A Manual of the Operations of Surgery Part 15

The author has in a case of osseous tumour removed the whole body of the scapula, leaving glenoid, spine, acromion and anterior margin with excellent result and a useful arm.

Large portions of the shafts of the humerus, radius, and ulna have been removed for disease or accident, and useful arms have resulted; but as the operative procedures must vary in every case, according to the amount of bone to be removed, and the number and position of the sinuses, no exact directions can be given.

For very interesting cases of such resections reference may be made to Wagner's treatise on the subject, translated and enlarged by Mr. Holmes, and to Williamson's _Military Surgery_, p. 227.

EXCISION OF METACARPALS AND PHALANGES.--To _excise_ the metacarpal implies that the corresponding finger is left. Except in cases of necrosis, where abundance of new bone has formed in the detached periosteum, the results of such excisions do not encourage repet.i.tion, the digits which remain being generally very useless. It is quite different, however, if it is the thumb that is involved; and every effort should, in every case, be made to retain the thumb, even in the complete absence of its metacarpal bone. For the good results of a case in which Mr. Syme excised the whole metacarpal bone for a tumour, see his _Observations in Clinical Surgery_, p. 38.

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 sh.e.l.l 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 const.i.tute the princ.i.p.al 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.

_Hanc.o.c.k'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 c.o.c.king 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]

FOOTNOTES:

[52] _On Diseases and Injuries of Joints_, p. 121.

[53] For a very large amount of most interesting and valuable information on the whole subject of excisions of joints, I would refer to Dr. Hodge's most excellent work on this subject--_On Excisions of Joints_. By Richard M. Hodge, M.D., Boston, Ma.s.sachusetts.

[54] See Syme's _Observations on Clinical Surgery_, pp. 55, 57; Hodge _on Excision of Joints_, p. 63.

[55] Maunder's _Operative Surgery_, 2d ed. p. 123.

[56] _Edin. Med. Journal_, May 1873.

[57] Quoted by Mr. Porter. _Dublin Quarterly Journal_ for May 1867, p.

264.

[58] A-A. Deep palmar arch; B. Trapezium; C. Articular surface of ulna; Dotted lines include the amount removed in Lister's earlier operations; Unshaded portions are those removed by Lister in cases where the disease is limited to the carpus. (Reduced from Lister's diagram in _Lancet_, 1865.)

[59] Skey, _Op. Surg._, 2d ed. p. 438.

[60] Abridged from Butcher, _Op. and Con. Surgery_, p. 208.

[61] _Science and Art of Surgery_, 3d ed. p. 745.

[62] _On the Surgical Treatment of Children's Diseases_, pp. 454-6.

[63] _Clinical Society's Transactions_, vol. xiii. p. 71.

[64] Billroth of Vienna and Pelikan of St. Petersburg, quoted from Heyfelder by Hodge _on Excision of Joints_, p. 161.

[65] _Operative and Conservative Surgery_, pp. 28, 138.

[66] _On Excision of Knee-Joint_, pp. 18, 20.

[67] _Operative and Conservative Surgery_, p. 169.

[68] Mr. Jones of Jersey, _Med. Chir. Trans._, vol. x.x.xvii. p. 68.

[69] _Lancet_, Oct. 1, 1859.

[70] Barwell _On Diseased Joints_, p. 464.