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.

    96/1282 (page 84)
    possible should be preserved. The longer it is after the operation, the stronger and more useful will it be found. But, when the leg is to be amputated, writers commonly advise the operation to be performed a little way below the knee, even though the disease, for which the limb js re- moved, may be situated in the foot, or ankle, and would allow the operation to be done much further down. ‘The common practice is to make the incision through the integuments, just low enough to enable the operatar to saw the bones, about four inches below the lowest part of the patella. About six inches below this point is generally an eligible place for the first circular cut through the skin. This degree of lowness is usually deemed necessary, in order not to deprive the stump of that power of motion, which arises from the flexor tendons of the leg continuing undivided. It is alleged also, as a reason for this mode of proceeding, that it is quite sufficient to preserve a few inches of the leg, in order to afford the body a proper surface of support, in walking with a wooden leg, whereas if a larger _ portion were saved, the superfluous part would be a great inconvenience both in walking, and sitting down, without being of the smallest utility, in any respect whatever. However, as I shall presently notice, experience proves, that, where according to these maxims, an injury, or disease would dictate the performance of amputation above the knee, the practice of amputating below this joint, but much higher than is generally sanctioned, may be followed with advantage. The tourniquet should be applied to the fe- moral artery, about two thirds of the way down the thigh, just before the vessel perforates the tendon of the triceps muscle. ‘This place is much more convenient than the ham, where it is very difficult to compress the vessel against the bone. The patient is to be placed upon a firm table, as in the amputation of the thigh, and the leg being properly held by one assistant, while the integuments are drawn upward by another, the surgeon, with one quick stroke of the knife, is to make a circular incision through the in- teguments all round the limb. Some recom- mend the operator to stand on the inside of the leg, in order that he may be able to saw both bones at once. No reflections could ever make me perceive, that any real advantage ought stri¢tly to be imputed to this plan. Many suppose, that it diminishes the chance of the fibula being splintered, this bone being com- pletely divided rather sooner, than the tibia. But splintering the bones generally arises from the not supporting it enough. If the assistant were to be guilty of this mismanagement, it would be difficult to explain, why, the tibia should not be splintered, instead of the fibula, when a certain thickness of it had been sawn through. At, the same time, it must be admitted, that if the surgeon prefer standing on the inside of the limb, there is no objection to it at the time of using the saw; but, before this period, in amputating the right leg, there is great con- venience in having the left hand next to the wound, as is the case, when the surgeon stands on the outside of the right limb. Hence I have seen many hospital surgeons, in amputating the right leg, cut the soft parts, while they stood on the outside of the limb, and having done this part of the operation, they proceeded to the other side of the member for the purpose of applying the saw. I have only to repeat, that, I do not think any particular reason exists against sawing the two bones together, yet, in such manner as- to let > the fibula be divided entirely through first; and, the advantage of fixing this bone against the tibia by the pressure of the hands of the assistants, while the surgeon is sawing it, is another circumstance, which influences a great many writers to commend the latter plan, Graefe, who, as already mentioned, prefers the true flap- operation, does not think it advisable for the surgeon to stand on the inside of the limb in his method of operating, because when the knife is introduced through the muscles of the calf, its point. would be apt to go between the two bones. (Normen fiir die Abl. grosserer Glicdm. p» 130.) : md A circular cut having been made through the integuments, about two inches below the place where it is intended to saw the bones, the next object is to preserve skin enough to cover the front of the tibia, and the part of the. stump, corres sponding to the situation of the tibialis anticus, ex- tensor longus pollicis pedis, and other muscles, between the tibia and fibula, and those covering the latter bone. Throughout this extent, there are no bulky muscles which can be made very serviceable in covering the end of the stump, and consequently, the operator must take care to preserve sufficient skin in this situation, by dis- secting it from the parts beneath, and turning it up. mrs ad On the back part of the leg, on the contrary, the skin should never be uselessly detached to a great extent from the large gastrocnemius mus- cle, which, with the soleus, will here form a suf- ficient mass for covering the stump. However, the experience which I had in the army, taught me the truth of a remark made by Graefe, that, in forming the posterior flap of muscle, it isa matter of the highest importance. to let the in-— teguments be somewhat longer than it;. for, otherwise, when it is turned forward, as it must be for the purpose of covering the ends of the | bones, its front edge will be left uncovered by — integuments, which, being the outermost, describe — a greater circumference, than the deeper. muscular : flap. (Normen fiir die Abl. grosserer Glied. ps 131.) I was fully convinced of the truth of this | observation, by two amputations which were done by myself, one in the neighbourhood of Antwerp, in 1814, and the other at Brussels, the day after | the battle of Waterloo. Yet Graefe, who per | forms the flap-amputation, strictly so called, (that | is to say, the operation in which a flap of skin, | corresponding in shape to the flap of muscle, is preserved) does not himself detach the skin from the muscles of the calf at all, but, at the time of j making the incision in that situation, directs one | assistant to pull up the integuments, while another bends the foot as much as possible, which mane | ceuvres have the effect of letting the muscles be | cut rather shorter than the skin. Unfortunately, | however, in many cases, the very nature of the} disease, or injury, for which the operation is’ performed, would not admit of these proceed=/ ings. Nor, in a very muscular limb, would they | be likely to suffice, as Graefe himself confesses, since, in such cases, he recommends the use of a) knife bent laterally, for the purpose of excavating,