Volume 1

A dictionary of practical surgery / [Samuel Cooper].

  • Samuel Cooper
Date:
1825
Catalogue details

Licence: Public Domain Mark

Credit: A dictionary of practical surgery / [Samuel Cooper]. Source: Wellcome Collection.

    84/1282 (page 72)
    of muscular flesh and integuments as are propor- tionate to the diameter of the limb. By a triple incision, he means first an incision through the integumentsalone; secondly, anincision through all the muscles, made: somewhat higher than that through the integuments; and thirdly, an- other incision through that part of the muscular flesh which adheres to the bone, made round that point of the bone where the saw is to be applied. The proper distance of these incisions from each other, he says, must be determined by the thick- ness of the limb upon which the operation is to be performed; making allowance for the retrac- tion of the integuments, and of those muscles which are not adherent to the bone. Supposing the circumference of the limb to be twelve inches where the bone is to be divided, the diameter is about four inches, and, if no retraction of the in- teguments were to take place, a sufficient covering of the stump would be afforded by making the first incision at the distance of two inches from the place where the bone is to be sawn, that is, at the distance of the semidiameter of the limb on each side. But, as the integuments, when in a sound state, always recede after they are divided, it is useful to make some allowance for this recession ; and to make the first incision, in this case, at least two inches and a half, or three inches below theplace where the bone is tobe sawn. As the posterior muscles of the thigh retract a great deal in the process of healing, Mr. Hey ad- vises their division to be begun half an inch above the place where the integuments were cut, and the anterior muscles three quarters of an inch. The integuments, says he, will retract a little both above and below the place where they were divided ; but, the distance from that place must be computed from the mark left upon the surface of the muscles in dividing the integuments. Thus, in fact, in a common thigh amputation, Mr. Hey deemed it necessary to detach the skin from the muscles merely to the extent of half an inch at the back part of the limb, and of three quarters in front: a very different practice from the old custom of making quite a bag of integu- ments, and turning them back, like the upper piece of a glove is turned down, or rather as the sleeves of a coat are turned up. In common amputations of the thigh, Roux strongly disapproves of separating the skin far from the muscles, as a circumstance highly un- favourable to the healing of the wound by ad- hesion ; he divides only a few of the cellular bonds between the integuments and fascia; and occasionally he has imitated M. Louis in cutting through the skin and superficial muscles together. (Mem. sur la Reunion de la Plaie aprés ? Am- I believe the generality of the best modern operators are now convinced of the impropriety of dividing the muscles exactly in the manner directed by Mr, Alanson, viz. by letting the knife revolve uninterruptedly all round the bone,withits edge turned obliquely upwards, towards the point It isa topic, indeed, to which I have already called the reader’s attention in the foregoing columns. of the impossibility of forming a conical wound with one stroke of a large amputating knife, and Joins Mr. Hey in approving of the triple incision. (Bibl. fiir die Chir. b. 1. p. 564.) The objec+ tions, first urged by Wardenburgh against Alan- son’s method, are mathematically correct, inas~ much as the course of the edge of the knife, in this gentleman’s method, must be spiral, and the end of the incision be considerably higher than the beginning of it. Such must be the result of performing the division of the muscles all round with its edge directed obliquely upwards ; for the idea of making the knife revolve in this’ manner, Jar, determinate circle on the bone, I believe, is now abandoned, as not really practicable. Yet, with the exception of Desault, who confined him+ self to the triple incision, conducted on the prin- ciples of M. Louis, (iwores Chir. T. 2, p. 547,) few experienced surgeons refuse to acknowledge, that, in this operation, immense advantage does proceed from the oblique division of the muscles, the honour of bringing which method into prac- tice, Mr. Alanson still unquestionably merits, however he may have erred in recommending the conical wound to be made with one sweep of the knife. Nor are there many living surgeons who entertain a doubt of the excellence of the princi- ple inculcated by M. Louis, respecting the utility of dividing the loose superficial muscles first, and then such as are deeper and adherent to the bone. In fact, a combination of this last method, with the oblique division of the muscles, not exactly by one, but several strokes of the knife, consti- tutes the mode of amputating at present most extensively adopted, and sometimes termed, as already mentioned, arnputation by a triple in- cision. ‘Thus, after the skin is cut, and as much of it retracted and saved as is deemed necessary, the operator next cuts through the loose muscles of the thigh, at the edge of the retracted skin, first those on the forepart of the limb, and then such as are situated behind. For this purpose, he makes two or more sweeps of the knife, as may be found necessary, carefully directing them obliquely upwards towards the point, where he means to saw the bone. the muscles does not merely enable the operator wise do, and leaves at the same time more muscle for covering its extremity, but it is a preservation of sound undetached integuments, which assured- for the stump. I say this, without precisely co- inciding with Briinninghausen, who trusting en- tirely to skin for covering his stumps, makes an extensive detachment of it from the muscles, and then cuts straight down to the bone. ‘The loose muscles, actually cut through, now retract con- siderably, leaving those which are deeper and at- tached to the bone, in a condition to be cut Lastly, these are also to be divided with the edge of the knife directed obliquely upwards to- Some opérators do more than this ; for, after Celsus, and detach the flesh from its whole cir- cumference upwards with a scalpel, to the extent of about another inch, in order to be enabled to saw the bone still higher up. ‘ Inter sanam ip i