A dictionary of practical surgery : comprehending all the most interesting improvements ... an account of the instruments ... the etymology and signification of the principal terms ... / by Samuel Cooper ; with numerous notes and additions ... together with a supplementary index ... by David Meredith Reese.

  • Cooper, Samuel, 1780-1848.
Date:
1844
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Licence: Public Domain Mark

Credit: A dictionary of practical surgery : comprehending all the most interesting improvements ... an account of the instruments ... the etymology and signification of the principal terms ... / by Samuel Cooper ; with numerous notes and additions ... together with a supplementary index ... by David Meredith Reese. Source: Wellcome Collection.

Provider: This material has been provided by the Woodruff Health Sciences Center Library at Emory University, through the Medical Heritage Library. The original may be consulted at the Woodruff Health Sciences Center Library, Emory University.

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    AMPUTATION. facet, ^ .'i,r0Uld'm 3X1 Probab«y. «u(Ter the same late as the linon, by getting under the teeth of the saw, no retractor were employed, in attempting to saw i Up' as dose'y as I)0Ssib,e tothe soft iians. i think no one can urge any but the most frivo- lous objections to the use of the retractor, and I know nat many who have been with mvself eve-witnesses oi tne mischief frequently done by the saw in amputa- tions, are deeply impressed with an aversion to the re- s'? of this bandage. I have often seen the soft parts skilfully divided, and I have, in these same instances, ( seen the operators directly afterward lose all the praise which every one was ready to bestow, by their actually sawing through one-half of the ends of the muscles together with the bone. Men who have had fortitude not to utter a sigh, nor to let a groan be heard, in their previous sufferings, have now had their invo- luntary cries extorted from them by unnecessary, un- ! justifiable torture. But besides defending the surface of the stump from the teeth of the saw, the retractor will undoubtedly enable the operator to saw the bone higher up than he could otherwise do. Mr. Liston, of Edinburgh, endeavours to show, that the saw is the only necessary thing in the case of am- putating instruments; and he adds (alluding, as I suppose, to operations at the joints), that it was sel- domer required than might be supposed; and he par- ticularly declares all kinds of retractors superfluous. Here it should be remembered, that this gentleman's practice is that .of flap-amputation, to which he gives the universal preference; a method in which unques- tionably the retractor may be dispensed with, as, while the saw is acting, one or both of the flaps can be effect- ually held out of the way by an assistant. The same preference also explains, in some measure, this sur- geon's rejection of the tourniquet, the application of which is inconvenient in certain flap-amputations.— (See Edinburgh Med. and Surg. Journ. vol. 20, p 43 ~4o.) Here, however, I am treating of amputation by the circular incision, in which practice I consider both the tourniquet and the retractor too useful to be com- monly relinquished. Another proceeding, which seems fit for reprobation and which, indeed, Mr. Alanson very properly con- demned, is the practice of scraping up the periosteum ■with the knife, as far as the muscles will allow No- thing seems more probable, than that this may be the cause of the exfoliations which occasionally happen after amputations. At all events, it is a superfluous useless measure, as a sharp saw, such as ought to be employed, will never be impeded by so slender a mem- brane as the periosteum. AH that the operator ought to do is, to take care to cut completely down to the hone all round its circumference. Thus a circular di- vision of the periosteum will be made, and upon this precise situation the saw should be placed. This is the method which was approved of by J. L. Petit — (Traite des Mai. Chir. t. 3, p. 159.) It is what I have always done and recommended; yet it must be con- fessed, that differences of opinion prevail about the ne- cessity and modes of dividing the periosteum. Graefe In common with several others, entertains considerable apprehension of the effects of the periosteim being torn and lacerated by the saw, exfoliations of the bone and abscesses up to the joint being possible conse- quences, of the rude separation and inflammation of this membrane. Hence he is an advocate for making a circular cut through at the place where the saw is to he applied, and then scraping away all below this point in the direction downwards.—fNormen fur die Abl griisserer Gliedm. p. 105 and 165.) Perhaps no very great objection may lie against this mode, which is not uncommonly follow ed, though I have some doubts of ts real utility, as it scarcely seems practicable in the midst of the oozing of biood to hit with the saw the precise line at which the remains of the periosteum terminate; and in confirmation of the safety of Petit's practice, Mr. Guthrie's experience may be alduced, who says, I have often sawed through the bone,' without previously touching the periosteum, and the stumps have been as soon healed, and with as little in- convenience as any others.—^n Gun-shot Wounds, p. 88.) A very modern author, impressed, like many others, with the fear of tearing the periosteum with the saw, differs from them, in thinking it best to scrape the periosteum upwards; by which means, he says, thai at least half an inch of this membrane, and n nro- I portionate quantity of muscular fibres, may be pre- served for covering the end of the.bone, inasmuch as the muscular fibres adherent to the periosteum wil< remain connected with it ; an advantage which this author deems very important while the edges of the bone are sharp. In amputation below the knee, he con- siders tho method highly usefui, as the sharp edge of the tibia may be not hierely covered with'skin, but peri- osteum and the cellular membrane connected with it. Since his adoption of this practice, he assures us that he has not for a very long time seen any exfoliation of the tibia, and never any protrusion of.the bone of a stump.—(Briinninghausen Erfahr. &o.,'uber die Amp p. 65, 66, 8vo. Bamb. 1S1&.) Such are the sentiments of a gentleman who has published a valuable tract on amputation, as well as some other works of deserved reputation. His opinion is unquestionably the reverse of what is most prevalent in England ; and I think his practice liable to the objection, that the disadvantages of scraping the bone at all, and denuding it, may exceed the benefit supposed to proceed from afterward bringing down the detached membrane over its sharp margin, even admitting this to be always practicable. But in no part of the operation of amputation do ope- rators in general display more awkwardness, than in sawing the bone; though, if we except directing the saw against the flesh, the faults are here less pernicious in their consequences than the errors already noticed. At the time of sawing the bone, much depends upon the assistant who holds the limb. If he elevate the lower portion of the thigh bone too much, the saw becomes so pinched that it cannot work. On the other hand, if he allow the weight of the leg to operate too much, the thigh bone breaks before it is nearly sawn through, and its extremity is splintered. It is one of the most common remarks of such persons as are in the habit of frequently seeing amputations, that the part of these operations, which a plain carpenter would do well, foils the skill of a consummate surgeon, and few operators acquit themselves well in the manage- ment of the saw. Many of them begin the action of this instrument by moving it in a direction contrary to the inclination of its' teeth. Many, seemingly through confusion, endeavour to shorten this part of the operation, by making short, very rapid, and almost convulsive strokes with the saw. Almost all opera tors fall into the error of bearing too heavily on the in strument. That operator will saw best, who makes the first stroke of the saw by applying its heel to the bone, and drawing the instrument across the part to- wards himself, so as to make a slight groove in the bone, which serves very materially to steady the future operations of the instrument; and who makes long regular sweeps with the saw, rather slowly than quickly, rather lightly than heavily. But there is often a fault m the construction of the saw itself, which im- pedes its action, quite independently of any fault on the part of the surgeon. I allude to the edge of the in- ™^mem; not beins a little hroader than its blade. When the saw is well made, the teeth always make plenty of space for the movement of the rest of the in- strument. The instrument, as Mr. Guthrie .recom- mends, should cut with both edges, backwards and forwards, which expedites the operation, and (what is of more consequence) helps to prevent splintering when the bone is nearly divided, because the division can be finished by the backward motions, which are the most gentle.—(On Gun-shot Wounds, p. 89.) Graefe commends the plan of oiling the saw, lor tho purpose of facilitating its action (Normcn fur die Abl grosserer Gliedmassen, p. 65); and though the method is innocent enough, the best operators in this metrouolis do not consider it sufficiently important for adoption If the bone should happen to break before the saw- ing is finished, the sharp-pointed, projecting spicule; thus occasioned, must be removed by means of a stronir' cutting sort of forceps, termed bone-nippers The ner pendicular division of the bone, leaves a sharp edfre at the extremity of its circumference. It is not the coin mon practice to take any measures for the removal of such sharpness; yet Graefe recommends filing it awav (Op. c.t p. 66), and Mr. C. Hutchison makes %7m invariable rule, whether there be any occasion to use the bone-nippers or not, to take off thTasoerities cut eSrPof°,rhendHeaV°Ur SreWh'« to rouL'trsha^ ™ ? the b0UC Wlth a stron? blunt scalpel, in order to prevent the soft parts from being injured.