Page images
PDF
EPUB

is there represented by a dotted line. The axillary artery will be found in this, the anterior flap, near its extremity, and it is, as it should be in all cases, nearly the last thing divided in this method of disarticulation.

Fig. 21.

Before proceeding to the amputations of the lower extremity it is advisable to perform the amputation of the breast, if the sex of the subject admits of the operation being practised with any advantage.

Amputation of the breast.-The main object in this operation is to leave sufficient integuments and soft parts to cover, without stretching, the wound inflicted by the removal of the gland. A large scalpel is the only instrument required for this operation on the dead body; it should be held as a pen if the breast is small, if voluminous, it may be grasped

more firmly in the second or third position (p. 4). The operator should stand on the same side of the body as that of the breast to be removed, the corresponding arm of the subject being carried out from the side; he should make two semielliptical incisions, having their long axes parallel with that of the ribs, and including between them, the nipple and a sufficiency of skin to allow of the removal of the gland through the wound. These incisions should meet one another beyond the axillary and sternal borders of the breast respectively. For the right breast the upper incision should be first made, commencing from the axilla; it should extend pretty deeply into the subcutaneous fat; it should not cut quite vertically through the skin, but rather in an upward direction, so as to pass over the convex surface of the breast without injuring the glandular structure. The lower incision should next be made from the sternum towards the axilla, and this also should be adapted somewhat to the convexity of the breast. While the assistant While the assistant grasps the gland and draws it upwards, the operator should seize the skin at the lower edge of the wound and dissect it off the breast until the lower border of the gland comes into view; lifting up this and dissecting between it and the pectoral muscle, he must completely undermine the gland. Taking the breast into his own hand, and drawing it downwards while the assistant raises the upper edge of the wound, the operator should dissect away the coverings from the upper part of the gland until he reaches its upper boundary, when the separation of the breast will be complete, and the operation concluded.

CHAP. VII.

AMPUTATIONS OF THE LOWER EXTREMITY.-AMPUTATION OF THE PENIS.

EXCISION OF THE TESTICLE.

Amputations of the Lower Extremity.—General Remarks on the Skeleton of the Foot, and the Position of its various Articulations.—Amputation of Phalanges of Tocs.-Ditto of Toes en masse. - Lisfranc's Amputation.— Chopart's. Syme's.-Operation of M. Roux.-Pirogoff's Amputation.— Ordinary method.—Dr. Eben Watson's method.-Amputations of the Leg: (1) circular, (2) flap, (3) combined method, (4) Teale's operation.-At the Knee Joint, by (1) anterior flap, (2) by posterior flap.-Amputation of the Thigh: (1) circular, (2) flap, (3) combined method, (4) Teale's operation. -Amputation at the Hip Joint.-Removal of Penis.-Excision of Testicle.

FOR the successful performance of the amputations about the tarsus a knowledge of the outline and exact position of its various articulations is so essentially necessary, that we make no apology for here introducing a few remarks on what may be called the external anatomy of the part, and for appending a sketch of the foot with an outline tracing of its bones. By attending to a few simple rules, the position of the various joints of the tarsus may be exactly ascertained, at any rate, when they have not previously been the seat of disease.

As was the case in the hand, the two distal phalangeal joints of all the toes, with the exception of the first joint of the great toe, are concave from side to side, the concavity being directed towards the ends of the toes, and they are all situated about two lines in front of the corresponding knuckles; the prominence of the knuckle belonging in

every case to the nearer of the two bones entering into its formation. The first, or metatarsal articulation of the phalanges of all the toes, is concave in its outline from side to side, with its concavity turned towards the tarsus; it lies just in front of the heads of the corresponding metatarsal bones, which latter can be plainly distinguished in any foot.

To ascertain the situation of the tarsal articulations, the operator, pulling the right foot over the edge of the table, and facing the body (turning his attention to the inner side of the foot), should place the forefinger of his right hand on the inner malleolus, and draw the point of the finger down the inner side of the foot. His attention will first be arrested by the tubercle of the scaphoid bone (fig. 22), which here forms a marked prominence, exceedingly useful as a guide, firstly to the articulation between it and the astragalus, opened in Chopart's amputation; and secondly, to its joint with the internal cuneiform bone; the latter of these articulations is situated half an inch in front of the prominence, the former lies a quarter of an inch behind it. Tracing onwards along the inner border of the foot, the projection of the proximal end of the first metatarsal bone may perhaps be distinguished, indicating the situation of the joint between that bone and the inner cuneiform, opened in performing Lisfranc's operation. But a more sure guide to the situation of this joint is afforded, by considering that it lies an inch and a half in front of the tubercle of the scaphoid bone (fig. 22), the latter point being easy of recog

nition.

Turning now to the other side of the foot, let the operator place the forefinger of the left hand on the outer malleolus, and trace along the outer border of the tarsus; here he will meet with two prominences, both deserving of attention. The first, a small, but sharply defined point of bone on the

CHAP. VII.] POSITION OF THE TARSAL ARTICULATIONS.

91

os calcis, about an inch below the malleolus, and generally called the peroneal tubercle (fig. 22); from an inch to an inch and a half farther on, he will encounter a well marked bony prominence, constituting the proximal end of the Fig. 22.

[blocks in formation]

metatarsal bone of the little toe (fig. 22). The articulation between the calcis and cuboid is situated about half an inch in front of the peroneal tubercle, or it may be said to be midway between that point and the prominence of the fifth metatarsal bone.

The joint between the cuboid and fifth metatarsal bone lies immediately behind the projecting extremity of the latter.

« PreviousContinue »