Skin, external, and internal ligaments, and the bones are the only parts divided, no tendons and no arteries of any size.[69]
Barwell's method by lateral incisions is briefly as follows:—
On the outer side, an incision over the lower three inches of the fibula turns forward at the malleolus at an angle, and ends about half an inch above the base of the outer metatarsal. The flap is to be reflected, fibula divided about two inches from its lower end by the forceps, and dissected out, leaving peronei tendons uncut. A similar incision on the inner side terminates over the projection of the internal cuneiform bone; the sheaths of the tendons under inner angle are then to be divided, and the artery and nerve avoided; the internal lateral ligament is then to be divided, the foot twisted outwards, so as to protrude the astragalus and tibia at the inner wound. The lower end of the tibia and top of the astragalus are to be sawn off by a narrow-bladed saw passing from one wound to the other.[70]
Dr. M. Buchanan of Glasgow has described an operation by which the joint can be excised through a single incision over the external malleolus.
Results.—So far as can be gathered from cases already published, the results are very often (at least in one out of every two cases) unsatisfactory. Sinuses remain, which do not heal, the limbs are useless, and amputation is in the end necessary.
Langenbeck has performed it sixteen times during the last Schleswig-Holstein war (in 1864), and the Bohemian war in 1866, with only three deaths. In these cases the operation was subperiosteal.
Excision of the Scapula.—More or less of the scapula has in many cases been removed along with the arm, and even with the addition of portion of the clavicle.
Excision of the entire bone, leaving the arm, has been performed in two instances by Mr. Syme. The procedure must vary according to the nature and shape of the tumour on account of which the operation is performed. Mr. Syme operated as follows:—
In the first case, one of cerebriform tumour of the bone, he "made an incision from the acromion process transversely to the posterior edge of the scapula, and another from the centre of this one directly downwards to the lower margin of the tumour. The flaps thus formed being reflected without much hæmorrhage, I separated the scapular attachment of the deltoid, and divided the connections of the acromial extremity of the clavicle. Then, wishing to command the subscapular artery, I divided it, with the effect of giving issue to a fearful gush of blood, but fortunately caught the vessel and tied it without any delay. I next cut into the joint and round the glenoid cavity, hooked my finger under the coracoid process, so as to facilitate the division of its muscular and ligamentous attachments, and then pulling back the bone with all the force of my left hand, separated its remaining attachments with rapid sweeps of the knife." ([Plate III.] fig. g.)
Mr. Syme's second case was also one of tumour of the scapula; the head of the humerus had been excised two years before.