THE

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW.

OCTOBER, 1857.

PART FIRST.

Analytical and Critical Reviews.

REVIEW I.

1. J. F. Heufelder über Resectionen und Amputationen. Steindrucktafeln.—Breslau und Bonn, 1855. pp. 269.

Mit vier

On Resections and Amputations. With four Lithographic Plates. By Dr. J. F. HEYFELDER, Professor of Medicine at Erlangen, &c. 2. Mittheilungen von Resectionen am Fuss. Von Dr. ROBERT, zu Coblentz. (Vierteljahrsschrift für die Praktische Heilkunde.) xii. Jahrgang. Dritter Band.-Prag. 1855.

Contributions on the Subject of Resections at the Foot. By Dr. ROBERT, of Coblentz.

3. De Articuli Humeri et Cubiti Resectione, Inauguralis Chirurgica Dissertatio. Auctore PANAGIOSTES GEORGIUS KYRIAKOS.-Berolini, 1854. pp. 22.

Dissertation on Resection of the Shoulder and Elbow-joints. By P. G. KYRIAKOS.

PP. 24.

4. De Articuli Cubiti Resectione, Dissertatio Inauguralis Chirurgica. Auctore ALBERTUS TOBOLD.-Berolini, 1855. Dissertation on Resections of the Elbow-joint. By ALBERT TOBOLD. 5. On Excision of the Knee-joint. By R. G. D. BUTCHER, Esq., M.R.I.A., Surgeon to Mercers' Hospital, &c. &c. (Dublin Quarterly Journal of Medical Science,' May, 1855.)

6. On Excisions of Joints. By the same Author. (Dublin Journal,' November, 1855.)

7. Second Memoir on Excision of the Knee-joint. By the same Author. ('Dublin Journal,' February, 1857.)

8. Cases of Operation upon Diseased Joints. By W. A. GREEN, M.D., Bengal Medical Service. (Indian Annals of Medical Science,' April, 1855.)

40-xx.

•1

9. Gun-shot Fractures, by Dr. STROMEYER, and Resection in Gunshot Injuries, by Dr. ESMARCH. (Slightly abridged.) Translated by S. F. STATHAM. With some Remarks on Tonic Treatment, by the Translator.-London, 1856. pp. 120.

10. An Essay on the Excision of Diseased Joints. By Mr. BLACKBURN. (Guy's Hospital Reports,' first series, vol. i. 1836.) 11. On Excision. By Surgeon THORNTON, 9th Regiment.

Reports

of Crimean Medical and Surgical Society ('Medical Times and Gazette,' Sept. 13th, 1856, and Sept. 20th, 1856.)

12. On Excision of the Hip-joint. By Mr. HANCOCK, Surgeon to Charing-cross Hospital, &c. ('Lancet,' April 18th and 25th, 1857.) THE subject of resection of the articular ends of bones having been so prominently brought before the profession during the last few years, and having been so ably discussed and strongly advocated in the case of individual joints, by many eminent surgeons, it will be our endeavour in the following pages to collect and analyse the evidence in favour of or against its employment, in the larger articulations, and by comparing the results of the operation, to deduce such rules of practice as may be gathered from what has been already published on the subject, and chiefly from the works enumerated in the foregoing list.

The practice of resection originated in this country, and was first performed by Mr. Filkin of Northwich, who operated on the kneejoint on August 23rd, 1762. This case, though perfectly successful, was not published until years afterwards-indeed, not until after the death of the operator, and thus its benefits were confined to the individual on whom it was practised, and furnished no suggestions or data for the guidance of the surgeon who in reality established the principle and practice of resection. In 1768, Mr. Charles White* of Manchester, removed the head of the humerus for acute destructive disease of the shoulder-joint; four months afterwards, this patient, to the surprise of his surgeon, had regained to a great extent the movements of his shoulder-joint. About the same period, Mr. Wainmant (see p. 294) removed the lower articular end of the humerus, in a case of compound dislocation, with success. These two latter recoveries, and a remarkable case of recovery after traumatic necrosis of the joint-ends at the elbow, with sloughing of the capsule of the joint, encouraged Mr. Park to put in practice the excision of the knee-joint-an operation he had long before conceived, and had since made a constant subject of reflection. July 2nd, 1781, Mr. Park performed the first resection of the kneejoint with perfect success. The patient, a sailor, returned to his ordinary duties of a scaman, and continued to follow his occupation until his death, which occurred eight years afterwards. The same surgeon again operated on a less favourable case, the patient never recovering from the effects of the operation.

On

It is to Mr. Park that we really owe the enunciation of this mode of treatment; he it was who not only first published the account of resection of the knee-joint, but in his memoir on the subject, suggested the applicability of the same operation to other articulations. The * Cases of Surgery, vol. i.

+ Mr. Park's Letters to Mr. Pratt.

truth of these speculations was soon put to the proof by M. Moreau, who excised the knee-joint once and the ankle twice*-in every case with a favourable result, so far as the operation was concerned.

Notwithstanding the encouraging success that attended these efforts of conservative surgery, resection met with but little general encouragement, and though on the Continent Sabatier,† Roux, Fricke, Textor, Müller, and others, made use of the operation for different joints, with variable results, yet in this country, at the beginning of the present century, it had fallen into disuse, and especially in the treatment of the diseases of the knee-joint.

In 1829, Mr. Syme, following the example of Sir P. Crampton, who seven years before had resected the knee-joint in two cases, revived the performance of this operation on the shoulder and elbow-joints, and soon established its practice by his successful operations on these articulations, while by the less satisfactory result he obtained in one of two cases of resection of the knee, he consigned this latter operation to unmerited oblivion. Twenty years afterwards, Mr. Fergusson was bold enough to put the operation again in practice. His example was quickly followed by Mr. Jones, of Jersey, and others, since when, the operation has been frequently and successfully practised.

The general result to be aimed at in all resections is the restoration of a useful limb to the patient. The very different functions of the upper and lower extremities of the body have led to the practice of endeavouring, in operating on the former, to preserve a yielding bond of union in place of the excised joint; while, in excising the joints of the lower extremity, we endeavour, by all means in our power, to promote bony ankylosis between the divided ends of bone. To secure ultimate motion, it is neither necessary to remove all the articular extremities of a joint, nor even to destroy the cartilaginous surfaces of the bones; our practice in this respect is guided by the condition of the parts themselves. While, on the other hand, to obtain osseous union, it is absolutely essential that the opposed cartilaginous surfaces of the joint be removed, and that fresh-cut surfaces of bone should be brought and maintained in apposition.

There are fifteen recorded cases of examination of joints that have been subjected to resection, and where repair had either fully taken place, or was in progress. They are recorded by Syme,§ Textor (quoted by Hey felder), Heyfelder,|| Roux, Thore, Dr. Green,¶ Reid, and Hutchinson.** Seven were elbow-joint excisions, six were shoulder-joints, and the remaining two were cases where the knee-joint had been resected. No cases are here included but those where repair to some extent had taken place. The above-mentioned examinations were made at periods varying from three months to nineteen years after operation. From these it appears that in the upper extremity, with a single exception, no false joint was formed, nor anything comparable with a synovial capsule, but rather that the ends of the bones were connected by a tough fibrous

Obs. Prat. relat. à la Résect. des Artic. Paris, 1803. † Mém. de l'Institut, tom. v. 1805.

Syme on Resection.

Indian Annals of Medicine. April, 1855.

De la Résection. Paris, 1812.
Ueber Resectionen.

** Med. Times and Gazette. 1857.

tissue, which in most cases, and under appropriate treatment, permitted of no inconsiderable amount of flexion and extension. This tissue is not only a boud of union between the bones, but prevents their ends from coming into contact, and is itself the seat of the movements of the new articulation. The exceptional case is related by M. Roux, where, after resection of the elbow-joint, the ends of the bone were found smooth and rounded off. In but one case was any reproduction of the excised ends of bone discovered. The two examinations of resected knee-joints were made at intervals of three months and fourteen years after operation respectively. In the former, a considerable formation of callus had taken place about the divided ends of bone, while in the latter the femur and tibia had become one, by the direct growth of bone from one to the other. In all cases, both of the upper and lower extremity, the divided muscles and tendons were found matted together in the cicatrix of the operation.

When a surgeon, after perhaps a long and anxious struggle to save a patient's limb, has at last decided on the necessity for amputation, and has performed the operation, he rests, as it were, from his labours, and for the future merely bestows that amount of care and attention which constitute all he can do to promote the recovery of his patient; the ultimate result, life or death, depends in most cases upon the vital powers of the patient, while the difference between a skilful and careless management of the wound will but result in the formation of a good or bad stump, as the case may be. But in resection it is far otherwise in both cases errors in constitutional treatment may bring on a fatal issue; and while, after amputation, want of skill will produce the effect above mentioned, the same fault after excision will endanger, in the case of the upper extremity, the loss of the limb; in that of the lower limb, the patient's life.

As in all efforts of conservative surgery, the greatest patience and skill are required; in these cases the surgeon's real responsibilities commence on the completion of the operation, nor do they cease until the patient has fairly become convalescent. Nothing but a personal superintendence of the local treatment, and a ready resort to such expedients as the necessities of the case may require, and the watchful care and ingenuity of the surgeon suggest; nothing short of this will be even likely to secure a favourable result.

From what is generally known of the cause of the failure of union in fractured bones, as well as from our personal examinations of ununited fractures, we venture to assert that "false joint" is a comparatively rare occurrence, and can only result where no attempt at the reparative process has taken place; whereas, by far the most frequent result of a maltreated fracture is the formation of a fibrous bond of union between the ends of bone, such as may be found in any fracture three weeks or so after its occurrence, or after a well-treated resection of the elbow-joint. This arrest of the ossifying process, though sometimes the result of constitutional defect, is too often brought about by the inefficiency of the apparatus used to keep the parts at rest.

The foregoing considerations may serve to account for the absolute necessity, in the treatment of resections of the lower limb, for main