SUK(4IG AL STITMPS. THE 
PATHOLOGICAL ANATOMY 
OF 
SURGICAL STUMPS 
JULES F. M. CHAUVEL, M.D., 
BY 
Director of the Imperial School <*• Mjarmacy at 
the Military Hospital, 
[Translated from the French by B. E. CotI 'Huijitt). 
Consulting Surgeon of the Boston City Hospital?]™ 
BOSTON : 
DAVII) CLAPP & SON, PRINTERS. 
1 869. Dr. Chauvbl’s Paper in the Archives Generates 
de Medecine for March, 1869, having been con- 
sidered a valuable contribution to Burgical knowl- 
edge, was translated for the Boston Medical and 
Surgical Journal. On asking for a few extra 
copies, the printer obligingly arranged the present 
form which those who wish to preserve the article 
for reference may find convenient. 
Roxbury (Boston Highlands'), U. S. 
May, 1869. CONTENTS. 
History of the subject .... 1 
Researches 7 
State of the Cicatrices .... 9 
State of the Muscles . . . .10 
State of the Vessels ..... 12 
State of the Veins ..... 16 
State of the Nerves 17 
State of the Bones ..... 33 THE PATHOLOGICAL ANATOMY OF 
SURGICAL STUMPS. 
While two years attached to the Infir- 
mary of the Hotel des Invalides, we dissected 
and examined all the surgical stumps of 
those who died there during that period, 
and we propose to give a condensed state- 
ment of the results of our researches in the 
following paper* after a few words on the 
history of the subject. 
History.—The first observations on the 
condition of surgical stumps date from the 
close of the last century. They were made 
in Germany, and form two inaugural theses. 
(Dezeimeris, Diet, de M4d.—Art. AImputa- 
tion.) 2 
In France Larrey took up these researches 
during his residence at the Invalides. The 
conclusions he arrived at may be found in 
volume third of his Clinique Chirurgicale. 
He insists mainly on the changes which 
take place in the divided nerves. He veri- 
fies the tumefaction of their extremities; 
from which he makes very delicate nerve- 
filaments issue to lose themselves in the ci- 
catrices. lie considers these filaments con- 
ductors of animal electricity. lie meets with 
unusual reunions of divided nerves in three 
stumps of the arm ; and sees in these nerve- 
anastomoses a provision of nature to pre- 
vent loss of nervous fluid by thus insuring 
its return to its source. 
Changes in the osseous extremities did not 
escape his notice. According to him, when 
these serve as supports upon their whole 
surface, they enlarge, and the ends become 
flattened, like nail-heads. On the contrary, 
when not pressed upon, or when hanging 
free, the ends diminish in all dkections and 
become rounded ; the medullary cavity clos- 3 
es up, and the fibrous periostic tissue ad- 
heres to the cicatrix. Larrey sustains these 
views by seven autopsies. 
Cruveilhier (Anal. Path., iii. p. 755), un- 
der the name of traumatic neuromata, desig- 
nates the bulbs usually developed on the 
ends of the nerves in surgical stumps. He 
attributes their formation to the friction 
and pressure necessarily endured by these 
parts, as such formations never occur when 
nerves are divided in continuity. Dissec- 
tion shows, says he, that nerve-filaments 
spread out into the surrounding mass, and 
are soon lost; but the supposition of anas- 
tomosing loops is, he thinks, without foun- 
dation in fact. 
Guthrie (Comm., p. 75) relates that he 
once knew an operation to be proposed 
where tenderness of the terminal bulb of 
the sciatic nerve, after amputation of the 
thigh, had been mistaken for disease. For- 
tunately he was able to dissuade the pa- 
tient. We have many times endeavored to 
feel the terminal bulb of the sciatic nerve 4 
in patients whose thighs had been ampu- 
tated, but have never been able to find it. 
Hutin (Anat. Path., <&c.—Mem. Acad. 
Med. 1855), long time Chief Physician of 
the Invalides, paid great attention to the 
condition of the several parts forming the 
stump. He studied the cicatrization of the 
arteries, finding them sometimes converted 
into fibrous cords, sometimes permeable to 
the very extremity, being simply obliterated 
by a long plug of fibrin, thick and discol- 
ored, without trace of organization. 
He also examined with much care the 
nerve-bulbs, their appearance, structure, 
and termination. According to him, the 
filaments which issue from them are either 
nerve fibres, or simple cellular prolongations 
furnished by the neurilemma. The nascent 
bulb is formed by the retraction of the nerve 
substance within the neurilemma stretched 
by the cicatrix. At a later period it be- 
comes more or less increased in size by ad- 
dition of fat and hypertrophy of the neuri- 
lemma. He declares that re-union, end to 5 
end, of divided nerves does not exist in re- 
ality. By chance, nerves may be found in- 
volved in common fibrous tissue, and thus 
apparently re-united, but there is never a 
true reunion of their substance. 
The bones, he says, soften at their ex- 
tremities ; their walls contract; and the 
medullary cavity closes by a calcareous de- 
posit in the cicatricial tissue. This substance 
in excess often forms prolongations, spines, 
and considerable masses, which, by pres- 
sure on the soft parts and nerves, cause se- 
vere pains to patients. 
M. Notta has endeavored to show that 
the fibrous cord continues even to the cica- 
trix, and what is usually thought to be the 
obliterated artery is in reality only inodular 
tissue formed by the cicatrization of a fis- 
tula produced by the thread of the ligature. 
Lobstein (Anat. Path.) calls attention to 
the mucous bursae sometimes occurring on 
the osseous extremities in stumps ; formed 
there, he thinks, by the repeated frictions 
these parts are liable to. 6 
Legouest (Ghirurg. d’Armee) admits the 
re-union of the nerve-extremities end to end. 
He describes growths on the ends of bones, 
from specimens in the collection of M. IIu- 
tin, and gives figures of some of the most 
remarkable. He points out a different re- 
sult in this respect, after disarticulations, 
where the bones, he finds, become atro- 
phied. 
Alphonse Guerin (Nouv. Diet, de Med. et 
de Chir. Prat., ii. p. 87) doubts the pro- 
priety of regarding the nerve-swellings in 
stumps as a disease like neuroma, whose 
symptoms they are far from presenting. 
We may mention, also, as bearing upon 
our subject, a notice of the atrophy of arte- 
rial walls by Maurice Raynaud (Nouv. Diet, 
de Med. &c., iii. p. 232); and Nelaton’s 
view of the transformation of an artery into 
a firm ligamentous cord (id. iii. p. 172). 
He regards this as constant after a section 
of a vessel, and as the normal mode of vas- 
cular obliteration. Researches.—Our own conclusions are 
based upon thirty-two cases, as follows :— 
f upper third, 
3 
Amputations, thigh < middle “ 
4 
(lower “ 
4—11 
“ leg 
8 
“ arm 
. 6 
“ forearm 
1 
“ hand 
. 1 
Disarticulation, ante-scaphoid . 
1 
“ shoulder 
. 4 
32 
In a general view, the form of the stump 
varied with the member amputated. In 
limbs of one bone (thigh, arm) the stump 
always tended to conicity. This was pro- 
duced by muscular retraction, and some- 
times had been increased by wearing an 
artificial limb. The skin was also retracted, 
and the cicatrix in this way so drawn upon 
as to keep up the tendency of the bone to 
protrude. 
There was less conicity in members of 
two bones, as the shorter muscular fibres 
were fixed to the bones near by, and the skin, held down by more compact cellular 
tissue, had less freedom in retraction. 
On first section of a stump one is struck 
by the abundance of fibrous tissue, dense 
and firm, enveloping the osseous extremity. 
It attaches muscles, nerves and vessels to 
the cutaneous cicatrix, and thus serves as a 
common bond, uniting all these dissimilar 
parts. Its volume is increased at the ex- 
pense of other substance lost by the opera- 
tion. 
The actual state of the stump in our cases 
varied according to the disease to which 
the patient succumbed. If he died of a 
constitutional affection, cancer or tubercle, 
the stump shared the atrophy and emacia- 
tion characteristic of the last stages of such 
diseases. Its skin was then dingy and sal- 
low, the muscles were atrophied, and all the 
parts infiltrated with serum. If, on the 
contrary, the patient continued in good 
case, the stump remained well nourished, 
while a deep layer of fat thickened the skin 
and enveloped the thoroughly degenerated 
muscles. 9 
State of the Cicatrices.—Can the method 
of operation be made out by the form and 
position of the cicatrix ? Not easily, says 
M. Legouest and rightly. In almost all 
the cases we examined the circular method 
had been practised; and, nevertheless, in our 
eleven amputations of the thigh, for exam- 
ple, we found six circular and five linear 
cicatrices, almost invariably drawn a little 
backwards and inwards. The cicatrix, in 
short, varied according as the union was 
wholly or in part by first intention, or in- 
terrupted in any way in its usual course. 
In two disarticulations of the shoulder, 
however, the cicatrix clearly indicated the 
method employed, that of Larrey in the first, 
of Dupuytren in the second. In the ampu- 
tations of the leg and arm, the method could 
not be ascertained by the cicatrix. 
Cicatrices resulting from the same method 
not only varied in form and extent, but also 
in their nature and color; sometimes smooth, 
dull white, and quite thin, at other times 
violet, rugous, deeply injected and of great 10 
thickness. Generally the cicatrix adhered 
to the end of the bone by short interwoven 
fibrous hands. Occasionally these bands 
were elongated, and formed a mucous sub- 
cicatricial bursa. We met with such a 
bursa three times. 
State of the Muscles.—Fatty degeneration 
of the muscles has been described by all 
writers. It was recorded, with the atrophy 
that accompanies it, in almost all our ob- 
servations. Naturally, a muscle unused 
loses its powers and normal structure. This 
is a gradual transformation, and requires 
considerable time. We met with it in all 
degrees, both in different subjects, and in 
different muscles of the same stump. In 
some the change was so slight that the 
color, volume, and tenacity of the muscle 
were as of healthy tissue; and the loss of 
strim, if any, in its fibres, and commencing 
granular condition, were ascertainable only 
by the microscope. In others the degene- 
ration was so complete that the naked eye 11 
could perceive only a shiny, bleached, and 
almost fluid mass, breaking down under the 
fingers; while the microscope revealed 
large globules of fat, and only here and 
there vestiges of primitive tissue. In these 
results not only age had an influence, but 
nutrition also, in its bearing upon the gene- 
ral health and free circulation. 
Nevertheless, it must not be thought that 
every muscle divided in amputation must of 
necessity become atrophied and fatty. 
Sometimes when thus deprived of one point 
of attachment the muscle soon begins to 
acquire others. It fixes itself upon the new 
formations of bone, or finds a point of sup- 
port in the common fibrous tissue to which 
itself contributes a portion, and, in as far 
as its nerves are not destroyed and its 
functions are called into action, we find its 
volume and structure preserved. We do 
not state this upon hypothesis ; five of our 
observations demonstrated the truth of the 
assertion. 
We need not add more upon fatty de- 12 
generation, as it has been studied for a long 
time, and is now well understood. 
State of the Vessels.—Many and very im- 
portant works have been published on the 
cicatrization of vessels cut in continuity, 
having for their special object the mode of 
occlusion of arteries. The solution of a 
problem in pathological anatomy has not 
been so much sought for as the surest way 
to obtain a closure of the vessel. Ligation 
continues still the usual practice in ampu- 
tations. 
Our observations have been confined to 
stumps long after cicatrization had finished, 
and therefore we will now discuss only the 
following points:— 
Does the fibrinous clot-plug continue in- 
definitely in the vessel ? 
Is the clot susceptible of becoming or- 
ganized and of establishing with the vascu- 
lar wall intimate adhesions, fully organized 
and traversed by vessels ? 
Can the clot-plug be completely absorbed; 13 
and in such case can the walls of the vessel 
unite so as to form only a fibrous cord ? 
Does the arterial wall become thin, so as 
to resemble that of a vein ? 
M. Ilutin, in his remarkable work, re- 
cords the persistence of the clot-plug, fill- 
ing the cavity of the vessel, long years 
after the amputation. This we have met 
with nine times in thirty-two cases, or in one 
more than a quarter part. In all these 
cases the clot was fibrinous, whitish, firm, 
and formed in concentric layers—variable 
in dimensions and extent. It was sometimes 
prolonged up to the first important collate- 
ral from the very extremity of the artery ; 
at others no collateral marked its upper lim- 
it, while below it was lost in the walls of 
the artery so closely united as to transform 
the vessel into a simple fibrous cord. 
In none of these cases did the clot-plug 
present any traces of organization. Micro- 
scopic examination showed only fibrin more 
or less disaggregated, never any vessels. 
Sometimes the adhesions to the arterial 14 
walls were very intimate, but more often 
the clot separated readily. 
The absorption of the clot-plug, with the 
intimate and complete fusion of the walls of 
the artery, which was thus transformed into 
a simple fibrous cord, was met with more 
frequently. We noticed this in fourteen, 
or almost half our cases. This transforma- 
tion varied greatly. The adhesions were 
rarely abrupt; and the vessel seldom main- 
tained its normal calibre upwards. Accom- 
panied by a vein still more feeble than it- 
self, and proportioned to the parts to be 
nourished, the artery at once began to lose 
its dimensions. As it approached the 
stump it contracted, sometimes gradually, 
sometimes suddenly after having given off 
an important collateral. This diminution 
of calibre was noted fifteen times in thirty- 
two cases, and this, too, where the anatomi- 
cal situation permitted the easiest demon- 
stration of its reality. It was thus that in am- 
putation of the arm at the upper third, and 
in disarticulations of the shoulder, the axil- 15 
lary artery, after having furnished scapula- 
ry branches, shrivelled and became a true 
arteriole. There was no further occasion 
for it. 
In one instance only have we noticed the 
vascular wall thinned, resembling that of a 
vein. Oftener, four times, we have found 
it notably thickened. 
Besides these two modes of termination, 
sometimes the artery continued permeable 
even to its extremity, without clot-plug or 
fibrous terminal cord. Then the calibre 
either gradually diminished to the point of 
closure, or, on the contrary, remained un- 
changed, presenting the appearance a ves- 
sel should have immediately after ligation, 
i.e., a true cul-de-sac. When the latter oc- 
curred, a cluster of arterioles was not in- 
frequently found arising from this cul-de-sac 
to spread themselves into the common 
fibrous tissue. We have met with this 
permeability eight times, and in half of 
these cases the calibre of the vessel re- 
mained unaltered to its extremity. 16 
Like M. Ilutin, we have very seldom 
met with a fibrous cord which prolonged 
the artery to the cutaneous cicatrix, or 
that which M. Notta thought to be an in- 
odular band, correspondingto the former pas- 
sage of the ligature of the vessel. We have 
always found the artery itself terminating 
at a distance from the cutaneous cicatrix, 
varying according to the greater or less 
hindrance to the vessel’s retraction. Cut 
in the middle of the thigh, the artery will • 
retract strongly within its sheath. It pre- 
serves its original position only when re- 
tained in it by fibrous adhesions. 
We have not found atheromatous degene- 
ration when present more frequent or more 
advanced in the arteries of the amputated 
member than in other parts. 
State of the Veins.—Cicatrization of the 
veins has not been studied with the same 
care as that of the arteries. The direction 
of the sanguineous current and the presence 
of valves opposing its return, render, in 17 
fact, venous hemorrhages less frequent than 
arterial. If a vein is tied, obliteration seems 
to take place by adhesive phlebitis, forming 
a clot which is afterwards absorbed. The 
walls of the vessel then immediately fall to- 
gether, and are soon completely united. 
Thus, at least, we have always found it in 
our investigations. 
State of the Nerves.—Nerve-anastomosis, 
maintained by Larrey as a constant fact, 
and denied by Hutin who saw in it only a 
simple contact, has never appeared under 
our observation. Once we saw an internal 
cutaneous nerve seeming to be confounded 
by a loop with a median in the same termi- 
nal enlargement, but it was only a sem- 
blance, a simple juxtaposition of the termi- 
nal neuromata of these two nerve-trunks. 
Sometimes two nerves in contact were 
thus commingled in the terminal tumor. 
Sometimes a whole cluster of nerves were 
likewise englobed in one neuroma, as was 
especially seen in disarticulations of the 18 
shoulder. But even in these cases there 
never was an anastomosis. At one time 
the separate neuromata were intimately 
united to form one single mass where each, 
nevertheless, could be distinguished. At 
another time these neuromata, although 
buried in a common adipose tissue, had no 
connection whatever between themselves. 
We met with each of these conditions four 
times in eight amputations, of the arm and 
at the shoulder-joint. 
We may conclude, then, that real nerve- 
anastomosis is very questionable ; that even 
apparent anastomosis is very rare; and 
that, for the most part, the nerves have 
isolated terminations, although their extre- 
mities be enclosed in the same fibrous cica- 
tricial tissue. 
Larrey first demonstrated the termination 
of the divided nerves of a stump in a tu- 
bercle more or less voluminous and round- 
ed ; from which, according to him, nerve- 
filaments diverged to conduct the animal 
electricity to the cicatrix. 19 
Now, nerves for which there is no longer 
any use, present to the naked eye normal 
dimensions and aspect; and, on section, 
we almost invariably found them healthy 
under the microscope. But in a certain 
number of cases we met with the following 
state of things :— 
On longitudinal section three layers were 
readily made out:—1, the external, thin 
and white, formed by the neurilemma, a 
dense connective tissue; 2, the middle, 
yellow and often increased by adipose mat- 
ter as it approached the terminal protube- 
rance, being composed of a very loose con- 
nective tissue, with interspaces filled with 
fat; 3, the central, consisting of a white 
cord, variable in thickness, and dividing so 
as to be lost in the terminal bulb. This 
cord was composed exclusively of unalter- 
ed primitive nerve-fibres. 
This condition we have only seldom fall- 
en in with. Is it a cadaveric phenomenon, 
the result of an alteration of a nerve after 
death ? Nothing appeared that could give 20 
rise to such a supposition ; and there were 
no peculiarities in the subjects adequate to 
the solution of the question. The autop- 
sies were made at equal intervals after 
death. We must add, however, that we 
have met with this condition only in obese 
individuals, in stumps loaded with fat, and 
where the muscles were fatty in the highest 
degree. It gradually diminished upwards, 
and entirely disappeared four or five inches 
above the terminal neuroma. 
We find that all authors (Larrey, Ilutin, 
&c.) lay stress upon the club-like termina- 
tion of nerve-cords cut in amputation—a 
result differing from that obtained in expe- 
rimental nerve-sections, where the central 
end of the divided nerve is found to retain 
nearly its normal size to the point of cica- 
trization. 
In concurrence with M. Ilutin, we ought to 
state that this protuberance is not constant. 
In our examinations it was wanting twice in 
amputations of the thigh, twice in the leg, 
once in the arm ; and this, too, sufficiently 21 
long—five years or more—after the ope- 
rations. 
In all our other cases the nerves have 
presented these little tumors ; variable in 
de-velopment, yet always in proportion to 
the size of the nerve-trunk. Eight times, 
according to our records, they were not re- 
markable ; sixteen times, they were volu- 
minous. We shall see presently whether 
it is possible to explain these variations. 
Four times we have met with many such 
tumors developed along the course of the 
same nerve near its extremity ; once on the 
tibial saphena, once on the external popli- 
teal sciatic, and twice on the median; 
without anything to explain the peculiarity. 
In general, the protuberance is, as it 
were, a continuation of the nerve on which 
it is developed; sometimes, however, it 
seems to be merely in apposition. 
Each nerve appears to have its special 
and very distinct neuroma. This should 
be so, necessarily, when their extremities 
are apart from each other. But the same 22 
condition is found also when nerve-trunks 
are divided at a point where they are 
brought quite together, as in the axilla, for 
example. Besides, it is not astonishing 
that all such neuromata, naturally in con- 
tact, should, though distinct, be englobed 
at their inferior portion in a common fibrous 
mass connected with the cicatrix. The 
fibrous bundles of hypertrophied neurilem- 
ma adhere, interlace, and form this common 
portion of the protuberance. 
In a single case of disarticulation of the 
shoulder, we found the extremities of the 
nerves so lost in the common mass that it 
was impossible to separate them or to dis- 
tinguish their particular bulbs. 
These protuberances generally had an 
elongated shape, in the direction of the 
trunks of the nerves. They varied greatly 
in size, even on the same nerves, under ap- 
parently identical circumstances. In eleven 
stumps of the thigh, the sciatic terminated 
seven times in quite large tumors, once in 23 
a small one, and three times without en- 
largement. 
Seven patients used, in walking, the pad- 
ded long peg (cuissard), having its princi- 
pal point of support at the ischium, and be- 
ing retained in place by a leather belt 
around the pelvis. In six of these the sci- 
atic bulb was very large. In one there was 
no terminal neuroma. 
The remaining four used crutches. Of 
these, one had a very large, one a very 
small, and two no apparent tumor of the 
sciatic. Almost all the operations dated far 
back—the most recent as far as 1854-55. 
It would seem, then, that the apparatus 
used in walking had some influence in the 
production of these swellings ; how much 
we shall soon see, and how it may be un- 
derstood and explained. 
The position of these tumors varied with 
that of the nerves on which they were situ- 
ated, and they were greatly modified by 
their connections with the neighboring 
parts. When the nerve was in the midst 24 
of the cellulo-adipose tissue, loose in 
surrounding parts, as the sciatic, the axil- 
lary plexus, &c., we found the neuromata 
free also in the fatty mass, and attached 
only to the cicatrix by the lower extremity. 
When, on the contrary, the nerves were 
fixed at the point of division, as, for in- 
stance, the radial in tile humeral groove 
and by external intermuscular aponeurosis, 
or the external popliteal sciatic at the neck 
of the fibula, then the terminal protube- 
rance was often found englobed in the 
fibrous cicatricial tissue, and at times in- 
separable from it. 
These tumors presented to the naked eye 
a smooth, pearl-white surface, and elastic 
consistence. Free throughout most of their 
extent, they were almost always attached 
to the cicatrix by fibrous prolongations from 
their inferior extremities. Once only have 
we found the tumor completely free, with- 
out any connection with the fibrous tissue. 
So great was their elasticity that it was 
difficult to cut them with scissors, or even 25 
with the scalpel. They presented a rosy- 
white, cut surface, with yellowish or at 
times still whiter and glaring patches at 
the centre and borders, or over the mass. 
In other respects these tumors were so va- 
riable that it is impossible to give a gene- 
ral description applicable to all. Never- 
theless two portions could ordinarily be 
made out:—1, the exterior envelope, the 
continuation and manifest expansion of the 
hypertrophied neurilemma, which could be 
traced onward even into the fibrous cord 
attached to the cicatrix ; 2, the central por- 
tion, which appeared to be rather the ex- 
pansion of the nerve itself and of its tissue 
more or less modified. 
We have said that the neurilemma spread 
out disunited bundles over the tumor, to 
form its external layer. Farther on, these 
bundles again approached each other, and 
condensed to form a simple fibrinous cord, 
which disappeared in the common fibrous 
tissue. Very rarely, these bundles contin- 
ued, as it were isolated, even to their union 26 
with the cicatrix. But we have never met 
with the nervous fibrils which Larrey re- 
garded as the conductors of animal electri- 
city, and which M. Ilutin also has some- 
times observed. 
Are these nerve-bulbs, which Cruveilheir 
described under the name of traumatic neu- 
romata, in reality tumors of such a nature ? 
Are they true nerve-tubes in their struc- 
ture, or simply, as Legouest and A. Guerin 
thought, the result of hypertrophy of the 
connective tissue ? We observe in the 
first place that in external characteristics, 
form, color, aspect, consistence, &c., these 
tumors greatly resemble common neuro- 
mata. True they usually differ from the 
latter in the symptoms produced. Spon- 
taneous, sharp, and sometimes insupporta- 
ble pains are constant attendants on patho- 
logical neuromata. In stumps, on the con- 
trary, so far as we have been able to ob- 
serve them, such pains are rare compared 
with the frequency of traumatic neuromata. 
But the histological structure is the same 27 
in both, and this settles the question. Mi- 
croscopic examinations which we practised 
in almost all these cases, and which MM. 
Paulet and Villemin kindly repeated, ena- 
ble us to affirm in all of these tumors the 
presence of true nerve-tubes. 
Two elements concurred to form these 
bulbs—the compact fibres of connective 
tissue, and the bundles of nerve-fibres. *0n 
the surface of the exterior appeared only 
fibrous tissue, arising from the hypertro- 
phied neurilemma which enveloped the 
tumor. The internal part, or the tumor 
properly so-called, was formed of very dense 
connective tissue, in which meandered bun- 
dles of nerve-fibres, more or less abundant, 
and more or less in apposition. Infrequent 
at the periphery, these nerve-bundles be- 
came so numerous in the central tract as to 
suggest a local development of nerve-fibres. 
These tumors were, then, true neuromata, 
as Cruveilhier and Hutin considered them. 
We have never seen nerve-fibres pass the 
limits of the tumor. The ligamentous cords 28 
and the loops which attached it to the com- 
mon fibrous tissue were exclusively formed 
of bundles of connective tissue, re-united in 
one instance, isolated and distinct in an- 
other. Even when there was no terminal 
bulb, the fibrous cord, almost uniformly 
present, was never composed of anything 
but connective tissue. 
We may now ask what is the mode of for- 
mation of these protuberances, and what 
causes tend to their development. M. IIu- 
tin gives the following explanation :—“ the 
nascent tubercle is either formed by the 
crowding back of the nerve-substance into 
the neurilemma as the latter is drawn upon 
by the cicatrix, to be afterwards augmented 
in volume by the addition of adipose mat- 
ter ; or else it is due to increased thickness 
of the cicatricial tissue, which continues to 
expand between the several nerve-threads 
within the common neurilemma.” 
This explanation appears to us very rea- 
sonable and perfectly admissible. We be- 
lieve, however, that he is describing a mere phenomenon of inflammatory irritation, es- 
pecially when we take into account the con- 
siderable development of fibrous tissue in 
the extremity of a stump. Divided mus- 
cles, vessels and nerves undergo a certain 
degree of inflammatory irritation during ci- 
catrization, and this irritation induces hy- 
pergenesis of the connective tissue. There 
is not, nor can there be, a direct union be- 
tween the extremity of a divided nerve and 
the adjacent tissues; but perhaps the de- 
velopment of a neuroma maybe proportion- 
ate to the latent irritation which always re- 
mains, for a longer or a shorter time, in the 
extremity of an amputated member. We 
would like to study this cicatrization of 
nerves at successive periods, to ascertain 
at what time the protuberances arise, and 
at what moment "‘diey cease to grow,, but as 
yet we have met with stumps of long stand- 
ing only. Hypergenesis of the connective 
nerve-tissue, of the neurilemma, and of the 
perineuron, is, in our opinion, the primary 
cause of the formation of these neuromata. 30 
The nerve-tubes are thus distributed in bun- 
dles through the new tumor, and remain 
there without alteration. 
Cruveilhier asks if friction and pressure, 
to which the extremities of the nerves in a 
stump are almost inevitably exposed, are 
not the active cause in the development of 
traumatic neuromata. 
Analyzing in this point of view our eleven 
amputations of the thigh, we see that of 
seven who used the stuffed long peg, six 
presented very large neuromata of the scia- 
tic. Of the four who used crutches, two 
only had medium-sized neuromata, and two 
almost nothing. It would appear from 
these facts that when the stump was wholly 
free, there was much less tendency to the 
production of neuromata. Although the long 
peg, in fact, ought not to take its bearing 
at the stump if properly stuffed, still there 
is an evident necessity, in order to make 
walking easy or even possible, that the pe- 
riphery of the thigh should be in contact 
with the apparatus. Hence a certain drag- 31 
ging and a pressure which tend to force 
back the soft parts towards the axis of the 
member. If, on the contrary, a badly made 
apparatus allows a displacement of the stump 
at each movement, the chafed parts soon 
become painful, and walking impossible. 
All these inconveniences of the long peg are 
increased necessarily when the remaining 
portion of the limb is very short, for which 
reasons two of the three whose thighs were 
amputated at the upper third, used crutches 
exclusively. But why in amputations of the 
leg, when the patient used a short peg (pilon) 
which left the stump entirely free ; in dis- 
articulations of the shoulder, where the 
stump was not enclosed in any apparatus, 
for our patients seldom used any in these 
cases; why were these neuromata, then, 
as one may truljr say, constant and almost 
always very large ? 
Even if the extremities of the nerves were 
found englobed in common fibrous tissue 
merely, still some authors would insist upon 
the influence of pressure. But even in this 32 
our facts appear contrary to such hypothe- 
sis. The neuromata were most commonly 
wholly free, in the midst of other parts, and 
buried in very loose large-celled cellulo- 
fatty tissue. We must therefore seek an- 
other cause, and one whose action may be 
as constant as the effect attributed to it. 
May we see in the formation of such tu- 
mors a provision of nature for the protec- 
tion of the ends of the divided nerves ? To 
justify such an hypothesis the nerve should 
be enveloped in this fibrous shell entire, 
and not separated into bundles diverging 
into connective tissue. And further, such 
a fibrous crust would rather produce the 
opposite effect, for the extremity of a nerve 
free in the midst of soft parts, would escape 
with greater certainty the action of foreign 
bodies than a large, hard, and elastic tumor, 
offering a greater resisting surface. 
We conclude, then, that the development 
of neuromata is due to inflammatory irrita- 
tion which follows the operation and ac- 
companies cicatrization, but that subsequent 33 
pressure and friction are not without influ- 
ence on their enlargement. It is to this 
latent and prolonged irritation that we must 
attribute the-hypergenesis of the connec- 
tive tissue which constitutes the neurilem- 
ma. The nerve-fibres undergo no alteration. 
State of the Bones.—The opinions of Lar- 
rey, Hutin, and Legouest, were cited above, 
in our History of the subject. We proceed 
with our own conclusions. 
The primitive phenomena which follow a 
section of a healthy bone are those of slight 
ostitis, with increased vascularity ; the for- 
mation of flesh}7 projections; and more often 
an exfoliation of superficial layers from the 
surface of the section. Then the fleshy pro- 
jections develope, run together, and, becom- 
ing calcareous, form osseous beds which 
close up the medullary canal opened by the 
operation. 
Often at an autopsy of a stump the bone 
no longer exhibits a natural condition. But 
a distinction must be made between ampu- 34 
tations in contiguity and those in continui- 
ty. In the first instance the bone, not sub- 
mitted to traumatic lesion, takes on only 
that degree of inflammation which is neces- 
sary to remove its articular cartilage, and 
to contract adhesions to the neighboring 
parts. It is this indispensable elimination 
of cartilage, sometimes a very slow process, 
that greatly retards cicatrization in these 
operations. The subcartilaginous parts of 
the head of the bone alone inflame, and the 
epiphysistic periosteum remains sound, if 
all proceeds as desired. This process being 
finished, the head of the bone becomes 
atrophied with the soft parts, sometimes to 
such a degree that it is said that the femur 
has been known to terminate in a point, 
after disarticulation at the knee, and thus 
to render the use of ordinary artificial appa- 
ratus very difficult. 
As to disarticulations, we have had chiefly 
stumps at the shoulders to examine, and all 
of long standing. In all four, the stumps 
were well nourished, and the shoulders 35 
were not sensibly atrophied. In three the 
shoulder-blade was natural. In one alone 
the glenoid neck was sensibly flattened, 
and slightly reduced in size. The only 
constant modifications were of the glenoid 
cavity. We always found it deprived of its 
articular cartilage, flat, or slightly convex 
instead of concave, and covered with a 
fibrous tissue not adherent to the cicatrix. 
The glenoid fibro-cartilage had disappeared, 
or become confounded with the fibrous tis- 
sue. The latter was only slightly adherent 
to the bone. The glenoidal surface was 
smooth, flat, and without marks of inflam- 
mation. 
In these cases, it is true, the stump was 
not submitted to any influence powerful 
enough to effect great modifications in the 
bones. A simple cover of leather served 
to protect the shoulder from direct blows, 
and no other artificial appliance was made 
use of. The soft parts abundantly covered 
the underlying bones, and produced no 
pressure upon them. 36 
When the bones are required to furnish a 
point of support to a member the modifica- 
tions are more grave. In partial amputa- 
tions of the foot, cicatrices often ulcerate, 
and the subjacent bones inflame, and become 
carious, or necrosed. In an autopsy of an 
ante-scaphoid disarticulation we found ul- 
cerations of the soft parts, caries of the 
bones, and vegetations surrounding the al- 
tered surfaces. There was at the same time 
a partial luxation of the foot upon the leg; 
the astragalus was carried far in front, its 
posterior portion only being in contact with 
the tibio-fibular articulation. Walking had 
become impossible on these parts, and the 
patient used the short peg (pilon). The 
muscles of the leg were wholly adipose ; 
and the tendons themselves had lost their 
pearl white appearance, had become fatty 
in their turn, and were easily broken. 
In amputations in contiguity the bony 
extremities are more apt to inflame and to 
change in form and size from ossific pro- 
ductions or new ossiform formations—the 37 
result always of a certain degree of inflam- 
matory irritation. 
The following were the results in this 
respect in our series of observations: In 
eleven amputations of the thigh, the ex- 
tremity of the bone was in seven instances 
considerably tumefied; twice it was not 
very sensibly modified; and twice no 
change could be discovered. 
According to the place of amputation we 
found—of three at superior third, all con- 
siderably enlarged ; of four at middle third, 
two considerably, one slightly, and one of 
natural size ; of four at inferior third, two 
considerably, one slightly, with bony crests, 
and one of natural size. 
Thus hypertrophy of the bony extremity 
by the addition of new layers, or the pro- 
duction of crests and ossific concretions, is 
to be found very frequently in amputations 
of the thigh, especially at its upper third. 
As to the leg, we always found that the 
tibia had undergone very slight or quite in- 
appreciable changes in form and volume. 38 
The fibula was uniformly dwindled, more or 
less pointed, and drawn towards the tibia. 
In the arm the results were about the same. 
The humeral extremity was not sensibly 
modified. Now and then there were ossific 
crests, or slender projections on its edges ; 
quite as often it was slightly shrunken and 
its walls compressed together. 
From our rapid sketch it would appear 
reasonable to adopt the conclusions of Lar- 
rey ; that when the bone does not serve as 
a point of support, or sustains no pressure, 
as in stumps of legs, arms, &c., it gradually 
tends to become atrophied; while on the 
other hand, under opposite conditions, as in 
stumps of the thigh, its extremity becomes 
enlarged and club-like. 
But we can admit only a part of the first 
proposition of Larrey. Instead of asserting 
with that illustrious surgeon that the end 
of the bone shrinks, flattens, and atrophies, 
our observations simply warrant us in say- 
ing that it usually preserves its natural vol- 
ume, or only becomes slightly atrophied, or 39 
at times thinly covered with crests or bony 
accretions. 
As to Larrey’s second proposition—we 
remark that of two who suffer amputation 
of the thigh, one of whom walks with the 
long peg, the other with crutches, the first 
only ought to have a club-shaped bone, 
for he alone has the point of support at the 
extremity of the stump. But in our eleven 
amputations of the thigh, three used crutch- 
es exclusively, and yet these three pre- 
sented large tumefactions of the femur. Of 
the eight which remain, four only showed 
such enlargements, and all these used the 
long peg; that is to say, were most exposed 
to frictions, dragging and pressure. 
It seems, then, difficult to attribute these 
osseous deposits to the mechanical influences 
invoked ; and yet, when one sees that these 
productions form almost exclusively on the 
thigh, and never, or very rarely, on other 
parts, he finds it difficult to believe that 
irritation or latent inflammation is the prin- 40 
cipal cause, since this should act on all 
kinds of stumps alike. 
There is, however, a special reason for 
this irritation in amputations of the thigh. 
Stumps of thighs, as we have said, have the 
greatest tendency to conicity. In spite of 
all precautions, the consecutive retractions 
of the soft parts are continually forcing for- 
wards the thigh bone. This bone, in this 
way becoming thinly covered and badly 
protected against exterior influences, is now 
more subject to pressure and friction. Thus 
a continued source of latent inflammatory 
irritation, whence the production of new 
osseous layers, is readily comprehended. 
These ossiQc concretions take on all pos- 
sible appearances, and give to the ends of 
the bone shapes as different as those of the 
stumps themselves. Sometimes there are 
only slight projections or crests of a few 
lines in height; sometimes, again, for a 
considerable extent there are very regular 
layers, which double or triple the thickness 
of the bony walls. In some this transfor- 41 
mation does not exceed a third or half an 
inch ; in others the hypertrophy rises three 
to five inches above the snrface of the sec- 
tion, and gives the bone the almost exact 
form of a pestle. 
When the medullary canal closes, it is 
almost invariably effected by a layer of new 
bone. We are wholly ignorant at what 
precise moment this takes place. We can 
only say that in three of the eleven anrputa- 
tions of the thigh we found this obliteration 
incomplete ; an exception still more rare in 
the tibia and fibula. The firm, rounded 
passage which led into the medullary canal, 
varied in diameter from one to three-tenths 
of an inch, or thereabouts. Surrounded by 
a very thin and fragile bony rim correspond- 
ing to the centre of the osseous section, this 
passage was closed up by a dense, almost 
cartilaginous tissue. The operations dat- 
ing back twelve or thirteen years, there 
seemed little probability that the oblitera- 
tion was of recent occurrence. 
When the medullary canal is closed, as 42 
it usually is, the thickness of the bony 
layer closing1 it varies from less than a 
twentieth to more than half an inch. This 
layer is often so thin as to be quite transpa- 
rent, but always so dense, hard and resist- 
ing that it cannot be pierced by the scalpel. 
All these osseous layers of new formation 
were, in fact, composed of compact tissue, 
hard as ebony. Ordinarily no decided line 
of demarcation existed between the old 
bone and the new accretion. Perhaps, never- 
theless, the new tissue may have had a little 
deeper color, while tending to a character- 
istic greyish tint, especially in the central 
portion of the growth. 
Unfortunately, we did not examine this 
new tissue with the microscope, to deter- 
mine whether it was formed of true bone or 
of mere calcareous deposits ; but its mode 
of formation, its aspect, and its structure, 
all led us to the former hypothesis. 
The surrounding fibrous tissue gave to 
these osseous productions a periostic cov- 
ering which adhered intimately. Vessels 43 
traversed it and passed into the bone. It 
is the internal layers of this fibrous tissue 
that become ossified by the latent irritation, 
which follows operations and is induced by 
shocks and friction. 
In members of two bones (leg, fore-arm), 
the bones, being no longer retained apart, 
tend, after section, towards each other at 
their extremities. On them osseous vege- 
tations were less abundant and less de- 
veloped. We have seen the shrunken fibula 
inclining towards the tibia, and united to it 
by strong fibrous bands ; and even, in one 
case, by a true, compact, and very resisting, 
osseous bridge. 
Such were the principal transformations 
we met with in Surgical Stumps. We re- 
gret that we had not a larger field and more 
varied observations to render a study of the 
subject at once more complete and more 
interesting.