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 Fig. 709

Teale’s method of amputation.

Bruns devised a method which is begun almost as an exsection, by an

oblique circular incision, with liberating lateral incisions, and division of all the
tissues over the inner border of the tibia and the outer side of the fibula; after
which, without disturbing skin attachments in front, the periosteum is
separated from the bones as high as the liberating lateral incisions permit, and
then the fibula first and later the tibia divided. It is practically a subperiosteal
excision of the leg bones and affords a well-protected stump. In effect it is an
anteroposterior flap method.
—It was Brinton who, in 1872, suggested the preservation of the semilunar
cartilages in all knee disarticulations, as in this way all the normal relations are
preserved and retraction is prevented. But the makers of prosthetic apparatus
have urged to abandon all true disarticulations, and to substitute for them the
 Fig. 710 The Knee.supracondyloid
method, which
affords ideal stumps.
Disarticulations are supposed
to produce less shock, less
loss of blood, and less danger
of sepsis from opening up the
bone-marrow, while muscle
insertions are less disturbed
and the stump covering usually
is mobile and not very
Stump after Stephen Smith’s amputation at knee.
sensitive. No disarticulation
should be thought of unless the
joint involved be free from disease and unless about it there be met sufficient
healthy integument to furnish a satisfactory flap.
For a true disarticulation Stephen Smith’s bilateral method is now almost
universally adopted. Here the incision is begun one inch below the tubercle of
the tibia and is carried directly down to the bone, downward and forward
around the side of the leg, and then inward and upward toward the middle of
the popliteal space, the lateral flaps thus made being nearly duplicates. The
flaps thus cut out are completely separated from the bone up to the joint level,
where the ligaments are divided, the joint being manipulated as may be
necessary to best expose them and facilitate division. In this operation the
patella is usually removed, the joint being opened by separating its ligament at
its insertion into this bone. One should remember that the internal condyle is
lower and longer than the external, and that the internal flap should be
perhaps made on this account a little the longer of the two. Fig. 710 illustrates
the stump resulting from this operation and shows the cicatrix drawn up out of
harm’s way and resting in the fossa between the condyles. Fig. 711 illustrates
the simple method by lateral flaps.
 Fig. 711

Amputation at knee by lateral flap. (Erichsen.)

Amputation of the Thigh.—Under this head, rather than that of amputation

at the knee, should be described the
supracondyloid amputations which give decidedly the best results of all, and
which are preferable to any others for the middle of the lower extremity. Of
these the best is that suggested by Gritti, which consists in not only removing
the condyles but sawing off the articular surface of the patella, which is then
drawn upward and applied to the end of the femur, the division of the latter
being made at a point above the condyles, where the diameter of both bones
will nearly correspond, this latter perhaps being a suggestion of Stokes rather
than of Gritti, who did not divide the bone quite so high. (See Fig. 712.)

Fig. 712

Gritti’s osteoplastic supracondyloid knee amputation, patella utilized: a, shaded parts are
those brought in apposition; b, appearance of Gritti stump after suture; c, correct apposition of
patella to femur; d, defective apposition. (Farabeuf.)

Fig. 712 will best illustrate the intent of the method as well as its
performance. The incisions are planned much as in the Stephen Smith
disarticulation method, only they are placed higher, and the patellar tendon is
divided as low down as possible, or even separated from the tibia, in order
that it may be made of use in attaching the divided patellar surface to the
femoral end. The rest of the operation is performed as by other methods, the
attachment of the patella being effected by tendon sutures, or, if necessary, by
an ivory peg, or even a metal tack or nail which may be left in place.
The beauty of this method is that the anterior surface of the patella is
preserved with its natural weight-bearing facilities and the bursa between it
and the skin, while the latter is undisturbed. On the end of this stump as much
weight can be steadily borne as when one ordinarily kneels, and to it a most
serviceable kind of artificial limb can be attached, with which one may walk as
though nothing had ever happened.
Another osteoplastic method, namely, that of Sabanejeff, is illustrated in
Figs. 713 and 714. In this instance the bone covering over the end of the
femur is taken from the upper end of the tibia, the patella not being disturbed.
It permits a lower division of the femur and the formation of a stump which is
of practically the same length as the original thigh.

Fig. 713 Fig. 714

Sabanejeff’s knee amputation. (Chalot.) Stump made as in Fig. 713. (Chalot.)

Amputation of the Thigh above the Knee.—For removal of the thigh it is

well to preserve as much of its
length as possible, and yet not at the expense of all other considerations. A
thigh stump too short is likely to be pulled awkwardly upward by the psoas
muscle, and upon such a stump it is difficult to secure an artificial limb
tolerable of control against such action of this muscle. On this account, then,
thigh stumps should be long. So far as the method is concerned the circular,
or some modification thereof, gives the best results in the majority of
instances. It may easily be modified into one of the oblique methods, or
liberating incisions may be used whenever they will be of service. If it be
absolutely necessary to make the amputation high hemostasis can be secured
by the same methods that are used in hip-joint amputations. The dense and
strong fascia lata, which lies beneath the superficial fascia, should be divided
at the same level with the skin, since it serves admirably, when secured by a
separate set of sutures, to make a good covering for the ends of the muscles,
after these have been themselves carefully united by buried sutures. The
sciatic nerve should be especially sought, thoroughly stretched, and divided
high up. The vessels often evince a tendency to retract within Hunter’s canal;
it is not, however, difficult to separate the vastus internus from the adductor
longus, between which they lie, and in this way gain access to them. Even for
high work on the thigh one may, if necessary, do as some have done at the
hip, make a preliminary ligation of the femoral artery. This may be especially
serviceable as an emergency measure, or in special cases of tumors which
have attained large size, are placed high up and call for somewhat atypical
methods.
The Hip-joint.—Amputation here is essentially a disarticulation and
constitutes one of the usually formidable and serious
operations of major surgery. Although the joint itself is generally easily
reached there are many things to be considered in the performance of this
operation, of which the mere arthrotomy is by no means the most important.
Preparations being all made, the first consideration is the control of
hemorrhage, for which several methods have been suggested, but of which
but two or three are in general use. Such procedures as compression of the
abdominal aorta, either with the hand or by tourniquet, or of the common aorta
through the rectum, with a lever, as suggested by Davey, or with the hand, as
suggested by Woodbury, or the exposure of the common iliac, either within the
peritoneum as practised by McBurney, or externally, or exposing the common
femoral above Poupart’s ligament, are now adopted by very few surgeons.
Langenbeck used to be fond of preliminary ligation of the femoral where it is
most accessible in the groin, and this is probably the best of all of these
methods. But they have been all practically discarded since Wyeth introduced
the simple method of transfixing the limb with his pins (i. e., long mattress
needles or skewers made for the purpose), these serving to hold in place an
elastic cord or tourniquet (Fig. 715). This has been found to be a great
improvement on the suggestion of Senn, who excised the femoral head and
then compressed each half of the limb with a separate elastic band.

Fig. 715

Wyeth’s bloodless method: pins inserted and tube applied.

The directions for the use of Wyeth’s pins are simple. Here, as in other
cases, it may not be practicable to use the elastic bandage from the lower end
of the limb, but one may at least elevate the limb and thus coax the blood out
of it by gravity or by gentle manipulation. While it is still in this position one of
the long pins is introduced just below the anterosuperior spine and a trifle to
its inner side, and made to emerge on a level with and about three inches
from the point of its entrance. The other needle is inserted just to the inner
side of the saphenous opening, and below the level of the crotch, and brought
out about one inch below the tuberosity of the ischium. Corks should then be
placed upon them so as to protect the needle points. Next a piece of elastic
tubing or band is placed around the limb above these pins and tightened, each
turn being made a little tighter, so as to absolutely control the circulation. The
effect of this is felt upon practically every vessel in that part of the body, and if
the method be properly practised it affords absolute security.
 The surgeon now has his choice of various methods of disarticulation, either
that by anteroposterior flaps or lateral flaps, or by the circular, with the free
liberating lateral incision; or he may devise any method of his own which will
best meet the indication in a given case. Fig. 715 illustrates the employment of
Wyeth’s pins and the first circular incision made as for the circular method. Of
these all the latter seems preferable when circumstances permit. It should be
combined with a sufficient lateral incision, which should be made to pass well
over the great trochanter. The cuff raised through this incision should extend
down to the deep fascia and up to the level of the lesser trochanter, at which
level the deeper tissues are divided transversely or by a circular cut.
It is well next to lay down the knife and secure the large vessels, after which
the deep muscles are separated from the upper end of the shaft and the
proximity of the joint, while the entire limb may be still used as a lever in so
stretching the joint capsule as to better expose and divide it. So soon as the
capsule has been opened, and the entrance of air thus permitted, it will be
easy to expose and divide the teres ligament, after which the balance of the
disarticulation is easily effected. The large nerve trunks are now sought,
retracted, and divided high up, all visible vessels are secured firmly, after
which the elastic constriction may be gradually released and any vessels that
spurt may still be secured. There will nearly always be troublesome oozing
from the cut ends of the large muscles, and here, if hot water prove insufficient
to check it, with large curved needles and catgut sutures the muscle ends may
be secured by ligature en masse, before they are brought together for the
purpose of closing the stump.
Whatever the method selected as perfect a closure of the wound as
possible should be made, with ample provision for drainage. By careful deep
suturing, with tiers of buried sutures, it is possible to avoid leaving dead
spaces at any point except perhaps the acetabulum. Through retaining
sutures may also be used to advantage. It is most desirable to so plan the
incisions and the closure of the wound as to keep them, so far as possible,
away from the region of the perineum. Therefore the longer the inner flap or
inside of the stump the better. As conditions which necessitate removal of the
limb at the hip-joint are always serious, and have each their own peculiarities,
any method which will best serve the purpose should be used.
Plates LIX and LX, designed by Prof. Matas, afford the best and briefest
epitome of the choicest amputation methods which can be furnished.

THE STUMP.
An amputation having been effected, and the stump closed, there is still
occasion to consider how it may best be treated to fit it for its future purposes.
When entire chapters, or even small monographs, can be written on the
subject of “diseases of stumps” it would appear that the consideration is not
one of merely trifling import.
A good stump has a regular outline, with a protected scar, and should be
firm, yet mobile, and without tender or sensitive surfaces. It should constitute
the lower end of a truncated cone, and needs to be of sufficient length to
permit leverage within the socket of the artificial limb which will be fitted about
it.
A stump failing in these characteristics is a bad stump, the features which
especially tend to make it bad being undue conicity (Fig. 716) or sensitiveness
of surfaces, ulceration from friction, or, worse yet, occurring without it, and
neuralgia from inclusion of nerve ends, or from bone ends which present
osteophytic outgrowths and thus distort and displace tissues (Fig. 717). Acute
osteomyelitis occurs in stumps, as do slower carious processes which may
call for re-amputation, perhaps even at a distance. The stump is for a long
time more or less tender and troublesome, and its owner may be a sufferer
from hyperesthesia or perverted sensations.
The possibility of the production of a conical stump in children as the result
of atrophic elongation was mentioned early in this chapter. While this cannot
always be prevented it may sometimes be foreseen, and one should be
prepared at any time in such cases to circumcise the bone, forcibly retract the
tissues, and then divide the bone ends on a higher level.
PLATE LIX
 The Right Lower Limb, Internal Lateral View (Surface
Incisions).

1, 2. Circular for middle and upper thirds of thigh.

3. Circular for lower third of thigh, showing tendency of circle to incline downward on
adductor side to compensate for greater retraction.
4. Incision for Gritti’s or Carden’s amputations at knee (single anterior flap).
5, 6. Stephen Smith’s bilateral flaps (posterior racquet).
7. Antero-posterior flaps, cut solid to the bone, the soft parts being elevated from the
periosteum (Marc See, von Brun’s method). This is the author’s preferred method for leg
only, simplified by making a simple circular with two lateral liberating incisions on fibular and
tibial sides.
8, 9, 10. Circular with posterior racquet extension to form bilateral flaps (Stephen Smith).
11. Guyon’s supra-malleolar amputation.
12. Lines of Syme’s amputation.
13. Inner aspect of Roux’s tibio-tarsal amputation; also subastragaloid.
14. Medio-tarsal amputation (inner aspect).
15. Tarso-metatarsal disarticulation (inner aspect).
16. Disarticulation of toe with its metatarsal.
17. Disarticulation of big toe; in front of this lines for amputating first or terminal phalanx
by long plantar flap.
PLATE LX
 Surface Outlines of Amputations Practised in the Lower
Extremity.

1. Low circular with external incision (Furneaux Jordan) or at a higher level (gluteo-
femoral furrow) applicable to Wyeth’s method of disarticulating hip.
2. Circular incision with tendency to racquet posteriorly in middle third amputations.
3. Circular with posterior vertical incision in amputation of lower third of thigh.
4. Long anterior flap for supra-condyloid amputation of thigh.
5. Racquet incision with long anterior flap for extreme upper third of leg. Note long
posterior tail, which facilitates upward retraction of a solid musculo-cutaneous flap cut down
to the periosteum, resembling a bilateral flap operation (Stephen Smith). The same incision
cut a little higher is most serviceable in disarticulating at the knee.
6. Long-hooded anterior flap, with posterior racquet (Stephen Smith and Bier’s
osteoplastic).
7. Amputation by equal antero-posterior flap (Marc See, von Bruns).
8. Amputation by long anterior and short posterior flaps (Teale’s principle).
9. Amputation of leg at extreme lower third, practically a circular amputation converted
into a solid antero-posterior flap by liberating incisions on fibular and tibial sides.
10. Guyon’s supra-malleolar amputation of leg.
11. Medio-tarsal and intra-tarsal amputations (Chopart and its derivatives).
12. Tarso-metatarsal amputation (Lisfranc and derivatives).

An exquisitely neuralgic stump is usually made so by the entanglement of

nerve ends and their subsequent enlargement into so-called amputation
stump neuromas (which are histologically fibromas), from pressure upon
nerve terminals. Under these circumstances their excision through incisions
planned for the purpose, or the exsection of a portion of the nerve trunk at a
higher level, may be necessitated (Fig. 717).
 Fig. 716 Fig. 717

Extreme case of conical stump. Neuromatous endings of nerves in a stump.

Fig. 718 Fig. 719

Ideal stump. Bad stump, because posterior flap was cut too
short, and there has been great retraction of
all soft tissues. (Farabeuf.)
 While patients may prefer disuse of a stump for as long a time as possible
the judicious surgeon will prepare it as rapidly as he may for early application
of the expected artificial limb. Inasmuch as leg stumps allowed to hang
downward become cyanotic and edematous it is well to keep them bandaged,
and the makers of artificial limbs prefer to have the bandages kept wet. When
the stump is healed, passive motion of the remainder of the limb should be
begun, in order that there may be a minimum of stiffening of joints. If, then,
such a stump be bathed, massaged, moved, and then bandaged with
comfortable snugness with cold, wet bandages, over which oiled silk may be
fastened, and if this be done at least once each day, the stump will be
prepared for the artificial limb, on the average, in two to three months. One
should not wait for this expiration of time if it be thoroughly healed; or, on the
other hand, he may have to wait much longer under unfortunate
circumstances; but the above general principles of treatment and general
statements will be found to prevail. Figs. 718 and 719 illustrate the difference
between good and bad stumps, while Plates LIX and LX (reproduced from
Matas) furnish the surface outlines for selection of the various amputations of
the lower limb.

CINEPLASTIC OR CINEMATIC AMPUTATIONS OF THE UPPER

EXTREMITY.
The most pronounced and illustrative of recent methods is perhaps the
“cinematic” or “cineplastic” procedure of Vanghetti. This Italian surgeon
proposed a prosthetic method, in 1898, which is illustrated in Figs. 720, 721
and 722. He has shown that tendon terminations may be left exposed in
stumps, under favorable conditions, and so utilized as to serve remarkably
useful purposes—though under exceptional conditions. For a description of
these methods the reader is referred to his monograph. (G. Vanghetti, Plastica
e Protesi Cinematiche, Empoli, 1906.)
Fig. 720 Fig. 721
 Fig. 722

Results of Vanghetti’s “cinematic” method, with preservation and utilization of tendons.

 INDEX.

A
Abdomen, diseases of, diagnosis of, 768
distention of, in appendicitis, 856
drainage of, 776
general considerations and conditions of, 767
inflation of, 769
inspection of, 768
measurement of, 769
operation on, technique of, 773
palpation of, 768
bimanual, 769
wounds of, gunshot, 214, 232
Abdominal aorta, aneurysm of, 346
ligation of, 356
cavity, irrigation of, 775
diseases, diagnosis of, 768
incisions, closure of, 777
operations, after-treatment of, 777
embolism following, 784
hemorrhage after, 780
peritonitis following, 780
technique of, 773
thrombosis following, 784
viscera, general considerations and conditions of, 767
wall, abscess of, 783
actinomycosis of, 783
burns of, 783
carcinoma of, 784
 contusions of, 781
cysts of, congenital, 783
endothelioma of, 784
epithelioma of, 784
erysipelas of, 783
fibroma of, 784
foreign bodies in, 783
gangrenous cellulitis of, 783
hematoma of, 781
injuries of, 781
lacerations of, 781
osteomyelitis of, 783
phlegmons of, 783
sarcoma of, 784
suppurative spondylitis of, 783
syphilis of, 783
tuberculosis of, 783
tumors of, 783
vascular, 784
wounds of, gunshot, 783
penetrating, 781
Abscess of abdomen, 783
atheromatous, 73, 339
bone, 419, 425
treatment of, 426
of brain, 567
prognosis of, 569
symptoms of, 568
treatment of, 573
of breast, 757
classification of, 58
acute, 58
cold, 58, 112
gravitation, 58
metastatic, 59
subacute, 58
subfacial, 59
 subperiosteal, 59
cold, 112
peri-articular, treatment of, 399
collar-button, 319
definition of, 58
frontal, 569
of heart wall, 733
ischiorectal, 879, 1013
of liver, 911
symptoms of, 912
treatment of, 912
lumbar, 114
of lung, 734
of mesentery, 939
metastatic, 59, 91
occipital, 569
of pancreas, 949
parietal, 569
peri-appendicular, 860
perilaryngeal, 704
perineal, 1013
treatment of, 1013
perinephritic, 961
perirectal, 879
treatment of, 879
peritracheal, 704
perityphlitic, 860
of prostate, 994
psoas, 114
of rectum, 879
treatment of, 879
renal, 957
retropharyngeal, 114, 682
signs of, 60
of spleen, 941
subphrenic, 753
treatment of, 754