Volume 1

The science and art of surgery : a treatise on surgical injuries, diseases, and operations / by John Eric Erichsen.

  • John Eric Erichsen
Date:
1895
Catalogue details

Licence: Public Domain Mark

Credit: The science and art of surgery : a treatise on surgical injuries, diseases, and operations / by John Eric Erichsen. Source: Wellcome Collection.

Provider: This material has been provided by The University of Leeds Library. The original may be consulted at The University of Leeds Library.

    99/1274 (page 67)
    the other hand, in very emaciated subjects, such a covering is very thin, and is apt to suffer from the direct pressure of the bone against it, and consequently in such cases it is well to protect it by raising a certain amount of muscle with it. Skin flaps also, if very long, are apt to slough, as their vascular supply is somewhat limited, and this accident is especially liable to happen in old people. In any patient, whether young or old, fat or thin, sloughing will almost certainly occur if the Surgeon turns the edge of the knife towards the flap instead of keeping it directed to the parts to be removed. Common sense would suggest also that it is wise to thicken the base of a flap with a little muscle when possible, if circumstances require it to be made of more than ordinary length. If the covering in most parts were made solely of skin and fat, the retraction of the muscles would lea\e the bone protruding sharply beneath the flaps, and the object of the Surgeon is therefore to save so much muscle that after full retraction has taken place it shall still be level with the sawn end of the bone. In order to obtain this result, the proportions usually sufficient are to provide one diameter of covering composed of the skin and subcutaneous structures, and half a diameter of muscle, or more if the retrac- tion is expected to be considerable, as in the lower part of the thigh. In all cases the operator should bear the principles in mind, and be guided in his performance by circumstances, considering the age and state of health of the patient, the amount of subcutaneous fat, the length of the flaps, and the situation of the amputation, and suiting the relative proportions of skin and muscular covering to the nature of the case. A mere mechanical amputator can never be a good one. In amputating for diseased joints, it often becomes a question whether the structures covering the articulation are in a lit state to be used in the forma- tion of flaps. As a general rule, it may be stated that the chronically inflamed tissues covering a diseased joint, even when perforated here and there by sinuses, form excellent flaps ; but it must be borne in mind that their vitality being somewhat lower than natural, they must be carefully handled to avoid unnecessary bruising, and that they are liable to shrink considerably as the stump heals, and consequently their length must be slightly greater than if the tissues were healthy. In tuberculous disease of joints any pulpy granulation tissue which may be left in the flap should be carefully dissected away, and sinuses scraped with a sharp spoon, and disinfected with some powerl'ul anti- septic. Such flaps yield a large amount of serous exudation during the first few hours after the operation, and ample drainage must be provided for this. In some of the modern methods of amputating about to be described it has been the object of the Surgeon to combine as far as possible the advantages of the circular and flap methods in one—following the rules just laid down as to the essentials of a good amputation. Amputation by the Modified Circular Method.—In 1839, Liston proposed a combination of the double flap and circular operations, which greatly improved the shape of the stump of the circular method, and somewhat increased the ease of the operation (Fig. 24). Two semilunar incisions, with their convexities downwai'ds, are made thi-ough the skin from side to side of the limb ; the flaps, which are each about one quarter of the diameter of the limb in length, are then dissected up and the skin and fat raised circularly above the angle of union for a distance equal to the length of the flaps, thus exposing the muscles half a diameter above the extremities of the flaps. The ]■ 2