« AnteriorContinuar »
tion are more dangerous to life. Still the exhausting effects of the subsequent processes after resection fully counterbalance the early dangers of the former operation. We find that out of the cases related by Mr. Butcher, eight were subjected to amputation. Seven of these recovered. Now, it may be without injustice concluded that had not amputation been performed, these cases would in all human probability have been added to the number of fatalities, making twenty-two deaths out of eighty-two cases, or about twenty-six per cent. And again, the very fact that amputation was performed in these cases to save life, opposes the notion of the greater danger of this latter operation.
We cannot conclude our account of Mr. Butcher's memoirs without noticing the great difference in success and comparative mortality of the two series of cases published by him. In the first table, containing cases “operated on from July, 1850, to December, 1854," we have 31 cases, with 25 recoveries, 5 deaths, and 1 amputation. In the second table we have recorded 51 cases; out of these, 9 died, 7 were subjected to amputation, with 1 fatal case; l remains in a precarious condition, and the remaining 33 recovered. The comparative want of success in the cases contained in Mr. Butcher's second memoir, together with the much greater number that were subjected to amputation, suggests forcibly that the difference between the results of the two tables is not a mere matter of accident-indeed, more than one instance related in the second memoir was obviously unfitted for the operation of resection.
"In my former essay (says Mr. Butcher) I forcibly dwelt upon the necessity of selecting the cases for excision, and pointed out the prominent features which should influence the surgeon; but I fear the caution has not been applied in every instance; I fear the panting after éclat has charmed away some from the stern dictates of judgment.”*
The well-known danger of wounds of the knee-joints, but especially of gun-shot injuries, where with laceration of the capsule there is fracture or bruising of the bones, had hitherto led to the practice of performing amputation in these cases, and it remains for additional experience to determine the advisability of attempting resection of the joint in such cases. Stromeyer says of these injuries,
"I have not undertaken resection of the knee-joint, because it affords little hope, even under favourable circumstances, and because, in the majority of cases, it cannot be certainly known how much of the bone should be cut off.”+
So far as our information extends, there are but two cases recorded where this operation has been performed for gun-shot injuries. The one occurred in the Schleswig-Holstein war,and the other during the Crimean campaign. Both were fatal. The former was performed for a bullet-wound of the capsule, with fracture of the external condyle. Three days after the injury, the articular ends of the femur to the extent of an inch and a half, were removed. The bullet, and a portion * Statham's Translation, p. 31. † Dublin Quarterly Journal, p. 58. Ibid., p. 95.
§ Medical Times and Gazette, September 20, 1856.
of cloth, were found loose in the joint. The result of this case was, as one might have anticipated, that the patient sank a month afterwards, with secondary pyæmic deposits in the lungs and elsewhere, and tubercular disease. The cartilage of the tibia was only partially thrown off, and a portion of the same still hung in shreds from the bone; the granulations from the femur, which had been “luxuriant,” were shrunk and discoloured, together with the semilunar cartilages. Here it appears as if the patient's strength was inadequate to support the ulceration and discharge necessary for the separation of the extensive cartilaginous surface of the tibia—a process which might have been avoided had the articular surface of the tibia been removed at the time of the operation. There is yet another case mentioned by Mr. Guthrie in the last edition of his Commentaries, where the knee-joint was resected for a shell-wound by Staff-Surgeon Lakin. This case is said to have recovered, though we have been unable to find any subsequent account of it.
The Ankle-joint.--Excision of the ankle-joint, originated by Moreau, strongly advocated and successfully practised by Sir Astley Cooper, has in these days, for some insufficient reason, met with but little countenance; and in comparison with the effects of the same operation on the knee, its advantages seem to be by no means adequately appreciated. Resection is applicable to the ankle-joint in its diseases, but still more so in its injuries, and this both on account of its structure and position. The synovial cavity of the ankle, unlike that of the wrist, may be laid open or destroyed by operation, without implicating the surrounding articulations; there is less danger here of inflicting an injury on a neighbouring joint, and of setting up a disease no less severe than that for which the operation was undertaken. Again, after removal of the articular extremities, the appearance of the wound contrasts most favourably with that left after resection of the knee-joint, where the exposed surfaces of bone are very extensive, and the cavity of the wound large and deep. In addition to this, the position of the anklejoint, far as it is from the centre of the circulation ; while, on the one hand, it is perhaps unfavourable for the healing process, yet, on the other, it enables us to put excision into practice with but little danger to the patient's life; indeed, we are not acquainted with a single case where the operation was followed by fatal consequences.
The diseases of the joint under consideration present considerable difficulties in the diagnosis of their extent; it not only requires great care to decide whether the disease is entirely limited to the tibio-tarsal articulation, but it is sometimes nearly impossible to distinguish between caries of the astragalus and the same disease of the os calcis. For this reason it is, as well as on account of the great difficulty of exposing the articular extremities when the bones are in their normal position, that the operation is best adapted for injuries of the joint, and especially for compound dislocations. In these the amount of mischief is more easily ascertained, and the protrusion of the bones, rendering their section easy, obviates the greatest difficulty of the operation. Sir Astley Cooper, in speaking of the compound dislocations of this joint, states that he knew of no fatal case where the operation was performed, though he had met with several where it was not put in practice. *
Resection may be substituted for amputation in any synovial or carious disease of the ankle-joint which does not extend among the other tarsal articulations, or involve any considerable portion of the shafts of the bones of the leg. It may be performed in rare cases of gun-shot wounds of the joint, with fracture of the bones; but in these accidents there is too often such considerable injury to the soft parts and vessels as to demand amputation. In compound dislocation,
"If the dislocation can be easily reduced without saving the ends of the bones, if the bone be not obliquely broken, but remains firmly on the astragalus when reduced, if the ends of the bone be not shattered, if the patient be not excessively irritable, the bones should be returned to their place; but rather than amputate the limb where the above-named circumstances were present, one would certainly saw off the ends of the bones.”†
The same author transcribes a letter from Dr. Kerr of Northampton, who, after sixty years' experience, writes:
“Several such cases have fallen under my notice, and it has been uniformly my practice to take off the lower end of the tibia; in my early life I have seen many attempts to reduce compound dislocations without removing any part of the tibia, but to the best of my recollection they all ended unfavourably, or at least in amputation; by the method which I have pursued, I have generally succeeded in saving the foot and a tolerable articulation.”
From the results of several operations on this articulation it appears that in many cases a considerable amount of motion has been restored to the patient, and also that this mobility has been found quite conpatible with the necessary strength of the limb. It may also be noticed, that in those cases where complete ankylosis has taken place, the loss of motion in the ankle-joint has been greatly compensated by the increased mobility in the other tarsal articulations, and especially by the movements of the astragalus upon the os calcis.
In performing the operation on this joint, there is said to be no absolute necessity for removing the opposing cartilaginous surfaces: in diseases, the affected surface of bone should be sawn off; in injury, the protruded or fractured portions of bone need only be excised. Many instances have occurred where, after sawing off the protruded ends of the tibia and fibula, the cartilaginous surface of the astragalus has been left untouched, and with the happiest result. In this particular we cannot but notice the much greater proneness to ulceration displayed by the articular cartilages of the long bones entering into the knee-joint, where exposure of the cartilage but too surely leads to its ulceration and separation; still we have no doubt that the safest course, and that which is most likely to promote recovery, is to remove the cartilaginous surfaces of the joint, whether healthy or diseased.
The plans of incision used for excising this joint have been various, having for their object the adequate exposure of its cavity without injury to the tendons; this can be best accomplished by the operation recommended and described by Mr. Guthrie in his Commentaries, at * Sir A. Cooper on Dislocations, p. 301.
† Ibid., p. 302.
p. 99, to which we refer the reader, as the limits of this paper will not permit us to transcribe it. After the operation, the limb may be best secured on a back splint and foot piece, having moveable sides, which can be let down to wash and dress the wound.
We have collected and have before us the histories of ten cases where resection has been performed for disease of the ankle-joint; they occurred in the practice of Messrs. Hancock, Wakley, Statham, Teale, Humphry, Ure, and Hutchinson. Of the ten cases, seven are reported cured, and the remaining three are said to be respectively, " under treatment," "slowly recovering,” and “going on well.” The cures were certainly rather tedious, but appear to have been in most cases complete; one, Mr. Wakley's patient, was shown three years afterwards at the Medical Society, and could walk well, with a slight halt, and possessed some motion in the joint. All these patients could walk; of four it is reported that they possessed motion in the anklejoint; of one, that the ankle was very weak, and liable to bend. In two cases the account merely states that they were cured and could walk. We have omitted in this account two operations quoted hy Heyfelder; in both these the tarsus was extensively diseased, and in consequence one or more of its bones were removed at the time of operation, thus constituting an operation like those on the wrist-joint, where the first conditions of successful resection are not fulfilled. The results of these two cases were such as might be anticipated: the one, Hey felder's patient, lived to have his limb amputated, but died seven days after the second operation, of pyæmia; while the other, a case of Dr. Roberts', eventually recovered so far as to be able to walk with a stick. Of all serious accidents to which the ankle-joint is exposed, there are few more liable to occur, or more dangerous in their consequences, than compound dislocations; and it is fortunate that in resection we possess an operation which in most cases will not only preserve life, but secure to the patient the possession and use of his limb. We refer, for confirmation of our remarks, to Sir A. Cooper's account of his experience of this operation; in his work On Dislocations,' nine cases are quoted as having occurred either in his own practice or that of his friends. In all these resection was performed for compound dislocation, with or without fracture; the fractured or protruded ends of bone were alone removed, and in no case does it appear that the cartilaginous surface of the astragalus was purposely destroyed. All recovered, five even retaining motion at the seat of operation. The only case we are acquainted with where the result of this operation, when performed for compound dislocation, was unfavourable, is one that occurred in the practice of Mr. Hey of Leeds, who removed, from a man, aged thirtyfive, the lower end of the tibia, for compound dislocation of that bone. This case appears to have gone on badly, and the last report we have been able to meet with states that the ultimate prospect of the patient's recovery was doubtful.
There are yet other points of importance connected with the subject of resection of joints to which we would wish to advert, but we must defer their consideration to another opportunity.
REVIEW II. Bijdrage tot de Kennis der Spijsvertering van de plantaardige Eiwitach
tige Ligchamen. Door Dr. RINSE Cnoop KOOPMANS. (“Neder
landsch Lancet,' No. 7, p. 385. 1855.) A Contribution to the Knowledge of the Digestion of Vegetable Albumi
nous Bodies. By Dr. RINSE ČNOOP KOOPMANS. The object of Dr. Koopmans' investigations was to ascertain, with more exactitude than had previously been done, the changes which vegetable albuminous matters undergo in the stomach during digestion. The author points out, that while the corresponding class of bodies in the animal kingdom and the non-nitrogenous constituents of vegetables had been duly studied in this respect, the substances alluded to had received but little attention. His first inquiry was, whether pepsin is necessary for the solution of the albuminous matters occurring in the cerealia and leguminose; consequently, whether these substances, during their solution in gastric juice, undergo a peculiar metamorphosis (pepton-formation), and what properties they thereby acquire. Lastly, whether a difference in the amount of acid contained in the digestive fluids exercises an influence on the solution, and whether this is the same as for other substances.
The quantity of albuminous matters in the seeds of most of the cerealia varies not only in different species, but also in the same species according to the place of growth. This difference was particularly remarkable in preparing gluten from Hungarian and Dutch wheat. In the Netherlands it was necessary to use much more flour in order to obtain the same quantity of gluten than was required in the experiments the author performed in Vienna. Moleschott, in his • Physiology of Aliments,' has collected numerous analyses of species of grain exhibiting this fact.
Gluten was the first substance examined by Dr. Koopmans in order to ascertain whether it is capable of solution in a dilute acid alone, or whether the co-operation of pepsin is necessary to produce this result; he comes to the conclusion, that while it is not perfectly soluble in dilute acid alone, it does not occur therein entirely unchanged, or merely in a state of mechanical suspension, since otherwise more accurately-defined forms than he observed should be visible under the microscope. He then asks whether a molecular swelling may have taken place! But no visible swelling of the whole mass, such as is met with in fibrin, is visible. In fine, he does not fully decide the question, but contents himself with intimating, that when in the sequel he speaks of a solution of gluten in an acid, he does not mean to refer to this condition in its strictest sense.
With reference to the second branch of his inquiry, the author feels justified in drawing the conclusion that, during digestion in the stomach, gluten is not merely dissolved, but that it is at the same time modified in its properties in like manner as the other albuminous bodies, and that, consequently, a “gluten-pepton" also exists.