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5. It is soothing to granulating wounds. 6. It reduces inflammation by relieving the congested capillaries. 7. It hastens the scaring of wounds. 8. It is non-toxic.
It will be readily seen that such an agent will be valuable in treating crushing injuries and lacerations on any part of the body. It would not be advisable to use this agent to the exclusion of everything else, for it is often necessary, when inflammation is high or infection imminent, that hot applications be applied until a healthy granulation is seen, and after this the boroglyceride will hasten the healing. If the use of this great agent is a hobby with myself, it has become so after an earnest and patient effort to get a dressing that would give the best results and give the patient the least inconvenience.
I have seen no cause to regret an almost routine application of this agent in suitable cases in hospital as well as in private practice, and feel quite sure that the more faithful adoption of this old remedy will bring better results than many of the more recent pharmaceutical efforts.
FARABEUF'S AMPUTATION AT THE SEAT OF ELEC
JAMES E. THOMPSON, M. D.,
After careful analysis of numbers of amputations coming under my observation, from various parts of the country, I have been forced to the conclusion that if they represent modern skill in this branch of surgery, there is room for a vast amount of improvement. It is a rare thing to see a stump that defies criticism. Some are fair, but the great majority are very bad. It is only fair to say that nearly all the cases are of the wandering type, that have been treated in hospitals, but it is just in such cases that one would expect to see the best work.
I found early, in my experience as a teacher of operative surgery on the cadaver, that it was next to an impossibility to make the average student learn the steps of each typical amputation, with sufficient accuracy to make him a safe operator. I was often told that I was too hard on them, and that they (the students) did not think it was necessary to remember all the anatomical points that I insisted on. Some even told me that their preceptors knew little anatomy, but had nevertheless great reputations as surgeons. To this I could only retort that their reputations would have been still greater if they had known more.
I argued that, if this objection to accuracy in learning is present in our youth with their active brains, when they become older the distaste will become stronger. However much anatomy a man learns, he will in time forget a certain proportion of it, unless he continually reviews the subject. Also, that if minute methods are not taught at school, they will not be required in after-life. So I have continued, year by year, to correct this at the fountain head, and have exacted the most minute attention to details.
Many amputations are emergencies. The doctor is called in, and has to perform amputations without a consultation and without referring to his books to refresh his memory. In this respect his position is unique. No other professional man is required to store up in his mind accurate information on all points. A lawyer has the privilege of consulting his books even in the presence of his client. But not so the doctor. It would, indeed, be a unique sight to see a doctor performing an amputation with an open text-book by his side. Any yet, it would be much better to do so, if by it a more satisfactory result could be obtained. Nevertheless, at the present time, such a procedure would jeopardize the reputation of the most famous man. We must then accept the inevitable, and fortify ourselves by accurate information. Thus only can we avoid bad or indifferent work.
It seems an easy matter to remove a limb; and, from a butcher's point of view, it is. Owing to the introduction of antisepsis and surgical cleanliness, we have robbed these operations of most of the terrors, and many of their evil consequences. We rarely pay, nowadays, the full penalty of slovenly or indifferent work by losing the life of the patient-a frequent occurrence before the antiseptic era-but the patient carries with him for life a painful or useless stump; and if knowledge comes to him afterwards, anathematizes us forever with vigor and pith.
Let us then consider the necessary points that should be carefully considered before and during an amputation.
1. Examine carefully the condition of the soft parts, and determine the lowest possible point that can be safely included in the flap. This can be done usually by a careful examination. In some cases doubtful areas can be safely explored by short incisions into the subcutaneous tissues. In very few cases, except in the hands and feet, is any doubtful tissue to be used in the formation of a flap.
2. Determine next the lowest possible point at which the bone or bones can be divided, and still be covered by well-nourished flaps.
(This many not be advisable in some cases, as for example in the leg, where we often amputate at the seat of election, although it would be possible to divide the bones at a much lower level.) This necessitates a knowledge of three distinct conditions.
(a) The distance the divided skin will retract.
(b) The distance the divided muscles will retract.
(c) The course and distribution of the blood vessels supplying the flap.
RETRACTION OF THE SKIN.
Owing to the elastic nature of the skin, the lips of an ordinary incision will retract from one another considerably. The extent of this retraction varies in different parts of the body. It is usually greater where the skin is thin and the subcutaneous tissue is loose and scanty, i. e., in the forearm over the prominence of the biceps, the front of the elbow, the anterior surface of the forearm, the back of the wrist, over the popliteal space, and the dorsum of the foot. On the other hand, it is least where the skin is thickest or firmly attached by subcutaneous tissue to the deep aponeuroses. Such tissues are the palm of the hand, the fingers, soft parts behind the elbow, in front of the knee, sole of the foot.
Speaking generally, we may say that if a part needs to be covered by a flap consisting entirely of skin, the flap will lose one-third of its length after it is cut. Thus, if a skin to cover a bone requires to be 8 c. m. long before cutting, it should actually be made 12 c. m. long. We must not forget that inflamed and edematous skin retracts but little. This, however, will not prevent the skin from subsequently regaining its powers, and the secondary retraction may cause the flap to contract over the stump somewhat tightly.
CONTRACTION AND RETRACTION OF MUSCLES.
All muscles contract unequally after division. Farabeuf states that if the sartorius muscle be freed from its sheath and divided near its lower end, it will shorten by four-fifths of its length. The muscles that contract most are those with a long distance between
their origins and insertions. Such are the "biceps humeri, the flexor muscles of the forearm, the hamstrings, sartorious and gastrocnemius." The muscles that contract least are those that are connected with bone near the seat of division, such as the "triceps humeri, brachialis anticus, extensors of the forearm (near the upper end), quadriceps extensor and flexor longus hallicis in the middle of the leg." In addition to this immediate contraction, there is almost always a subsequent retraction. This, however, is insignificant.
In cutting flaps, this unequal contraction must always be carefully considered. Otherwise, if the muscles are cut through at the same level, as occurs in cutting flaps by transfixion, there will be unequal retraction, and the resulting flap will be very irregular. The longer muscles must be cut at a lower level than the shorter. This is exemplified in amputation of the arm, where it is necessary to divide the biceps at the level of the retracted skin incision, and then after further retraction, which is then possible, the other muscles are divided at a higher level. Also in amputation through the leg, the gastrocnemius is divided at a lower level than the other muscles.
In circular amputations, where a terminal scar is desired, the unequal contraction of the muscles will often make the skin incision elliptical, and the scar will then be lateral. This is often seen in amputation through the lower thirds of the arm and leg.
To avoid the evil results of unequal contraction, the tendency seems to be to divide each muscle separately, cutting from the surface toward the deeper planes, and allowing each muscle to contract before dividing those placed deeper. This practically means the abandoment of the transfixion method of cutting flaps.
THE COURSE AND DISTRIBUTION OF THE BLOOD VESSELS SUPPLYING THE FLAPS.
Accurate anatomical knowledge of the blood vessels that will nourish the flap is a first essential. Flaps, consisting of skin and subcutaneous tissue only, can not be made too long without danger.