Amputation, from amputo, to cut off, is one of the most common, simple, and, however para doxical, one of the most difficult operations in surgery; for, to execute it scientifically and dex terously, requires a most intimate knowledge of the relation of the arteries to the veins, nerves, and muscles. This operation is performed, when a member of the body is so injured or useless, as to be of no service to the individual, and the surgeon is placed in a most critical and perplexing situation, and requires a firm mind to decide, whether or not nature, if assisted by art, might not restore the use of the limb, a consideration of such importance to the individual, that am putation ought never to he performed without the deepest reflection. In private practice, there are all the various comforts of life; but in an hospital, there is extensive suppuration and gan grene staring the conscientious operator in the face; on board of ship, there are the inconvenience of the elements to contend with, and the distance from port; and on the field of battle, there is the exposure of the wounded to the inclemencies of the weather, the transportation to a house or hos pital, the breaking up of that hospital on the approach of the enemy, and a thousand incidents at once embarrassing and perplexing; so that, too often, the most fixed axioms in surgery are overturned by these fortuitous events. We have already stated under mortification, that gangrene resulting from mechanical causes, or traumatic gangrene, requires amputation: and it may be set down as a general law, to amputate whenever a joint is exposed together with fracture of one or more bones entering into the formation of that joint, or the main artery of a limb so injured as to cut off its circulation, or the limb extensively contused and lacerated: in short, in such a con dition, that it is the surgeon's conscientious belief and conviction, that no other means than this will save the limb, or probably the patient's life. But such a variety of opinions exist on these points, that much must be left to the discretion of the surgeon. Compound and mutilated fractures afford other grounds for amputation, and when these injuries occur from musket-bullets or grape shot, the bone is generally much shattered, and the fracture very oblique; hence in such cases there can be no precise rule. When a limb is torn off by machinery or cannon-shot, amputation is performed, in order to make a clean and neat stump. White swelling of a joint in the last stage, large exostosis of a bone impairing the health by its bulk and weight; osteo-sarcoma attacking the bones of the extremities; caries and necrosis affecting these bones and injuring the health, or producing luxation of a joint, with anchylosis and deformity, require this operation. Fungus h2ema todes, or medullary sarcoma affecting the ex tremities, or even other species of sarcoma in capable of extirpation; old ulcers of the leg or arm, affecting the bones or articulations, or producing hectic fever; deformity of a limb itself may require amputation. From these cases it appears, that a limb should he amputated, when there is no pros pect of saving it; and when the disease threatens to endanger the patient's life; when the limb is cum brous and useless, and that its removal would be of essential service to the individual.
In extensively contused and lacerated wounds, in compound fractures, in compound luxations, in cases where the arterial trunk of the limb is de stroyed. and where the limb is torn off, amputation should be performed whenever the system has ral lied from the shock of the injury. For, at first, the patient is exhausted, cold and lifeless, and requires some minutes or even hours, before the nervous and circulating systems regain that degree of strength to bear such another shock; because in so great a dismemberment of the body as a thigh, the patient must be overcome, even granting that not a drop of blood were spilt. If therefore amputation be performed too early, one shock is added to another, and the individual is destroyed. When i the patient has rallied from the shock of the injury, his skin becomes warmer, the pulse beats stronger, and he complains of thirst; and if this critical pe riod be overlooked, or if the surgeon does not ar rive until it is passed, inflammatory action has commenced, and then the operation must be defer red until all inflammation i3 subdued. Afterwards, when suppuration is completely established, and if then there appears no prospect of saving the limb, it should be amputated: and should the inflamma tory action run on even to mortification, this ope ration must also be performed. In cases of caries,
necrosis, fungus hamatodes, and tumours of the bones, if the patient has just arrived from a jour ney, or has any degree of fever, some days of re pose should be allowed him before operating. Prior to the use of the ligature, a limb was either cut off with a red hot knife, or the stump seared with a red hot iron or boiling oil; and before Petit's tourniquet was invented, a general circular compression was employed to compress the arte ries. Objections arc urged against the tourniquet, but if it is properly applied they are fallacious. This instrument, delineated in Fig. 3 of Plate DXVII, ought to be always used in amputation, when a large artery is to be divided. A bandage of calico four inches in breadth is firmly rolled up until it is about two inches in diameter, which is to be applied in the course of the artery on the proximal portion of the limb, sufficiently distant from the point where it is to be amputated, and the roller fixed to the limb with a bandage suffi cient to surround it; the screw of the tourniquet is then placed on the roller, and the buckle on the outside of the limb. The screw is not to be tight ened until the operator has the knife in his hand, in order that the artery and other textures may be compressed for as short a period as possible. The deviation of the superficial femoral artery, which occurred lately to Mr. C. Bell, when securing it for aneurism, is a satisfactory evidence of the ne cessity of a tourniquet, and of not trusting to the compression of the artery by means of the fin gers of an assistant, who may become agita ted or seized with sickness, fainting, cramp, or epilepsy.
There are various ways of performing amputa tion. In the days of Celsus it was done by the skin being previously retracted, and a circular incision made at once to the bone, from which the soft parts were detached and drawn upwards, and the bone sawn, which in our opinion is the best mode of performing the circular amputation, and, if ap plicable any where, to the middle of the arm. Pare and Wiseman operated in the same way, but used stitches to the wound, as practised by some mo dern surgeons, and Wiseman laid aside the use of retractors, which are formed of linen, leather, or tin, to keep the soft parts out of the way of the saw. The flap operation below the knee-joint was next invented by Lowdham. J. L. Petit made the double circular incision of the soft parts, the first through the integuments, the second through the muscles of the bone, after the integuments had beewdrawn upwards; and this is the method corn monly adopted when the circular operation is pre ferred. Ravaton made a circular incision to the bone, then one on the fore part and another on the hack part of the limb upwards or proximad for four fingers breadths detached these flaps from the bone, which he afterwards sawed. Vermale ope rated by transfixion, with a long bistoury, which is the mode followed by Desault, Lisfranc, and others. Various instruments and other inventions were contrived by Verduin and others, to super sede the necessity of ligatures to the divided arte ries, and, strange to tell, some of these are at the present day used in Germany by Dr. Koch. Man quest de La Mothe seems to have been the first who carefully drew out the arteries from the con tiguous veins and nerves with the forceps, before securing them with the ligature, and Alanson with the tenaculum. The forceps are best for large ar teries, or arteries surrounded with loose cellular substance; the tenaculum for small arteries imbed ded in the muscles, and the curved needle the latter arc indurated or converted into cartilage Louis invented the division of the loose muscles in the first incision, and in the second those adherent to the hone, a mode much used by those who re commend the circular incision. Allanson, af ter the circular division of the skin and its retraction, attempted to make a circular oblique incision of the muscles upwards or proximad, so that when the bone was sawn, the stump should present a concave cone, the apex being the trun cated bone; but in effecting such a form of stump, he must clearly have deceived himself, for in no other way than by two or three circular sweeps in succession can a concave cone be accomplished, as is clearly proved by Marten, Richter, Hey, Graefe, and Langenbeck. Yet this mode of forming a concave cone is talked of by the majority of sys• tematic writers. Kirland cut off a piece of skin at each angle to prevent puckering.