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370
Chapter 8 – The Vitamins

Multiple Choice
1. The rate and extent to which a vitamin is 6. Which of the following statements about fat-
absorbed and used by the body is called: soluble vitamins is false?
a. vitamin efficiency. a. They are readily excreted from the body
b. bioavailability. when consumed in excess.
c. fortification. b. They must be bound to proteins to
d. vitamin equivalency. travel in the blood.
c. They may be consumed less frequently
2. Which of the following is not a fat-soluble than the water-soluble vitamins.
vitamin? d. They may accumulate to toxic levels in
a. vitamin A the body.
b. vitamin C
c. vitamin D 7. How are vitamins similar to carbohydrates,
d. vitamin E fats, and proteins?
e. vitamin K a. typical roles in the body
b. organic nature
3. It is not absolutely necessary to consume the c. chemical structure
fat-soluble vitamins every day because they: d. amounts required in the diet
a. would just be excreted from the body.
b. are only absorbed in limited amounts. 8. The active form of vitamin A for vision is:
c. can be stored in the body for future use. a. opsin.
d. would reach toxic amounts in the body. b. retinoic acid.
c. retinal.
4. Overconsumption of the fat-soluble d. rhodopsin.
vitamins results in:
a. accumulation, which aids in the 9. Which form of vitamin A is involved in gene
prevention of colds and infections. expression?
b. no ill effects because they are excreted. a. retinoic acid
c. possible toxicity, due to an b. retinol
accumulation in the body. c. retinal
d. weight gain due to increased fat intake. d. retinol-binding protein
5. The fat-soluble vitamins: 10. A dietary deficiency of vitamin A can

a. are less stable than the water-soluble produce:
vitamins. a. rickets.
b. are first absorbed into the lymph. b. night blindness.
c. are usually constituents of coenzymes. c. a prolonged blood-clotting time.
d. are not essential. d. sensitivity to light.
© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
371
11. Vitamin A plays a role in cell differentiation. 16. Children with measles or measles-related
What does this mean? infections may benefit from
a. It helps cells differentiate between the supplementation with:
vitamins. a. vitamin C.
b. It allows cells to mature so they can b. vitamin A.
perform their intended functions. c. iron.
c. It promotes the storage of fat-soluble d. folate.
vitamins.
d. It aids in differentiating between fat- 17. Excessive vitamin A during pregnancy
and water-soluble vitamins. poses a teratogenic risk. This means that:
a. it can increase the risk of birth defects.
12. Vitamin A is involved in all of the following b it can build up in the blood and cause
except: calcification of soft tissues.
a. maintaining healthy epithelial tissues. c. it can result in a low-birth weight infant.
b. maintaining healthy eye tissues. d. it can increase the risk of infectious
c. fighting infection. disease.
d. releasing energy from the energy-
yielding nutrients. 18. Vitamin A toxicity is likely to result from:
a. consuming too many dark green and
13. Beta-carotene prevents _____ from deep orange vegetables.
damaging cells. b. overconsumption of whole grains.
a. free radicals c. consuming large amounts of fortified
b. antioxidants foods or vitamin A supplements.
c. blood clots d. drinking too much orange juice.
d. vitamin E
19. If your eyes have difficulty adjusting to dim
14. Which of the following is a major cause of light, eating which of the following foods
childhood blindness worldwide? daily might improve your vision?
a. vitamin C deficiency a. steamed carrots
b. riboflavin deficiency b. a peanut butter sandwich
c. pantothenic acid deficiency c. brewer’s yeast
d. vitamin A deficiency d. pork chops
15. Many of the symptoms of vitamin A 20. Identify the food group that is the best
deficiency, such as blindness and an source of beta-carotene.
increase in respiratory infections, are related a. protein foods group
to the role of vitamin A in: b. milk group
a. blood clotting. c. vegetable group
b. synthesis of visual pigments. d. grain group
c. maintaining the epithelial cells.
d. synthesis of hormones. 21. Among fruits and vegetables, the best
sources of beta-carotene are:
a. green or yellow, like lettuce and corn.
b. dark green or deep orange, like broccoli
and sweet potatoes.
c. green, like lettuce, peas, and snap beans.
d. brightly colored, like tomatoes and
lemons.
372
22. Vitamin D can be made in the body with the 28. An excess of vitamin _____ can cause excess
help of: calcium withdrawal from the bones.
a. bacteria. a. A
b. tryptophan. b. B6
c. vitamin A. c. B12
d. sunlight. d. C
e. D
23. The main function of vitamin D in bone
growth is to: 29. Excessive intakes of vitamin D by adults
a. synthesize 7-dehydrocholesterol. may result in:
b. assist in the absorption of calcium and a. greater bone density.
phosphorus. b. mineral deposits in soft tissues such as
c. mobilize calcium from the bone. the kidney.
d. secrete calcitonin. c. deformity of the leg bones, ribs, and
skull.
24. The effects of a deficiency of vitamin D are d. increased bone calcification.
most readily observed in the:
a. nervous system. 30. After 30 minutes of sun exposure, which of
b. skeletal system. the following people would have
c. muscular system. synthesized more vitamin D?
d. epithelial tissue. a. a light-skinned person
b. a dark-skinned person
25. A deficiency of vitamin _____ can cause c. neither, because skin pigmentation is
rickets. not related to vitamin D synthesis
a. A d. they would both synthesize the same
b. B12 amount
c. C
d. D 31. Vitamin D deficiency is most likely among:
e. E a. dark-skinned people who live in the
south.
26. The vitamin D-deficiency disease of children b. fair-skinned people who live in the
is: south.
a. xerophthalmia. c. dark-skinned people with limited
b. osteomalacia. exposure to sunlight.
c. osteoporosis. d. fair-skinned people with limited
d. rickets. exposure to sunlight.
27. Osteomalacia is mainly due to a deficiency 32. Factors that may limit vitamin D synthesis
of: in the body include all of the following
a. vitamin A. except:
b. vitamin D. a. geographic location.
c. parathormone. b. season of the year.
d. calcitonin. c. sunscreens.
d. use of tanning beds.
373
33. From the list below, choose the most reliable 38. Vitamin E deficiency causes:
food source of vitamin D. a. xerophthalmia.
a. whole grains b. rickets.
b. fortified breakfast cereal c. erythrocyte hemolysis.
c. yogurt d. osteomalacia.
d. orange juice
39. Vitamin E is widespread in all of the
34. The chemical name for vitamin E is: following foods except:
a. beta-carotene. a. margarine.
b. cholecalciferol. b. salad dressing.
c. ascorbic acid. c. wheat germ oil.
d. tocopherol. d. butter.
35. The major role of vitamin E in the body 40. Vitamin E deficiencies in human beings are
seems to be to: associated with:
a. aid in normal blood clotting. a. diseases of the pancreas.
b. act as an antioxidant. b. low-carbohydrate weight-loss diets.
c. aid in formation of normal epithelial c. use of vitamin K supplements.
tissue. d. strict vegetarian (vegan) diets.
d. aid in protein metabolism.
e. prevent skin cancer. 41. Vitamin K has long been known for:
a. its functions in energy metabolism.
36. Vitamin E: b. promoting healthy epithelial tissue.
a. functions as an effective antisterility c. its role in blood clotting.
agent in human beings. d. enhancing calcium utilization.
b. protects vitamin A and polyunsaturated
fatty acids from oxidation. 42. Which vitamin is synthesized in the
c. is needed by human beings as a dietary intestine by bacteria?
supplement because of the variety of a. vitamin A
functions it has in the body. b. vitamin C
d. slows down the aging process. c. vitamin D
d. vitamin E
37. What can be concluded from the results of e. vitamin K
research on vitamin E supplementation?
a. There is not enough evidence to 43. Overconsumption of the water-soluble
recommend taking supplements to vitamins will likely result in:
prevent heart disease. a. a reserve supply, which will aid in the
b. Sufficient evidence exists to recommend prevention of colds and infections.
that everyone over 40 should take a b. no apparent change, because they are
supplement. stored in the adipose tissues.
c. Large doses are more beneficial than c. no apparent change, because they are
low doses. excreted.
d. All people who have had a heart attack d. toxic accumulation in the liver.
should take a supplement.
374
44. Thiamin is involved in: 50. The most well-known role of vitamin B6 is in
a. formation of red blood cells. relation to:
b. blood coagulation. a. carbohydrate and lactose metabolism.
c. collagen formation. b. fat metabolism.
d. energy metabolism. c. protein and amino acid metabolism.
d. mineral metabolism.
45. Abuse of alcohol may lead to a severe form
of thiamin deficiency called: 51. Vitamin B6:
a. beriberi. a. does not play a role in the metabolism of
b. Wernicke-Korsakoff syndrome. energy-yielding nutrients.
c. pellagra. b. helps to regulate blood glucose.
d. rickets. c. is absorbed like the fat-soluble vitamins.
d. is only found in animal foods.
46. Riboflavin is used by the body to:
a. facilitate energy metabolism. 52. Which vitamin is most vulnerable to
b. prevent the disease pellagra. interactions with alcohol and other drugs?
c. provide building material for red blood a. vitamin C
cells. b. vitamin E
d. maintain epithelial tissue. c. folate
d. biotin
47. Which of the following foods would make
the greatest contribution to a person’s intake 53. The replacement of red blood cells and
of riboflavin? digestive tract cells depends most heavily
a. oatmeal on:
b. milk a. thiamin.
c. oranges b. riboflavin.
d. yellow squash c. niacin.
d. folate.
48. Which of the following statements is true of
niacin? 54. An important role of vitamin B12 is to assist
a. It can be synthesized in the body from folate in:
the amino acid tryptophan. a. cell division.
b. It can be used successfully to cure b. conversion of tryptophan to niacin.
schizophrenia. c. release of energy from food.
c. It is water soluble and therefore safe to d. regulation of the body’s use of calcium
administer in large doses. and phosphorus.
d. It is an antioxidant.
55. Absorption of _____ requires the presence of
49. Which vitamin can be used as a intrinsic factor.
pharmacological agent for the treatment of a. vitamin B6
high cholesterol? b. vitamin D
a. thiamin c. vitamin B12
b. vitamin E d. vitamin A
c. niacin
d. vitamin C
375
56. Which of the following groups of people is 62. Among the following, the best food sources
most at risk for a primary deficiency of for the water-soluble vitamins are:
vitamin B12? a. butter and vegetable oils.
a. the elderly b. oranges and cereals.
b. infants c. sugar and cornstarch.
c. athletes d. egg yolks and apples.
d. vegans
63. Which of the following groups needs an
57. Ascorbic acid is another name for: intake of vitamin C in excess of the RDA?
a. niacin. a. smokers
b. thiamin. b. professional athletes
c. vitamin C. c. the elderly
d. vitamin B6. d. growing children
e. vitamin E.
64. Which of these meals is lacking in vitamin
58. The formation of collagen requires an C?
adequate intake of: a. hotdog, cabbage, french fries, and milk
a. vitamin K. b. roast beef, cheese sauce, noodles, and
b. vitamin E. tea
c. vitamin C. c. roast beef, broccoli, noodles, and coffee
d. folate. d. spaghetti with tomato sauce, meatballs,
garlic bread, and cantaloupe
59. Many of the symptoms of vitamin C
deficiency, such as dry scaly skin and failure 65. The absorption of iron from iron-containing
of wounds to heal, are related to the role of foods can double or triple when eaten at the
vitamin C in the synthesis of: same meal with foods containing:
a. calcium and iron. a. folate.
b. thyroxin. b. protein.
c. collagen. c. vitamin C.
d. adrenal hormones. d. calcium.
60. The first signs of vitamin C deficiency 66. What vitamin deficiency causes pernicious
appear in the: anemia?
a. blood vessels. a. vitamin B6
b. bones. b. vitamin B12
c. hair. c. folate
d. fingernails. d. thiamin
61. _____ may result from taking megadoses of 67. Coenzymes are important because:
vitamin C. a. they function as antioxidants.
a. Iron overload b. they facilitate vitamin absorption.
b. Scurvy c. they function as catalysts.
c. Gout d. they facilitate chemical reactions.
d. Gallstones
376
68. A deficiency of niacin causes _____, whereas 73. Phytochemicals:
a deficiency of thiamin causes _____. a. are essential nutrients.
a. pellagra; beriberi b. are bioactive compounds found in
b. beriberi; pellagra foods.
c. scurvy; megaloblastic anemia c. have no biological activity in the body.
d. megaloblastic anemia; scurvy d. are nonessential nutrients.
69. Which of these pairs of vitamins are the 74. Studies suggest that a diet rich in
most widespread among food groups? carotenoids is associated with a lower risk
a. vitamin E and beta-carotene of:
b. pantothenic acid and biotin a. diabetes.
c. folate and vitamin B12 b. arthritis.
d. vitamin C and vitamin D c. heart disease.
d. osteoporosis.
70. Which of the following has an AI?
a. inositol 75. The best way to reap the benefits of
b. carnitine phytochemicals is by:
c. ubiquinone a. eating a variety of plant foods.
d. choline b. taking a variety of supplements.
c. increasing your consumption of animal
71. Which of the following groups of foods.
phytochemicals includes lycopene? d. frequently consuming manufactured
a. resveratrols functional foods.
b. carotenoids
c. flavenoids 76. Research concerning the safety and
d. phytoestrogens effectiveness of manufactured functional
foods:
72. Which of the following provides a. is inconclusive at this time.
resveratrol? b. shows definite benefits to consuming
a. soy such foods.
b. carrots c. suggests that they may be substituted
c. flaxseed for prescription drugs.
d. red wine d. is supported by the FDA.
377
Matching
1. antioxidant a. the vitamin D–deficiency disease in children.

2. beriberi b. a bone disease characterized by softening of the bones.
3. erythrocyte c. literally, porous bones; reduced density of the bones.
hemolysis
d. a vitamin B12–deficiency disease caused by lack of intrinsic factor and
4. free radicals characterized by large, immature red blood cells and damage to the nervous
system.
5. gout
e. rupture of the red blood cells, caused by vitamin E deficiency.
6. hemorrhagic
disease f. the vitamin K–deficiency disease in which blood fails to clot.
7. neural tube g. the thiamin-deficiency disease.
defects
h. the niacin-deficiency disease.
8. niacin
i. malformations of the brain, spinal cord, or both during embryonic
equivalents
development.
9. osteomalacia
j. a metabolic disease in which crystals of uric acid precipitate in the joints.
10. osteoporosis
k. the vitamin C–deficiency disease.
11. pellagra
l. a compound that protects other compounds from oxygen by itself reacting
12. pernicious with oxygen.
anemia
m. highly reactive chemical forms that can cause destructive changes in nearby
13. rickets compounds, sometimes setting up a chain reaction.
14. scurvy n. the amount of niacin present in food, including the niacin that can
theoretically be made from tryptophan, its precursor, present in the food.
378
15. beta-carotene a. a fat-soluble vitamin with the three chemical forms retinol, retinal,
and retinoic acid.
16. cornea
b. a vitamin A precursor made by plants and stored in human fat
17. differentiation
tissue.
18. enrichment
c. the specific protein responsible for transporting retinol.
19. epithelial cells
d. the hard, transparent membrane covering the outside of the eye.
20. epithelial tissue
e. the layer of light-sensitive nerve cells lining the back of the inside of
21. follicle the eye.
22. fortification f. the slow recovery of vision after exposure to flashes of bright light at
23. keratin night.
24. mucous membrane g. the development of specific functions different from those of the
original.
25. night blindness
h. cells on the surface of the skin and mucous membranes.
26. preformed vitamin A
i. tissue composing the layers of the body that serve as selective
27. retina barriers between the body’s interior and the environment.
28. retinol activity j. membrane composed of mucus-secreting cells that lines the surfaces
equivalents of body tissues.
29. retinol-binding protein k. a water-insoluble protein; the normal protein of hair and nails.
30. teratogenic l. a group of cells in the skin from which a hair grows.
31. vitamin A m. vitamin A in its active form.
n. causing abnormal fetal development and birth defects.
o. a measure of vitamin A activity; the amount of retinol that the body
will derive from a food containing preformed retinol or its precursor
beta-carotene.
p. the addition to a food of nutrients to meet a specified standard.
q. the addition to a food of nutrients that were either not originally
present or present in insignificant amounts.
Essay
1. Identify three ways vitamin D helps to maintain blood concentrations of calcium and phosphorus.
2. Describe the factors that may interfere with vitamin D synthesis.
3. Identify factors that can place people at risk for vitamin E deficiency and explain why.
4. Define the term coenzyme. Name and describe the role of the B vitamins that function as part of the
structure of coenzymes.
379
5. For each of the following vitamins, identify its chief functions in the body, the symptoms
characteristic of a deficiency, and significant food sources.
a. thiamin d. vitamin B6 g. pathothenic acid
b. riboflavin e. folate h. biotin
c. niacin f. vitamin B12 i. vitamin C
6. Why is milk usually sold in cardboard or opaque plastic containers?
7. What vitamin needs special consideration for those eating vegan diets? Explain why and make diet
planning recommendations.
8. Name the antioxidant vitamins and describe how they function in the body.
Answer Key (ANS = answer, DIF = level of difficulty, REF = page reference, TOP = chapter section)
Multiple Choice
1. ANS: b DIF: Knowledge-level REF: 196 TOP: 8.1
3. ANS: c DIF: Knowledge-level REF: 198 TOP: 8.2
4. ANS: c DIF: Application-level REF: 198 TOP: 8.2
6. ANS: a DIF: Application-level REF: 198 TOP: 8.1
7. ANS: b DIF: Application-level REF: 196 TOP: 8.1
8. ANS: c DIF: Knowledge-level REF: 199 TOP: 8.2.1
9. ANS: a DIF: Knowledge-level REF: 199 TOP: 8.2.1
10. ANS: b DIF: Knowledge-level REF: 199 TOP: 8.2.1
12. ANS: d DIF: Knowledge-level REF: 199-200 TOP: 8.2.1
14. ANS: d DIF: Knowledge-level REF: 200-201 TOP: 8.2.1
15. ANS: c DIF: Application-level REF: 200-201 TOP: 8.2.1
19. ANS: a DIF: Application-level REF: 199|202 TOP: 8.2.1
21. ANS: b DIF: Application-level REF: 202 TOP: 8.2.1
22. ANS: d DIF: Knowledge-level REF: 202 TOP: 8.2.2
28. ANS: e DIF: Knowledge-level REF: 204 TOP: 8.2.2
30. ANS: a DIF: Application-level REF: 205 TOP: 8.2.2
31. ANS: c DIF: Application-level REF: 205 TOP: 8.2.2
380
37. ANS: a DIF: Application-level REF: 206|207 TOP: 8.2.3
38. ANS: c DIF: Knowledge-level REF: 206-207 TOP: 8.2.3
43. ANS: c DIF: Application-level REF: 209 TOP: 8.3
62. ANS: b DIF: Application-level REF: 211|219-220 TOP: 8.3.1|8.3.10
64. ANS: b DIF: Application-level REF: 219-220 TOP: 8.3.10
67. ANS: d DIF: Knowledge-level REF: 209|211 TOP: 8.3.1
71. ANS: b DIF: Knowledge-level REF: 228 TOP: NIP 8
72. ANS: d DIF: Knowledge-level REF: 227 TOP: NIP 8
73. ANS: b DIF: Knowledge-level REF: 226 TOP: NIP 8
74. ANS: c DIF: Knowledge-level REF: 228 TOP: NIP 8
75. ANS: a DIF: Knowledge-level REF: 231 TOP: NIP 8
76. ANS: a DIF: Knowledge-level REF: 230 TOP: NIP 8
Matching
1. ANS: l DIF: Knowledge-level REF: 200 TOP: 8.2.1
2. ANS: g DIF: Knowledge-level REF: 211 TOP: 8.3.1
381
4. ANS: m DIF: Knowledge-level REF: 200 TOP: 8.2.1
5. ANS: j DIF: Knowledge-level REF: 219 TOP: 8.3.10
6. ANS: f DIF: Knowledge-level REF: 208 TOP: 8.2.4
7. ANS: i DIF: Knowledge-level REF: 214 TOP: 8.3.7
8. ANS: n DIF: Knowledge-level REF: 213 TOP: 8.3.4
11. ANS: h DIF: Knowledge-level REF: 211 TOP: 8.3.1
14. ANS: k DIF: Knowledge-level REF: 218 TOP: 8.3.10
17. ANS: g DIF: Knowledge-level REF: 199|200 TOP: 8.2.1
18. ANS: p DIF: Knowledge-level REF: 211 TOP: 8.3.1
19. ANS: h DIF: Knowledge-level REF: 199|200 TOP: 8.2.1
20. ANS: i DIF: Knowledge-level REF: 199|200 TOP: 8.2.1
21. ANS: l DIF: Knowledge-level REF: 201 TOP: 8.2.1
22. ANS: q DIF: Knowledge-level REF: 211 TOP: 8.3.1
23. ANS: k DIF: Knowledge-level REF: 200|201 TOP: 8.2.1
24. ANS: j DIF: Knowledge-level REF: 200 TOP: 8.2.1
25. ANS: f DIF: Knowledge-level REF: 199 TOP: 8.2.1
26. ANS: m DIF: Knowledge-level REF: 201 TOP: 8.2.1
28. ANS: o DIF: Knowledge-level REF: 202 TOP: 8.2.1
30. ANS: n DIF: Knowledge-level REF: 201 TOP: 8.2.1
Essay
1. DIF: Knowledge-level REF: 204 TOP: 8.2.2
2. DIF: Knowledge-level REF: 205 TOP: 8.2.2
3. DIF: Knowledge-level REF: 206-207 TOP: 8.2.3
5. DIF: Knowledge-level REF: 212-217|218-220
TOP: 8.3.2|8.3.3|8.3.4|8.3.5|8.3.6|8.3.7|8.3.8|8.3.10
7. DIF: Application-level REF: 217 TOP: 8.3.8
8. DIF: Knowledge-level REF: 200|206|218 TOP: 8.2.1|8.2.3|8.3.10
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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]
[75] The following is taken from the article of Professor Matas in the third edition of
“Surgery by American Authors.” It furnishes a brief but admirable introduction to the
general study of amputation methods:
“From Hippocrates to the time of Celsus the surgeon simply followed in the wake of
Nature, never venturing to apply the knife for the removal of a limb except within the
limits of the mortified tissues; and this seems to have prevailed for at least four hundred
years. Celsus, the prince of Roman physicians, who lived shortly after the time of
Christ, introduced the first innovation by cutting down to the bone between the living
and the dead tissues. It is probable, according to the evidence furnished by his writings,
that he was aware of the value of the ligature and that he applied it to control bleeding
vessels. Archigenes, following closely after Celsus, was the first to attempt prophylactic
hemostasis by applying a cord or band around the limb to control the hemorrhage
during the amputation. With the fall of the Roman empire and the advent of the long
night of the middle ages the Celsian method was lost in the general darkness and the
old Hippocratic doctrines survived, and were maintained by the all-potent influence of
Galen and his Arabian commentators. As late as the middle of the seventeenth century
the only hemostatic was the actual cautery and boiling oil, though Guy de Chauliac had
revived the teaching of Archigenes by constricting the limb, on a level with a joint, with
a cord which was allowed to remain in situ, to ensure not only hemostasis, but a certain
mortification of the stump. In cutting limbs huge chisels and mallets were used. At this
period Botalli invented his guillotine, consisting of a sharp, heavy, axe, which, being
allowed to fall from a height upon the limb, severed it instantaneously at a single blow.
The revived or independent rediscovery of the ligature by Ambrose Paré in 1579, and
the discovery of the circulation of the blood by Harvey, in 1628, led to the invention of
Morel’s tourniquet (1674), more commonly known as the Spanish windlass, and to the
familiar instrument, Pettit’s tourniquet, which (introduced in 1718) perfected the means
of securing prophylactic and direct hemostasis. From this time onward the treatment of
the stump began to receive more systematic attention. Instead of merely chopping off a
limb, the soft parts were detached from the bone, so that this could be sawed off at a
higher level, in order to avoid the conical projection of the stump which invariably
resulted when the primitive methods were adopted. All the methods of amputation that
followed—and these were numerous—aimed chiefly at celerity, to reduce the pain of
the operation to a minimum; hence the rapid, circular section of the soft parts or the
rapid transfixion methods which were so much popularized by the brilliant work of
Liston, Lisfranc, Desault, Dupuytren, Langenbeck, and others. These finally yielded, in
this modern period, to less rapid but more conservative and perfected methods, which
aim chiefly at the preservation of useful tissue and at securing the very best functional
prosthetic stump for the patient. Such methods could only be perfected after the advent
of anesthesia and antisepsis.”
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.
Fig. 677
Neudörfer’s method of amputation by primary division of the bone, before shaping

the flaps. Neudörfer used the chisel, but one may use the Gigli saw with special
advantage in performing this operation. The method is applicable to any portion of
the upper or lower extremity, especially in the continuity of the long bones. (Matas.)
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.
Fig. 678 Fig. 679
Bier’s osteoplastic amputation of the leg Bier’s osteoplastic amputation of the leg, with
(procedure advocated by Bier in 1897 osteoperiosteal flap in position.
and 1899): F, long anterior flap reflected
on the tibia; A, cross-section of tibia; B,
periosteal flap after excision of
intervening section of bone; C,
osteoperiosteal flap; D, projecting border
of periosteum to be sutured to tibial
periosteum.
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.
Fig. 680 Fig. 681
Typical amputation of finger in continuity Typical or preferred method of disarticulating a

(through a phalanx); long palmar and short finger by long single palmar flap. (Farabeuf.)
dorsal flaps. (Farabeuf.)
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.
Fig. 682 Fig. 683
Stump resulting from the procedure shown in Illustrating various finger amputation.
Fig. 681. (Farabeuf.)
Fig. 684 Fig. 685 Fig. 686 Fig. 687
Removal of index Removal of little finger. Results of Hand after removal

finger. (Erichsen.) (Erichsen.) amputation above of metacarpal bones
metacarpo- and three fingers,
phalangeal leaving thumb and
articulation in little finger.
middle, index, and (Erichsen.)
ring fingers.
(Erichsen.)
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.
Fig. 688
Outline of amputation of fingers, with their metacarpals. (Modified by Matas from Mignon.)
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.
Fig. 689
Outline of amputation of two fingers simultaneously with their metacarpals; also thumb with its
metacarpal. (Modified from Mignon.)
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.
PLATE LVII
Cutaneous Incisions in Amputations of the Upper Extremity
(Ventral or Flexor Side).
1. Anterior oval or racquet incision for disarticulation of the shoulder by attacking the joint
through the delto-pectoral groove (modified Spence’s operation).
2, 3. Circular amputation of lower and middle thirds of arm transformed into double
square, antero-posterior flap operation by unilateral or bilateral vertical incisions.
4, 5, 6, 7. Circular amputation at various levels of forearm, including the disarticulation at
elbow. In all of these, one or two lateral liberating incisions, cut down to the bone, may be
required, on ulnar or radial side, or both, to permit easy retraction of solid musculo-
tegumentary antero posterior flaps.
8, 9. Circular amputation at lower third of forearm; lateral liberating incision should be
added on ulnar side, or radial side, or both, according to tonicity of limb.
10. Long palmar projection of oval method in disarticulating hand.
PLATE LVIII
Surface Tracings showing Some of the More Useful Lines
of Skin Incision in Amputations of the Upper Extremity
(Dorsal or Extensor Surface).
1. Racquet incision (Larrey) intradeltoid for disarticulation at shoulder.

2. Solid circular with liberating incisions for upper third.
3. Solid circular with liberating incisions for middle third.
4. Circular amputation at lower third of humerus; incision slightly favoring the flexor side,
to compensate for greater retraction; two lateral liberating incisions, to facilitate retraction of
musculo-cutaneous flaps from bone.
5. Neudörfer’s racquet incision for disarticulation at elbow; preferred in all cases in which
a preliminary exploration of the elbow, as in advanced tubercular cases, is attempted before
proceeding to disarticulate at elbow.
6. Elliptical or oval incision with long projection on flexor side to compensate for greater
retraction of skin and muscles on flexor (ventral side); the longer end of the oval may be
advantageously reversed, the long end on the exterior side, when the tissues on the flexor
side are injured. Usually, a slightly elliptical circular, with two lateral liberating incisions, cut
squarely to the bone with all the soft parts, including the periosteum, is the preferred
method in this region.
7. Antero-posterior flap incision for amputation at lower third of forearm; tendinous region.
8. Oval or elliptical incision in typical amputation of the hand (radio-carpal disarticulation).
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.

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5. The fat-soluble vitamins: 10. A dietary deficiency of vitamin A can

1. antioxidant a. the vitamin D–deficiency disease in children.

Neudörfer’s method of amputation by primary division of the bone, before shaping

Flaps may be formed by transfixion, for which purpose a long, sharp,

AMPUTATIONS OF THE UPPER EXTREMITY.

Fig. 680 Fig. 681

Typical amputation of finger in continuity Typical or preferred method of disarticulating a

Removal of index Removal of little finger. Results of Hand after removal

When an entire finger is to be removed it is a question whether the

1. Racquet incision (Larrey) intradeltoid for disarticulation at shoulder.

Circulation being thus controlled, a modified circular operation may be made

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