A Manual of the Operations of Surgery, Joseph Bell [suggested reading .txt] 📗
- Author: Joseph Bell
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Partial incisions of the elbow-joint are, as a rule, less successful and more dangerous to life than complete ones, except in cases of excision for anchylosis. Even in gunshot wounds, where the bones were previously healthy, and where uninjured portions might have been left with some hopes of success, this is the case.
Dr. Heron Watson has devised the following operation for cases of anchylosis the result of injury:—(1.) A linear incision over ulnar nerve at inner side of olecranon. (2.) The ulnar nerve to be carefully turned over the inner condyle. (3.) A probe-pointed bistoury to be introduced into the elbow-joint in front of the humerus, and then behind and carried upwards, so as to divide the upper capsular attachments in front and behind. (4.) A pair of bone-forceps to be next employed to cut off the entire inner condyle and trochlea of the humerus, and then introduced in the opposite diagonal direction so as to detach the external condyle and capitulum of the humerus from the shaft. (5.) The truncated and angular end of the humerus to be divided, turned out through the incision, and smoothed across at right angles to the line of the shaft by means of the saw, whereby (6.) room might be afforded, so that partly by twisting and partly by dissection the external condyle and capitulum are removed without any division of the skin on the outer side of the arm.[56] Six cases have had satisfactory results.
The mortality from this operation is considerably less than that from amputation of the arm. Of a series of excisions for disease, injury, and anchylosis, 22.15 per cent. died, while out of a similar series of amputations of the arm the mortality was 33.4 per cent.[57] Our mortality of excision of the elbow here is certainly much less than the above. All of the cases, between thirty and forty, in which I have done it have recovered with but one exception, and Mr. Syme lost only one during the time I was his assistant.
Professor Spence lost only 16 in 189 cases, or 8.3 per cent.
Gurlt's statistics for gunshot injury give a mortality of over 24 per cent.
Out of 82 cases where the joint was excised for injury in the Schleswig-Holstein and Crimean campaigns, only 16 died; and out of 115 cases in which the joint was excised for disease, only 15 died.
The period after the injury at which the excision is performed seems to be important.
Deaths. Thus of 11 cases within first twenty-four hours, 1 = 1-11 " 20 " between second and fourth days, 4 = 1-5 " 9 " " eighth and thirty-seventh, 1 = 1-9 — — 40 6Excision of the Wrist.—Very various methods have been proposed and executed for the purpose of excising this joint. These vary much in difficulty and complexity, in proportion to the endeavours made to save the tendons from being cut.
The principles which must guide all attempts at operative interference with this joint are—
1. To remove all the diseased bone, including the cartilage-covered portions of the radius, ulna, and of the metacarpal bones, as little of these bones being removed as possible, beyond the cartilage-covered portions.
2. To disturb the tendons as little as possible, especially to avoid isolating them from the cellular sheath.
3. To commence passive motion of the fingers very soon after the operation.
It is rarely possible to remove the carpal bones as a whole, from the diseased condition which renders the operation necessary, and the digging out of the various bones piecemeal renders the operation very tedious, especially if the proximal ends of the metacarpal bones are involved and require to be removed, hence this operation was practically impossible till after the discovery of anæsthesia.
In describing the operation elaborated and described by Professor Lister, the type of the various plans in which the tendons are saved is given, while a very few words descriptive of the incisions used by others who cut the tendons will suffice.
Lister's Operation of Excision of the Wrist-Joint.—Even an abridgment of Mr. Lister's account of his operation must necessarily be long, because the operation itself is so complicated and prolonged, and guided by such precise principles, as to render much abridgment almost impossible.
A tourniquet is put on, to prevent oozing, which would conceal the state of the bones; any adhesions of the tendons must be then broken down by free movement of all the joints.
The radial incision (Plate IV. fig. a.) is then made. It commences at the middle of the dorsal aspect of the radius, on a level with the styloid process, passes as if going towards the inner side of the metacarpo-phalangeal joint of the thumb, in a line parallel to the extensor secundi internodii, but turns off at an angle as it passes the radial border of the second metacarpal, and then longitudinally downwards for half the length of that bone. The extensor carpi radialis brevior tendon is divided in the incision. The soft parts at the radial side are to be carefully dissected up, and the tendon of the extensor carpi radialis longior divided at its insertion. The cut tendons, and the extensor secundi internodii tendon and the radial artery can thus be pushed outwards, enabling the trapezium to be separated from the carpus by cutting-pliers. The extensor tendons being relaxed by bending back the hand, the soft parts must be cleared from the carpus as far as possible towards the ulnar side.
Fig. vi.[58]
The ulnar incision (Plate IV. fig. b.) extends from two inches above the end of the ulna, in a line between the bone and the flexor carpi ulnaris, straight down as far as the middle of the palmar aspect of the fifth metacarpal. The dorsal lip of this incision is then raised, and the tendon of the extensor carpi ulnaris cut at its insertion, and reflected up out of its groove in the ulna along with the skin. The extensor tendons are then raised from the carpus, and the dorsal and lateral ligaments of the wrist divided, the tendons still being left as far as possible undisturbed in their relation to the radius. In front the flexor tendons are cleared from the carpus, the pisiform bone separated from the others though not removed, and the hook of the unciform divided by pliers. The knife must not go further down than the base of the metacarpal bones, in case of dividing the deep palmar arch. The anterior ligament of the wrist being now divided, the carpus and metacarpus are to be separated by cutting-pliers, and the carpus extracted by strong sequestrum forceps. By forcible eversion of the hand, the ends of radius and ulna can be protruded at the ulnar incision; as little as possible should be removed, consistent with removing all the disease. The ulna should be cut obliquely, leaving the base of the styloid process, and removing all the cartilage-covered portion. A thin slice of the radius is then to be cut also with the saw, so thin as to remove only the bevelled ungrooved portion, and leaving the tendons as far as possible undisturbed in their grooves. The ulnar articular facet is to be snipped off with bone-pliers. If the bones are more deeply carious, the diseased parts must at all hazards be removed with pliers or gouge. The metacarpal bones must then be treated in precisely the same way, their ends sawn off and their articular facets snipped off with the bone-pliers longitudinally. The trapezium is then to be seized by forceps and carefully dissected out, the metacarpal bone of the thumb pared like the others, the articular surface of the pisiform removed, the rest of the bone being left if it is sound. The radial incision is stitched closely throughout, and also the ends of the ulnar incision, any ligature being brought out through the centre of the ulnar incision, which is kept open with a piece of lint, which also gives support to the extensor tendons.
The after-treatment is important, the principal specialities being—(1.) early and free movement of the fingers; (2.) secure fixing of the wrist to procure consolidation. (1.) By passive motion of the joints of the knuckles and fingers, commenced on the second day, and continued daily after the operation; (2.) By a splint supporting the fore-arm and hand, the fingers being held in a semiflexed position by a large pad of cork fastened firmly on to the splint and made to fit the palm; this prevents the splint from slipping up the arm, and by a turn of a bandage insures fixation of the wrist-joint. The anterior part of this splint below the fingers may be gradually shortened, allowing more and more passive motion of the fingers, but the patient must wear it for months, indeed, till he finds his wrist as strong without it as with it.
Among the various operations that have been devised, the following require notice:—Mr. Spence, Dr. Gillespie, Dr. Watson, and the author, use a single dorsal incision with excellent results, and find it quite easy to remove all the bones from it. Mr. Spence had sixteen cases without a death.
Posterior Semilunar Flap, from carpal attachment of metacarpal of index finger round to styloid process of ulna; dividing integuments only, then separating the tendons of the common extensor longitudinally, and drawing them aside by blunt hooks, the diseased bones are removed piecemeal by curved parrot-bill forceps.[59]
Posterior Curved Flap.—An incision down to the carpal bones, extended from a point two lines to the ulnar side of the extensor secundi internodii pollicis, and from a quarter to half an inch below the radio-carpal articulation, swept in a curvilinear direction downwards, close to the carpal extremities of the metacarpal bones, to a point just below the end of the ulna. The flap thus marked out was dissected up, and consisted of the integuments, areolar tissue, and extensor tendons of the four fingers, together with large deposits of fibrine, the products of repeated and prolonged inflammatory action. The tendon of the second extensor and its soft parts around were separated from the bones. The remains of the ligaments were cut, flexion of the hand protruded the carious ends of radius and ulna. The bones were then dissected out, leaving the trapezium, which was not diseased, and hand placed on a splint.[60]
Excision of the Hip-Joint.—The question as to the propriety of performing this operation in any case is still debated by some surgeons, and the selection of suitable cases for the operation is greatly modified by the varying opinions of the different schools of surgery. Enough here to describe the method of operating, and the amount of the bone which is to be removed.
As in the shoulder-joint, the head of the femur is much more liable to disease, and, as a rule, much earlier attacked than is the acetabulum, but unfortunately the acetabulum does eventually become affected also in probably a much larger proportionate number of cases than the glenoid. Caries of the head, neck, and trochanters of the femur is a very common disease in this variable climate, and frequently connected with the strumous taint. After much suffering, abscesses form and discharge, giving considerable pain, and often end by carrying off the patient. As a result of the abscess and destruction of the ligaments, the head of the bone is apt to be displaced, and under some sudden muscular exertion or involuntary spasm, consecutive dislocation of the femur (generally on to the dorsum ilii) very often occurs.
In such a case the operation of excision of the
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