Volume 2

A manual of surgical treatment / by W. Watson Cheyne and F.F. Burghard.

Date:
1912-1913
Catalogue details

Licence: Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)

Credit: A manual of surgical treatment / by W. Watson Cheyne and F.F. Burghard. Source: Wellcome Collection.

Provider: This material has been provided by the Royal College of Physicians of Edinburgh. The original may be consulted at the Royal College of Physicians of Edinburgh.

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    exposed thoroughly. Attempts to extract it through too small an opening are sure to result in fracturing it, and then fragments are almost certain to be left behind vvliich may be difficult to find afterwards ; if left behind they will prevent the wound from healing. If the area of bone e.xposed be not that in which the cloaca; are present, the exposed portion should nevertheless be chiselled away until the cavity in which the sequestrum is lying is reached, and then the opening should be enlarged to any extent that may be necessary. The most difficult cases are those in which the necrosis has involved a considerable segment of the bone, and the sequestra are curved, so that a single opening in the bone will not suffice for their removal. It may then be necessary to make an incision on the opposite side of the limb and chip away bone there, and then possibly to break the sequestrum in two, and remove part through the one incision and part through the other. The important points are to obtain free access to the cavitv, and to remove the sequestrum in one piece if possible. Disinfection of the Cavity left.—After the whole of the sequestrum has been removed, the granulation tissue in the cavity is scraped away in order to make sure that no small sequestrum is left behind among the granulation tissue ; removal of the granulation tissue also increases the chance of getting the wound aseptic, and thus eradicating the sepsis. In order to facilitate the disinfection of the wound, the cavity should be soaked with undiluted carbolic acid, and any sinuses present should be treated similarly. The best treatment for these septic sinuses, however, is to excise them completely if their situation renders this possible. The tourniquet should now be relaxed and any spouting vessels tied. If the oozing from the bone and the tissues be severe, it may be necessary to plug the woimd tightly with gauze, and elevate the limb. Obliteration of the Cavity.—Healing does not necessarily follow remo\'al of the sequestrum ; if the dead bone be removed through a compar- atively small opening, the cavity in the bone may never close, as the opening in the soft parts contracts rapidly, and long before the cavity has become filled up with granulations, the exit from it has become so small that the discharge cannot escape freely. When this condition has become established, the cavity will suppurate just as if a sequestrum were present, and it is impossible to keep it properl}- open and \ery difficult to keep anything but a metal drainage tube in it. Hence, in order to get healing, not only must all sequestra be removed, but also, if possible, perfect drainage must be established for any cavity that is left. To secure this, as free an opening should be made into the ca\'itv as is practicable, short of endangering the strength of the bone ; the sides of the cavity should be bevelled away so as to leave a wide shallow depression in the bone, instead of a deep narrow cavity. When this can be done in deep-seated bones, such as the femur, the periosteum and soft parts may fall over and adhere to the raw surface. In more