Selections from American and Foreign Journals.

A Monograph on Excisions, translated from the French of J. F. MALGAIGNE, for the Western Journal of Medicine and Surgery, by BENJAMIN DENNIS, M. D., of Cincinnati.

GENERAL OBSERVATIONS ON EXCISIONS.

UNDER this title we shall comprehend not only the ablation of the articular extremities of the bones, but also the excision of the long pieces in their continuity, and finally the entire extirpation of certain bones, without amputation of the soft parts.

Before we proceed further, let us lay down some general precepts.

1. It is necessary before commencing the operation, to have a clear perception of the anatomical derangements, which render it much more difficult on the living than on the dead subject; these are, the swelling of the bones; sometimes their union; induration and engorgement of the soft parts, and the difficulty of recognizing the nerves and blood-vessels, which must be carefully avoided.

Let the operator, says the younger Moreau, proceed with composure and tranquillity of mind: surgery requires prudence and is devoid of timidity.

2. Besides the ordinary dressing apparatus, we must have at hand, the excision forceps, a gouge, a mallet, and saws of different sizes and forms, so that we may not be taken unawares should it become necessary to change any of them during the operation.

3. An assistant should be in readiness, with a good supply of water and fine sponges, to wipe away the blood, so that the color of the bones may be recognized.

4. In making the external incisions, our object should be, to procure a sufficient and commodious passage to the bone, without unnecessarily injuring the muscles and tendons.

When we wish to remove completely a long bone, should a simple longitudinal incision not suffice, we may, as a general

proposition, add a small perpendicular incision to each extremity of the first, in order to obtain a quadrilateral flap.

5. It is necessary to avoid carefully the division of the nervous, venous, and arterial trunks.

6. The bone being exposed, we should probe it with the gouge or a pointed stylet for the purpose of ascertaining the depth of the caries.

7. Before employing the saw, we should carefully protect the soft parts from the action of that instrument, by means of compresses or by passing the handle of a bistoury between. them and the saw.

8. The first law is to remove completely all that portion of the bone which is carious. To this all the others are subordinate.

9. The second law is to save as far as possible the tendons and muscular attachments. Nevertheless the carious portion of the bone should be entirely removed.

The slightest layer of compact substance will be sufficient to preserve the attachment of the muscles.

10. When an articular surface is composed of several bones, we should generally cut off the pieces at the same level, in order to avoid obliquity of the section, which would force the limb to one side or the other. This rule is particularly important in relation to the articulations of the wrist and ancle.

11. If the excision is practised in the continuity of a long bone, or if we wish to extract the bone entirely, we should preserve as much of the periosteum as the malady will permit. In children it furnishes the matter for a new bone, and in adults it serves as the basis of a fibrous tissue, which replaces to a certain extent, the old bone.

12. Having performed the operation, the lips of the wound are to be brought into contact, and retained in that state by adhesive strips and the interrupted suture.

13. In operating on the articulations of the inferior extremities, the bones should be brought together, and the limb extended; but when the operation is performed on the superior extremities, the limb should be semi-flexed, leaving the bones slightly separated, in order to obtain, if possible, an artificial joint.

OF EXCISIONS OF PARTICULAR BONES.

We shall treat successively of partial or complete excisions of the bones of the superior extremities then of those of the inferior, and finally of the bones of the trunk.

ART. 1.-EXCISION OF THE BONES OF THE SUPERIOR EXTREM

ITIES.

1. Excision of the Metacarpo-Phalangeal Articulation.

In performing this operation the condition of the case may render necessary the removal either of the head of the metacarpal bone, the extremity of the phalanx or both together.

The operation should be commenced by making an oblique incision, beginning at the middle of the dorsal face of the metacarpal bone, about half an inch beyond the point where we wish to apply the saw, and terminating at the commissure of the finger; a second incision should be made commencing at the same point and ending at the other commissure; circumscribing thus a flap in the shape of the letter v with its base downwards. This flap should be dissected up and turned backwards; the tendon of the extensor, thus brought into view, removed; and the interosseous muscles on each side of the bone, detached. The articulation should then be opened; and the lateral and anterior ligaments cautiously divided, avoiding all injury to the flexor tendons. After which the phalanx must be dislocated backwards; and having carefully freed the diseased portion of bone from the soft parts, and introduced behind it a piece of wood or pasteboard, the operation should be finished by the application of the saw. The excision of the head of the metacarpal bone is conducted in the same manner.

If the excision is to be practised on the articulation of the thumb, the index, or the little finger, the flap should be made on the free side of the finger, with its base above or below as the state of the case may require. By adopting this method, we shall not be compelled to push the tendon of the extensor muscle much out of the way on account of the saw.

M. Bobe once excised the head of the first phalanx of the thumb, in a case of irreducible luxation; this circumstance removed many of the difficulties attending the operation.

II. EXTRACTION OF THE FIRST PHALANX.

Although, this operation has never been attempted, nor even proposed, yet it appears to be sometimes indicated on the thumb. M. Velpeau has seen the smaller phalanx of this finger preserve its movements after the extraction of fragments of the first phalanx affected with necrosis.

In conducting this operation, we should make the incision on the radial side of the thumb; remove the soft parts cautiously in order to save as much of the periosteum as possible;

tenderly destroy the metacarpal articulation; and dislocate the bone outwards. The rest will be easy.

III.-EXTRACTION OF THE METACARPAL BONE.

Proposed by M. Troccon in 1816, and afterwards performed with success, by M. Roux and M. Blandin.

This operation is performed by making an incision along the radial side of the bone, extending about half an inch beyond each of its articulations; the skin and the extensor tendon of its dorsal face and the muscles of its palmar face should be cautiously detached. An assistant should forcibly separate the lips of the wound; whilst the surgeon carries the point of the bistoury on the external side of the carpal articulation; divides the tendon of the abductor longus, which is attached to the metacarpal bone; and destroys the articulation. The bone should then be luxated outwards; and the bistoury carried along its internal face, in order to separate the flesh from it completely. Finally its articulation with the phalanx should be destroyed, by dividing successively the internal, external, and anterior lateral ligaments.

The radial artery can be easily avoided; and the rest secured by the application of the ligature. The lips of the wound should be retained in apposition by the aid of lint or compresses; and union by the first intention induced. The palm of the hand should be so dressed, that the thumb may be maintained in its natural position. After recovery, the finger is contracted and at first incapable of any use; however, it will gradually acquire all its natural movements.

If the first incision should not suffice, another should be added to each of its extremities, according to the general method indicated.

IV.-EXTRACTION OF THE OTHER METACARPAL BONES.

The metacarpal bone of the index finger, can be easily extracted by means of an incision on its external surface: and that of the little finger by the aid of an incision on its external side. But the probable shortening of these fingers will leave a deformity as great perhaps, as that produced by their amputation, and will, without doubt, lessen the general force of the hand.

A different method should be adopted for the extraction of the metacarpal bones corresponding to the middle and ring fingers. The incision should be made along the dorsal face of the bone, by the side of the extensor tendon; (which

must be carefully protected) and the disarticulation begun at the joint of the phalanx. These two fingers can be easily maintained in their natural positions, by their connection with the neighboring ones.

V.-EXTIRPATION OF THE BONES OF THE CARPUS.

Sir A. Cooper extracted with success the os scaphoides in a case of luxation of that bone, occasioned by pressure from a wool-carding machine. He lays down this principle, that, when, by the effect of an analogous cause, one or two bones of the carpus are displaced, extraction may be practised; but, if the injury be greater, amputation is necessary.

VI.-EXCISION OF THE ARTICULATION OF THE WRIST.

Method of M. Roux.-M. Roux makes, along the anteroexternal part of the radius and antero-internal margin of the ulna, without interfering with the vessels and nerves of the fore-arm, two longitudinal incisions terminating inferiorly on a level with the joint of the wrist; also, two transverse incisions extending backwards from the inferior part of the fore-arm, to the sides of the bundle of the extensor tendons at the posterior surface of the articulation. Two flaps in the shape of the letter V were thus obtained, which he dissected up, carefully avoiding the tendons which play in the dorsal grooves of the bones; these were then held out of the way by a compress, spatula, or piece of paste-board; he then applied the saw to the ulna; an assistant forcibly bent the hand outwards in order to aid the operator in separating the interosseous attachments with the radius and carpus. Finally, the hand was forced inwards, which rendered it easy, either to saw the radius before or after the disarticulation. The wound thus made was large enough to expose the surface of the carpal bones, wnich enabled him to remove as many of them as the necessity of the case required.

M. Dubled made a single longitudinal incision on the side of each bone, commencing always with the ulna; forced the hand inwards; destroyed the ulnar articulation; and dislocated the bone, before excising it. He then passed to the radius which he excised in the same manner.

M. Velpeau on the contrary, completely unites the longitudinal incisions, by means of a transverse one on the back of the wrist, in order to procure a quadrilateral flap with its base downwards; which he dissects up and turns back on the hand. Having protected the tendons as much as possible, he