cutting them in the manner I have directed, and drawing them up before sawing the bone, and as it is a point of importance to leave the limb as long as possible, instead of four inches and a quarter, a limb of this size, when the first incision is managed in this manner, will not require a flap longer than three inches and a quarter, and so in proportion, according to the size of the limb. The flap at its base should be as broad as the breadth of the limb will permit, and should be continued nearly, although not altogether, of the same breadth till within a little of its termination, where it should be rounded off so as to correspond as exactly as may be with the figure of the sore on the back part of the limb. This being marked out, the surgeon, standing on the outside of the limb, should push a straight double-edged knife with a sharp point to the depth of the bone, by entering the point of it at the outside of the base of the intended flap; and carrying the point close to the bone, it must here be pushed through the teguments at the mark on the opposite side. The edge of the knife must now be carried downwards in such a direction as to form the flap, according to the figure marked out; and as it draws toward the end, the edge of it should be somewhat raised from the bone, so as to make the extremity of the flap thinner than the base, by which it will apply with more neatness to the surface of the sore. The flap being supported by an assistant, the teguments and muscles of the other parts of the limb should, by one stroke of the knife, be cut down to the bone, about an inch beneath where the bone is to be sawn; and the muscles being separated to this height from the bone with the point of a knife, the soft parts must all be supported with the leather retractors till the bone is sawn," etc., arteries tied, and dressings applied.[47]

AMPUTATION OF THIGH BY RECTANGULAR FLAP--(Teale's).--I take the opportunity here of describing fully, and as far as possible in his own words, Mr. Teale's method of amputating, this being the situation where his method is most frequently available. The same principle may be applied to amputations at almost any other part of the body.

After advising the surgeon to mark out the proposed line of incision with ink before the operation, he gives the following directions for fixing the exact size of the flap:--"Supposing the amputation to take place (Plate II. figs. 9, 10) at the lower part of the middle third of the thigh, the circumference of the limb is to be measured at the point where the bone is to be divided.[48] Assuming this to be sixteen inches, the long flap is to have its length and breadth each equal to half the circumference, namely, eight inches. Two longitudinal lines of this extent are then traced on the limb, and are met at their lower points by a transverse line of the same length. The inner longitudinal line should be first traced in ink as near as practicable to the femoral vessels, without including them within the range of the long flap. The outer longitudinal line, which is somewhat posterior, is next marked eight inches distant from the former and parallel to it. These two lines are then joined by a transverse line of the same extent, which falls upon the upper border of the patella, or upon some lower portion of this bone. The short flap is indicated by a transverse line passing behind the thigh, the length of this flap being one-fourth that of the long one; or, assuming the circumference of the limb to be sixteen inches, and the length of the long flap eight inches, the length of the short flap is two inches. The operator begins by making the two lateral incisions of the long flap through the _integuments only_. The transverse incision of this flap, supposing it to run along the upper edge of the patella, is made by a free sweep of the knife through the skin and tendinous structures down to the femur. Should the lower transverse line of the flap fall across the middle or lower part of the patella, the transverse incision can extend through the skin only, which must be dissected up as far as the upper border of the patella, at which place the tendinous structures are to be cut direct to the thigh-bone. The flap is completed by cutting the fleshy structures from below upwards close to the bone. The posterior short flap, containing the large vessels and nerves, is made by _one sweep_ of the knife down to the bone, the soft parts being afterwards separated from the bone close to the periosteum, as far upwards as the intended place of sawing.... In adjusting the flaps, the long one is folded over the end of the bone, and brought, by its transverse line, into union with the short flap, the two corresponding free angles of each being first united by suture. One or two additional stitches complete the transverse line of union. Care is now required in arranging the two lateral lines of union. As the long flap is folded upon itself so as to form a kind of pouch for the end of the bone, it is requisite that it should be held in its folded state by a point of suture on each side. Another stitch on each side secures the lateral line of the short flap to the corresponding part of the long one. A longitudinal line of union thus passes at right angles each end of the transverse line."[49]

Mr. Teale's account of the resulting stumps is too long to quote entire, but in a few words, we find that by retraction of the short posterior flap, the cicatrix is drawn up quite behind and out of the way of the bone, that a soft mass without any large nerves or vessels is the result of the partial atrophy of the long flap, and that the patient is able to bear one-half, two-thirds, or even in some cases the entire weight of his body on the face of the stump. Such a power of support is to be found in no other flap except in Mr. Syme's amputation at the ankle-joint.