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.

    97/1282 (page 85)
    us it were, as the incision is made, the thick mus- cular flap. (Op. cit. p. 134.) In the common method, with the circular incision, Iam disposed to think it best, therefore, to let a small quantity of skin be detached and saved at the back part of the leg, so that there may be a certainty of having enough to cover well the extremity of the divided muscles of the calf. As soon as the skin has been separated in front, and on the outside of ihe leg, the surgeon is to detach the skin from the calf for about an inch, and having reflected or drawn this preserved portion out of: the way, he is to place the edge of the knife close to the edge of the re- tracted or reflected skin at the back of the limb, and cut obliquely upwards through the muscles of the.calf, from the inner edge of the tibia quite across the fibula, supposing the operator to be on the outside of the right leg, and that it is this member, which is undergoing removal. In per- serves, it is essential to incline the edge of the knife obliquely upwards. In this manner the skin will be longer than the muscles, and the cure considerably accelerated. : (Mém. de? Acad. dz Chir. T'. 5. edit. in- 12m.) In the leg, the necessity of dissecting the skin from the subjacent parts, is acknowledged to be greater, than in the thigh: thus, Mr. Guthrie Says, ‘‘as the attachment of the skin to the bone will not readily allow of its retraction, it must be dissected back all round, and separated from the fascia, the division of which in the first incision would avail nothing, from its strong attachment to the parts beneath.” (On Gunshot Wounds, p- 220.) In dissecting the skin, however, a much greater. detachment of it should be made at the front and.guter part of the limb, than at the oppo- site points, as already explained. The flap, formed of the integuments, and mus- cles of the calf, is then to be held back by one of the assistants, while the surgeon completes the ‘division of the rest of the muscles, together with that of the interosseous ligament, by means of the catling, a kind of long, narrow, double-edged knife, — In amputating below the knee, very particular care must be taken to cut every fasciculus of ‘muscular fibres, before the saw is used. Every part, except the bones, being divided, the soft parts are next to be protected from the teeth of the saw by a linen retractor, made with two slits to receive the two bones, care being taken to let the unslit part be applied to the muscles of the calf, as particularly advised by Graefe. (Op. cit. ro ae bh arteries, requiring ligatures, viz. the anterior and posterior tibial, and the peroneal or fibular arteries.. In. addition to these, however, the Surgeon is sometimes obliged to tie large mus- cular branches. The anterior tibial artery will be found in front of the interosseous membrane, and between the extremities of the bones; the fibular artery behind the fibula; and the posterior tibial, situated more inwardly than ‘the last, amongst the fibres of the soleus, near the tibia. (C. Bell, Oper. Surgery, vol. 1. p. 385.) When the seft parts have been cut in the pre- ceding way, the bones sawn, aud the arteries tied, the wound is to be closed by bringing the flap of skin over the front and external part of 85 the stump, so as to meet the flap composed of the gastrocnemlus, soleus, and integuments on the opposite side. This should be done without let- ting any tight strap of plaster press the skin against the sharp edge of the tibia, a serious and hurtful practice, which has often occasioned ul- ceration and sloughing of the integuments, and protrusion and necrosis of the bone. It is this danger which leads Mr. Guthrie to prefer closing the wound vertically, or nearly so, and applying the adhesive straps from side to side. (On Gunr- shot Wounds, p. 221.) 1 think, however, the above mode of operating’ almost necesgarily re- quires the wound to be closed,’ so as to form a line, extending in a direction from the tibia to the fibula. But, where a great deal of skin’ is saved all round the limb, and the muscles of the’ calf are not chiefly calculated upon for covering the bones, the perpendicular line of the wound will answer very well. Many surgeons, however, operate differently. They first make the circular incision through the skin, two inches below where they mean to saw the bones. ‘They next detach the skin from the muscles and bones equally all round the Jimb to the extent of about a couple of inches. The integu- ments are then turned up, and a division of the muscles made all round down to the bones, on a level with the line where the detachment of the skin has terminated. The parts between the bones are afterwards cut through, &c. The hemorrhage having been stopped, the integu- ments are drawn down over the stump, and the line of the wound made perpendicular. In the army, the practice has sometimes been adopted of sawing off the sharp upper ridge of the tibia; but Ican offer no exact judgment on the merits of the innovation, which has made but slow progress. It has been done a few times at St. Bartholomew’s, and I should have no objec- tion to giving it a fair trial, especially as it has the sanction of Mr. Guthrie, who says, that, in thin persons, where the spine of the tibia is very sharp, this part should be removed with the saw. ( P. 222.) Occasionally, surgeons have also removed the small remnant of the fibula, and such was some- times the practice of Larrey, when he amputated nearer the knee thancommon. (Mém. de Chir. Mil. T. 3. p. 389.) HF, Whether the above plan of amputating the ley so high up, when the foot or ankle is the part diseased or injured, be on the whole most ad- vantageous, lL cannot: presume to determine. By some clever men the practice has been condemned; and though we see it pursucil by the best surgeons in this metropolis, and my own sentiments incline me to believe they are right, | I will not say, that the matter is so settled ag nas to require further consideration. sya : Mr. White of Manchester, in a paper dated 1769 (Med. Obs. and Ing. vol. 4.), informs us, that he took the hint to amputate a Jittle above ° been done by a simple incision, with such suc- cess, that the patient could walk extremely well, though with a machine that was very badly con- structed. After this, Mr. White began to operate above the ankle with the double incistom; and ° he invented a machine much better calculated