OSTEOPLASTIC AMPUTATION OF THE ARM.
has published his investigations regarding the carrying capacity of amputation stumps, formed according to his osteoplastic method, it is but natural that we should have adopted his plan of operation when performing amputations on the lower extremities, except in cases of diabetic and senile gangrene. As a matter of course, the employment of his method has been more rarely extended to amputations on the upper extremities. Up to January, 19oo, Bier himself had used it in amputation of the arm only once. (A. Bier : " Ueber Amputationen u. Enartikulationen," Sammlung klin ische Vortrage, neue Folge, No. 264, page 35).
Feeling convinced that also this class of cases must be benefited by this procedure, I recently performed osteoplastic amputation of the arm in a man, fifty-eight years of age, who had within the last six months twice undergone extirpation of an ulcerating epithelioma at the lower end of the dorsum of the forearm, at the hands of another surgeon. He now presented a second recurrence of the disease. Amputation of the arm at the junction of middle and lower thirds seemed in dicated. and was done, according to Bier, in November, 1900, at the Post-Graduate Hospital.
Under artificial anmmia a large tongue-shaped skin-muscle flap was formed, with its convexity downward. Quite a number of muscular fibres were left adherent to the periosteum, which was divided by an incision corresponding to about 270 degrees of a circle, a little larger than a fifty-cent piece, with its upper base about a finger's width below that of the skin-muscle flap. Then, the periosteum having been pushed back for about one-quarter of an inch with the raspatorium, a bone-flap was sawed out with the convexity downward. The saw used (see Fig. 2) was con structed by me last summer for this class of operations. When approaching the periosteum at the upper end, the saw was re moved and quite a portion of the bone broken with the help of two sharp pointed elevatoria. I had to refrain from biting off the upper, irregular part of the bone-flap with the rongeur forceps on account of the extreme frailness and thinness of the periosteum, which, in spite of most gentle handling, tore in different places. However, I succeeded in well stripping back the periosteum at the upper end for at least one-fourth to one-third of an inch upward, so as to give the bone-flap a good pedicle. Now a small posterior (internal) skin-flap was formed and the shaft of the bone sawed off in a curve, with its convexity upward. When placed in posi tion, the convexity of the bone-flap nicely fitted into the concavity of the shaft, thus sealing the marrow cavity and fully covering the bone itself. The operation was then finished in the usual way. It proved impossible, however, to fasten the periosteum which overlapped the osteoplastic bone-flaps to the surrounding tissues with catgut stitches, as it ought to have been done. Every stitch tore. The piece of bone was therefore simply placed in position in front of the marrow cavity ; suture of the skin; one short drainage tube at inner angle. When completing the dressing, it was distinctly felt, to our annoyance, that the small bone-flap slipped to some extent. Healing took place by primary union. In order to give the bone-flap time to become attached to the sur rounding tissues, the dressing was not touched for the first twelve days.
Three weeks later the chain of infiltrated glands below the subclavian and axillary veins were removed. On January 9 the patient was presented before the New York Surgical Society with a good stump.
As will be seen from the accompanying X-ray picture (Fig. 1), which was kindly taken for me by Dr. F. N. Wilson, Instruc tor in Surgery at the Post-Graduate School, the bone-flap really had moved put of place a trifle. Nevertheless, as the illustration shows, its one side well sealed the marrow cavity, so that hard pressure against the lower end of the bone, as well as a hard blow against it, was absolutely painless. According to Bier, the sealing of the marrow cavity with bone generally suffices to make the stump painless. However, it is better and easier to cover the entire cut surface of the shaft with a piece of bone.
In my next osteoplastic amputation of the arm, I shall let the periosteum overlap the bone-flap for a good deal more still, in order to be sure to have sufficient when putting in the neces sary catgut stitches, folding up the brittle periosteum if neces sary. I shall also make the inner skin-flap somewhat larger than I did in this instance.
Of course, when amputating other parts of the extremi ties according to Bier, especially the tibia, we need not fear annoyance from the friability of the periosteum, as here the periosteum is invariably firm and not likely to tear.
As regards the saw, I am well aware that Gigli's saw may be used to some advantage in osteoplastic amputations, par ticularly on the tibia. When operating on humerus and femur, it will, however, be found unsatisfactory.
Bier makes use of Helferich's bow-saw, modified by him self. The traction-hook at either end carries three slits, one in line with the bow, and one each on the right and left side, at an angle of about 85° to the first.
As mentioned above, I have constructed a saw for this kind of work, which enables the surgeon to give the blade any angle desired. It is made by Messrs. George Tiemann & Co. This saw will be found especially useful, I think, in forming the small round bone-flap of femur and humerus, as required in this mode of amputation. It may also be advantageously used when making a concave or convex cut of bones for other purposes, for instance, in Kocher's resection of the knee or elbow. In the case just reported, it has given me entire satisfaction. The accompanying cut (Fig. 2) nicely illus trates the instrument.
The traction-hooks at either end of bow are octagonal; this permits of setting the blade at almost any angle. To change angle of blade, loosen traction-screw, C; then push back the traction-hook at end nearest the handle of the saw and turn the blade to the desired angle. Then push back the traction hook nearest the handle into the slot of the socket corresponding to the angle of the blade. The traction-hook D will follow voluntarily. This being done, the blade is again made taut by the traction-screw, C, when the saw is ready for use.
The saw is thoroughly aseptic, as both traction-hooks can be easily removed from the bow after the blade has been unhooked.
S OF LACERATION OF THE SPLEEN AND OF THE KIDNEY FOLLOWED BY AFTER THE REMOVAL OF THE INJURED ORGAN.
case of laceration of the spleen is reported at this time to make more complete the record of work in the Surgery of the Spleen contained in the memoir of Professor Warren published in the May number of the ANNALS OF