Prosthetic device

“ The German surgeon, Lorenz Heister, was more appreciative of the innovation. After describing the older method of making sixteen to twenty small wounds in the skin with a knife, he announced that “The modern surgeons have, for Conveniency for themselves and Ease to the Patient, contrived a Scarificator ... which consists of 16 small Lancet-blades fixed in a cubical Brass Box, with a Steel Spring.” ”

“ Having determined upon the method to be followed in securing the flap, the surgeon is advised to consider such apparatus as he may be able to procure to retain the parts, or to use his own ingenuity to construct one of plaster-of-Paris bandages to meet the requirements of the case at not only less expense, but with greater comfort to the patient. At best, any apparatus employed will do little to overcome the agony of the retained member, which must be held in position. ”

“ And accordingly there is among the appliances of medical men an instrument by which the private parts are dilated with a priapiscus worked by a screw, and also a ring-knife whereby the limbs are cut off in the womb with judicious care, and a blunt hook by which the whole mass is extracted and a violent form of delivery in this way effected. There is also a bronze stylet with which a secret death is inflicted ”

“ There is less danger also of any membrane getting between the groove and the knife, as the point of the cutting edge, being buried in the groove, will divide whatever lies before it, which is not done by a beaked instrument. The opening made in the prostate, and also in the perineal muscles, can, in some measure, be regulated by the angle which the knife makes with the director as it enters the bladder. ”

“ In the thin wasted wrists of the aged, or in any case where the skin is very lax, this amputation may be very easily performed by the circular method. While an assistant draws up the skin as much as possible, the surgeon makes an accurate circular incision through the skin, about an inch below the styloid processes, just grazing the thenar and hypothenar eminences. Another circular sweep just above the pisiform and unciform bones divides all the soft textures, after which the joint may be opened, and, if necessary, the styloid processes cut away with saw or pliers. ”

“ The little wound being then stretched open between the finger and thumb of the operator, the incision is moistened with the matter, by gently touching it with the flat side of the infested lancet. This operation is generally performed in both arms, and sometimes in two places in one arm, a little distance from each other. For as I have not observed any inconvenience from two or three incisions, I seldom trust to one; that neither I nor my patient may be under any doubt about the success of the operation from its being performed in one place only. ”

“ It can be applied without the use of an anæsthetic without causing undue suffering to the patient, it allows of ready change of the dressing, it is comfortable and permits considerable range of movement on the part of the patient, it is as efficient with patients lying on the ground as in a bed, it keeps the limb in good position and allows of constant inspection on this point, and it is the only method which provides satisfactory extension without constant readjustment. ”

“ When, for example, a displaced bone or a mass of callus is pressing upon the nerve, steps must be taken to relieve the pressure, by operation if necessary. When there is reason to believe that the nerve is severely crushed or torn across, it should be exposed by incision, and, after removal of the damaged ends, should be united by sutures. When it is impossible to make a definite diagnosis as to the state of the nerve, it is better to expose it by operation, and thus learn the exact state of affairs without delay; in the event of the nerve being torn, the ends should be united by sutures. ”

“ When a total rhinoplasty has to be undertaken the paraffin group of protheses of course cannot be resorted to, owing to a lack of the necessary retentive walls of tissue, except perhaps in such cases where the so-called double flap, or French method, is employed, and there only after the parts have become thoroughly organized. ”

“ We have dealt chiefly with the conditions which are suitable for the re-education of a man who has lost an upper limb, or, speaking more generally, is disabled in one arm, for whom resumption of work in a workshop will often be out of the question. The question is easier of solution for the lower limb. Cases of amputation of the leg can work standing, if supplied with an artificial limb, at practically any trade. Cases of amputation of the thigh have numerous manual occupations open to them in which they sit for at least part of the time. ”

“ When for any cause there is a loss of the entire nose, and the patient is unwilling to undergo surgical operation for its restoration, the surgeon may resort to the use of protheses or artificial noses. ”

“ Patients are sometimes anxious for such operations in preference to amputation of the whole finger. The surgeon should, however, never amputate through a finger higher up than the distal end of the second phalanx, unless absolutely compelled by the patient, for the resulting stump, being no longer commanded by the tendons, will prove merely an incumbrance, and may possibly require a secondary operation at no distant date for its removal. ”

“ The elevation of the skin is in the meantime partly kept up with the needle itself, while the syringe is grasped with the freed hand, the thumb and forefinger of the right hand being placed upon the handle of the screw or piston rod, which they must rotate to force the semisolid mass from the instrument.
Before beginning the injection an assistant is instructed to press with his fingers the tissue about the margin of the defect to prevent the filling from becoming misplaced or being forced into undesirable channels, especially if the skin over the defect is found to be thick and inelastic. ”

“ When the patient is less than fourteen or fifteen years of age a general anesthetic should be employed, but in older patients the operation can be easily undertaken under local use of two-per-cent eucain solution.
Author’s Method.—The method followed by the author is to thoroughly anesthetize the back of the ear, the patient lying in a recumbent position with the head to one side, sufficient to place the ear to be operated upon in as convenient position for operation as is possible. A rubber cap is drawn over the head to cover the hair. ”

“ The hand of the surgeon may also be rested on the back of the couch, as, if ambidextrous, he will invariably take his position behind the patient, in order that he may have the command of the upper eyelid in his own hands. The incision is made either in the lower or upper half of the cornea. The knife should have a very keen edge, and become gradually broader and thicker, from its point backwards: in using a narrow instrument there is danger of the aqueous humour escaping. The best knife is Beer’s, well made. ”

“ The knife resembles in form a common scalpel, but is longer in the blade, and is slightly convex in the back near the point, to enable it to run with more facility in the groove of the director. The scalpel blade has this advantage over the common beaked lithotome, that the external incision can be made with the same instrument as the section of the prostate gland, thus rendering a change of instrument unnecessary. ”

“ Care, however, should be taken to inject just sufficient of the solution to penetrate beyond the zone of operation laterally, to insure sufficient space for the insertion of sutures into anesthetized tissues. Only a small quantity of fluid is necessary in this procedure as it comes in direct contact with nerve terminals. By touching the injected line with the needle in several places along its length and inquiring of the patient if it is felt, we may make sure of the completeness of the anesthesia before making the incision which should begin and end inside the anesthetized area. ”

“ The surgical epilation forceps is, as we have seen, usually a simple instrument. Occasionally we meet with a forceps combined with some other instrument. These are, as a rule, toilet articles. A pocket ear-scoop and epilation forceps combined was found in Paris. Precisely similar articles of steel may be bought in chemists’ shops to-day. Another has a small unguent spatula combined with a forceps, while others carry olivary probes. ”

“ Whatever drug is used, strong solutions are seldom necessary for application to the mucous membranes but the necessary time for its absorption is a prime requisite. To secure anesthesia of the conjunctiva and cornea, the solution is dropped into the eye at the outer canthus and as it flows off with the tears, it must be replenished three or four times until anesthesia is accomplished. In the nose, a spray over the site of incision or a pledget of cotton saturated with the anesthetic solution and allowed to rest in contact with that locality, will suffice. ”

“ Should a hyperplasia of connective tissue result from such an operation, a small linear incision, under four per cent eucain anesthesia, should be made directly over the greatest prominence, through which the offending mass can be removed by the aid of a small hooked knife or a fine pair of curved scissors.
The mass should be removed beyond the plane of the skin ”

“ An assistant then holds it upwards, while the surgeon, or (if the arm is very muscular) another assistant, brings the arm forwards well across the patient's chest, thus exposing the posterior aspect of the joint. This may have very possibly been already opened during the transfixion; the attachments of muscles must now be divided, the knife passed behind the head of the bone, which is dislocated forwards, and a suitable flap of the tissues in front cut from within outwards. The assistant is to follow the knife with his finger and compress the vessels. ”

“ That the growth is not limited by the size of the mass injected is the author’s belief; in other words, the replacement of the new tissue is not proportionate to the injection, but that other forces, such as adjacent tissue pressure and presence and outer influences, as, for instance, the daily massage of the parts with the hands, have much to do with the final amount of tissue caused to be developed by the initial stimulus of the injection. ”

“ Apart from internal and proper external electrical and other treatment the simplest surgical method to be employed is to remove an elliptical piece of skin from the eyelid and to suture the margins of the wound together. Care should be taken not to take out too much tissue, as this would involve inability to close the lid. ”

“ Continuous irrigation of the part by a slow, steady stream of lotion, at the body temperature, such as eusol, or Dakin's solution, or boracic acid, or frequent washing with peroxide of hydrogen, has been found of value.
A suitably arranged splint adds to the comfort of the patient; and the limb should be placed in the attitude which, in the event of stiffness resulting, will least interfere with its usefulness. The elbow, for example, should be flexed to a little less than a right angle; at the wrist, the hand should be dorsiflexed and the fingers flexed slightly towards the palm. ”

“ So that in order to have in addition an artificial hand, which is capable of being removed and replaced by one or more of the appliances which will be described later, it would be necessary for the patient to possess two complete artificial limbs, and changing from one to the other would evidently be inconvenient. ”

“ This in the majority of cases will give better results than when an entire cheek is injected, for the reason that the larger mass is likely to be displaced by the unconscious act of the patient in sleeping on one or both of the rebuilt cheeks or the willful massage to improve the handiwork of the surgeon in their own belief. ”

“ Such noses are made of papier-maché, rubber, wood, or light metal, and painted to imitate the color of the skin of the individual. They should be made after a model previously prepared by molding the new organ upon the face of the patient or after such patterns as the surgeons may have to choose from, fitting the skin juncture accurately in such cases.
If the surgeon lacks such artistic ability, a sculptor should be employed to model the proper organ suitable for and on the face of the patient, from which a plaster cast or mold may be made from which the maker of protheses can work. ”

“ The surgeons utilizing the robot for prostatectomies tout the increased magnification, 3D visualization, and precision movements the wristed instruments as advantages over the open surgical procedure. The neurovascular bundles are well visualized, as is the apical dissection of the prostate and urethra. Performing deep pelvic surgery such as ureteral reimplantation in postpubertal patients is a situation where the robotic approach may have an advantage over traditional open surgical reimplantation. ”

“ A strong screw must be fastened in the wall near the window at the height of about seven feet to support the fountain syringe, which will be filled with whatever solution the surgeon requires for irrigating the wound.
One slop-jar stands at the side or end of the large table, the other beside the table that holds the basin of sponges.
The bureau (covered with a sheet) or the mantle-shelf will serve to hold the dressings and rubber gloves. A small stand or table will be needed by the doctor who gives the anesthetic for his hypodermic, clean towels, and ether or chloroform. ”