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.

    99/1282 (page 87)
    operated as'follows; to ascertain the place where the bones are to be sawn, together with the length and breadth: of the flap, he draws; upon the limb five:lines, three circular, and two longi- tudinal ones. He first measures the length of the leg from the highest part of: the’ tibia. to the middle of the inferior protuberance of the fibula. At the mid-point, between the knee and: ankle, he makes the first or highest circular. mark upon the leg. Here the bones are to be sawn. Here Mr. Hey also measures the circumference of the leg, and thence determines the length and breadth of the flap, each of which is to be equal to one- third of the circumference. In measuring the circumference of the limb, Mr.. Hey employs a piece of marked tape, or riband, and places one end of it on the front edge of the tibia. Sup- posing the circumference to be twelve inches, he makes a dot in the circular mark on each side of the leg, four inches from the anterior edge of the tibia. These dots must, of course, be four inches: apart behind.. From each of these dots Mr. Hey draws a straight line downwards, four inches in length, and parallel to the front edge of the tibia. These lines show the direction which the catling is to take in making the flap. At the termination of these lines, Mr. Hey makes. a second mark: round the limb, to show the place. where the flap \ made, an inch below the upper one, first made for the purpose of directing the circular cut through the integuments, in front of the limb. The catling, for making the flap, should be longer than those commonly employed in amputations. Mr. Hey uses one which is seven inches long in the blade, and blunt at the back, to avoid making any Jongitudinal wound of the arteries, which is very difficult to close with a ligatures and, for the same reason; he pushes the catling through cles are to be divided, as are not included in the flap. The limb being nearly horizontal, and the fibula upward, he pushes the catling through the leg, where the dot was made, and carries it down- ward along the longitudinal mark, till it ap- which the instrument is brought out. The flap being held back, Mr. Hey divides the integu- ments on the front of the limb along the course of the second circular mark. The muscles not included in the flap are then divided a little bea low the place where the bones are to be sawn. No great quantity of these muscles can be saved, nor is it necessary, as the flap contains a sufficient portion of the gastrocnemius and soleus muscles, to make a cushion for the ends of the bones. After sawing the bones, Mr. Hey advises a little of the end of the tendon of the gastrocnemius to be cut off, as it is apt to project beyond the skin, when the flap is put down; and he recommends the large crural nerve, when found on the inner surface of the flap, to be dissected out, lest it should suffer compression. As strips of adhesive plaster cause great pres- sure on the end of the stump, Mr. Hey prefers sutures for keeping the flap applied; small strips of court plaster being put between the ligatures. The sutures may be cut out on the eighth or ninth day, and the flap supported by plasters. Mr. C. Bell describes another sort of flap- 67 amputation. The operation is not to be done so low, as there will not be a sufficiency of muscle to cover the end of the bones. An oblique cut is to be made, with the large amputating knife, up- ward, through the skin of the back part. of the leg. The assistant is to draw up the skin, and the knife is to be again applied to the upper mar- gin) of the wound, and carried obliquely upward till it reaches the bones. The knife, without being withdrawn, is next to be carried, in a cireular direction, over the tibia and fascia, covering the tibialis anticus, until it meets the angle of the first incision on the outside of the limb, The surgeon is then to pierce the interosseous mem- brane, ke. The sawing being completed, and the arteries secured, the flap is to be laid down, and the integuments of the two sides of the wound will be found to meet. (Operative Surgery, vol. 1.). Langenbeck disapproves of the plan of pushing the knife through the calf of the leg, as practised by Alanson, Hey, Graefe, Liston, Lisfrane, Symes, &¢. because an inexperienced surgeon may run the point between the two bones, and in this way the wound is never made evenly. His manner of forming the flap is very similar to Mr. C. Bell’s, except that he first makes three cuts in the integuments, two longitu- dinal and one transverse, by which the shape of the flap of skin is determined. (Dibl. fur die Chir. B. 1. p. 571.) The regular flap-amputation of the leg, I mean that operation in which the circular incision is abandoned, and a semi-circular flap both of skin and muscle preserved, is often considered more painful than the common method. Yet, when we come to see what respectable names are recorded in its favour, how soon the stump gene- rally heals, how well the ends of the bones are cover- ed, and how all dissection of the integuments from the fascia is avoided in this mode of operating, at least as far as the flap extends, the method must be allowed to possess weighty recommendations. Indeed in its present improved state, and with the peculiar fitness of such a stump for adhesion, this operation, I think, is again rather rising in the estimation of the profession. 1n 1816, Klein had performed flap-amputation of the leg, about twenty times. If the flap should happen to be made too large, he particularly dwells on the propriety of removing part of it at once; and, when it is too short, he enjoins carrying the in- cision a little further upwards without delay. He confesses that the plan is attended with some lit- tle trouble in securing the interosseous arteries, which are apt to retract considerably, but, such has been the success of his practice, that out of twenty cases, seventeen got well, and most of them very soon, without the least exfoliation ; and the other three died of typhus. (Practische Ansichten der bedeutendsten Chir. Op. 1 tes Heft p. 47.) In the same work, this experienced surgeon, convinced how much more quickly and certainly the wound heals after amputations with two flaps, than those with one, has sug- gested a plan of amputating. below the knee, so as to form two lateral flaps. I regret that my limits prevent me from entering into a descrip- tion of it. I have already specified the principal reasons, which have established the common custom of amputating the leg, about four inches below the -