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.
93/1188
![•tourniquet was proposed, the pad of which was calcu- lated to press upon the subclavian artery under the ■clavicle, and enabled the operator to dispense with tying the vessels in the first instance. Camper had observed, that if the scapuia were pushed backwards, and the axillary artery pressed with the finger between the clavicle, coracoid process, and great pectoral mus- cle, the pulse at the wrist might be instantly stopped. Dahl's tourniquet was obviously constructed in con- sequence of what Camper had observed. It is made of a curved, elastic plate of steel, to the shortest end of which a pad is attached, capable of projecting farther by means of a screw. The instrument embraces the shoulder from behind forwards, while the pad presses on the hollow under the clavicle, between the margins of the deltoid and pectoral muscles. The long extremity ■of the steel plate, which descends behind the shoulder, is fixed to the body by a sort of belt. The pad is de- pressed until the pulsation of the axillary artery is etopped. Farther experiments have proved, however, that this tourniquet may be dispensed with, and the flow of blood in the axillary artery commanded, by properly, compressing this vessel with a pad, or even the fingers alone, as some operators prefer, at the place where it emerges from between the scaleni muscles above the middle part of the clavicle. Thus the artery is p ised between the pad or fingers and the first rib, -across which it runs. In certain plans of operation, hereafter to be described, all compression of the artery either above or below the clavicle is dispensed with. Some practitioners, forgetful of the horizontal posture in which the patient is usually placed after the opera- tion, have feared that in La Faye's method the lower flap may sometimes confine the discharge. In order to avoid this inconvenience, Desault recommended the formation of two flaps, one of which was anterior, the •other posterior. The axillary artery was compressed from above the clavicle, at its coming out from between the scaleni muscles, while the integuments and flesh of the upper and internal part of the arm were pushed away from the humerus. A knife was plunged be- tween these and the other soft parts behind, to make the anterior flap. The arm being inclined backwards and outwards, the humeral artery was tied, the articu- lation opened, and the head of the bone dislocated. The knife was then carried downwards and backwards so as to form the posterior flap, the incisions meeting in the axilla.—(See Sabatier's M -.decine Oporatoire, t. 3, p. 39.1—399, ed. 2.) Larrey, who had frequent opportunities of amputa- ting at the shoulder-joint, aimed at the same object which Desault did; but in his earlier operations, he was in the habit of beginning with the formation of the ex- ternal or posterior flap, for the following reason: by proceeding in this way, the surgeon can tie the hume- ral artery more safely, because the ligature is applied after the operation is entirely finished, and conse- quently at a time when there is nothing to be attended to but the hemorrhage. Thus, the patient being placed on a stool, and well supported, the arm is to be raised from the side, and the axillary artery compressed from above the clavicle. The integuments and other soft parts of the upper and outer parts of the arm are then to be pushed away from the humerus, and the ex- ternal flap formed. It is now very easy to cut the ten- dons of the infra-spinatus and teres minor, and open the outside of the joint. The 'imb is to be carried in- wards and luxated backwards. The tendons of the su- pra-spinatus and biceps are to be divided, and as soon as the head of the bone is out of the glenoid cavity, the knife is to be carried along the internal part of the head and neck of the humerus, with its edge clo-;c to the bone. An internal flap, equal to the external one, is to be formed, consisting of a portion of the deltoid, great pectoral, biceps, and coraco-brachiaiis muscles, and including the brachial vessels and nerves. The artery is to be taken hold of with a pair of forceps, and tj£d. Any other vessels which require a ligature are also now to be secured. Larrey puts some charpie between the flaps, and brings them towards each other bv the usual means.— See M '.m. de Chir. Militaire.t. 2* p. 170.) Of this method of putting charpie to pre- vent union by the first intention, I entertain the most unfavourable opinion. When Larrey published his campaign in Egypt, he bad operated m this way on nineteen patients, thirteen of whom recovered. But, at a subsequent period, ho and his colleagues had amputated at the shoulder, in the above manner, in upwards of a hundred cases, more than ninety of which recovered.—(Mem. de Chir. Mil. t. 4, p. 432, 8vo. Paris, 1817.) In his latter operations he adopted the innovation or first making a longitudinal incision from the acromion to about an inch below the neck of the humerus down to the bone, so as to divide the fleshy part of the del- toid into two even parts. This cut, he says, facili- tates and renders more exact the rest of the operation From this wound the incisions for the flaps are con- tinued. Having made the foregoing incision, I di- rect an assistant to draw up the skin of the arm to- wards the shoulder, and I form the anterior and poste- rior flaps by two oblique strokes of the knife made from within outwards and downwards, so as to cut through the tendons of the pectoralis major and latis- simus dorsi. There is no risk of injuring the axillary vessels, as they are out of the reach of the point of the knife. The cellular connexions df these two flaps are to be divided, and the flaps themselves raised by an as- sistant, whp, at the same lime, is to compress the two divided circumflex arteries* The whole joint is now exposed. By a third sweep of the knife, carried circu- larly over the head of the humerus, the capsule and tendons running near the articulation are cut; and the head of the bone being inclined a little outwards, the knife is to be carried along its posterior part in order to finish the section1 of the tendinous and ligamentous attachments in that direction. The assistant now ap- plies his fore-fingers over the brachial plexus, for the purpose of compressing the artery, and commanding the current of blood through it. Lastly, the edge of the knife is turned backwards, and the whole fascicu- lus of axillary vessels is cut through, on a level with the lower angles of the two flaps, and in front of the assistant's fingers. The patient does not lose a drop of blood ; and ere the compression is remitted, the ex- tremity of the axillary artery is ireadily seen, taken up with a pair of forceps, and tied. The circumflex arte- ries are next secured, which completes the operation. — Mem. de Chir. Mil. t. 4, p. 428, Paris, 1817.) In addition to these important deviations from his earlier method, he subsequently preferred bringing the flaps together with two or three straps of adhesive plaster, and interposes no charpie.—iP. 429.) It should be ob- served also, that he lays no stress on first making the outer flap, though, from the description, it does not ex- actly appear which flap he now begins with. He has changed likewise, on another point, of importance, viz. instead of preferring La Faye's plan in certain exam- ples already specified, he affirms that the above-de- scribed way of operating is applicable to almost every case met with in military practice. First, because ail gun-shot wounds, generally, which mutilate the arm so as to create the necessity for the operation, partly or entirely destroy the centre of the deltoid, while there is always enough flesh left at the sides for mak- ing the two flaps. Secondly, because, in the very rare instances where the lateral parts of the shoulder are destroyed, and the middle untouched, no advantage would be gained by operating in La Faye's manner, as Larrey conceives that the detached flap would slough, or become, as he terms it, disorganized. He now prefers dividing the middle piece of flesh, and giving the flaps the same shape as if they were uninjured. He even asserts, that the operation, done without any flaps at all, answers better than any method in which the sur- geon preserves flaps not naturally intended for the part. Thus, when all the flesh of the shoulder has been shot away, he has seen surgeons cover the gle- noid cavity with a flap saved from the soft parts of the axilla; but such flaps invariably sloughed, hemnr rhages ensued, and the patients died.—(P. 430 43].) Some of these latter observations are, clearly enough, the result of great partiality to a particular method of operating; because who can doubt, when the lateral parts of the shoulder are injured, as they freouently are (and not very rarely, as Larrey asserts) 'bv the passage of a musket-ball through the shoulder 'from before backwards, that the right method is that'of La Faye; or the same operation, with the slight differ- ence of making the flap of a semicircular shape I It was for cases of this description that Mr. Collier and I operated after La Faye's plan, with perfect success, after thj battle of Waterloo; and a poor fellow of the](https://iiif.wellcomecollection.org/image/b2103719x_0093.jp2/full/800%2C/0/default.jpg)
