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taining complete rest, to promote osseous union; while, after excisions of the shoulder and elbow-joints, it is as essential to endeavour, by passive motion and other means, to arrest, as far as possible, the osseous transformation of the new tissue between the divided ends of bone.

We propose to consider the resections of the larger articulations only, and first, those of the upper extremity, the shoulder, elbow, and wrist, and then to discuss the merits of the same operation on the three large joints of the lower limb.

The Shoulder-joint.-Resections of the shoulder, unlike those of the knee, generally necessitate the removal of but one of the articular extremities entering into the joint; it is very seldom that more than the head of the humerus need be removed, either for disease or injury, and this from the very nature of the affections of the joint, which, while they seriously damage or even destroy the head of the humerus, rarely attack the glenoid cavity of the scapula. Again, the exposed position of the humerus, which renders this bone so peculiarly liable to injury from gun-shot wounds, forms a protection for the scapula. Fortunately, the full benefit of resection may be secured by the removal of one articular extremity, as it is not our object to obtain bony ankylosis.

The operation of excision was first applied to the shoulder-joint by Mr. Charles White* of Manchester, who, in 1768, removed the head of the humerus from a boy, aged fourteen, for acute necrosis, with destruction of the joint. He adopted a longitudinal incision, extending from the acromion half-way down the upper arm. Through this opening the head of the bone, which was denuded and dead, was thrust, and removed by a saw; the arm was then confined to the side by a bandage; the case went on well, though during the convalescence a large portion of dead bone separated from the sawn end of the humerus. At the end of four months the patient had recovered the perfect use of his arm, and upon examining the parts, Mr. White informs us that, apparently, the head and shaft of the bone had been completely reproduced; there was no deformity, and the extremity was only an inch shorter than the opposite one. Mr. Bentt and Mr. Orred of Chester, soon followed Mr. White's example, and before long other surgeons, both in England and on the Continent, put it in practice. M. Moreau§ was the first to remove the whole articulation; this he did with success in 1786. For some time after this the operation met with little general encouragement, though practised from time to time by various surgeons with variable success, and though used by Larrey occasionally, its practice had well nigh died out when Mr. Syme, in 1829, took it up, and by the fortunate issue of his cases soon established it as one of the most encouraging undertakings in conservative surgery.

This operation is applicable to compound dislocations, to cases where a bullet may have lodged in the head of the bone, and to all wounds of the shoulder-joint complicated with crushing or fracture of one or both bones entering into the articulation, unless, of course, the ⚫ Cases of Surgery in Phil. Transact., vol. lix. + Philosophical Transactions, vol. Ixvi.

+ Phil. Transact., vol. lxix. § Obs. Prat. relat. à la Résect. des Artic. Paris, 1803.

severity of the injury, by division of the great vessels, or by extensive laceration of the soft parts, necessitates ex-articulation of the limb. Nor need the extension of the injury to the shaft of the humerus deter the surgeon from attempting the operation. During the Schleswig-Holstein war, in more than one case, as much as four or five inches in length were removed from the shaft of the bone, and that with the most complete success.

In disease, either one or both articular extremities of the joint may be removed for caries, or indeed for any other incurable affection of the articulation, which renders it not merely useless as a joint, but by its presence either destroys the utility of the whole extremity, or seriously affects the general health of the patient. Lastly, this operation may be substituted for ex-articulation, in cases where tumours affecting the head of the humerus do not by their extension to the shaft necessitate the removal of the entire limb. We apprehend that resection of the joint is by no means justifiable for mere ankylosis, provided that this is the only inconvenience the patient suffers from. The movements of the fore-arm and the rotation of the scapula compensate so considerably for this, that we cannot see the necessity for the operation. The operation is counter-indicated where, together with compound fracture, there is any excessive destruction of the soft parts, or injury to the great vessels or nerves. Neither should cases of necrosis or caries be submitted to operation, unless the disease be confined to the articular extremity of the bone, or at any rate be within reach of removal.

The objects of this operation are to restore to the patient a strong, painless, and, if possible, a moveable articulation; and these results are best secured by a careful selection of suitable cases, a well-planned operation, and appropriate after-treatment.

The object of any mode of operation must be the sufficient exposure of the joint, with the least possible injury to the parts about. It appears, from the history of former operations on this articulation, that though Park, White, and others had adopted a single longitudinal incision for the removal of the head of the humerus, yet previous to its performance by Professor Langenbeck, the long tendon of the biceps had always been divided. He it was who first practised an operation which had for its object the preservation of this tendon. Langenbeck's method consists in an incision commencing at the acromion, and extending downwards on the anterior aspect of the joint for three or four inches; this should fall just over the bicipital groove, which is then opened, and the tendon drawn inwards; the muscles inserted into the tuberosities are now divided, and the head of the bone thrust out of the wound and removed by an ordinary saw. This operation is sufficiently easy of execution when the head of the bone retains its connexion with the shaft, and the soft parts are not tense or swollen. On the other hand, it is difficult by this incision to remove the disconnected head of the humerus, and especially when the integuments are swollen and oedematous. To remedy this, and to provide a more dependent aperture for the escape of the secretions. from the wound, Stromeyer made use of a semicircular incision, com

mencing at the posterior edge of the acromion, and extending downwards and outwards for three inches, having its concavity forwards; the joint is thus freely opened from above and behind, the tendon of the biceps can be preserved, and a free and dependent aperture is left for pus. Stromeyer states that patients recover from this operation much more quickly than from Langenbeck's, owing to the much greater facility it affords for cleansing the wound. That perfect recovery may take place after division of the tendon of the biceps is well known, and indeed Esmarch relates three cases of resection in which it had been torn across by a ball, and yet in each case the patients recovered, with good use of their arms. It may also be gathered from similar evidence that transverse division of the fibres of the deltoid but little affect the ultimate success of the case. Whatever mode of incision be adopted, the deltoid, with few exceptions, becomes much atrophied after the operation; perhaps this is caused by the division of its nerve, which, with the posterior circumflex artery, are the only nerve and vessel of importance that are liable to injury.

The after-treatment of these cases is far more simple and more easy of execution than that of excision of some other joints. Absolute rest, cleanliness, and appropriate constitutional support constitute the principal measures to be adopted; but we will refer to the plan pursued during the Schleswig-Holstein war. Absolute quiet was maintained by bandaging the arm to the side. Ice was freely applied to the parts, and maintained there until suppuration was fully established. Bleeding, both constitutionally and locally, was unsparingly employed during the stage of reaction, and upon this Stromeyer strongly insists. The wound was never, if possible, disturbed, all cleansing was effected by allowing water to flow over the wound. Matter, if it formed, was let out by incisions, and not squeezed out. Cicatrization was promoted by dressings of nitrate of silver lotions; flannel bandaging was employed to consolidate the parts; passive motion was commenced as soon as the cicatrix had formed, and was continued at the discretion of the surgeon, and as the patient could bear it, until considerable voluntary motion of the extremity had been regained.

Stromeyer and Esmarch both agree as to the most favourable time for resection after gun-shot injuries. They divide the period after the receipt of a wound into three stages. The first stage lasts for twentyfour hours, during which time there is comparatively little or nothing going on at the seat of injury. The second or inflammatory stage extends from the second day until suppuration is established; and the third includes any period after the occurrence of suppuration. We think this division is of great importance, and far preferable to the old separation of operations into primary and secondary, which is a mere. arbitrary division of time, irrespective of any changes which may be going on in the wound. In the class "primary" were included those operations performed, either before any pathological change has taken place at the seat of injury, or during the first stages of inflammation and reaction; two states which very differently influence the ultimate result

to the patient for good or evil. The most favourable time for resection is either within the first twenty-four hours, or when suppuration is fully established. Out of six excisions of the shoulder performed during the former period two died. Ten were operated on after the occurrence of suppuration, of these two died. While three were operated on during the inflammatory stage, with two deaths. There was another inconvenience which attended operations in this stage— namely, the very free hemorrhage that occurred at the time of their performance. The truth of these remarks, and the facts indicated by these resections of the shoulder-joint, were fully confirmed by the results of operations on other articulations, to which reference will be made hereafter.

Nineteen patients were subjected to resection of the shoulder-joint during the Schleswig-Holstein war, of these seven died, and twelve recovered with useful and moveable articulations; of these latter it is recorded that one patient returned to his work as a farm labourer, and when last heard of, was engaged in threshing corn. The others, at the time when their histories cease, were either engaged in their ordinary employments, or were fast regaining the usefulness of their limbs. It has been used as an argument against resection in general, that the convalescence is tedious beyond endurance; but Stromeyer states that the average time occupied in acquiring firm cicatrisation, was about three months, though of course patients did not regain the full use of their limbs in this time. Of the seven fatal cases, two were primary operations, two were performed during the reactive stage, and three were secondary resections. They all died of pyæmia, and in most, secondary abscesses were found fully developed in the internal organs. In five of these, before death, profuse "pyæmic hæmorrhage" occurred, the result, as Esmarch states, of obstruction of the axillary vein.

The mortality here recorded at first sight appears high for such an operation as the one under discussion; but we must take into consideration the conditions under which these operations were performed. "They were done," says Esmarch, "under circumstances in which more than a third of all amputations of the arm died." Again, we must remember that they died of pyæmia-a disease which, as far as our present knowledge extends, does not attach itself to any one of the capital operations in preference to another. In fact, so various are the conditions in military surgery that affect the well-doing of patients after operations, that we can scarcely with any justice compare the results of an operation as they occurred after two distinct battles; much less can we estimate the success and judge of the comparative fitness of two plans of operating, by arguing from their respective results in any two campaigns. For instance, after the battle of Fredericia, out of all the cases of amputation of the thigh, but one recovered; and yet out of 128 occurring in the whole war, sixty-seven survived. Nor can we compare the results of excision of the shoulder-joint in this campaign with those recorded by Larrey, who relates ten cases of excision of the same articulation for gun-shot fractures, and of these all recovered. Nor these latter with the results of the same operation

performed in the Crimea. But we receive Esmarch's statements, and weigh them, bearing in mind, as far as we know them, the conditions to which the patients were exposed after the operation-" circumstances under which more than a third of all amputations of the arm died." And perhaps we gain some further knowledge of the comparative merits of the proceeding by referring to the histories of eight cases that were observed and noted by Esmarch. These were all injuries suitable for resection, but were, from insufficient experience of the value of the operation, "left to nature." Five out of these died, and the remaining three, after six months' time, had not recovered, but seemed rather still to need operative interference.

The results of our Crimean experience, so far as they are at present published, give a more favourable impression of the value of the operation under discussion. Before Sebastopol, twelve excisions of the shoulderjoint were performed, with but two deaths, while the survivors all regained more or less motion in their limbs. For injuries to the same articulation, sixty suffered amputation at the joint. Out of these, nineteen died, being 150 per cent. in favour of the former operation.* We can scarcely with justice compare the mortality after resection with that after ex-articulation in former wars; for in these it appears that amputation of the joint was adopted for almost all gun-shot fractures occurring high up in the humerus. This is true with regard to the practice of Larrey in the earlier part of his career, and no less of Pirogoff, who, in his work published in 1840, makes the inquiry, whether, in cases of gun-shot fractures of the humerus, it is allowable to make an attempt to save the limb ?t The statistics afforded by Larrey of his success in ex-articulation of the upper limb, give a more favourable impression of this operation than the statements of any surgeon we are acquainted with. In 1817, Larrey and his assistants had amputated at the shoulder-joint upwards of one hundred times, and of these ninety recovered.‡

Mr. Guthrie's statistics, taken from the hospitals in the Peninsula, give us a far greater mortality. Of fifty-six cases submitted to amputation at the shoulder-joint, thirty-three recovered. We must regret that at present we possess no sufficient number of cases of resection of this articulation to admit of our making any fair comparison on a large scale between the mortality after excision and after amputation of the shoulder-joint. As far as we can decide from the information we at present possess-namely, from the experience gained in the Schleswig-Holstein and Crimean wars-the evidence clearly shows resection to be the less dangerous operation. There are but few recorded instances of complete resection of the shoulder-joint. MM. Moreau, Syme, Heyfelder, Larrey, and Lauer have each removed the entire articulation. These five cases were all perfectly successful, except Heyfelder's, whose patient sunk on the twenty-first day, apparently as the direct result of the operation. Larrey's case is well worthy of remark, showing, as it does, the power of recovery after ⚫ Medical Times and Gazette, Sept. 20th, 1856. † Rapport Méd. d'un Voyage en Caucase. + Cooper's Surgical Dictionary, Article " Amputation."

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