&G5K
ON
DOUBLE    CAPITAL    AMPUTATIONS,

               WITH  TWO  CASES  AND, PLATES.




Professor of the Principles and Operations of Surgery in the New-York
   Medical  College, Surgeon to the State Emigrants' Hospital, <kc.

              [From the New-York Medical Gazette, April, 1853.]

   The Surgeon is at times called upon to perform more amputations
than one upon the same individual.  Cases of this kind are met with
on the field of  battle, but they may also occur in civil practice.  It
is not uncommon  for two or more limbs  to be injured by accidents
occurring on railways; the passage of the wheels of any heavy vehicle
may implicate more than one limb beyond the reach of curative art;
mortification, either spontaneous or  traumatic, may bring about the
same result;  as may also strumous or other constitutional disorders,
affecting many of the joints simultaneously, or attacking the tissues
of the abdominal  or  thoracic members on both  sides of the body.
Under such circumstances, life can only be saved  by primary or  se-
condary amputation of the diseased or mutilated limbs.
   I shall here  record two successful  cases of double amputation of
the inferior extremity, where I pursued a plan of operating, differing,
as far as I know, from any heretofore practised.  In one  case, I
severed both legs below the knee, in immediate succession; and then
with a tenaculum in each hand, I proceeded to pick up the bleeding
vessels, right and  left;  the ligatures being simultaneously  applied
on either side by my assistants.  In the other case, I performed Hey's
operation on the foot of  one side, and Chopart's operation on that of
the other, following the same plan.
   In double amputations, the  constitutional effect of the succession 
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of one shock upon another is necessarily a cause of anxious solicitude.
Pain, when prolonged beyond a certain point, will exhaust the vital
energies of the  system,  and may actually be,  singly, the cause of
death.  To avoid this possibly fatal prostration of the nervous energy,
and enable the patient to rally from the shock of the first amputation,
Beclard and  Dupuytren  advise that a certain interval of time should
be allowed to elapse before the second is  performed.   Thus  Dupuy-
tren, in a case of double  amputation below the knee, delayed the re-
moval of the second leg fully one half hour.   It is obvious, however,
that there must  be  a limit  beyond which  delay would be improper,
and that, therefore,  the occurrence of reaction, which itself cannot be
predicated with  certainty, is not a criterion to  be relied upon, for the
guidance of the Surgeon in proceeding to the amputation of the second
limb.
    The introduction of Anaesthetic agents into medicine  has modifi-
ed, in many instances, the several steps  of surgical operations.   In
conditions requiring double amputations of the members, they must
now be regarded as especially serviceable.  I have had extensive op-
portunities of observing the  effects of chloroform in operations,  and
am convinced that  the time during which a person can be safely sub-
jected to its influence is a question for grave consideration.  Chloro-
form evidently  acts  primarily upon the  cerebro-spinal  system of
nerves, but it may  reach that part of the  nervous system which pre-
sides over the functions  of organic life and so cause paralysis of the
heart and death.
    Where two  members have to be  removed, if the operations are
performed in the ordinary manner, a double dose of chloroform must
be administered.  So far  as the anaesthetic agent is  concerned, the
patient is thus subjected to a risk twice as great as in single amputa-
tions.  Impressed  by these considerations, I  propose to convert the
double operation into one, by severing the limbs in immediate suc-
 cession, as soon  as  the anaesthetic influence is produced.   By this  pro-
 ceeding, the patient need not be in the anaesthetic state, longer than a
 few seconds.  In the cases referred to in this paper, thirty-five seconds,
 was the time I occupied  in removing the two limbs, at the place of
 election below the  knee-joint;  sixty-one, in severing the left foot by
 Hey's operation, and the right by Chopart's operation;  as noted by
 Dr. Francis King,  of North Carolina, who was present.
    I subjoin the relation of the two cases upon which I operated, and
 of which a record was kept by the House Surgeons, Drs. A. K. Smith
 and Thompson.  The wood cuts will show the character and  appear-
 ance of the stumps, when cicatrization was completed. 
Double amputation of the leg at the place of election.
    Case 1.  Henry Ottling, tanner, German by birth set: 39, entered
the State Emigrants' Hospital, 14th February, 1851.  Some days
prior to his  admission, he had been exposed to extreme cold and wet,
the result of which was sphacelus of both legs.  He was brought from
Catskill, where he had been employed, in that condition, to the Hos-
pital, almost in a dying state; the mortification extending half way
up, in front on either leg, and slanting  backward  and downward  to
the lower part of the calf.   When first seen after his admission,  he
was  laboring under extreme  prostration, delirium, with a  pulse fee-
ble and scarcely to be counted, hiccough, cold surface, and the other
constitutional symptoms, denoting the presence of extensive gangrene.
Under such circumstances, it was  not thought  expedient to  remove
the diseased limb  immediately. Cordials  and  stimulants,  were pre- 
4
 scribed; and the system was supported by nourishment, as far as the
 condition of the stomach would allow.   On the fourth day, the con-
 stitutional symptoms became more favorable; the delirium had abated,
 and the system had rallied.  At this juncture, the disposition to the
 extension of gangrene having ceased, the removal of the  sphacelated
 limbs was deemed opportune.   To  effect this as rapidly as possible,
 it was proposed to place the patient under the influence of chloroform,
 and upon the first evidences of the anaesthetic state, to amputate both
 limbs, in  immediate succession.  The  patient was so low that it was
 not thought  proper to remove him to the operating room.  The in-
 struments  were arranged and the assistants so placed as to afford
 readily  the aid required, at each  step of the operation.  One assistant
 was entrusted with the administration of chloroform; two, placed on
 either side of the table, with the management of the tourniquets; two
 were directed to support the limbs to be removed; two to retract
 the flaps as they were made;  one to hand the instruments;  one, on
 either side, to tie the arteries; and three others to sponge, to keep
 the  patient steady and  administer stimulating  cordials, as might be
 needed.
    A tourniquet was now placed on each  thigh.  The patient was
 allowed to snuff the chloroform in small quantities, and as  soon as the
 anaesthesia was manifested, the limbs were elevated  so as to empty
 them of blood.   The tourniquets  were then immediately screwed •
 and, standing on the left of the patient, armed with a long straight-
 backed pointed knife, I severed in rapid succession both limbs, at the
 place of election below the knee; following the method of Verduin, by
 the single flap, as modified by Liston.   Next, taking a tenaculum in
 each hand, I promptly picked up the arteries; commencing with the
 larger, which were as  instantaneously  tied by the assistants.   As
 soon as  the limbs were amputated, the further administration of chlo-
 roform was at once stopped; so that the patient was under its influence
 considerably less than one minute.   The dressings being  completed
 the patient was  placed  in bed;  having  sustained the operation well'
 without suffering much additional  prostration or losing more than a
few ounces of blood.
    During the  following  two weeks,  cordials, opiates,  tonics and
nourishment  were administered, carefully and  assiduously,  and at
their expiration, the prospects of the  patient began to brighten.   The
pulse became less frequent and fuller; food was borne better and re-
lished ; the nervous system became more tranquil; and the vital ener-
gies, generally, showed  signs of recuperation.  From this time  for-
ward, with the exception of a slight transientdiarrhcea, no complica- 
                                5

tion, local or general, interfered with the healing and  cicatrization of
the stumps.   Both progressed nearly equally towards cure; and on
the forty-second  day after the operation, the patient was in a condi-
tion to be discharged from the Hospital.
           Double amputation.
Hey's operation.            Chopart's operation.
    Case 2. In the following case of double amputation, Hey's opera-
tion was performed upon one foot, and Chopart's, upon the other.—Vide
plates.
    Pat. Henly,  laborer, set:  25, was  admitted to the  Emigrants'
Hospital, 10th February, 1852.   Four  days previous to his admis-
sion, both  of his feet were attacked by sphacelus,  induced  by expo-
sure, while working on the canal near Trenton, New Jersey.  He was 
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 in a condition of great prostration, and  exhibited the constitutional
 symptoms  usually accompanying gangrene.  The feet and adjacent
 parts were  discolored and tumefied beyond the ankle.  The extent to
 which the sphacelus would extend could not be accurately determined.
    The patient was put upon appropriate  constitutional remedies, and
 cataplasms  smeared with balsam Peru were ordered to be applied, so as
 to envelop  the feet entirely.  By the  first of March, the line of de-
 marcation formed, and revealed  the extent to which  the tissues were
 deprived  wholly of their vitality.   The destruction of the  tissues of
 the left foot extended, on the dorsum, from the toes  to half an inch
 beyond the line of the tarso-metatarsal  articulation, and  on the sole
 of the foot, to about  an inch beyond the metatarso-phalangeal articu-
 lation.  The right foot was similarly affected; the sphacelus, however,
 not extending as far by about half an inch.
    The tissues, above  the  lines  of demarcation,  having  resumed a
 healthy character, and the pathological condition permitting, I deemed
 it expedient to remove the  diseased parts by Chopart's operation on
 one foot and by Hey's, on the other. The same general disposition of
 the patient, instruments and assistants was observed as  in the pre-
 ceding  case.  Using  the same long narrow blunt-backed knife, and
 standing upon the left of the patient, for Chopart's operation,  a semi-
 lunar incision was made across the foot, beginning and terminating at
 the two ends of the joint, formed by the  articular surfaces of the cal-
 caneum and cuboid bones, behind,  and the astragalus and scaphoid
 bones, in  front.   The disarticulation was  speedily effected, and a suf-
 ficiently large flap obtained from the sole of the foot.   Next, without
 waiting to take up the arteries, and not changing my position,  I forth-
 with proceeded to perform Hey's operation, as modified by Lisfranc, on
 the other foot.  A semilunar incision down to the bones was made across
 the dorsum  of the foot, beginning externally opposite  the tuberosity
 of the fifth  metatarsal bone, and terminating  half an inch more for-
 wards on  the internal side of the joint.   The line of articulation be.
 tween the tarsus and metatarsus was promptly  disjoined, and the
 operation  finished, by forming the flap from the plantar aspect of the
 foot.
    The diseased  parts once removed, the administration of  chloro-
form was discontinued.  The arteries were now picked up by tenacula
held in  either hand, and tied by the  assistants.   The tourniquets were
then removed, and the dressings for both stumps being completed  the
patient was  conveyed to bed.  From  this time, the healing process
went on kindly and without complication; and in six weeks after the
operation  the patient was able to walk about.   It  may be remarked 
7
that the stump resulting from Hey's operation, became entirely cica-
trized one week earlier^ than that resulting  from Chopart's operation.
The patient is now pursuing his vocation as a ferryman on the East
River.