The principles and practice of modern surgery

Amputations are performed for (a) the results of injury, (b) the results of disease, and (c) removal of deformity or mutilation, or the possible results of congenital defects. While generally they are measures of necessity, made such by traumatism or by actively advancing disease, there are occasional instances where an individual decides that an artificial limb will be more useful or that he will be freed from an intolerable annoyance by the sacrifice. The principal diseases which may require such mutilation are the exceedingly acute, e. g., osteomyelitis, the slower destructive forms of ulcer, tuberculosis or of sepsis, the gangrene caused by vascular or diabetic conditions, or the slow involvement of tumors, usually malignant, but sometimes benign.

When a serious and mutilating injury has been received, if there have been complete crushing of a limb or avulsion, of course no doubt exists as to the necessity. Amputation is not now made for compound fractures nearly as often as in former times, for if only the vascular supply be good much may be done by resection of bone ends, wiring, or other expedients; and the attempt should always be made to save a limb unless it appear that even should the effort succeed the limb itself would be too useless to justify the attempt. With the possibilities of modern asepsis, and with immediate attention to the injury, the question of what should be done with an injured limb is largely a question of its blood supply. Extensive contusions with lacerations do not of themselves necessitate amputation, neither does injury to the skin unless it be most extensive.

It is unfortunate when vacillation or any misguided effort at conservatism call for great delay. While this may sometimes be advantageous, at other times the favorable moment has passed before permission to amputate may be obtained. Should delay seem advisable the surgeon should use his best endeavor to effect suitable antisepsis, to provide physiological rest, and to preserve the circulation, all of which require a thorough antiseptic technique, which will include the removal of blood clot, of fragments, and of all tissue which evidently cannot live, and suitable splinting or its equivalent, and of everything that can be done by local warmth and general stimulation to maintain the vigor of the circulation. When once infection has occurred, and especially been allowed to spread, the possibility of recovery inheres only in immediate amputation.

Such mutilations as necessitate immediate amputation are usually accompanied by profound degrees of shock, as well as perhaps by other complicating injuries, whose existence may change the whole complexion of the case. For example, with a patient suffering from probably fatal fracture of the skull one would hardly seriously discuss the matter of immediate amputation of a foot; nevertheless he should take such care of the local lower injury as to permit operation to be done under still favorable circumstances should the head condition justify it. Wide discretion is therefore called for in all these cases. Furthermore the condition of lowered blood pressure or shock may be so extreme that the operator is compelled to delay, for at least a certain time, in order that by the employment of those measures already considered in the chapter on this subject the circulation may be sufficiently restored to make it adequate for the purpose, remembering that scarcely anything predisposes to infection more than such lowered vitality. While resorting to general stimulation, hypodermoclysis, or infusion, with or without adrenalin, the use of such antiseptics should not be omitted, as the local condition may require in order to combat what otherwise may be actively occurring.

Amputations are sometimes referred to as typical, when done according to long-established methods, or atypical, when the entire procedure is planned to fit the necessities of the case. Amputation at a joint is usually spoken of as disarticulation. Amputations, again, are classified as (a) immediate, i. e., before complete reaction from shock or within the first few hours; (b) primary, when done after reaction has occurred, but before visible occurrence of inflammatory changes, (c) intermediate, as done when suppuration is threatening, but before its actual occurrence; (d) secondary, i. e., after the occurrence of suppuration.

The control of hemorrhage is one of the most conspicuous and necessary features of any amputation method. Below the shoulder and at the hip this may be effected by the old-fashioned tourniquet, or the modern elastic bandage, which may or may not be combined with the more complete bloodless method with which Esmarch’s name will always be connected. The pure rubber gum bandage, I believe, was introduced by Martin, of Boston, but the method of its use for bloodless operations upon the extremities is to be credited to Esmarch. The surgeon may avail himself of this method in all suitable cases, but should never resort to it in septic or malignant disease. It includes the application of a Martin elastic bandage from the tip of the extremity to the necessary height, by turns which shall make gentle and equable pressure, gradually forcing the blood from the compressed tissues and out of the limb, and up to a height where another elastic, or, at all events, suitable constricting band is placed with a sufficient degree of tightness to completely shut off access of blood. To so apply a bandage in septic and malignant cases would be to coax septic and malignant material into the veins, and would evince the worst possible judgment. A sufficiently strong rubber tubing forms an effective tourniquet, which, however, should be applied over a folded towel, or in some manner so that it does not too deeply constrict and compress the soft tissues of the limb. Instead of tying a knot it may be secured with an ordinary clamp forceps.

The tourniquet should never be applied over the leg or forearm, for it can here make no impression upon the interosseous vessels. Its application should be begun by pressure upon the vascular, i. e., the adductor side of the limb, so that venous choking may be avoided. After it is once in place the limb should not be completely flexed nor extended, lest the tissues firmly enclosed by the constriction be more or less spontaneously torn; nor should the tourniquet be too long left in place, as injury to the vessels is the possible result.

The bloodless method of Esmarch is furthermore subject to the following disadvantages. It is sometimes followed by serious and permanent paralysis of the limb, the result of prolonged or excessive constriction and compression of the motor nerve trunks. Similar results (in the arms) follow the use of crutches as well as of pressure of the side of the operating table when the limbs are allowed to hang over it. Again after removal of the bandage there is sometimes most pronounced capillary oozing due to vasomotor paresis. This may be controlled by the stimulation of hot irrigation or applications, and by more or less massage of the limb. The dangers of forcing undesirable material into the circulation have been mentioned, in addition to which should be recorded the increased absorption of toxic substances.

When there is good reason for not using the elastic bandage, save as a tourniquet, much of the desired effect may be obtained by holding the limb for a few minutes in a vertical position, so that its contained blood is drained out of it by gravity, after which the tourniquet may be applied as before.

The cocainization of nerve trunks, as they are exposed and divided, is one of the new measures for the prevention of shock for which we are largely indebted to Crile. It has proved to be a most valuable expedient which should not be neglected. (See Chapter XVIII.)

Under modern methods more is expected of an amputation stump than in days gone by, and the first demand is that it shall be useful, to which end it is necessary that it be both movable and that its end be not too irritable, nor the scar too sensitive to stand at least a certain amount of pressure. It is expected that suitable prosthetic apparatus, i. e. artificial limbs, shall take the place of severed lower extremities and of most arms or hands removed. The skill and the mechanical ingenuity of the maker of artificial limbs have now reached a point where most acceptable substitutes are thus provided, but for them suitable stumps should be afforded by the surgeon, and there should be coöperation from each direction. Thus it used to be held that the bone end in every stump should be covered with periosteum, yet it has been recently shown, especially by Hirsch, that such bone ends are as acceptable, and perhaps more so, when stripped of rather than covered with this membrane, the latter being sensitive, and there being no advantage in the presence of such new bone as may be formed by its preservation.

Many a good stump may be molded in various ways, but always provided that the end of the bone be smoothly divided, and have no corners or osteophytic outgrowths to make pressure upon the sensitive scar. For this reason it should be manipulated as early as possible, and should not be allowed to undergo the atrophy noticeable in stumps left after old operations. If primary union be gained, so long as the cicatrix and the nerve ends be kept out of the way, one may expect a stump which is serviceable in every respect. The ideal method is that the skin and the periosteum should retain their normal relationship, an ideal best attained in the supracondyloid operation after Gritti’s method. Various osteoplastic methods have been devised, first by Walther, in 1813, and since him especially by Ollier, Pirogoff, Gritti, and Bier. The latter would cover every bone end not merely with periosteum, but with a bone flap so arranged that its lower surface is one normally covered by periosteum. The introduction of the x-rays has permitted a more thorough study of bone ends in stumps which are, on one hand, extremely tender, or, on the other, extremely serviceable, and the osteoplastic methods seem to conduce to the latter condition. Another matter of great importance is to so place the scar that it shall be neither subject to pressure nor to traction. If, therefore, the sawed surfaces be covered with a periosteum which shall retain its normal relation to its coverings, a minimum of disturbance in the scar is the result.

The value of early use of the stump and of accustoming it to pressure is considerable, as atrophic stumps are tender, like other disused parts, and there is, therefore, every reason for resorting to prosthetic apparatus as early as possible. As Kocher puts it, the following is the best procedure for the normal operation: “An oblique incision, combined if necessary with a longitudinal one, in the form of a racket or lanceolate incision through skin and fascia. After retracting the elastic skin the muscles are divided obliquely down to the bone. The periosteum is also to be divided obliquely. Periosteum is then separated along with the superficial layer of the cortex of the bone, by means of a sharp raspatory or chisel, or, when possible, a flap of bone having a movable periosteal hinge is made by means of the saw. Lastly, if only a thin shell of the cortex have been raised up along with the periosteum, the end of the bone is simply rounded off, while if a distinct flap of bone, by any osteoplastic method, have been divided, the end of the bone must be sawed in a curved direction so as to fit it. The periosteal or bony flap is sutured over the sawed surface of the bone to its periosteum, and the stumps of the muscles or tendons are sutured to each other, or to the surface of the bone at a distance from the sawed surface. Finally the skin and fascia are sutured; but in case where a periosteal flap or flap of bone and periosteum cannot be obtained in normal relation to other soft parts it is better to remove the periosteum entirely from the end of the stump, to scrape out the medullary cavity, and to round off edges of the bone as dentists do.”

While these methods give better results than those formerly in vogue, they also consume more time; but the days of brilliancy and rapidity in amputation are past, as time should be devoted to careful work, except only in those cases where emergency demands the most rapid and dexterous removal of a limb in the shortest possible time, and where every other consideration is sacrificed to the principal interest of preserving life.[75]

AMPUTATION METHODS.

With a view to simplifying this subject as much as possible the following methods alone will be considered: (1) The circular with its modifications, the oblique, the elliptical, the ovoid, etc.; (2) the flap method; (3) the mixed or skin flap and deep circular.

Choice of method sometimes leaves much, sometimes nothing, to the tastes or wishes of the operator. It should be based solely on the primary consideration of saving life and the secondary consideration of furnishing the most useful possible stump. To obtain the latter it is necessary that the bone be amply covered, except that its coverings be not adherent, that there be a minimum of disturbance of blood supply, that nerves be drawn down and divided as far from the stump end as possible, in order that they may not be entangled in the scar, and that the scar be so planned for and arranged that it shall be at one side, at all events in such position that no pressure shall be made upon it, and, if possible, also no tension by muscle action.

Elasticity of skin and contractility of the muscles vary much in different individuals, and it is not always easy to estimate either of them previous to their division. Consequently it is much better to make cuffs or flaps too long at first rather than too short. The existence of previous disease will always modify these local conditions, but, in general, the rule is laid down that the external flaps should be longer than the bone by from one-third to one-half the diameter of the limb.

1. Circular Method.

—The simple circular method is the simplest and easiest of all. It may be so performed as to furnish a solid musculotegumentary division, or skin cuffs may be made, which being turned up, permit a further circular division of the muscles and other tissues directly down to the bone. The former is preferable when possible. With an ordinarily long amputating knife the skin, down to and including the superficial fascia, is divided by one clean circular incision, made in one stroke; then by further circular cuts the muscles are divided in sections, the outer group being allowed to retract and expose the deeper layers, which are then divided at a higher plane. In this way the periosteum is reached. If sufficient time be afforded it may be circularly divided at the level of the last incision through the muscles, and then separated with a strong elevator or, as done by Kocher, with a chisel, in order that some portion of the exterior of the bone be raised with it. In this way a cuff of periosteum, or enough of it to cover the bone end, is detached upward, to the level where the bone itself is finally divided. The bone division is done with the ordinary amputating saw, or with the wire or chain saw.

The skin-cuff (Manchette) method differs in that the exterior flap is made wholly of skin, which is dissected as a cuff nearly up to the level of bone section, at which point the muscles are divided directly down to the bone. In this method the skin, fat, and superficial fascia should be raised together, and at no points separated from each other.

Modification of the cuff method, by which it is more easy to evert the circular flap, is made by one or two vertical incisions, by which the cuff is split some distance on one or both sides, thus transforming the cuff proper into two nearly square skin flaps. At other times the first method may be similarly modified, in which case we have to deal with two square flaps, including not only the skin, but all the tissues down to the bone.

Neudörfer still further modified the circular method for certain purposes by first making an incision along the outer or least vascular part of the limb, carrying the knife directly down to the bone, retracting the wound edges, and thus exposing the bone, which is then divided with a chain or Gigli saw. After the bone is divided the soft coverings are lifted to a sufficient distance below the saw line to ensure ample covering, then divided as above. The method is a slow one and is especially serviceable for amputation of the thigh, at its middle, for diabetic or senile gangrene, where it is so desirable to protect vascular supply from injury (Fig. 677).

The so-called elliptical method is practically a circular incision carried obliquely around the limb, the upper and lower ends of the ellipse being indicated by previous small incisions at the proper height. The skin and superficial fascia are retracted from the lower portion of the ellipse by turning them up to the level of the highest point, at which level the muscles are divided transversely by a plain circular incision. A modification of this method is the so-called ovoid or racket, which is simply an oval division with a pointed end, the margins of the flap being united in the long axis of the bone. This method is frequently applied in amputation of the fingers. (See Fig. 683.)

2. Flap Methods.

—Flaps are either cutaneous or musculocutaneous. In every case the skin surface must be larger than the muscular. They are objectionable in that the skin flap is apt to slough, although least so about joints. The flap method is advantageous in that one flap may usually be made much longer than the other, and the longer one so doubled over at its end as to place the scar out of harm’s way. In certain injuries where the skin is much more injured on one side of the limb than on the other the operator is compelled to resort to flaps, unless he divide the limb much higher than might otherwise be demanded. Double flaps may be anteroposterior or lateral. A double flap practically results from a circular incision, carried through to the bone, with lateral division on either side, while a double flap with one long member may be similarly furnished by an oblique circular incision with the lateral prolongations.

Flaps may be formed by transfixion, for which purpose a long, sharp, amputating knife is required. Inasmuch as it makes an oblique and irregular division of the principal vessels, which are in consequence more difficult to secure, and by which nutrition of flaps is endangered, it is not to be commended, save perhaps in certain amputations about the wrist. A better method of making the flap is to divide the skin and fascia with an ordinary stout scalpel, and then, permitting them to retract, to divide the muscles obliquely toward the bone in such a way as to leave a flap wedge-shaped at its base. The anteroposterior amputations of the foot, thigh, and arm are better performed in this way, each flap being in length preferably three-fourths the diameter of the limb. (Matas.) An extension of this method furnishes the possibility for various subperiosteal amputations to be described below.

The osteoplastic methods of today furnish desirable operative procedures. One of the earliest of the good ones was Teale’s method, as applied to the leg, of double quadrangular flaps, the anterior being much the longer. A minor degree of this work includes simply the preservation of a cuff of periosteum, which is supposed to afford protection to the marrow cavity and a smoothly rounded bone end, without adhesions to the overlying soft parts; but much more complete operations are afforded by Pirogoff’s amputation at the heel, and by Wladimiroff and Mikulicz’s amputation of the foot (practically an exsection of the heel), or by Gritti’s and the other methods of supracondyloid knee amputation, with preservation of the patella. Bier and other foreign and domestic surgeons have also devised methods of reflecting or raising bone flaps from the continuity of bone shafts, which, being still connected by periosteal bridges, are so turned and fastened in place as to furnish a complete bone end over the stump (Figs. 678 and 679).

The choice of method must depend, to a large extent, on the character of the case. Some injuries will leave parts so exposed that a portion of a limb can still be utilized if only flaps be cut in an atypical way. One need never hesitate to resort to these, especially about the hand and upper extremity, where it is so desirable to save every inch of tissue. It is not necessary to preserve every possible inch of tissue in the foot and leg, as the makers of artificial limbs can adapt an artificial leg to any kind of a stump. The intent in making these statements is that while it is best to follow conventional methods under ordinary circumstances, there need be no hesitation in departing from them when occasion demands it.

It is essential in caring for every stump, after the actual amputation has been performed, (1) that bleeding be absolutely controlled; (2) that nerve ends be placed out of the way of cicatricial entanglement; (3) that proper drainage be provided; (4) that the soft parts be so brought together as to unite in the promptest and most perfect fashion. The possibility of the latter will depend very much on the occasion for the operation and the condition of the tissues. Operating in the presence of previous disease, as when the parts are inflamed or edematous, or as when one amputates at a point where more or less sloughing and separation of tissues have already occurred, the surgeon cannot look for such primary repair as furnishes an ideal termination, nor should he endeavor to make such close suturing or approximation as he would otherwise attempt. In fact, under these circumstances, it is often desirable to leave the wound widely open, perhaps packing it with yeast, in order to hasten sloughing and secure healthy granulating surfaces, which may be then brought together by secondary suture or by suitable strapping and bandaging. Nothing worse can happen than imprisonment of the debris resulting from the sloughing process.

But an amputation wound made with faultless technique, and in tissues previously healthy, may be closed with a minimum of drainage, or often without any, providing it be so closed as to leave no dead spaces in which blood clot may accumulate. This requires careful suturing, by numerous buried sutures, of muscle to muscle, tendon to tendon or to periosteum, and the like, the wound being gradually closed from its depth, and finally so bandaged that equable pressure shall be made, with comfortable support, but without undue pressure at any point. In aseptic cases animal ligatures and sutures (chromic gut) will prove reliable and efficient. In septic cases it would probably be better to trust to (secondary) silk, especially if parts are to be long exposed, so that it can be later removed. For the superficial wound silkworm sutures answer admirably.

For drainage a gauze packing for the worst cases, one or two tubes for ordinary cases, and for those which scarcely need it strands of catgut or of silkworm-gut, or two or three little rolls of oiled silk, will be sufficient.

In this country Link and in Germany Credé have practised the method of bringing parts together merely by equable pressure and bandaging. This has been of late modified by the use of strips of sterile adhesive plaster; and in certain instances, everything else favoring, it has given good results. It might be advantageously adopted in cases where it is feared that it may be necessary to reopen the wound, as it would permit an easy method of so doing.

Dressings should be copious and snugly applied, and the limb involved should be immobilized. Thus after a leg amputation it is well to bind the leg and thigh upon a suitably arranged splint, physiological rest, which is so essential to success, being in this way attained. The same is also true of the arm.

AMPUTATIONS OF THE UPPER EXTREMITY.

Amputations of the Finger and Thumb.

—It is desirable in the upper extremity to save every portion which can be preserved and still made useful. This is particularly true of the fingers, where every half-inch adds to their usefulness. When it is possible the palmar surface should be saved and made to cover the stump end, as it is not only more sensitive but denser and stands wear better. This is equally true of disarticulations or of divisions between the joint ends of the phalanges, which are best exposed by bending the finger, cutting the dorsal flap in this position, then stretching it and cutting the palmar flap (Fig. 680).

The vessels and nerves lying on the lateral aspect should be secured against hemorrhage, and cocaine solution introduced if local anesthesia is being practised. It is important also to remember the arrangement of the common palmar synovial bursa, with the digital prolongations to the thumb and the little finger, and that the three middle fingers are ordinarily shut off from it. Nevertheless if tendons be divided near the hand, and short finger stumps be made, it is easy to infect this common palmar bursa through retraction of the tendon and the consequent opening up of a tunnel directly into that cavity.

Figs. 680 and 681 illustrate the best methods of amputating fingers through a phalanx or at the joints, while Fig. 682 shows the best method of closing the wound. In this way a serviceable finger-tip is preserved which will stand every irritation to which it will probably be subjected.

When the finger is to be disarticulated from the hand a modified oval flap is preferable, with its long flap on the radial side and the scar on the dorsum rather than in the palm. The thumb is perhaps best separated at an articulation by a single palmar flap, without the preservation of the sesamoids which belong to its short flexor. Fig. 683 illustrates the various flaps and methods preferable at the bases of the different fingers.

When two or more fingers have to be removed the incision should be planned to meet the indications. When the first three fingers have to be removed, with or without that portion of the hand to which they are attached, leaving only the thumb and little finger, I have repeatedly followed to advantage the suggestion of Lauenstein, and through a small incision properly placed have, with cutting forceps, divided the first and fifth metacarpal bones at about their middle, and have then given to each of the remaining digits a quarter of a revolution toward each other, in such a way that when their tips are flexed there was better prehensile power, the hand acting similarly to a more perfect claw. If they are to be maintained in this position during healing they must be suitably held upon the splint to which the entire hand and forearm should be attached.

When an entire finger is to be removed it is a question whether the metacarpal belonging thereto should also be sacrificed for cosmetic purposes. In general this is undesirable except in the case of the fifth metacarpal with the little finger. This is easily exposed by lateral incision along the ulnar border of the hand, sufficient to disclose the bone and permit its disarticulation from the carpus. The same is also true, in at least some instances, of the thumb, but it is unwise to expose the carpal joints to the possibility of infection when this can be avoided; moreover, the deep palmar arch crosses just in front of the bases of the second to the fourth metacarpals, where it must be carefully avoided. If, then, the metacarpal is to be sacrificed this should be done rather from the dorsal side, while for cosmetic purposes alone it is usually sufficient to disarticulate the finger at its base and then simply remove the head end of the corresponding metacarpal. Figs. 688 to 692 furnish illustrations of how the incisions may be best planned to effect either of these purposes.

Hand Amputations and Wrist Disarticulations.

—While it makes but little difference whether the metacarpals be disarticulated from the carpus or the latter from the radial end, it is advisable to adopt whichever line of separation will best meet the indications. For a removal of the hand at or near the wrist two flaps usually afford the most serviceable method, the palmar tissues being preserved, if possible, in order that they may cover the stump. This operation is usually done for injury, and it is more than likely that one will have to plan his flap according to the tissues which still are serviceable.

In the lower part of the forearm the flap method furnishes a serviceable stump. As the elbow is approached the circular or elliptical methods are preferable, as illustrated in Fig. 690.

The Elbow.

—With elbow disarticulations caution should be observed to have flaps of sufficient length. The joint is opened more readily from its radial side. The integument of the back of the elbow region lies closely upon the bone, is thin, and retracts but slightly. Anteriorly there is more muscular covering and consequently a tendency to retraction. Therefore the anterior flap should be made longer than might otherwise seem to be required. Here the ideal scar will be behind the end of the humerus, but it is difficult to obtain because of the tendency to drag it around beneath the end of the bone. An elliptical incision, directed obliquely downward and forward, is the easiest method and furnishes the best stump. The lower end of the posterior part of the flap should be at a distance below the articulation, at least equal to the transverse diameter of the joint itself, i. e., in an adult nearly one hand-breadth from the line of the joint to the point of dissection. (Matas.) (Fig. 690.)

The Arm.

—The arm furnishes that nearly cylindrical outline best adapted for circular amputations. Here, as at the elbow, the greatest retraction is on the flexor side. With the arm should be saved all that is possible even up to its upper extremity.

Remembering the greater tendency of the flexors to contraction the truly circular method should be modified to a somewhat elliptical incision, in order to compensate for this difficulty, while an external liberating incision is often of assistance. Abrupt transverse division of the muscle down to the bone should be made after the oblique incision of the skin.

Disarticulation at the Shoulder.

—Until accurate methods of blood control were introduced this was an amputation viewed usually with disfavor, in spite of the fact that compression of the axillary artery in theory is easy. The older methods comprised this compression, either above the clavicle, or by exposure of the vessel and its proximal ligation, or by opening and separating the joint and then seizing the vessels within the inner flap, and controlling them by digital pressure until their division. Now with the use of Wyeth’s pins and the elastic bandage, effectual control may be secured without resorting to any of the former expedients. If the removal is to be a high amputation, just below the neck of the humerus, the method shown in Fig. 691, of application of the tourniquet and its control by a constricting strap, may be adopted.

If the surgeon expect to disarticulate he should resort to the pins of Wyeth (i. e., to the use of long mattress needles), which are passed through from above downward, or from the axilla upward, one of them being passed anteriorly and the other posteriorly, and brought out at corresponding points on the upper aspect of the shoulder, where, their points being protected by sterilized corks, they serve to prevent sliding of the elastic bandage or tourniquet, which is now placed proximally to them, and is thus held more securely than is possible in any other way.

Circulation being thus controlled, a modified circular operation may be made or a long external and superior flap cut, matching it with another one dissected from the axillary aspect. In the former case the circular incision is made on a level a little below the anatomical axillary border. Then a cuff of skin being raised while the arm is held in adduction, all the soft parts are divided to the bone and separated from it. Now a liberating incision may be made from the anterior border of the acromion to the coracoid process, then over to the deltoid groove, and along it to the first circular incision. Through this all the soft tissues surrounding the glenoid margin are separated, and then the bone is enucleated by opening the capsular ligament, reserving perhaps the detachment of the group of scapular tendons until the last. If one have any fear as to the efficiency of his hemostatic precautions he may secure the axillary vessels so soon as they are divided and then proceed with the disarticulation as above. In some cases it may be preferable to cut a wide flap from the deltoid region, preserving that muscle or not as may be desired, and, after having thus exposed the joint, make the disarticulation, separating the head of the bone sufficiently to allow the passage of an amputating knife behind it and down along the shaft to a distance sufficient to justify turning it abruptly and toward the surface, and then cutting out the axillary flap. The attempt should be to cut all the vessels at right angles rather than obliquely.

Plates LVII and LVIII, prepared by Professor Matas, afford a synoptic view of the more useful lines of skin incision in the principal amputations of the arm and shoulder.

Interscapularthoracic Amputations.

Removal of the Entire Upper Extremity.

—This includes removal not only of the arm, but of the scapula and clavicle as well, or at least its outer portion. It is not often required, and inasmuch as the circumstances which justify it are seldom duplicated, a suitable method for each individual case should be planned, rather than try to make one set of directions cover them all. Much will depend upon whether sufficient skin can be saved in order to cover the large defect thus made. In general, however, an incision should first be made along the clavicle, exposing it and dividing it near its middle. It is convenient to take out the middle portion at this time, and in this way to afford ample room through which a proximal ligation of the subclavian vessels may be made, they being here carefully dissected out, secured by double ligation, and divided. From the outer part of the above incision another is carried downward and outward toward the deltoid groove and then beneath the axilla to its posterior margin. The posterior flap is then furnished by an incision continuous with the last one, which terminates below about opposite the lower angle of the scapula, and is then continued upward along the inner scapular border and over the shoulder until it reaches the outer end of the incision first made. In this manner will be furnished a sufficient covering. The balance of the operation consists in the gradual separation of the entire mass from the outer wall of the thorax. With a preliminary ligation of the subclavian vessels there will be no hemorrhage which cannot be easily checked by pressure and forceps.

The above, however, is only a general description, which may need to be modified in most cases. If the amputation be done for injury all the skin which is still viable should be utilized, no matter how shaped, while if done for disease the incisions may have to be modified materially, taking more skin from one side and less from the other, in order to avoid that involved in the disease process.

In the majority of cases the result is satisfactory, in spite of the mutilation thus afforded.