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.

    95/1282 (page 83)
    posed to the danger of a protrysion of the bone, and, hence, I think it may be advisable, when- ever any reasons exist in the state of the parts, or the constitution, for apprehending that dis- agreeable occurrence. An experienced military surgeon informs us, that, in the first years of his ractice, he performed several amputations by the ouble incision, strictly according to the precepts of Sabatier, Desault, Pelletan, and Pott, but had the mortification to have three cases, in which the bone protruded, though the greatest cireum- spection was used in the operation and after- treatment. Hence, he was induced to make trial of the flap-amputation, and although he imitates O'Halloran in not attempting to bring the flaps close together for the first six or eight days, he reports, that the stump is generally healed in twenty or thirty days, and exfoliations rarely happen, on account of the bone being so well covered, In short, he says, that this method is to be preferred to all others. (J.B. Paroisse Opusc. de Chir. p.185-203. Paris, 1806.) Mr. Symes also informs us, that, though the flap-amputations seen by him have been very nu- merous, he has never met with an instance of the bone protruding, or exfoliating after them. (Ed. Journ. vol. 14. p38.) - A description of Desault’s or rather Ver- male’s mode of operating, being given in the 4th Ed. of the First Lines of the Practice of Surgery, Vol. 2, I need not here repeat it, nor say, by how many respectable names the practice is sanctioned. The operation. is sometimes adopted by my friend Mr. Vincent in St. Bar- tholomew’s Hospital, who showed me some time ago a capital stump, which he had made in this manner, and which healed with great expedition. By Mr. Guthrie, the flap-operation is con- sidered preferable to the circular incision at the upper part of the thigh, “ asit permits the head of the bone to be removed, if found necessary, allows it to be examined and cut shorter with greater ease, and makes a much better covering afterwards.” (On Gunshot Wounds, p. 200.) In military surgery, flap-amputation of the thigh is often advantageous, because all the flesh on one side of the limb is frequently torn away, or left in so terribly a mangled state, as to be unfit for making a covering for the end of the bone. Here a flap, sufficient to cover the whole face of the stump, should be saved from the sound flesh on the other side of the limb, When the surgeon chooses the flap-amputation, not from necessity, as under these last circum- stances, and the flesh is sound all round the member, the best way is to save a flap on each side of the limb, by making two semicircular cuts, the convexities of which extend ina parallel manner forwards, and the terminations of which Meet at the upper and lower surfaces of the limb. The skin is not to be at all dissected from the muscles, which are to* be obliquely divided as high as the base of the flap on each Side.” However, though this is the best plan, particular cases may require a flap to be made | from the anterior, or even the posterior side of the thigh. The latter method should never be followed, but from necessity. (See Hey’s Pract. Obs. in Surgery, p.531, Ed. 2. | According to Mr. Guthrie, the difference be- ‘tween the flap-operation, at the upper part of the thigh, and that at the hip, consists in its ; 83 being done lowcr down, and in the flaps being saved more immediately from the external and internal sides of the thigh, the inner flap being the largest, in order to prevent the inconvenience, which might arise from the external one being tightly stretched over the end of the bone. For the same reason, Mr. Guthrie also re- commends the bone to be sawn off close to the lesser trochanter, even’ when the nature of the injury would allow of its being left an inch longer. (On Gunshot Wounds, p. 200.) Flap-amputation of the thigh, after the man- ner of Vermale, is now preferred by Klein, one of the best operating surgeons in Germany, and by Messrs. Liston and Symes, two surgeons of great merit in Edinburgh. (See Edinb. Med. and Surg. Journ. Vol. 14, p. 36-46, §c.) Of seven cases, in which Klein adopted this method, the greater number were healed in ten days, and the rest in three weeks; and this success deter= mined him in future always to practise it, After this mode, he finds there is no danger of the muscles retracting themselves, and leaving the end of the bone protruding, even though the patient be transported from one place to another. With respect to the occasional difficulty of taking up the obliquely cut vessels, Klein admits this objection, but thinks that it equally applies to Alanson’s method. He lays great stress on the utility of giving due support to the flaps with compresses and aroller. (See Practische An- sichten der bedcutendsten chirurgischen Ope- rationen, p. 35-38, 4to, Stuttgart, 1816.) In one instance, where a ball had broken the upper third of, the femur, and mortification had spread so far towards the great trochanter and buttock, that it was impossible to operate, except by the flap-operation, or by taking the head of the bone out of the joint, Klein made a broad flap six inches long at the inner and upper part of the thigh, and then he cut the soft parts straight across just below the great trochan- ter, so as to make this wound meet the termination of the incision, by which the inner flap was formed. This patient got perfectly well in three weeks; (Op. cit. p. 39.) and so did another very similar case operated upon by the same gentleman. (P.43.) Where the bleeding is con- siderable, the femoral artery and profunda should be tied previously to sawing the bone; but, if the vessels are well commanded by the pressure, the sawing ought to be first completed. ‘ At the middle of the thigh, Lisfrane also prefers amputating with two lateral flaps; pressure is made on the femoral artery as it passes over the brim of the pelvis; and the vessel is tied immediately the inner flap is formed. Lisfrane makes the flaps with a very long narrow two- edged knife, which he introduces through the limb on each side, and then cuts obliquely out-. ward and downward with it; but, 1 think Mr. Symes is right in recommending the knife used by Mr. Liston, and the back of which is thin and blunt except for an inch from the point. (Ld. Med. Surg. Fourn. Vol. 14, p. 37.) Mr. Hey also preierred a knife witha blunt back, lest the vessels should be cut with it in a way that would render the securing of them troublesome. AMPUTATION BELOW THE KNEF. Tn treating of amputation of the thigh, T have remarked, that as much of the limb as G2