A Manual of the Operations of Surgery, Joseph Bell [suggested reading .txt] 📗
- Author: Joseph Bell
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The operation is not difficult, and requires merely a straight incision over the dorsum, extending the whole length of the bone.
In the same way the proximal phalanx of the thumb may be excised, and yet, if proper care be taken, a very useful limb be left. I quote entire the following case by Mr. Butcher of Dublin:—
Excision of Proximal Phalanx of the Thumb.—The thumb of the right hand was crushed by the crank of a steam-engine. The proximal phalanx was completely shivered; its fragments were removed, the cartilage of the proximal end of the distal phalanx, and also of the head of the metacarpal bone, were pared off with a strong knife. The digit was put up on a splint fully extended. In about a month cure was nearly complete, a firm dense tissue took the place of the removed phalanx, and the power of flexing the unguinal was nearly complete.[72]
Excision of the Joints of the Fingers.—These operations may be performed for compound dislocation, specially when the thumb is injured; no directions can be given for the incisions.[73]
In cases of disease it is rarely necessary or advisable to attempt to save a finger, but if the metacarpo-phalangeal joint of the thumb be affected, excision should be performed with the hope of saving the thumb. A single free incision on the radial side of the joint will give sufficient access.
Excision of the Os Calcis.—In those comparatively rare cases in which the os calcis is alone affected, the rest of the tarsus and the ankle-joint being healthy, a considerable difference of opinion exists as to the proper course to be followed. By some surgeons it is considered best merely to gain free access to the diseased bone, and then remove by a gouge all the softened and altered portions, leaving a shell of bone all round, of course saving the periosteum and avoiding interference with the joint. This operation requires no special detailed instruction. We find many surgeons, among them Fergusson and Hodge, supporters of this comparatively modest operation. The author has many times performed this operation with excellent results. Even when nothing but periosteum is left, the new bone becomes strong and of full size.
Excision of the whole of the diseased bone at its joints, with or without an attempt to leave some of the periosteum, has been deemed necessary by others. Holmes, who has had considerable experience, removes the bone at once by the following incisions, without paying any reference to the periosteum:—
Operation.—An incision (Plate III. fig. f.) is commenced at the inner edge of the tendo Achillis, and drawn horizontally forwards along the outer side of the foot, somewhat in front of the calcaneo-cuboid joint, which lies midway between the outer malleolus and the end of the fifth metatarsal bone. This incision should go down at once upon the bone, so that the tendon should be felt to snap as the incision is commenced. It should be as nearly as possible on a level with the upper border of the os calcis, a point which the surgeon can determine, if the dorsum of the foot is in a natural state, by feeling the pit in which the extensor brevis digitorum arises. Another incision is then to be drawn vertically across the sole, commencing near the anterior end of the former incision, and terminating at the outer border of the grooved or internal surface of the os calcis, beyond which point it should not extend, for fear of wounding the posterior tibial vessels. If more room be required, this vertical incision may be prolonged a little upwards, so as to form a crucial incision. The bone being now denuded by throwing back the flaps, the first point is to find and lay open the calcaneo-cuboid joint, and then the joints with the astragalus. The close connections between these two bones constitute the principal difficulty in the operation on the dead subject; but these joints will frequently be found to have been destroyed in cases of disease. The calcaneum having been separated thus from its bony connections by the free use of the knife, aided, if necessary, by the lever, lion-forceps, etc., the soft parts are next to be cleaned off its inner side with care, in order to avoid the vessels, and the bone will then come away.[74]
Attempts may occasionally be made in such an operation to save a portion of periosteum in attachment to the soft parts, but success or failure in this seems to have very little effect on the future result.
Hancock's Method.—A single flap was formed in the sole, with the convexity looking forwards, by an incision from one malleolus to the other.
Greenhow's Method.—Incisions made from the inner and outer ankles, meeting at the apex of the heel, and then others extending along the sides of the foot, the flaps being dissected back so as to expose the bone and its connections.[75]
Excision of Astragalus.—A curved incision on the dorsum of the foot extending from one malleolus to the other, and as far forwards as the front of the scaphoid. The chief caution required is to divide all ligaments which hold the bone in place, and dissect it clean on all other parts before meddling with its posterior surface where the groove exists for the flexor longus pollicis tendon near which the posterior tibial vessels and nerve lie.[76]
Excision of Astragalus and Scaphoid.—An incision similar to the anterior one in Syme's amputation at the ankle. The flap was then turned back from the dorsum of the foot. The joint was then opened, the lateral ligaments of the ankle-joint divided, the foot dislocated so as to show the astragalo-calcanean ligaments, and allow them to be divided. The bones were then grasped with the lion-forceps and pulled forwards, while the posterior surface of the astragalus was very cautiously cleaned, so as to avoid the posterior tibial artery.[77]
Excision of Metatarso-Phalangeal Joint of Great Toe.—Butcher performs it by splitting up the sinuses leading to the carious joint, exposing it and cutting off with bone-pliers the anterior third of the metatarsal bone, and the proximal end of the first phalanx. He also cuts subcutaneously the extensor tendons to prevent them from cocking up the toe.[78] Pancoast prefers a semilunar incision. A lateral incision is usually to be preferred.
The author has performed this excision frequently for disease; when the whole cartilages are removed and the wound is freely drained, an admirable result is obtained.
In cases of compound dislocation of the head of the metatarsal bone, it will occasionally be found necessary to excise it either by the original, or a slightly enlarged wound.
The author lately excised one-half of shaft of metatarsal and the corresponding half of proximal phalanx of great toe for exostosis, with antiseptic precautions. The result was a useful toe with a mobile joint.
Excision of Metatarsal Bone of Great Toe.—For this operation a quadrilateral flap has been recommended, but this is quite unnecessary. A single straight incision along the inner border of the foot, extending the whole length of the bone, renders it very easy to remove the whole bone from joint to joint. This is an operation, however, which is rarely needed, and which would leave a very useless flail of a toe. The operation, which is at once more commonly required, and also gives promise of a more satisfactory result, is the one performed for cario-necrosis of the shaft only, and in the following manner:—
A straight incision through all the tissues, including the periosteum, right down to the bone; then with nail or handle of the knife to separate the periosteum from the bone; then with a pair of bone-pliers or a fine saw to divide the shaft from both its extremities and remove it entire.[79]
CHAPTER IV. OPERATIONS ON CRANIUM AND SCALP.Trephining and Trepanning are the names given to operations for the removal of portions of the cranium by circular saws which play on a centre pivot. When the motion is given to the saw simply by rotation of the hand of the operator, as is common in this country, it is called trephining; when (as used to be the case in this country, and still is on the Continent) the motion is given by an instrument like a carpenter's brace, the operation is called trepanning.
The nature of the operation varies according to the nature of the case for which it is performed. Thus (1.) it may be performed through the uninjured cranium in the hope of evacuating an abscess of the diploe or dura mater, or of relieving pressure caused by suppuration in the brain itself, or by extravasation into the brain or membranes; or (2.) it may be required in cases of punctured and depressed fracture for the purpose of removing projecting corners of bone and allowing elevation of the depressed portions; or (3.) it is sometimes used to remove a circular portion of bone in cases of epilepsy in which pain or tenderness is felt at some limited portion of the cranium.
1. In cases where the cranium and its coverings are entire.—There are certain positions where, if it is possible, the trephine should not be applied. These are the longitudinal sinus, the anterior inferior angle of the parietal bone, where the middle meningeal artery is in the way, the occipital protuberance, and the various sutures. These being avoided, a crucial incision is to be made through the skin, and its flaps reflected. The pericranium should then be raised from the centre, for a space large enough to hold the crown of the trephine. The pericranium should never be removed, but carefully raised and preserved, as its presence will greatly aid in the restoration of bone.[80] The centre pin should then be projected for about the eighth of an inch and bored into the bone. On it as a centre the saw is then worked by semicircular sweeps in both directions alternately, till it forms a groove for itself. Whenever this groove is deep enough the pin should be retracted, lest from its projection it pierce the dura mater before the tables of the skull are cut through. Were the cranium always of the same thickness, and even of similar consistence, the operation would always be exceedingly easy; but in both these particulars different skulls vary much from each other, and thus by a rash use of the instrument the dura mater may possibly be injured. The tough outer table is more difficult to cut than the softer and more vascular diploe, and the inner table is denser than either, but more brittle. In many old skulls, however, the diploe is wanting altogether, and the two tables are amalgamated, and often very thin.
Great care must be taken in every case to saw slowly, to remove the sawdust, and examine the track of the saw by a probe or quill, lest one part should be cut through quicker than another. The last turns of the instrument must specially be cautious ones. When the disk of bone does not at once come away in the trephine, the elevator or
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