20. From what has been said it follows, 1st, that these cartilages
floating through the joints, do mischief mechanically (14), by coming
into contact with the articular surfaces: 2dly, that to obviate this
mischief, it is necessary either to prevent their contact, by fixing
the bodies in a spacious part of the joint, and thus doing constantly
what nature does on certain occasions, or to extract them through an
opening made into the articular cavity.
21. Hence, art can have recourse to but two methods of cure, all hope
of discussing these tumours by external applications being, as Bell
observes, entirely extinguished.
22. The first method was proposed by Middleton and Gooch, who having
brought the foreign body into a situation where it produced no pain,
endeavoured to confine it there a length of time sufficient to make it
form adhesions with the corresponding part of the capsule. As we are
not informed of the result of the experiments of these two physicians,
we are left to our own conjectures on the subject.
23. Are these foreign bodies capable of forming adhesions? Supposing
they are, will the internal surface of the capsule attach itself to
them at the pleasure of the surgeon? Even admitting the existence of
both these conditions, by what means can the bodies be kept stationary
for a length of time sufficient for the formation of these adhesions?
Will they not be displaced by the slightest motion? Besides,
experience seems to be unfavourable to the expedient. I have already
said (17) that, in a certain case, the foreign body disappeared for six
months, remaining, no doubt, during that whole time, in the same place:
but, if it could not, on that occasion, form adhesions, if a motion was
sufficient to produce its reappearance, can we expect that art will be
more fortunate in her attempts?
24. But, even admitting that the foreign body does form these adhesions
with the capsule, if it should increase in size in the part of the
joint which it occupies, becoming in a short time disproportioned to
its extent, it will impede motion as before, and produce, by degrees,
nearly the same affections.
25. From these considerations it follows, that the only expedient which
can promise a radical cure is, the extraction of the foreign body. In
the performance of this extraction, an incision must first be made
through the integuments and the capsule.
26. This operation, simple and easy in itself, has given rise to
apprehensions as to its consequences, which have long prevented
practitioners from undertaking it.
It was in former times a maxim in surgery, that wounds of the joints
are, if not mortal, at least extremely dangerous, in consequence of
their admitting air into contact with the articulating surfaces. But
observation has demonstrated the fallacy of this doctrine, and Desault
in particular, has thrown great light on the subject, as I have
frequently had occasion to mention in the course of this work: so that,
at the present day, it is clearly ascertained, that, if judiciously
treated, these wounds are seldom productive of serious consequences.
27. Hence it follows, that the operation we are considering, when
skilfully performed, never gives rise to any dangerous or disagreeable
affections. Experience has proved the truth of this assertion in the
practice of Theden, Simson, Gooch, Broomfield, Bell, and Desault,
the latter of whom performed the operation five times with complete
success. The only case in which he was less fortunate, was that
of a man, in whom the wound of the integuments closed up at first
without any accident, but which was succeeded by two abscesses, one
in the thigh, and the other in the leg, but without any affection of
the interior of the joint. This patient was subject to a wandering
rheumatism, which oftentimes attacked the lower extremities, and
was perhaps in the present case the chief cause of the unfavourable
occurrences.
28. It is to the English that we are indebted for the first operation
performed for the extraction of these bodies. An account of this is
given in the Transactions of a society in Edinburgh. Since that, the
operation has been frequently repeated, and more than ten instances of
it were already on record, when Desault first performed it in France.
His method, somewhat different from that of others, was as follows.
1st, The patient must be laid on a bed, or seated on a high chair.
The first position, however, is to be preferred, because when it is
adopted, the patient need not be moved after the operation.
2dly, The leg is extended on the thigh, in order to relax the anterior
part of the capsule of the joint.
3dly, The surgeon then searches for the foreign body, moves it to the
internal side of the joint, against the attachment of the capsule, and
secures it between his thumb and the fore-finger of his left hand,
while an assistant draws the skin over the fore part of the rotula.
4thly, Taking then a common bistoury, he makes, on the protuberance
formed by the body, a longitudinal incision of an extent proportioned
to its size, through both the integuments and the capsule, so as to lay
the body bare at the first stroke.
5thly, Sometimes the body escapes immediately of its own accord, in
consequence of the compression made on it by the fingers. If its
passage out be not spontaneous, a small scoop or a taper-pointed
spatula passed under it, answers the purpose of extracting it. But,
in the introduction of these instruments, it is necessary to avoid
touching the articulating surfaces with their ends, lest, by being
irritated, they might swell, and give rise to troublesome accidents.
6. If any resistance be met with, enlarge the opening and the
extraction will become easy. Without this precaution, the edges of the
wound, being bruised and irritated by the passage of the body, will
swell, inflame, and unite again with difficulty.
7. When the extraction is finished, the assistant who draws the
skin towards the inside of the joint, suddenly lets it go, when it
returns to its natural situation. This causes the two incisions, which
corresponded, at the time of the operation, to change their relative
situation, the one remaining internal and the other becoming external.
8. Hence arises a twofold advantage; the entrance of air into the
interior of the joint is prevented, and the external and loose portion
of the capsule, being drawn inwards with the skin, unites with the
condyl, if it be not brought into exact apposition with the other
portion of the capsule, divided near its attachment.
9. The extraction being finished, it is then necessary to examine
carefully, in order to ascertain whether or not the joint contain any
more of these foreign bodies. On some occasions, when this is even the
case, they cannot at the time be discovered. Desault himself was once
deceived on this score, in consequence of which his patient was obliged
to submit to a second operation.
10. The incision in the integuments is now united by means of adhesive
plaster. Over this are laid compresses and a little lint, and the whole
secured by a few turns of a roller drawn moderately tight.
11. The leg being then placed on a pillow, is kept in a state of
extension, by means of a splint applied, for a few days, behind the
joint.
29. If we examine but for a moment the process in this operation, we
must perceive, that an incision made through the skin and capsule at a
single stroke, is, in no respect, less advantageous than one made at
two strokes, as recommended by all practitioners, and that, it is in
the following respects greatly preferable to it: 1st, it shortens the
operation very considerably: 2dly, it diminishes the pain: 3dly, it
exposes the joint a much shorter time to the contact of the air.
30. The object of the operator is better answered by drawing the
skin outward and towards the rotula, than by either depressing it,
as Broomfield did, or raising it, as Bell does. Being more loose and
more easily stretched in this direction, the opening in it is removed
farther from that in the capsule, which prevents more certainly the
access of air to the joint, and also favours the examination of the
capsule.
31. In the mean time, the operation may succeed, even although the
openings in the integuments and the capsule correspond to each other.
Many English and German practitioners, without previously stretching
and changing the natural situation of the skin, make a common incision,
which they dress afterwards like a simple wound, and are yet no less
successful than others in the result of their operations. This is
a further proof of the fallacy of the ancient surgical doctrine,
respecting the admission of air into the cavities of joints. Perhaps
Desault might have omitted this precaution, had any operations of the
kind occurred in his practice during the last years of his life.
32. The operation is seldom attended with much pain. Only one patient
manifested signs of this in the practice of Desault. Nor have those
operations of the kind performed in England been more painful, so that
it may be laid down as a principle, that in most cases no primitive
accident is to be dreaded.
33. With regard to hemorrhagy, as there is no large artery near the
place of the incision, there is nothing to be apprehended on that
score. Oftentimes there is scarcely any loss of blood at all, as may be
seen in the first case published in the Journal of Surgery. But, even
admitting that a small articular branch be divided, the reunion of the
edges of the wound will be sufficient to check the hemorrhagy, in the
same manner as in the operation for the hare-lip, the contact of the
divided integuments of the lip, puts an end to the hemorrhagy from the
small arteries of the part.
§ XIV.