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.
- Samuel Cooper
- Date:
- 1844
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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![three out of four. The method is preferable, says he, to the old one, in whatever point of view it is con- sidered. This union is more expeditious; a few days being sufficient for its completion. A woman, whose thigh I took off in 1810. was very well in a week, &c. Besides the advantage of a quick cure, and such quick- ness is especially of great importance where the patient has been much reduced, so that he would hardly be able to bear a long suppuration, union by the first in- tention has the recommendation of saving the patient from a great deal of pain, the flap of integuments, with which the bleeding surface of the stump is covered, being much less irritating to the flesh than the softest charpie would be, &c. Three years have elapsed since the publication of the third edition of this book. During this interval I have performed more than a hundred and fifty amputations, and the utility of immediate union has been more and more proved to me.— [I^oso- graphie Chirurg. p. 475. 477, edit. 4.) But notwithstanding these and other encomiums on the practice, Richerand, like other French surgeons, is not an advocate for it in certain cases ; as, for instance, limbs shattered by gun-shot wounds, or affected with hospital gangrene. Here, he maintains, that it hardly ever succeeds.—(P. 478.) But though it be true that amputations after gun-shot wounds do not generally heal so well as many other cases, it cannot be denied that they do sometimes unite more or less by the first intention; and why should not the chance be taken 7 It is productive of no danger; there is nothing better, to be tried; and if it fail, what is the harm? Why, the wound will then heal by suppuration and the gra- nulating process, just as soon as if the hollow of the stump had been filled with charpie or left open ; it will in fact heal in a way which is less advantageous than union by the first intention, but which is the best which can now happen. From what has been said, it appears that the practice of healing the wound by the first intention after am- putation is less general in France than it is in England; a circumstance which may perhaps be explained by over the stump tolteep the edges approximatedI without being in contact; and where the part are but .little diseased, this may be attempted.; but if *e' ^ump j»- comes uneasy they should be cut, and a poultice applied. When only a part of the slump has appeared o slou , I have found the spiritus camphora?, alone or diluted witn a watery solution of opium, applied with the lint, ver> useful.—(On Gun-shot Wounds, p. 104,) The reasons which led Mr. Guthrie to incline to the plan of not bringing together the edges of the wound, in cases of this description, must be learned by refer- ence to his own valuable work. His cases and ar- guments are entitled to serious consideration; and though they, as well as the observations of Koux (Mi ni, sur la Reunion immediate de la Plaie apres 1'Amputa- tion 8vo. Paris, 1814:, leave me unconvinced of the use- fulness of not bringing the edges of the wound to- gether immediately after the amputation of bad com- pound fractures, there are soihe of his observations re- specting the injurious effects of too much pressure in certain conditions of the stump, perfectly agreeing with my own sentiments. At present, I have never seen any case of amputation in which I should not have thought the surgeon wrong, had he not brought the sides of the wound together directly after the operation, so as to af- ford the chance of union by the first intention [A mode of amputating the thigh with two flaps was proposed a few years since by Professor J. B. Dav dge, of the University of Maryland, which combines several important advantages! The first incision is made with the large knife on the outside and inside of the thigh through the integu- ment, so as to surround the limb, with the exception of an inch or more in the centre above and below. The surgeon having calculated the size of the flaps required, which are to be as long as the semi-diameter of the limb, makes with a scalpel a second and third inci- sion through the skin, in form of the letter V, com- mencing above the centre of the space left vacant on the superior and inferior surface, and continued until its diverging extremities reach the ends of the semi circular cuts first mentioned. The flaps of integu tlip fart of its beina much newer to the French than to us taSSvlZnt must encounter for a time the merit are then dissected back until they equa in length Uinnnf Sri™**,- hut one. so important as that a little more than the semi-diameter of the limb, to a- opposition of prejudice; but one so important as which we are considering, must at length prevail and meet with universal adoption. Our extraordinary par- tiality to union by the first intention arises from a con- viction of its superior efficacy, and is a decisive proof of the goodness of English surgery in respect to wounds. The observations of Roux and Richerand tend to prove, that they are not altogether unaware of its advantages, and they therefore recommend it for certain cases; but their backwardness to extend it to all ampu- tations without exception, is little in favour of the comparison which they are so fond of making of French with English surgery. Even the justly emi- nent Dupuytren still fills the hollow of the stump with charpie.—(Syme, in Edinb. Med. and Surgical Journ. No. 78, p. 32.) However, that stumps may fall into a state m which the pressure of all plasters and bandages whatever should be most carefully avoided and emollient poul- tices used, is a truth of which every surgeon of expe- rience must be fully convinced. This happens when- ever the parts are affected with considerable tension, inflammation, and swelling, or painful acute abscesses. There is also no utility in keeping the edges of the wound very closely compressed together when all chance of adhesion is past, and the parts must heal by the granulating process. My friend Mr. Guthrie, after amputations performed from necessity in parts not in a healthy state, as in most secondary amputations after compound fractures of the thigh, does not insist upon the edges of the wound beiiig brought into close contact by sticking plaster, compress, and bandage. In these cases he also recommends the bon: to be sawed an inch shorter than usual, or than would be necessray under other circumstances, in order to prevent its protrusion, and the ligatures to be cut off close to the knots, so as to lessenirritation, The integuments and muscles are to be brought forwards and retained so by a mode- rately tu'ht rofler, but not laid down against the bone. Some fine lint, smeared with cerate or oil, is to be put between the edges of the wound ; and a piece of linen and a Malta cross over it, supported by a few light turns of the roller. In some eases,' says Mr. Guth- rie I have put one and even two straps of plaster low for the retraction that may occur. A circular inci- sion is then made through the muscles down to the bone with the large knife. The bone is then denuded for an inch or two, the retractor employed, and the bone sawed off at the edge of the divided flesh. The arte- ries are then secured, the muscles drawn down, the ligatures so arranged as to come out of the superior and inferior angles of the wound, and the flaps are brought together and kept in place by adhesive straps, supported by a cross bandage, roller, <fcc. By this am- putation the bone is cut off an inch or more within the actual face of the stump, and the flaps of integument having the angle cut out above and below do not pre- sent that unnecessary and inconvenient lump or puck- ering, formed at the angles after the common circular amputation. I have seen this operation performed by Dr. Davidge and others with singular success. The stump heals by the first intention, without any of the deiays which are often encountered with the common flap-operation, and I prefer it for the arm as well as the thigh, unless the limb be much emaciated.—Reese.] HEMORRHAGE AFTER AMPUTATION. Bleeding after the operation is of two kinds in re- gard to the time when it occurs. The first takes place within twenty-four hours after the operation. Hence an assistant should always be left with the patient, with directions carefully and repeatedly to look at the stump; and if any bleeding should arise, to apply the tourniquet until farther aid be obtained. In case no assistant can be spared for this purpose, as must fre- quently happen in country practice, the tourniquet should be left slacklv round the limb, and the nurse or patient himself directed to turn the screw of the instrument, in order to tighten it in case of need. A slack tourniquet left round the limb after amputation cannot do harm, and its not having been ready in this way has cost many patients their lives, as I have known instances of. This kind of hemorrhage has often been known to arise from the pressure of a tight bandage round tho stump. As Monro observes, the circular turns of tho bandage, when tight, must stop the return of blood in the cutaneous veins, and thus by making a greater re-](https://iiif.wellcomecollection.org/image/b2103719x_0079.jp2/full/800%2C/0/default.jpg)
