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bandaging employed to consolidate the parts, and when cicatrization had been accomplished, passive motion, friction of the joint, and warm water-baths were assiduously made use of. Great value is attached by German surgeons to the use of ice in moderating the inflammatory stage after resection or compound fracture; of the five deaths which occurred out of the forty cases submitted to operation, four happened in the year 1849, and are attributed to the want of ice, which could not at that time be procured. Stromeyer ranks the local application of ice as next in importance to venesection, a position which, to our ideas, implies its general inutility rather than its importance. Still we would not venture to call in question the efficacy of bloodletting in military surgery, when such surgeons as Guthrie, Langenbeck, and Stromeyer so strongly advocate its use and testify to its advantages, which must depend upon the general physical condition of the wounded, the nature of the climate to which they are exposed, and the type of endemic disease prevalent.
The value of passive motion, frictions, and warm water-baths for restoring free movement to the articulation, is well illustrated by the results of some cases where these means were not employed. After the battle of Idsted, several patients who had been submitted to the operation of resection fell into the hands of the Danes, who, according to Esmarch, do not perform resections of joints ; in the beginning of the year 1851, when these patients were released, they returned with their fore-arms for the most part wanting in sensibility, and destitute of motion; and “these evils,” says Esmarch, “could only be partially bettered by means of warm water-baths and methodical passive motion.”
In his valuable records of the surgery of the war in Schleswig, Esmarch furnishes us with the results of forty cases of resection of the elbow-joint for gun-shot injuries. Of these, six have died; thirty-two have recovered with a more or less useful arm; one had not yet recovered when last under observation, and in one the arm was subsequently amputated. Among the thirty-two recoveries, eight are said to possess very extensive motion in the arm; nine a fair amount of mobility, which in many of them is still increasing; thirteen have a more or less complete ankylosis of the joint. In two cases, the amount of motion in the joint is not mentioned. The average time required for complete cicatrization in these cases was from two to three months.
The most favourable period for operation in cases of injury was found to be either within the first twenty-four hours, or after suppuration is fully established. Stromeyer and Esmarch give us the result of their experience on the point, which agrees in every respect with the comparative mortality of the primary, secondary, and tertiary resections performed on the shoulder-joint. Of eleven excisions of the elbow performed within the first twenty-four hours, but one proved fatal; twenty secondary operations were performed on the same joint with four deaths; nine were operated on after the eighth day from the receipt of the injury, and of these, one died.
The cause of death in five out of the six fatal cases was pyæmia; and this occurred at periods varying from the third to the thirtieth day after the operation. In all these, the presence of pyæmia was verified by the discovery of secondary abscesses in the internal organs; the remaining case died from tubercular disease of the lungs and mesenteric glands. One case is recorded in which the fore-arm became gangrenous, and was eventually submitted to amputation. This un. fortunate event was in no way attributable to the operation, but to the fact that the brachial artery and ulnar nerve had been divided by the bullet wbich injured the articulation, though by some oversight the absence of pulsation at the wrist was not observed until after the operation.
One case was submitted to amputation by Danish surgeons, but on what account has not been ascertained.
It appears that nearly all the ankylosed joints were flexed at an obtuse angle of from 130° to 140°. This most inconvenient and undesirable result was owing to their being put upon splints fixed at that angle, and it is stated that in no other position could the patient obtain complete rest and freedom from pain. We shall on this point venture to disagree with Esmarch, having ourselves witnessed the successful treatment of resected elbow-joints on splints fixed at a more acute angle, and, indeed, in a position in which, had they eventually become ankylosed, the patient would have possessed a useful arm.
Having in our possession the account of the resections performed on the elbow during the Schleswig-Holstein war, as well as the statement of the results of the same operation in the Crimea, we may form a fair estimate of its comparative mortality. In the former campaign, 54 amputations of the arm were performed, with 19 deaths, while 40 elbow-joints were resected with 6 deaths. In the Crimea, 153 arms were amputated, and of these 29 died; 17 elbow-joints were excised, with 2 fatal cases. In all these we have 207 cases of amputation, with a mortality of 48, or about 23 per cent. Of resections we have 57, with 8 deaths, or 14 per cent. Thus, then, in comparing amputation of the upper arm with resection of the elbow-joint, we obtain a per-centage of nine in favour of the latter operation.
No large collection of cases is requisite to prove the advantages of this operation, as applied to the treatment of articular caries, or other incurable joint-disease. General experience has long ago decided in its favour in snitable cases, and we believe that at the present day there is no surgeon of eminence or consideration who does not appreciate the advantages it offers in comparison with amputation. But surgeons still differ as to the advisability of submitting certain cases to operation, and especially whether it is justifiable to resect the joint for permanent ankylosis iu a position which renders the limb nearly useless.
“To many persons this state of things might be productive of no inconvenience sufficiently serious to warrant an operation; but there are others on whom its effect would be to deprive them of their livelihood and to ruin every prospect in life."*
Blackburn on Excision of Joints: Guy's Hospital Reports, vol. i., first series.
Under these circumstances, and where age and constitutional peculiarities do not forbid it, we have no hesitation in recommending resection of the joint, with a view to restore, if possible, a moveable articulation, or at any rate to obtain ankylosis at a suitable angle.
The new articulation resulting from this operation appears to suffer in no respect, but rather to gain strength from daily use. Many patients have been under observation for years, having passed through the wear and tear of a laborious occupation without injury. Relapse and extension of the original disease may take place a short time after the operation, either from a want of discrimination in selecting the case, or from some constitutional defect. Indeed, this has sometimes occurred; but we are acquainted with only one, and that a doubtful case, in which after the cure had been fully completed, the new tissue between the divided ends of the bone became the seat of disease. This instance is recorded by Heyfelder, who relates a case where the entire elbow-joint had been resected from a patient suffering from painful ankylosis with articular caries. Three months after the operation, she had recovered good motion in the articulation. Flexion, supination, and pronation could be effected with ease, but there was no power of extension. After relaxation of the flexors, the arm fell into the extended position. In addition to this, some pain always remained about the joint, so that it could not be used for work. Some months afterwards, an abscess appeared at the cicatrix of the operation, and subsequently, from time to time, others formed at the same spot. Eight years afterwards, her arm had become perfectly useless, very painful, and she could not accomplish any voluntary movement of the fore-arm, though it could be flexed so as to touch the humerus. In this condition, and suffering as well from spasmodic movements of the muscles of the whole limb, Dr. Heyfelder amputated the arm. On examination, the muscles and nerves, together with the newly-formed fibrous bond of union between the bones, were found softened, and everywhere infiltrated with fat. About the ends of the humerus and ulna were circumscribed purulent deposits, while the shafts of the bones themselves were in a state of inflammatory softening. Heyfelder himself inclines to the belief that this was a case of secondary disease, originating in the newly-deposited material between the resected ends of the bones.
The Wrist.-We pass from the consideration of resection of the elbow-joint, to the less favourable and indeed almost discouraging results of the same operation on the wrist. In all operations for excision, a general and indispensable condition must be fulfillednamely, that together with the partial or complete removal of the articular extremities of the bones, there should be a free exposure or destruction of the synovial cavity of the joint; any operative proceeding which leaves the articulation in a condition approaching to that of a wounded joint will lead to no good result, but will rather thenceforth be exposed to the dangers attendant on joint wounds, and will terninate as such accidents are wont to do.
In excisions of the wrist, owing to the complexity of the joint, it is seldom that we can fulfil these conditions; in removing disease here, while we take away the carious bone, or destroy the useless joint, in all probability we partially open or puncture one of the neighbouring articulations, which may be healthy or otherwise, and thus we leave a wound from which the subsequent phenomena of inflammation, profuse suppuration, and ulceration of the cartilages will but too surely result. There are other, but minor, objections to this operation, such as the difficulty of its performance, and the injury to the tendons which is often unavoidable, though these form no serious objection to the operation. Moreau the younger seems to have been the first to perform this operation on the wrist; the result he reports as successful, but we have been unable to meet with any distinct history of the case. In 1849, Heyfelder operated on the same articulation with equal success; five years afterwards this patient had regained perfect use in the hand and fore-arm, a result but rarely attained in similar cases; more recently the operation has been performed by Messrs. Fergusson, Stanley, Erichsen, and others.
In operations on the dead subject it is sufficiently easy to remove the extremities of the radius and ulna without injury to the tendons or vessels in the neighbourhood, and indeed this has been accomplished by more than one surgeon on the living body; but very often, in disease, it is impossible, and indeed useless, to attempt to save the extensor tendons, matted together as they may be by inflammatory deposits, and closely adherent to the bone. The principal modes of performing this operation are three :- 1st, by lateral longitudinal incisions running along the ends of the radius and ulna respectively; 2nd, by a semilunar or conveniently-shaped flap, formed from the back of the wrist; and 3rd, by making two long incisions, the one in the palm, and the other on the posterior aspect of the joint. This latter operation has been performed by Mr. Simon, but we should imagine that the great length of the incision would form a serious objection to this method. By the first and last modes of operation, the tendons may without difficulty be saved; whereas, by forming a flap on the dorsum of the hand, though a good view of the joint may thus be obtained, yet some of the extensor tendons will necessarily be divided. Mr. Butcher maintains, with great justice, the importance of avoiding, if possible, any interference with the carpal articulation of the thumb, or its extensor tendon. This he effects by commencing his incision just to the ulnar side of the tendon of the extensor secundi internodii, cutting a semilunar flap from the back of the wrist, and ending his incision on the ulnar half an inch higher up the fore-arm than the point where it commenced; thus the extensor tendons of the fingers only are divided, while those of the thumb are turned aside; this operation has also the advantage of being easy of execution in nearly all cases,
Resection as applied to the wrist is justifiable in young patients, as & substitute for amputation in caries, or in cases of general destructive synovial disease ; it has also been performed with success for osteoid disease of the carpal end of the radius. Probably, the cases to which
it is most applicable are those of compound dislocation of one or both bones of the fore-arm, where the protruded portions of bone may be sawn off with a good prospect of success.
We subjoin the results of fifteen cases of resection of this joint for disease; of these more than one occurred under our own observation, but the majority are collected from the published accounts contained in the medical journals of the day. Operations on the carpus, which do not involve the wrist-joint, are purposely excluded from this account.*
Out of the whole number subjected to operation, three died-one of continued fever, another from carious disease of the vertebræ, and the third with some cerebral affection. Five are reported cured, with more or less useful hands; three are said to be in progress of cure when their history ceases. Of three it is stated that the prospect for one was hopeful, one unsatisfactory, and the third is said, nine months after the operation, to" have some chance of recovery.” The remaining patient never regained any use in his hand, though the wound eventually healed perfectly.
The three deaths that occurred can scarcely be attributed to the effects of the operation, though Mr. Butcher's patient,t who died with cerebral effusion, probably had her death hastened by the shock to her system. Still we venture to suggest that fifty-eight is not an age at which to undertake resection of the joint with a very hopeful prospect of success. The same remark may be applied to Mr. Page's case, where, although the wound healed, the patient could make but little or no use of the hand. This patient was sixty-two years of age. Of the five cases that recovered, all regained a useful hand, though Dr. Green's patient, as shown by the woodcut in the Indian journal, appears to have acquired by no means an ornamental member. In this case, a considerable portion of the radius was removed, while the ulna was left entire, and thus the hand became drawn to the radial side of the fore-arm, and there fixed at a right angle.
To take the most favourable view of these cases, it may be said that eight of them were successful that is, if we include with the cured those in progress of recovery. This is but a small proportion among fifteen, and though from such insufficient evidence it is unsafe to draw general conclusions, yet we cannot but think that these results will be found to represent pretty accurately the comparative value of this operation on the wrist-joint-an articulation unfitted as it is by its complexity for the favourable performance of resection.
The Hip-joint. - This bold and hazardous operation was first recommended by Mr. Charles White of Manchester, in 1769, whose suggestion was put into practice by Mr. A. White of the Westminster Hospital. He in 1818 excised the head of the femur for carious disease, with a more fortunate result than has since attended many operations on the same articulation. Subsequently, in 1844,
• The operators in these cases were-Moreau, Heyfelder, Fergusson, Dr. Green of Bengal, Mr. Simon, Mr. Erichsen, Mr. Stanley, Mr. Butcher, Mr. Cock, Mr. Page. Dublin Journal, Nov. 1855.
1 Indian Annals of Medicine, April, 1853,