A treatise on operative surgery : comprising a description of the various processes of the art, including all the new operations : exhibiting the state of surgical science in its present advanced condition / by Joseph Pancoast.

  • Pancoast, Joseph, 1805-1882.
Date:
1844
Catalogue details

Licence: Public Domain Mark

Credit: A treatise on operative surgery : comprising a description of the various processes of the art, including all the new operations : exhibiting the state of surgical science in its present advanced condition / by Joseph Pancoast. Source: Wellcome Collection.

Provider: This material has been provided by the National Library of Medicine (U.S.), through the Medical Heritage Library. The original may be consulted at the National Library of Medicine (U.S.)

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    fingers. The thumb and middle finger are opposed upon its upper and lower faces, and the fore finger carried a little in ad- vance upon the blade. The last three fingers are flexed so as to secure the free end of the handle against the palm. The direc- tion of the cutting edge of the bistoury may be varied. This position is convenient with the blade presented flat, for the pur- pose of making punctures, as in the opening of a lumbar abscess; or if the edge be held vertical, in making a crucial or X incision, cutting from within outwards after the knife has penetrated suffi- ciently far. STRAIGHT INCISIONS. (PL. II.) These may be very briefly noticed; they are made either from without inwards, by pressing downwards with the knife, or from within outwards, by raising the parts, and running it through the base of the fold. The incisions from without inwards and from left to right, are divided into the simple and compound. Simple incisioiis.—Every incision should be preceded with a previous tension of the skin, made either by the left hand of the operator, or, as in some cases will be necessary, by the aid of assistants. This may be done with the thumb and fore finger of the surgeon's left hand upon either side of the knife; by sinking in the ends of the fingers in the direction of the incision, as in cutting down upon an artery; by applying the ulnar border of the hand behind the track of the knife, the cross tension being made by the thumb and little finger; or by raising a fold of the skin with the aid of an assistant, as shown at fig. 6. 1*/ Process. Oblique incision ivithpuncture, as in opening an abscess, or dividing a deep-seated fascia.—The bistoury is to be held in the first position. Tension having been made with the thumb and finger, the point of the instrument is applied vertically between them, so as to be entered by puncture in the direction proper to the particular case till it has reached a suffi- cient depth. If it be abscess for which the puncture is made, the want of resistance to the point, the freedom with which it may be moved from side to side, and the appearance of pus on the side of the blade, indicate its arrival in the cavity. The bistoury is then to be brought more or less parallel with the surface, and by a movement of the hand from left to right, the puncture is enlarged so as to make a free exit for the pus. The incision com- pleted, the bistoury is to be raised and removed in the perpen- dicular position in which it was first entered. Where important parts are concerned, it is not, however, always safe to make a bold incision in this wa*y, at a single cut; and it will be found better to resort to one of the following processes instead. 2d Process. Incision on the flat surface of the skin without puncture.—This differs from the preceding in employing the cut- ting edge, for the purpose of dividing the different layers of the part from above downwards, more slowly and by successive strokes with the knife. This process is much longer and more painful, but is more safe, and is, therefore, under many circum- stances to be preferred. 3c? Process. Incision on a fold of the skin, (fig. 6.) The in- teguments are to be raised in a fold, in a direction transverse to that in which the parts are to be divided with the knife. The section may be made at the will of the surgeon from above downwards, by holding the bistoury in the first position and drawing it from heel to point; or, by passing it by puncture in the second position with the edge upwards through the base of the fold, and cutting from within outwards. The skin is then relaxed, and we have a cutaneous incision rapidly made, twice as long as the height of the fold of skin. If it requires to be further lengthened, the surgeon may raise with his thumb and finger one of the lips of the incision, and prolong it by cutting from above downward, with rapidity, safety, and with compara- tively little pain to the patient. Incision in the 1th Position.—This mode of incision is pecu- liarly appropriate for the removal of excrescences from the skin, for the opening of the layers covering the arteries, as well as hernial and various other tumours. The convex bistoury or scalpel, is well suited to this incision. It forms a part of the pro- ceeding in most of the great operations, and requires light and delicate manipulation on the part of the surgeon. The portion to be incised requires to be raised with the forceps, hook, or the thumb and finger; the first cut of the knife is to be made ob- liquely downwards, then horizontally under the end of the hook or forceps; the knife is finally brought out obliquely on the oppo- site side, having moved in a sort of irregular crescentic line. Slight rotatory movements of the knife between the thumb and finger of the right hand suffice to place it in the position proper for these separate steps. In removing cancroid excrescences from the face, with the object of completing the cure ulteriorly with the arsenical paste, we may in this way, by first raising the tu- mours, extirpate them below the level of the surrounding skin. For the removal of large tumours, or even of smaller ones situated below an aponeurosis, or when we wish to remove a part at some distance from the surface, straight incisions will not afford sufficient space. Under these circumstances it becomes necessary to resort to the compound incisions. These may be either crucial, T, V, or star-shaped, and consist merely in a com- bination of the simple straight incisions. COMPOUND INCISIONS. (PL. II.) Crucial incision, fig. 5.—The first incision from left to right is made, as has already been mentioned, with the bistoury in the first position, or, if the surgeon should prefer it, in the third. The two other limbs of the cross cannot be neatly formed at a single cut, as the skin would slide before the knife on the right hand side of the wound. For this side, therefore, the skin having been previously made tense, the cut should be commenced from the bottom of the first incision; that of the other side is made in the opposite direction, or towards the first wound. The two smaller incisions may, however, if it be preferred, be made in another direction—from within outwards—by entering the knife under each lip of the first incision, passing it for the requisite distance parallel with and below the skin, through which the point is to be passed by lowering the handle, and the division effected by a cut from the point to the heel: the bistoury for the right half being changed to the left hand. The right hand may, however, be used for this latter purpose if the surgeon shift his position to one side, or which will be found more convenient,