A Manual of the Operations of Surgery by Joseph Bell (shoe dog free ebook .txt) 📖

Note.—As in the lower limb at page 24, and for the same reasons, I here insert a brief account of the methods of tying the ulnar and radial arteries.

1. Ligature of Ulnar.—Only admissible in the lower half of its course. Operation.—Use the tendon of the flexor carpi ulnaris as a guide, and make an incision along its radial edge, at least two inches in length; expose the deep fascia of the arm and then cautiously divide it; then bending the hand, the flexor carpi ulnaris is relaxed, and the artery is found lying pretty deeply between it and the flexor sublimis digitorum. The ulnar nerve lies at its ulnar side, and the venæ comites accompany the artery. In a tolerably muscular arm, the incision will have to be about an inch inside of the ulnar border of the limb.

2. Radial.—This artery lies more superficial than the preceding, and may be tied at any part of its course.

A. Operation in upper part of fore-arm. Here the artery lies in the interval between the supinator longus and the pronator radii teres. In a muscular arm, the edge of the former muscle is the best guide; in a fat one, the incision may be made in a line extending from the centre of the bend of the arm to the inner edge of the styloid process of the radius. The deep fascia must be exposed and opened, and the muscles relaxed and held aside. The radial nerve lies on the radial side of the vessel.

B. Operation in lower half of arm. Here the vessel is more superficial, lying in the groove between the flexor carpi radialis and supinator longus. An incision two inches in length, and parallel with these tendons, easily exposes the artery. The nerve is still on its radial side.

C. Operation at first metacarpal. The artery may be tied easily enough in the triangular space bounded by the extensors of the thumb, on the dorsum of the proximal end of the first metacarpal bone. Skey[22] recommends a transverse,—Stephen Smith[23] and others, a longitudinal incision. The author had lately to secure the radial in its lower third, the superficialis volæ, and the radial again in the triangular space, in a case where division of the artery by a transverse cut had caused a large aneurism to form close above the annular ligament.

Table illustrating anastomotic circulation after ligature of arteries of neck and upper limb.

1. Common carotid.

(a) Across middle line: thyroids, linguals, facials, occipitals; also terminal branches of external carotids; also internal carotids by circle of Willis.

(b) Of same side: occipital with vertebral; superior thyroid with inferior thyroid, etc.

2. Subclavian, 3d part.

Suprascapular with dorsal branches of subscapular; posterior scapular with costal and muscular branches of subscapular. Thoracic anastomosis between internal mammary and intercostals, with branches of axillary.

3. Axillary and brachial. Anastomosis varies with the position of the ligature, but is very free between the various muscular branches of these vessels.

In ordinary surgical language the name Amputation is applied to all cases of removal of limbs, or portions of limbs, by the knife, though in strict accuracy it should be restricted to those cases in which a limb is removed in the continuity of a bone, its removal at a joint being called a Disarticulation.

The briefest outline of a history of amputation would fill a work much larger than the present. I may be allowed in a few sentences to attempt to show the principle on which such a sketch should be written, in describing the three great eras of progress in improvement of the methods of amputating.[24]

I. Prior to the invention, or at least prior to the general introduction, of the ligature and the tourniquet, the great barrier to all improvement in operating was the impossibility of checking hæmorrhage during an operation, and after its conclusion. Many surgeons would not amputate at all, others only through gangrenous parts; others more bold, only at the confines of parts in which gangrene had been artificially induced by tight ligatures.

With the exception of Celsus, who in one place recommends a flap to be dissected up, and the bone thus divided at a higher level, all were in too great a hurry to get the operation completed to think of flaps. Cut through all the parts at the same level with a red-hot knife, if you will, like Fabricius Hildanus; by a single blow with a chisel and mallet, like Scultetus; or by a crushing guillotine, like Purmannus: or by two butchers' chopping-knives fixed in heavy blocks of wood, one fixed, the other falling in a grove, like Botal; and then try to check the bleeding by tying a pig's bladder over the face of the stump, like Hans de Gersdorf; or tying it up in the inside of a hen newly killed; or by plunging it at once into boiling pitch.

We are the less surprised to read of Celsus's description of a flap operation, when we remember that it is almost certain that Celsus was acquainted with the ligature as a means of checking hæmorrhage.[25]

II. A new era was ushered in when, about 1560, Ambrose Paré invented, or re-introduced, the ligature as a means of arresting hæmorrhage, but not for more than a century after this did the full benefit of his discovery begin to be felt, when the tourniquet was introduced by Morel at Besançon in 1674, and James Young of Plymouth in 1678, and improved by Petit in 1708-10.

Now surgeons had time to look about them during an amputation, and to try to get a good covering for the bone, so that the stump might heal more rapidly and bear pressure better. Great improvements were rapidly made, and any history of these improvements would need to trace two great parallel lines, one the circular method, the other the flap operation.

1. The old method in which the limb was lopped off by one sweep, all the tissues being divided at the same level, might be called the true circular. This, however, was soon improved—

A. By Cheselden and Petit, who invented the double circular incision, in which first the skin and fat were cut and retracted, and then the muscle and bone were divided as high as exposed.

B. By Louis, who improved this by making the first incision include the muscles also, the bone alone being divided at the higher level.

C. By Mynors of Birmingham, who dissected the skin back like the sleeve of a coat, and thus gained more covering.

D. Then comes the great improvement of Alanson, who first cut through skin and fat, and allowing them to retract, next exposed the bone still further up by cutting the muscles obliquely so as to leave the cut end of the bone in the apex of a conical cavity.

E. An easier mode, fulfilling the same indications, is found in the triple incision of Benjamin Bell of Edinburgh, who in 1792 taught that first the skin and fat should be divided and retracted, next the muscles, and lastly the bone.

F. A slight improvement on E, made by Hey of Leeds, who advised that the posterior muscles of the limb should be divided at a lower level than the anterior, to compensate for their greater range of contraction.

2. In the progress of the flap operation fewer stages can be defined. Made by cutting from within outwards, after transfixion of the limb, the flaps varied in shape, size, position, and numbers, from the single posterior one of Verduyn of Amsterdam, to the two equal lateral ones of Vermale, and the equal anterior and posterior ones of the Edinburgh school.

Then came the battle of the schools: flap or circular.

Flap.—Speedy, easy, and less painful; apt to retract, and that unequally.

Circular.—Leaving a smaller wound, but more slow in performance, and apt to leave a central adherent cicatrix.

3. The last era in amputation began after the introduction of anæsthetics. Now speed in amputation is no object, and the surgeon has full time to shape and carve his flaps into the curves most suited for accurate apposition, and suitable relation of the cicatrix to the bone. It has also been brought clearly out that different methods of operating are suitable for different positions, and also that even in the same operation it is possible to unite the advantages of both the flap and the circular method.

In the modified circular, which is best suited for amputation below the knee, in the long anterior flaps of Teale, Spence, and Carden, we have illustrations of the manner in which the advantages of both the flap and circular methods have been secured, without the disadvantages of either. The long anterior flap, not like Teale's to fold upon itself, but like Spence's and Carden's to hang over and shield the end of the bones, and the face of a transversely-cut short posterior flap, seems to be now the typical method for successful amputations. There may be exceptions, as when the anterior skin is more injured than the posterior, or where an anterior flap would demand too great sacrifice of length of limb, but as a rule it will be found the best method for the patient.

Fig. i.

Amputation of the Upper Extremity.—The extreme importance of the human hand, its tactile sensibility, its grasping power, and the irreparable loss sustained by its removal, render the greatest caution necessary, lest we should remove a single digit or portion of one that might be saved. In cases of severe smashing injuries involving the fingers, it is the surgeon's bounden duty not recklessly to amputate the limb with neat flaps at the wrist-joint, but carefully to endeavour to save even a single finger from the wreck, though at the risk of a longer convalescence, or even of a profuse suppuration. While a toe or two, or a small longitudinal segment of the foot, may be comparatively useless, and a good artificial foot, with an ankle-joint stump, certainly preferable, a single finger, provided its motions are tolerably intact, will prove much more valuable to its possessor than the most ingeniously contrived artificial hand.

However, while in cases of extensive smash we endeavour to save anything we can, the case is very much altered when it is only one or two fingers that are injured. Here we find another principle brought into play, and our conservative surgery must be limited by the following consideration. In endeavouring to save a portion of the injured finger or fingers, will the saved portion interfere with the important movements of the uninjured ones? These two principles—1. Generally to save as much as we can; 2. Not to save anything which may be detrimental or in the way,—will guide us in describing the amputations of the upper extremity.

Fig. ii.

Amputation of a distal phalanx.—This small operation is not very often required. In cases of whitlow in which the distal phalanx alone has necrosed, removal of the necrosed bone by forceps is generally all that is necessary. In cases of injury,