EXCISION OF JOINTS.
_Historical._--Beyond a passage ascribed to Hippocrates, but of very
doubtful authenticity, and slight allusions in the works of Celsus and
Paulus Ægineta, the ancients give us no information whatever on this
subject.
Hippocrates says,--"Complete resections of bones in the neighbourhood of
joints both in the foot, in the hand, in the tibia up to the malleoli,
and in the ulna at its junction with the hand, and in many other places,
are safe operations, if that fatal syncope does not at once occur, and
continued fever does not attack the patient on the fourth day."
Celsus and Ægineta both advise the removal of protruding ends of bone in
compound dislocations, but without giving any cases.
From the days of these classic fathers of Surgery, we have hardly an
indication of any attention whatever having been paid to their hints
till quite within the last hundred years.
The first distinct publication on the subject was by Henry Park of
Liverpool, in a letter to Percival Pott in 1783. He proposed the removal
of the articulating extremities of diseased elbow and knee-joints to
obtain cures. He says he was led to this by its having been the
invariable custom, for more than thirty years, at the Liverpool
Infirmary, to take off the protruded extremities of bones in cases of
compound dislocation.
The chief credit, however, in practically elevating excisions into the
catalogue of recognised surgical operations, is owing, British surgeons
most cordially own, to two provincial surgeons of France, the Moreaus
(father and son) of Bar-sur-Ornain. They took the lead in the most
marked manner, having excised the shoulder in 1786, the wrist and elbow
in 1794, knee and ankle in 1792, and had followed this up so well that,
in 1803, the younger Moreau could boast, "the town has become in some
sort the refuge of the unfortunate afflicted with carious joints, after
they have tried all the means usually recommended by professional men,
or have had recourse to empirical nostrums, or when amputation seemed to
them the last resource."
Moreau's papers and cases, which, between 1786 and 1789, he frequently
read to the French Academy, were, some violently opposed, others utterly
neglected by his compatriots, and many of them lost and buried in the
unpublished papers of that body.
And though diseased joints did not decline in frequency, and though
injured ones were extremely numerous during these long years of European
war, excisions were but rarely performed.
With the exception of the removal of head of humerus after gunshot
injury, hardly any British, and but very few French, limbs were saved by
excision taking the place of amputation.
The limbs that were saved by Percy by excision of the head of the
humerus really owe their recovery and safety to the elder Moreau; for an
operation of his, at which he was assisted by that distinguished
military surgeon, gave the latter the hint, which he followed so
successfully, that by 1795 he had performed it nineteen times, and had
indoctrinated Sabatier, Larrey, and others, and elevated it into a
recognised operation of military surgery.
So far, however, as the application of the great improvement of the
Moreaus to disease went, the French surgeons have little reason to
boast, for it is to English surgery, and especially to one Edinburgh
surgeon, that this class of operations owes nearly all its improvement
in methods and frequency of performance.
For though (as we shall see under the special heads) here and there one
or two cases were performed, it was not till the publication of Mr.
Syme's monograph on the excision of diseased joints, in 1831, that the
importance and value of the discovery were fairly brought before the
profession; and the conservative surgery, of which excision as preferred
to amputation is the great type, must ever be associated with British
surgeons--Syme, Fergusson, Mackenzie, Jones of Jersey, Butcher of
Dublin.
On the Continent--Langenbeck, Stromeyer, Heyfelder, Ollier, Esmarch of
Kiel, specially in the surgical history of the first Schleswig-Holstein
war, have followed up the example set them here.
Before proceeding to describe the operations on the various joints, one
or two questions may be briefly asked and answered by way of
introduction.
In what cases, or sorts of cases, are excisions suitable?
1. In cases of compound injury or dislocation of a large joint, as used
by Filkin, Park, White, and other English surgeons long ago. In hospital
practice, or in private, where there is every advantage of rest, food,
and appliances, such operations will frequently be found suitable where
the joint is alone or chiefly the seat of injury, and where the general
health seems fit to bear a prolonged suppuration. But long and sad
experience has shown that, as a general rule in military practice, with
the difficulties of transport, the generally bad sanitary state of the
hospitals, and the want often of adequate dressings and attention,
excisions are much more fatal than amputations, and, except in elbow and
shoulder (_q.v._), should be as a general rule avoided.
2. Excision for deformity (generally speaking for bony anchylosis) will
require for decision the consideration of many points, _i.e._ the joint
affected, the nature of the disease or injury which has caused the
anchylosis: and in each case--(1.) the state of health of the patient;
and (2.) his occupation, and the consequent position of limb which would
suit him best. As a general rule, I believe, experience will prove that
such operations on the lower extremity are almost absolutely
inadmissible, except under very special urgency on the part of the
patient, and a very high condition of health--while in the upper, the
elbow-joint is the only one which you will ever be likely to be asked to
remedy, or should comply with the request if asked; as the shoulder,
even if anchylosed, will (1.) from its own weight generally become so in
the most favourable position; and (2.) from the extreme mobility which
the scapula can acquire, its anchylosis will not be so much felt.
The elbow, however, from the frequency of fractures of the condyles of
the humerus obliquely into the joint, and from the manner in which these
are so often neither recognised nor properly treated, very often becomes
anchylosed in the most awkward possible position, _i.e._ nearly
straight; and operations undertaken for such deformities are in general
both quite safe and very satisfactory. Mr. Syme had one case (resulting
from a fall, causing a double fracture), in which both arms were thus
firmly anchylosed in such a position that the sufferer could absolutely
perform none of the commonest duties of life without assistance.
Excision of both joints cured him.
The author excised with success for disease the elbow-joint of a patient
whose other arm had required the same operation.
The occupation of the patient must always be taken into consideration
when settling the position of an anchylosis, or the necessity or
advantage of a resection.
Thus, Bryant[52] tells of a painter who wished his arm to be fixed in a
straight position, and of a turner whose knee at his own request was
permitted to stiffen at a right angle, as that position allowed him to
turn his wheel.
3. _Excision for Disease of the Joint._--In our cold climate, so cursed
by scrofula, and specially among the children of the labouring poor,
such joint diseases are very prevalent, and whether the disease
commences in the synovial membrane, the articular cartilages, or the
heads of the bones, it frequently so disorganises the joint as to make
it a question whether something must not be done to preserve the very
life of the patient.
The difficulty of diagnosing the cases in which excisions are suitable
or necessary is often very great; and we must balance its
performance--(1.) against the possibly good results of an expectant
treatment; (2.) against amputation of the limb.
(1.) _Against expectant Treatment._--The patient has youth on his side,
could we give him fresh sea air, good diet, cod oil, etc., we might very
likely obtain anchylosis; true, but he may die while trying for this
anchylosis, and also this anchylosis, when got, may so lame or deform
him that resection may still be required.
These points must all be considered, but as a general rule, I would say
that such attempts at preservation of the limb are much more
justifiable, and longer justifiable in the hip and knee-joints than in
the elbow or shoulder; for the results in the lower limb will probably
be as good, if the patient survive, if not better, than those obtained
by excision, while the danger of the operation is greater; while in the
upper limb, the danger to life in operating is less than that of leaving
the limb on, and the results obtained by a successful operation, with
well-managed after treatment, are far more satisfactory than the best
possible anchylosis.
Another point bearing on this, of very great importance: In children,
the most frequent subjects of such disease, excision of the lower limb
may, by removing the epiphyses, cause to a very considerable degree
disparity in their length, thus rendering them nearly useless, while in
the upper such disparity is neither so extensive nor so injurious to the
usefulness of the limb, which is not required for purposes of
progression.
In the hip-joint especially, all the resources of the art should be
tried in the expectant treatment, for amputation at the hip-joint is
hardly ever admissible for disease of the joint, while excision has
anything but satisfactory statistics.
(2.) _Against Amputation._--Many questions must be considered, chiefly
under the heads of the separate joints:--
1. As to the difficulties and dangers of the operations contrasted.
Such as the following:--
Excisions give the surgeon more trouble, require more manual dexterity;
take longer to perform; are very painful operations. Not valid
objections in these days of chloroform and operative surgery on the dead
body.
Excisions have the special peculiarity and danger of dealing chiefly
with cancellated bone, broadened out, open, with numerous patulous
canals for large veins, tending on any irritation or inflammation to set
up a diffuse suppuration, and to culminate in phlebitis, myelitis, and
other pyæmic conditions.
Excisions are performed through degenerate or disorganised, amputations
through healthy, tissue.
Excisions require extreme care and absolute rest (_i.e._ in lower limb)
for many weeks and months after the operation.
But, on the other hand,--
Amputations remove a portion of the body; excisions a much less one.
Amputations are always necessarily nearer the centre than the
corresponding excisions, and statistics show that the fatality of
operations increases in exact proportion as they approach the centre.
A successful excision, especially in arm, saves a limb nearly perfect;
an amputation at best is only the stump for a wooden one.
On the whole, there is actually very little difference in the mortality
of excisions and amputations.
2. As to the results of the operation on the usefulness of the limb,
depending on joint involved, age of patient, and amount of bone
removed:--
A. _Joint involved._--These must be noticed separately, but one thing is
absolutely certain, that a much higher standard of usefulness, both in
equality of length, amount of anchylosis, and position, is needed in the
lower than in the upper limb. For a leg hanging like a flail, or
shortened by some inches, is not so good for purposes of locomotion as a
wooden leg is, while an arm, even though powerless at the elbow, and
perhaps much shortened, can be so strengthened and supported by slings
and bandages as to give a most useful hand, the complex movements and
uses of the fingers of which no mechanism can at all imitate.
B. _Age of Patient._--It must be remembered that excision in a child
removes the epiphyses by which in great measure the growth of the bone
is to be managed, and the stunted limb, especially in the leg, will
eventually be of little advantage, though after the operation it looked
excellently well, if a few years later it be found to be seven or eight
inches shorter than its neighbour.
C. _Amount of Bone removed._--From an erroneous view of the pathological
changes in the bone affected, far too much was removed by many of the
earlier operators, especially Moreau and Crampton.
The reason that this is often still the case, is well seen in many
preparations. The bones are thickened to a considerable distance, and
covered with irregular warty excrescences. These, which used to be
considered evidences of disease, are only compact new healthy bone,
thrown out like the callus of a fracture in consequence of the
irritation.
In a word, what we require to remove is the following:--
1. All the cartilage, dead or alive, healthy or diseased.
2. Only the bone involving the articular extremities, in thin slices, or
with the occasional use of the gouge, till a healthy bleeding surface is
obtained.
3. The synovial membrane, however gelatinous or thickened looking,
really requires very little care or notice; it will disappear of itself,
partly by sloughing, partly by absorption during the profuse
suppuration.[53]
EXCISION OF THE SHOULDER-JOINT.--Before considering the method of
operating, a word or two is required on the subject of how much is to be
removed, and in what cases the operation should be performed. The
shoulder and hip joints are the only ones in which partial excision is
ever admissible, indeed, in the shoulder excision of the head of the
humerus only is in many cases found to be all that is necessary, while
in all it is much less dangerous to life than when the glenoid cavity
also requires to be interfered with.
It is rarely necessary to remove more of the bone than merely its
articular extremity (when performed for disease of the joint), and if
possible this should be done inside the capsule, _i.e._ through an
incision in the capsule, but without involving its attachment to the
neck of the bone. When the glenoid is also diseased, mere gouging or
scraping the cartilaginous surface will not suffice, but the neck must
be thoroughly exposed, so that the whole cup of the glenoid may be
removed by powerful forceps.
_Cases suitable for Excision._--Cases of chronic disease of the head of
the humerus (generally tubercular), or of chronic ulceration of the
cartilages which has resisted counter-irritation. Cases of gunshot
injury of the joint, or of compound dislocation, or fracture involving
the joint. Cases of limited tumours affecting merely the head and upper
third of the bone, and non-malignant in character. Anchylosis very
rarely requires and would not be much benefited by such an operation.
_Operation._--Though perhaps not the easiest, the following method is
the one followed by the best results. It is suited especially for cases
of caries or other disease of the joint, where the head of the humerus
is either alone or chiefly affected:--
A single straight incision (Plate I. fig. A.) is made from a point just
external to the coracoid process downwards along the humerus for at
least three inches. It corresponds almost exactly to the bicipital
groove, and has the advantage of avoiding the great vessels and nerves.
The long head of the biceps may then be raised from its groove, and
drawn to a side so as to be preserved. This is deemed of importance by
Langenbeck and others. Mr. Syme, however, did not attach much value to
its preservation, as it is often diseased. The capsule, which is often
much altered, perhaps in part destroyed, is then opened, and the tendons
of the muscles which rotate the head of the humerus divided in
succession, while the elbow is rotated first inwards and then outwards
by an assistant so as to put them on the stretch. The arm being then
forced backwards, the head of the bone can be protruded through the
wound, and sawn off at the necessary distance down the shaft. The
glenoid must then be carefully examined, and any diseased bone removed
by the cutting pliers. One or two small branches supplying the anterior
fold of the axilla are the only vessels divided, and may not even
require ligature, unless, indeed, from necrosis, or to remove a tumour,
a larger portion of the humerus than usual has been removed. If the
limit of capsule has been infringed on below, the circumflex vessels may
probably be cut, in which case the bleeding may be considerable.
_N.B._--In cases of fracture of neck of humerus, or of compound gunshot
injury, or where the head has been separated by necrosis from the shaft,
or where, as has happened to Stanley and others, the bone broke in the
endeavour to tilt the head out, the surgeon will require to seize the
detached head with strong forceps, and dissect it out with care.
_Other methods of Resection._--When from great thickening and induration
of the soft parts, enlargement of the head of the bone, or other reason,
the straight incision may be deemed insufficient for the purpose (and we
may remark that there are comparatively few cases in which it is
insufficient), access may be obtained to the joint by raising a flap
from the deltoid (Plate III. fig. A). Its shape--V-shaped, semilunar, or
ovoid--is not of much consequence, for there are no great nerves or
vessels to wound on the outside of the joint, and the surgeon should be
guided, as in all other operations on the joint, very much by the
position of any pre-existing sinuses. This flap being raised upwards
towards its base, very free access is gained to the joint.
In these cases, fortunately comparatively rare, in which there is reason
to believe that the glenoid is chiefly involved in disease, and yet that
the disease can be removed without amputation, access will be gained
most easily by an incision (Plate III. fig. B.) on the posterior surface
of the joint, corresponding in size and direction to the linear incision
in front. This gives a much easier mode of access to the glenoid. I have
seen this practised in one very remarkable case by Mr. Syme, in which
the glenoid cavity and neck of the scapula were extensively diseased,
while the head of the bone was quite sound.
_After-treatment_ is exceedingly simple; for the first day or two the
shoulder is to be supported on a pillow with a simple pad in the axilla,
if there is any tendency for the arm to drag inwards; after this the
patient should be encouraged to sit up and move about with his arm in a
sling, the elbow hanging freely down.
_Results._--Hodge records ninety-six cases in which this excision was
performed for gunshot injury, of which twenty-five proved fatal, and
fifty for disease, of which only eight died,--results which are more
encouraging than those of amputation at the shoulder-joint for disease;
though for injury the mortality is much greater than Larrey's famous
Statistics of Amputation, _q.v._ p. 65.
Spence had thirty-three cases, with three deaths. He generally made a
counter-opening behind to get rid of discharges, and inserted a
drainage-tube.
Gurlt's statistics of excision for gunshot injury give of 1661 cases
1067 recoveries, 27 doubtful results, and 567 deaths, the mortality
being 34.70 per cent.
EXCISION OF THE ELBOW-JOINT--_In what cases should it be performed?_--1.
For disease of the elbow-joint which has resisted ordinary remedies, and
is wearing down the patient's strength, including caries, ulceration of
cartilages, and gelatinous synovial degeneration.
2. For wounds of the elbow penetrating the joint, the prognosis both as
to the patient's life and the usefulness of his arm is much better after
excision than after endeavours to save the joint without excision. This
is especially the case when the wound of the joint is small and
punctured, but if the case is seen early and treated by free drainage,
with antiseptic precautions, excision may not be required.
3. For anchylosis, in cases where after disease or injury the limb has
stiffened in a bad position, especially when, with a straight elbow,
the hand is rendered almost perfectly useless.
_How much should be removed?_--In the elbow-joint, more than any other
joint in the body, complete excision is absolutely necessary; any
portion of the articular surface being left proves a source of
unfavourable result.
The surgeon is apt to err rather in removing too little than too much.
For the removal of too little bone is, on the one hand, apt to result in
long-standing sinuses, on the other, to induce anchylosis.
In making the section of the bones, the saw ought to be applied to the
humerus transversely just at the commencement of its condyloid
projections, and to the radius and ulna, at least at a level with the
base of the coronoid process of the ulna.
But while removing enough, we must not be led into the error of removing
too much. If this is done, as was done by Sir Philip Crampton in his
first case, and as happens occasionally of necessity in cases of
excision for gunshot wounds or other accidents, much of the power of the
arm is lost as a consequence of the shortening and excessive mobility.
A mistaken pathology sometimes deceives in the examination of the state
of the bones, and causes an unnecessary amount to be removed. For in
many cases of disease the bones in the neighbourhood of the joint are
stimulated to an excessive amount of what is in reality Nature's effort
at repair, and while the cartilaginous surfaces are denuded of
cartilage, soft, and porous, the bones close by are roughened with a
stalactitic-looking growth, projecting in knobs and angles. Now, if this
be mistaken for disease and removed, too much will almost certainly be
taken away, and the result will be unsatisfactory.
Much less care need be taken exactly to discriminate and remove the
diseased soft parts; indeed they may be left alone; the synovial
membrane in a state of gelatinous degeneration sometimes presents a
very formidable appearance of disease, but if the bones be properly
removed, all this swelling will soon go down, and a healthy condition of
parts succeed, without any clipping or paring on the surgeon's part.
_Operation._--The back of the joint is of course chosen for the seat of
the incisions, both because the bones are there just under the skin, and
because the great vessels and nerves lie in front of the joint. The form
and number of the incisions vary considerably, and ought to vary
according to the nature of the case and the amount of disease or injury.
Though it is now little used, for historical interest I retain the
description of the H-shaped incision (Plate III. fig. C.), used first by
Moreau, and re-introduced by Mr. Syme, and used by him for most of his
very numerous cases.
The posterior surface of the joint being exposed, the surgeon, with a
strong straight bistoury, makes a transverse incision into the joint
just above the olecranon. It should begin just far enough outside of the
internal condyle to avoid the ulnar nerve, which the surgeon should
protect by the forefinger of his left hand, and should extend
transversely across to the outer condyle. From each end of this incision
the surgeon should next make at a right angle two incisions, each about
one inch and a half or two inches long, right down to the bone, thus
marking out two quadrilateral flaps. These should next be raised from
the bones, up and down, as much of the soft parts being retained in them
as possible, so as to add to their thickness. The olecranon is thus
exposed, and should be removed by saw or pliers by cutting into the
greater sigmoid notch; the lateral ligaments must then be cut, if they
are not already destroyed by the disease, and the humerus protruded, a
proper amount of which is then to be sawn off in a transverse direction.
The head of the radius is then easily removed by the bone-pliers, and
the ulna also protruded, the attachment of the brachialis anticus to the
coronoid process divided, and the bone sawn across just at the base of
that process.
Few vessels, if any, will require ligature, and the arm being bent to
nearly a right angle, the transverse incision must be very carefully
sewed up with silver sutures closely set and deeply placed, as much of
the future success of the joint depends on the completeness of the
primary union of this incision. The external incision may also be
accurately adjusted, the internal one not so completely, to allow free
vent for the discharge, which is aided by the ligatures, if any are
required, being brought out at its lower angle. A figure-of-8 bandage
should be applied over pads of dry lint, and the limb laid on a pillow.
No splint is necessary; in a few days the patient will be able to rise
and walk about.
Passive motion should be begun so soon as the first inflammatory
symptoms have passed off.
If properly performed, in a tolerably healthy subject, the surgeon
should not be satisfied with any results short of almost perfect
restoration of motion in the joint. Flexion and extension to their full
extent, with a very considerable amount of pronation and supination, are
to be expected, with proper care, in a patient of average intelligence.
Numerous cases are now on record where almost perfect performance of all
the duties of life was retained after excision of the elbow-joint.[54]
In most cases it is possible, and in nearly all advisable, to excise the
joint by means of a less complicated incision. Thus one long vertical
incision at the posterior surface, with its centre about midway between
the ulna and the external condyle, with a transverse incision at right
angles to it, and reaching almost to the internal condyle, has been
often practised with a very good result.
By nearly universal consent this single straight incision is now used,
and when it is properly dressed and _drained_ gives admirable results.
A single vertical incision (Plate III. fig. D.) without any transverse
one, as long ago recommended by Chassaignac, is, in most cases, quite
sufficient to give access. It is most suitable in cases of anchylosis,
where there is little deposit of new bone, or in cases of disease of the
joint, accompanied with little swelling or thickening of surrounding
tissues. It has the advantage of avoiding the cicatrix of a transverse
incision, which doubtless may, if at all a broad one, somewhat interfere
with the future flexion of the limb, but, on the other hand, unless care
is taken, it does _not_ give such free egress for the discharge, and
when there is much delay in healing, the vertical incision may leave a
cicatrix nearly as troublesome as the other.
The following modification, suggested and practised by the late Mr.
Maunder, seems to be a step in the right direction when it is
practicable. "After a longitudinal incision crossing the point of
the olecranon I next let the knife sink into the triceps muscle,
and divide it longitudinally into two portions, the inner one of
which is the more firmly attached to the ulna, while the outer
portion is continuous with the anconeus muscle, and sends some
tendinous fibres to blend with the fascia of the fore-arm. It is
these latter fibres that are to be scrupulously preserved.
"Two points have to be remembered: first, the ulnar nerve, often
unseen, must be lifted from its bed, and carried over the internal
condyle to a safe place, and then the outer portion of the triceps
muscle with its tendinous prolongation, the fascia of the fore-arm
and the anconeus muscle must be dissected up, as it were, in one
piece, sufficiently to allow of its being temporarily carried out
over the external condyle of the humerus."[55]
This method aids in retaining the power of _active_ extension of
the elbow-joint.
Excision for osseous anchylosis in the extended position of the joint
may be sometimes rendered very difficult by the density, firmness, and
extensive hypertrophy of the bones, which become fused into one solid
mass. Any attempt to isolate the bones, and remove the anchylosed joint
entire, by incising the bones as if for disease, will both prove very
laborious, and also probably end in doing some damage to the vessels and
nerves in front. But by sawing through the anchylosis about its centre,
as was pointed out many years ago by Mr. Syme, the fore-arm may be
flexed, and the bones as easily displayed, cleaned, and removed, as in
the operation for disease. In this operation, as there is less
thickening of the skin and subjacent textures, and in consequence more
risk of deficiency and even sloughing of the flaps made by the H-shaped
incision, a single straight incision will serve the purpose admirably.
Partial incisions of the elbow-joint are, as a rule, less successful and
more dangerous to life than complete ones, except in cases of excision
for anchylosis. Even in gunshot wounds, where the bones were previously
healthy, and where uninjured portions might have been left with some
hopes of success, this is the case.
Dr. Heron Watson has devised the following operation for cases of
anchylosis the result of injury:--(1.) A linear incision over ulnar
nerve at inner side of olecranon. (2.) The ulnar nerve to be
carefully turned over the inner condyle. (3.) A probe-pointed
bistoury to be introduced into the elbow-joint in front of the
humerus, and then behind and carried upwards, so as to divide the
upper capsular attachments in front and behind. (4.) A pair of
bone-forceps to be next employed to cut off the entire inner
condyle and trochlea of the humerus, and then introduced in the
opposite diagonal direction so as to detach the external condyle
and capitulum of the humerus from the shaft. (5.) The truncated and
angular end of the humerus to be divided, turned out through the
incision, and smoothed across at right angles to the line of the
shaft by means of the saw, whereby (6.) room might be afforded, so
that partly by twisting and partly by dissection the external
condyle and capitulum are removed without any division of the skin
on the outer side of the arm.[56] Six cases have had satisfactory
results.
The mortality from this operation is considerably less than that from
amputation of the arm. Of a series of excisions for disease, injury, and
anchylosis, 22.15 per cent. died, while out of a similar series of
amputations of the arm the mortality was 33.4 per cent.[57] Our
mortality of excision of the elbow here is certainly much less than the
above. All of the cases, between thirty and forty, in which I have done
it have recovered with but one exception, and Mr. Syme lost only one
during the time I was his assistant.
Professor Spence lost only 16 in 189 cases, or 8.3 per cent.
Gurlt's statistics for gunshot injury give a mortality of over 24 per
cent.
Out of 82 cases where the joint was excised for injury in the
Schleswig-Holstein and Crimean campaigns, only 16 died; and out of 115
cases in which the joint was excised for disease, only 15 died.
The period after the injury at which the excision is performed seems to
be important.
Deaths.
Thus of 11 cases within first twenty-four hours, 1 = 1-11
" 20 " between second and fourth days, 4 = 1-5
" 9 " " eighth and thirty-seventh, 1 = 1-9
-- --
40 6
EXCISION OF THE WRIST.--Very various methods have been proposed and
executed for the purpose of excising this joint. These vary much in
difficulty and complexity, in proportion to the endeavours made to save
the tendons from being cut.
The principles which must guide all attempts at operative interference
with this joint are--
1. To remove all the diseased bone, including the cartilage-covered
portions of the radius, ulna, and of the metacarpal bones, as little of
these bones being removed as possible, beyond the cartilage-covered
portions.
2. To disturb the tendons as little as possible, especially to avoid
isolating them from the cellular sheath.
3. To commence passive motion of the fingers very soon after the
operation.
It is rarely possible to remove the carpal bones as a whole, from the
diseased condition which renders the operation necessary, and the
digging out of the various bones piecemeal renders the operation very
tedious, especially if the proximal ends of the metacarpal bones are
involved and require to be removed, hence this operation was practically
impossible till after the discovery of anæsthesia.
In describing the operation elaborated and described by Professor
Lister, the type of the various plans in which the tendons are saved is
given, while a very few words descriptive of the incisions used by
others who cut the tendons will suffice.
LISTER'S OPERATION OF EXCISION OF THE WRIST-JOINT.--Even an abridgment
of Mr. Lister's account of his operation must necessarily be long,
because the operation itself is so complicated and prolonged, and guided
by such precise principles, as to render much abridgment almost
impossible.
A tourniquet is put on, to prevent oozing, which would conceal the state
of the bones; any adhesions of the tendons must be then broken down by
free movement of all the joints.
_The radial incision_ (Plate IV. fig. A.) is then made. It commences at
the middle of the dorsal aspect of the radius, on a level with the
styloid process, passes as if going towards the inner side of the
metacarpo-phalangeal joint of the thumb, in a line parallel to the
extensor secundi internodii, but turns off at an angle as it passes the
radial border of the second metacarpal, and then longitudinally
downwards for half the length of that bone. The extensor carpi radialis
brevior tendon is divided in the incision. The soft parts at the radial
side are to be carefully dissected up, and the tendon of the extensor
carpi radialis longior divided at its insertion. The cut tendons, and
the extensor secundi internodii tendon and the radial artery can thus be
pushed outwards, enabling the trapezium to be separated from the carpus
by cutting-pliers. The extensor tendons being relaxed by bending back
the hand, the soft parts must be cleared from the carpus as far as
possible towards the ulnar side.
[Illustration: FIG. VI.[58]]
_The ulnar incision_ (Plate IV. fig. B.) extends from two inches above
the end of the ulna, in a line between the bone and the flexor carpi
ulnaris, straight down as far as the middle of the palmar aspect of the
fifth metacarpal. The dorsal lip of this incision is then raised, and
the tendon of the extensor carpi ulnaris cut at its insertion, and
reflected up out of its groove in the ulna along with the skin. The
extensor tendons are then raised from the carpus, and the dorsal and
lateral ligaments of the wrist divided, the tendons still being left as
far as possible undisturbed in their relation to the radius. In front
the flexor tendons are cleared from the carpus, the pisiform bone
separated from the others though not removed, and the hook of the
unciform divided by pliers. The knife must not go further down than the
base of the metacarpal bones, in case of dividing the deep palmar arch.
The anterior ligament of the wrist being now divided, the carpus and
metacarpus are to be separated by cutting-pliers, and the carpus
extracted by strong sequestrum forceps. By forcible eversion of the
hand, the ends of radius and ulna can be protruded at the ulnar
incision; as little as possible should be removed, consistent with
removing all the disease. The ulna should be cut obliquely, leaving the
base of the styloid process, and removing all the cartilage-covered
portion. A thin slice of the radius is then to be cut also with the saw,
so thin as to remove only the bevelled ungrooved portion, and leaving
the tendons as far as possible undisturbed in their grooves. The ulnar
articular facet is to be snipped off with bone-pliers. If the bones are
more deeply carious, the diseased parts must at all hazards be removed
with pliers or gouge. The metacarpal bones must then be treated in
precisely the same way, their ends sawn off and their articular facets
snipped off with the bone-pliers longitudinally. The trapezium is then
to be seized by forceps and carefully dissected out, the metacarpal bone
of the thumb pared like the others, the articular surface of the
pisiform removed, the rest of the bone being left if it is sound. The
radial incision is stitched closely throughout, and also the ends of the
ulnar incision, any ligature being brought out through the centre of the
ulnar incision, which is kept open with a piece of lint, which also
gives support to the extensor tendons.
The after-treatment is important, the principal specialities being--(1.)
early and free movement of the fingers; (2.) secure fixing of the wrist
to procure consolidation. (1.) By passive motion of the joints of the
knuckles and fingers, commenced on the second day, and continued daily
after the operation; (2.) By a splint supporting the fore-arm and hand,
the fingers being held in a semiflexed position by a large pad of cork
fastened firmly on to the splint and made to fit the palm; this prevents
the splint from slipping up the arm, and by a turn of a bandage insures
fixation of the wrist-joint. The anterior part of this splint below the
fingers may be gradually shortened, allowing more and more passive
motion of the fingers, but the patient must wear it for months, indeed,
till he finds his wrist as strong without it as with it.
Among the various operations that have been devised, the following
require notice:--Mr. Spence, Dr. Gillespie, Dr. Watson, and the author,
use a single dorsal incision with excellent results, and find it quite
easy to remove all the bones from it. Mr. Spence had sixteen cases
without a death.
POSTERIOR SEMILUNAR FLAP, from carpal attachment of metacarpal of
index finger round to styloid process of ulna; dividing integuments
only, then separating the tendons of the common extensor
longitudinally, and drawing them aside by blunt hooks, the diseased
bones are removed piecemeal by curved parrot-bill forceps.[59]
POSTERIOR CURVED FLAP.--An incision down to the carpal bones,
extended from a point two lines to the ulnar side of the extensor
secundi internodii pollicis, and from a quarter to half an inch
below the radio-carpal articulation, swept in a curvilinear
direction downwards, close to the carpal extremities of the
metacarpal bones, to a point just below the end of the ulna. The
flap thus marked out was dissected up, and consisted of the
integuments, areolar tissue, and extensor tendons of the four
fingers, together with large deposits of fibrine, the products of
repeated and prolonged inflammatory action. The tendon of the
second extensor and its soft parts around were separated from the
bones. The remains of the ligaments were cut, flexion of the hand
protruded the carious ends of radius and ulna. The bones were then
dissected out, leaving the trapezium, which was not diseased, and
hand placed on a splint.[60]
EXCISION OF THE HIP-JOINT.--The question as to the propriety of
performing this operation in any case is still debated by some surgeons,
and the selection of suitable cases for the operation is greatly
modified by the varying opinions of the different schools of surgery.
Enough here to describe the method of operating, and the amount of the
bone which is to be removed.
As in the shoulder-joint, the head of the femur is much more liable to
disease, and, as a rule, much earlier attacked than is the acetabulum,
but unfortunately the acetabulum does eventually become affected also in
probably a much larger proportionate number of cases than the glenoid.
Caries of the head, neck, and trochanters of the femur is a very common
disease in this variable climate, and frequently connected with the
strumous taint. After much suffering, abscesses form and discharge,
giving considerable pain, and often end by carrying off the patient. As
a result of the abscess and destruction of the ligaments, the head of
the bone is apt to be displaced, and under some sudden muscular exertion
or involuntary spasm, consecutive dislocation of the femur (generally on
to the dorsum ilii) very often occurs.
In such a case the operation of excision of the head of the femur is by
no means difficult, and not excessively dangerous, especially in young
children.
_Operation._--It is hardly necessary, or indeed possible, to lay down
exact rules for the performance of this operation, in so far as the
external incisions are concerned, for the sinuses which exist ought in
general to be made use of.
When the surgeon has his choice, a straight incision (Plate II. fig.
A.), parallel with the bone, extending from the top of the great
trochanter downwards for about two inches, and also from the same point
in a curved direction with the concavity forwards, upwards towards the
position of the head of the bone (see diagram), will be found most
convenient. The incisions should be carried boldly down to the bone,
which will often be felt exposed and bathed in pus, any remains of the
ligamentous structures must be cautiously divided with a probe-pointed
bistoury, and then by bringing the knee of the affected side forcibly
across the opposite thigh, with the toes everted, the head of the bone
is forced out of the wound. The head, neck, and great trochanter should
be fully exposed, and the saw applied transversely below the level of
the trochanter, so as to remove it entire. If this is not done, it
prevents discharge, protrudes at the wound, and besides this it is
almost invariably diseased along with the head. Chain saws are quite
unnecessary, it being in most cases easy to apply an ordinary one to the
bone, if it is properly everted.
Great care in the after-treatment is required to prevent undue
shortening of the limb, or in the event of a cure to secure the most
favourable position for the anchylosis. The femur occasionally tends to
protrude at the wound, and hence may require to be counter-extended by
splints. If required at all, the splint should be made with an iron
elbow opposite the wound to admit of its being easily dressed. In most
cases counter-extension may be best managed by a weight and pulley.
Various forms of hammock swings to support the whole body, and slings of
leather or canvas to support the limb only, have been found to aid
recovery, and render the patient much more comfortable.
When the acetabulum is also diseased the prognosis is much more
unfavourable than when it is sound.
The experiments of Heine and Jäger on the dead body, and operations by
Hancock, Erichsen, and Holmes, on patients, have shown that in cases of
extensive disease of the acetabulum it is quite possible by a prolonged
and careful dissection to remove it all without injury of the pelvic
viscera.
The details of incisions for such an operation need scarcely be given,
as they must vary in each case with the amount of bone diseased, and the
position of the already existing sinuses. The amount of bone that _may_
be removed varies much. Erichsen in one case excised "the upper end of
the femur, the acetabulum, the rami of the pubis, and of the ischium, a
portion of the tuber ischii, and part of the dorsum ilii."[61]
A less formidable proceeding may be useful in cases where the acetabulum
is diseased, but not deeply. The moderate use of an ordinary gouge may
succeed in removing the diseased bone.
Experience and the cold evidence of statistics prove, however, that the
prognosis in any case is modified very much for the worse by the
presence of any disease of the acetabulum, more than one-half of the
cases proving fatal in which it is diseased, whether attempts to remove
the disease of the acetabulum be made or not, and that those cases do
best in which the head of the femur has been displaced, and lies outside
the joint almost like a loose sequestrum among the soft parts.
The results of excision of the hip have as yet been very discouraging,
the mortality of the whole series of published cases being, according to
Dr. Hodge's careful table, very little under 1 in every 2 cases, viz., 1
in 2-5/53. Later statistics are however more favourable.
Like all other excisions, the mortality increases very much with the
patient's age.
Thus of 103 completed cases in which the age is given, 53 recovered and
50 died, but dividing the cases at the end of the sixteenth year, we
find that of the children below this age 43 recovered and 29 died, a
mortality of 40.2 per cent.; of the adults, 10 recovered, and 21 died,
or a mortality of 67.6 per cent.
If we remember the marvellous power of recovery from joint diseases we
find in childhood, under the influence of good diet, cod-liver oil, and
fresh air, we cannot shut our eyes to the fact that such results and
such a mortality are by no means encouraging.
From an extensive experience in a special hospital for hip-disease,
where fresh air, abundant nourishment, and very excellent nursing are
provided, the author is learning more and more to trust to the power of
nature in the cure of even very advanced cases of hip-disease in
children, and he believes that operation is rarely necessary, or even
warrantable, except for the removal of sequestra.
Mr. Holmes's[62] statistics are interesting. He has operated on no
fewer than nineteen cases. Of these seven died, one after secondary
amputation at the hip. Another required amputation and recovered.
Two others died of other diseases without having used their limb.
Of the remaining nine, three were perfectly successful, four were
promising cases, and two unpromising.
Professor Spence in 19 cases had 6 deaths, or a mortality of 31.6
per cent.
Culbertson's collection gives out of 426 cases, 192 deaths, or 45
per cent.
Mr. Croft, whose skill and success as an operator are well known,
has recorded 45 cases of excision of hip in his own practice; of
these 16 died, 11 were under treatment, 18 had recovered, of which
16 had moveable joints and useful limb; the other two are
"potentially cured."[63]
Various other incisions have been devised for gaining access to the
joint. The most noticeable are those in which a flap is made
instead of a linear incision. Sedillot makes a semilunar or ovoid
flap, the base of which is just below the great trochanter, and
which includes it, the convexity being upwards and the flap being
turned down. Gross's modification of this is preferable, being
turned the opposite way, the convexity being downwards (Plate III.
fig. E.), and the flap thus being turned up.
_Results in successful cases._--Of fifty-two in Hodge's table,
thirty-one had useful limbs, six indifferent, three decidedly useless,
four died within three years, and of the remaining eight no details are
given.
The shortening is always considerable, a high-heeled shoe being required
in most cases; a stick is indispensable; in many, crutches are
necessary.
Various operations have been devised for the treatment of osseous
anchylosis of the hip-joint when in a bad position. All are more or
less dangerous. Perhaps one of the least dangerous is the plan of
subcutaneous division of the neck of the femur by a narrow saw,
proposed by Mr. Adams of London. It is sometimes a very laborious
operation.
EXCISION OF KNEE-JOINT.--_Removal of Bone._--In every case the excision
of the joint ought to be complete. Some attempts have been made to save
one or other of the articular surfaces, but they have proved failures.
The patella has frequently been left when it was not diseased, as is
often the case, but the results have not been such as to recommend such
a practice.
_Direction of Section of the Bones._--The bones should be cut
transversely, and, as far as possible, be in accurate and complete
apposition. A slight bevelling at the expense of the posterior margin
will produce an anchylosis of the limb in a very slightly flexed
position, which is found to aid the patient in walking.
It has been proposed by some[64] to cut both bones obliquely, so as to
obviate the difficulty of making the transverse surfaces parallel. This
involves a still greater practical difficulty in keeping these oblique
surfaces in position during the after-treatment.
This plan might possibly be valuable in cases where the disease was
limited to one or other edge of the bone.
Among the various incisions recommended, the best seems to be the
_Semilunar Incision_.
_Operation._--The limb being held in an extended position, a single
semilunar incision (Plate I. fig. B.) is made, entering the joint at
once, and dividing the ligamentum patellæ. It should extend from the
inner side of the inner condyle of the femur to a corresponding point
over the outer one, passing in front of the joint midway between the
lower edge of the patella and tuberosity of the tibia. The flap is then
dissected back, the ligaments divided, when by extreme flexion of the
limb the articular surface of the tibia and femur are thoroughly
exposed. The crucial ligaments must then be divided cautiously, and the
articular portion of the femur cleaned anteriorly by the knife,
posteriorly by the operator's finger, so far as possible to avoid injury
of the artery. The whole articular surface of the femur must then be
removed by a transverse cut with the saw as exactly as possible at a
right angle with the axis of the bone. The amount of the femur which
will require removal will in the adult vary from an inch to an inch and
a half or even more. It _must_ involve all the bone normally covered by
cartilage; and this being removed, if the section shows evidence of
disease, slice after slice may require removal till a healthy surface is
obtained. Occasionally, if the diseased portion appears limited, though
deep, the application of a gouge may succeed in removing disease without
involving too great shortening of the limb. Specially in children, it is
of great importance to avoid removing the whole epiphysis. The tibia
must then be exposed in a similar manner, and a thin slice removed; if
the bone be tolerably healthy, even less than half an inch will prove
quite sufficient.
This method has an immense advantage in that it provides an excellent
anterior flap for the amputation, which may be required in cases where
the disease of bone is found too extensive to admit of the excision
being practised.
This method, with slight deviations, is substantially that of Richard
Mackenzie of Edinburgh, Wood of New York, Jones of Jersey.
Hæmorrhage must then be stopped, and that as thoroughly as possible, by
torsion, cold, and pressure, and the flap brought accurately together
with sutures.
In some rare cases, it may be found necessary to divide the hamstring
tendons to rectify spastic contraction of the muscles; but this can
generally be done quite well from the original wound.
Holt makes a dependent opening in the popliteal space for drainage. This
is unnecessary if the incisions are made sufficiently far back, and if
the wound is properly drained. It is unsafe, as approaching so close to
the artery and veins. If much bagging takes place, the use of a
drainage-tube will prove quite sufficient.
_After-treatment._--Wire splints lined with leather and provided with a
foot-piece; special box-splints with moveable sides, as Butcher's;[65]
plaster-of-Paris moulds are used by Dr. P.H. Watson[66] of Edinburgh and
others; this last form of dressing is the best, and allows the limb to
be suspended from a Salter's swing.
H-_shaped incision._--The internal incision should commence at
a point about two inches below the articular surface of the tibia, and
in a line with its inner edge; it should then be carried up along the
femur in a direction parallel to the axis of the extended limb, so as to
pass in front of the saphena vein, and thus avoid it, for a distance of
five inches. The external incision, commencing just below the head of
the fibula, must be carried upwards parallel to the preceding for the
same distance. Both incisions must be made by a heavy scalpel with a
firm hand, so as to divide all the tissues down to the bone. The
vertical incisions are then united by a transverse one passing across
just below the lower angle of the patella. The flaps thus formed must
then be dissected up and down, and the internal and external lateral
ligaments divided, thus thoroughly opening the joint and exposing the
crucial ligaments. These must be divided carefully, remembering the
position of the artery. The bones are then to be cleared and divided, as
in the operation already described. This is the method of Moreau and
Butcher.[67]
_Patella and Ligamentum Patellæ retained._--"A longitudinal incision,
full four inches in extent, was made on each side of the knee-joint,
midway between the vasti and flexors of the leg; these two cuts were
down to the bones, they were connected by a transverse one just over the
prominence of the tubercle of the tibia, _care being taken to avoid
cutting by this incision the ligamentum patellæ_; the flap thus defined
was reflected upwards, the patella and the ligament were then freed and
drawn over the internal condyle, and kept there by means of a broad,
flat, and turned-up spatula; the joint was thus exposed, and after the
synovial capsule had been cut through as far as could be seen, the leg
was forcibly flexed, the crucial ligaments, almost breaking in the act,
only required a slight touch of the knife to divide them completely. The
articular surfaces of the bones were now completely brought to view, and
the diseased portions removed by means of suitable saws, the soft parts
being hold aside by assistants."[68]
Results of Excision of Knee-joint:--Holmes's Table of recent cases from
1873-1878--
245 cases; 25 deaths, and 47 failures.
Spence's--33 cases; 22 recovered, 11 died.
BUCK'S OPERATION FOR ANCHYLOSED KNEE-JOINT.--The principle of this
operation is to remove a triangular portion of bone, which is to include
the surfaces of the femur and tibia, which have anchylosed in an awkward
position, and by this means to set the bones free, and enable the limb
to be straightened. Access to the joint may be obtained by either of
the two methods already described. Sections of the bones are then to be
made with the saw, so as to meet posteriorly a little in front of the
posterior surface of the anchylosed joint, and thus remove a triangular
portion of bone; the portion still remaining, and which still keeps up
the deformity, is then to be broken through as best you can, either by a
chisel, or a saw, or forced flexion. The ends are to be pared off by
bone-pliers, and the surfaces brought into as close apposition as
possible. The operation is a difficult one, a gap being generally left
between the anterior edges of the bones, from the unyielding nature of
the integuments behind, and the difficulty of removing the posterior
projecting edges from their close proximity to the artery. Of twenty
cases on record, eight died, and two required amputation.
_Relation of Age to result in Excision of Knee-Joint from Hodge's
Tables._
Of 182 complete cases:--
68 below 16 years: 50 recovered--18 died; or 26 per cent. died.
114 above 16 years: 55 recovered--59 died; or 51.7 per cent. died.
EXCISION OF THE ANKLE-JOINT.--_In what cases is it to be done, and how
much bone is to be removed?_
In cases of compound dislocation of the ankle-joint, the tibia and
fibula are apt to be protruded either in front or behind. When this
happens it is a dislocation generally very difficult to reduce, and when
reduced to retain in position. In such cases, if there seems to be any
chance of retaining the foot, excision of the articular ends of tibia
and fibula greatly add to the probabilities in its favour. It may be
done without any new wound, and, in general, by an ordinary surgeon's
saw.
When the astragalus does not protrude, it seems to matter little for the
future result whether its articular surface be removed or not. When, on
the other hand, it protrudes, as a result either of the displacement of
the entire foot, or of a dislocation complete or partial of the
astragalus itself, there is no doubt that excision either of its
articular surface or of the entire bone will give very excellent
results. Jäger reports twenty-seven such cases, with only one fatal, and
one doubtful result.
_In cases of disease of the Ankle-joint._--Excision has been performed a
good many times, and should in most cases be complete. A work like this
is not the place to discuss the propriety of operations so much as the
method of performing them, but one remark may be permitted. Few points
of surgical diagnosis are more difficult than it is to tell whether in
any given case disease is confined to the ankle-joint, and whether or
not the bones of the tarsus participate. If they do even to a slight
extent, no operation which attacks the ankle-joint only has any
reasonable chance of success. It may look well for a time, but sinuses
remain, the irritation of the operation only hastens the progress of the
disease of the bone, and the result will almost certainly be
disappointing, amputation being almost the inevitable _dernier ressort_.
_Methods of Operating_:--
_Mr. Hancock_ has been very successful by the following method:--
Commence the incision (Plate II. figs. B.B.) about two inches above and
behind the external malleolus, and carry it across the instep to about
two inches above and behind the internal malleolus. Take care that this
incision merely divides the skin, and does not penetrate beyond the
fascia. Reflect the flap so made, and next cut down upon the external
malleolus, carrying your knife close to the edge of the bone, both
behind and below the process, dislodge the peronei tendons, and divide
the external lateral ligaments of the joint. Having done this, with the
bone-nippers cut through the fibula, about an inch above the malleolus,
remove this piece of bone, dividing the inferior tibio-fibular
ligament, and then turn the leg and foot on the outside. Now carefully
dissect the tendons of the tibialis posticus and flexor communis
digitorum from behind the internal malleolus. Carry your knife close
round the edge of this process, and detach the internal lateral
ligament, then grasping the heel with one hand, and the front of the
foot with the other, forcibly turn the sole of the foot downwards, by
which the lower end of the tibia is dislocated and protruded through the
wound. This done, remove the diseased end of the tibia with the common
amputating saw, and afterwards with a small metacarpal saw placed upon
the back of the upper articulating process of the astragalus, between
that process and the tendo Achillis, remove the former by cutting from
behind forwards. Replace the parts _in situ_; close the wound carefully
on the inner side and front of the ankle; but leave the outside open,
that there may be a free exit for discharge, apply water-dressing, place
the limb on its outer side on a splint, and the operation is completed.
Skin, external, and internal ligaments, and the bones are the only parts
divided, no tendons and no arteries of any size.[69]
_Barwell's_ method by _lateral incisions_ is briefly as follows:--
On the outer side, an incision over the lower three inches of the fibula
turns forward at the malleolus at an angle, and ends about half an inch
above the base of the outer metatarsal. The flap is to be reflected,
fibula divided about two inches from its lower end by the forceps, and
dissected out, leaving peronei tendons uncut. A similar incision on the
inner side terminates over the projection of the internal cuneiform
bone; the sheaths of the tendons under inner angle are then to be
divided, and the artery and nerve avoided; the internal lateral
ligament is then to be divided, the foot twisted outwards, so as to
protrude the astragalus and tibia at the inner wound. The lower end of
the tibia and top of the astragalus are to be sawn off by a
narrow-bladed saw passing from one wound to the other.[70]
Dr. M. Buchanan of Glasgow has described an operation by which the joint
can be excised through a single incision over the external malleolus.
_Results._--So far as can be gathered from cases already published, the
results are very often (at least in one out of every two cases)
unsatisfactory. Sinuses remain, which do not heal, the limbs are
useless, and amputation is in the end necessary.
Langenbeck has performed it sixteen times during the last
Schleswig-Holstein war (in 1864), and the Bohemian war in 1866, with
only three deaths. In these cases the operation was subperiosteal.
EXCISION OF THE SCAPULA.--More or less of the scapula has in many cases
been removed along with the arm, and even with the addition of portion
of the clavicle.
Excision of the entire bone, leaving the arm, has been performed in two
instances by Mr. Syme. The procedure must vary according to the nature
and shape of the tumour on account of which the operation is performed.
Mr. Syme operated as follows:--
In the first case, one of cerebriform tumour of the bone, he "made an
incision from the acromion process transversely to the posterior edge of
the scapula, and another from the centre of this one directly downwards
to the lower margin of the tumour. The flaps thus formed being reflected
without much hæmorrhage, I separated the scapular attachment of the
deltoid, and divided the connections of the acromial extremity of the
clavicle. Then, wishing to command the subscapular artery, I divided
it, with the effect of giving issue to a fearful gush of blood, but
fortunately caught the vessel and tied it without any delay. I next cut
into the joint and round the glenoid cavity, hooked my finger under the
coracoid process, so as to facilitate the division of its muscular and
ligamentous attachments, and then pulling back the bone with all the
force of my left hand, separated its remaining attachments with rapid
sweeps of the knife." (Plate III. fig. G.)
Mr. Syme's second case was also one of tumour of the scapula; the head
of the humerus had been excised two years before.
He removed it by two incisions, one from the clavicle a little to the
sternal side of the coracoid, directed downwards to the lower boundary
of the tumour, another transversely from the shoulder to the posterior
edge of the scapula. The clavicle was divided at the spot where it was
exposed, and the outer portion removed along with the scapula.[71]
The author has in a case of osseous tumour removed the whole body of the
scapula, leaving glenoid, spine, acromion and anterior margin with
excellent result and a useful arm.
Large portions of the shafts of the humerus, radius, and ulna have been
removed for disease or accident, and useful arms have resulted; but as
the operative procedures must vary in every case, according to the
amount of bone to be removed, and the number and position of the
sinuses, no exact directions can be given.
For very interesting cases of such resections reference may be made to
Wagner's treatise on the subject, translated and enlarged by Mr. Holmes,
and to Williamson's _Military Surgery_, p. 227.
EXCISION OF METACARPALS AND PHALANGES.--To _excise_ the metacarpal
implies that the corresponding finger is left. Except in cases of
necrosis, where abundance of new bone has formed in the detached
periosteum, the results of such excisions do not encourage repetition,
the digits which remain being generally very useless. It is quite
different, however, if it is the thumb that is involved; and every
effort should, in every case, be made to retain the thumb, even in the
complete absence of its metacarpal bone. For the good results of a case
in which Mr. Syme excised the whole metacarpal bone for a tumour, see
his _Observations in Clinical Surgery_, p. 38.
The operation is not difficult, and requires merely a straight incision
over the dorsum, extending the whole length of the bone.
In the same way the proximal phalanx of the thumb may be excised, and
yet, if proper care be taken, a very useful limb be left. I quote entire
the following case by Mr. Butcher of Dublin:--
EXCISION OF PROXIMAL PHALANX OF THE THUMB.--
The thumb of the right hand was crushed by the crank of a steam-engine.
The proximal phalanx was completely shivered; its fragments were
removed, the cartilage of the proximal end of the distal phalanx, and
also of the head of the metacarpal bone, were pared off with a strong
knife. The digit was put up on a splint fully extended. In about a month
cure was nearly complete, a firm dense tissue took the place of the
removed phalanx, and the power of flexing the unguinal was nearly
complete.[72]
EXCISION OF THE JOINTS OF THE FINGERS.--These operations may be
performed for compound dislocation, specially when the thumb is injured;
no directions can be given for the incisions.[73]
In cases of disease it is rarely necessary or advisable to attempt to
save a finger, but if the metacarpo-phalangeal joint of the thumb be
affected, excision should be performed with the hope of saving the
thumb. A single free incision on the radial side of the joint will give
sufficient access.
EXCISION OF THE OS CALCIS.--In those comparatively rare cases in which
the os calcis is alone affected, the rest of the tarsus and the
ankle-joint being healthy, a considerable difference of opinion exists
as to the proper course to be followed. By some surgeons it is
considered best merely to gain free access to the diseased bone, and
then remove by a gouge all the softened and altered portions, leaving a
shell of bone all round, of course saving the periosteum and avoiding
interference with the joint. This operation requires no special detailed
instruction. We find many surgeons, among them Fergusson and Hodge,
supporters of this comparatively modest operation. The author has many
times performed this operation with excellent results. Even when nothing
but periosteum is left, the new bone becomes strong and of full size.
Excision of the whole of the diseased bone at its joints, with or
without an attempt to leave some of the periosteum, has been deemed
necessary by others. Holmes, who has had considerable experience,
removes the bone at once by the following incisions, without paying any
reference to the periosteum:--
_Operation._--An incision (Plate III. fig. F.) is commenced at the inner
edge of the tendo Achillis, and drawn horizontally forwards along the
outer side of the foot, somewhat in front of the calcaneo-cuboid joint,
which lies midway between the outer malleolus and the end of the fifth
metatarsal bone. This incision should go down at once upon the bone, so
that the tendon should be felt to snap as the incision is commenced. It
should be as nearly as possible on a level with the upper border of the
os calcis, a point which the surgeon can determine, if the dorsum of the
foot is in a natural state, by feeling the pit in which the extensor
brevis digitorum arises. Another incision is then to be drawn vertically
across the sole, commencing near the anterior end of the former
incision, and terminating at the outer border of the grooved or internal
surface of the os calcis, beyond which point it should not extend, for
fear of wounding the posterior tibial vessels. If more room be required,
this vertical incision may be prolonged a little upwards, so as to form
a crucial incision. The bone being now denuded by throwing back the
flaps, the first point is to find and lay open the calcaneo-cuboid
joint, and then the joints with the astragalus. The close connections
between these two bones constitute the principal difficulty in the
operation on the dead subject; but these joints will frequently be found
to have been destroyed in cases of disease. The calcaneum having been
separated thus from its bony connections by the free use of the knife,
aided, if necessary, by the lever, lion-forceps, etc., the soft parts
are next to be cleaned off its inner side with care, in order to avoid
the vessels, and the bone will then come away.[74]
Attempts may occasionally be made in such an operation to save a portion
of periosteum in attachment to the soft parts, but success or failure in
this seems to have very little effect on the future result.
_Hancock's Method._--A single flap was formed in the sole, with the
convexity looking forwards, by an incision from one malleolus to
the other.
_Greenhow's Method._--Incisions made from the inner and outer
ankles, meeting at the apex of the heel, and then others extending
along the sides of the foot, the flaps being dissected back so as
to expose the bone and its connections.[75]
EXCISION OF ASTRAGALUS.--A curved incision on the dorsum of the foot
extending from one malleolus to the other, and as far forwards as the
front of the scaphoid. The chief caution required is to divide all
ligaments which hold the bone in place, and dissect it clean on all
other parts before meddling with its posterior surface where the groove
exists for the flexor longus pollicis tendon near which the posterior
tibial vessels and nerve lie.[76]
EXCISION OF ASTRAGALUS AND SCAPHOID.--An incision similar to the
anterior one in Syme's amputation at the ankle. The flap was then turned
back from the dorsum of the foot. The joint was then opened, the lateral
ligaments of the ankle-joint divided, the foot dislocated so as to show
the astragalo-calcanean ligaments, and allow them to be divided. The
bones were then grasped with the lion-forceps and pulled forwards, while
the posterior surface of the astragalus was very cautiously cleaned, so
as to avoid the posterior tibial artery.[77]
EXCISION OF METATARSO-PHALANGEAL JOINT OF GREAT TOE.--Butcher performs
it by splitting up the sinuses leading to the carious joint, exposing it
and cutting off with bone-pliers the anterior third of the metatarsal
bone, and the proximal end of the first phalanx. He also cuts
subcutaneously the extensor tendons to prevent them from cocking up the
toe.[78] Pancoast prefers a semilunar incision. A lateral incision is
usually to be preferred.
The author has performed this excision frequently for disease; when the
whole cartilages are removed and the wound is freely drained, an
admirable result is obtained.
In cases of compound dislocation of the head of the metatarsal bone, it
will occasionally be found necessary to excise it either by the
original, or a slightly enlarged wound.
The author lately excised one-half of shaft of metatarsal and the
corresponding half of proximal phalanx of great toe for exostosis, with
antiseptic precautions. The result was a useful toe with a _mobile
joint_.
EXCISION OF METATARSAL BONE OF GREAT TOE.--For this operation a
quadrilateral flap has been recommended, but this is quite unnecessary.
A single straight incision along the inner border of the foot, extending
the whole length of the bone, renders it very easy to remove the whole
bone from joint to joint. This is an operation, however, which is rarely
needed, and which would leave a very useless flail of a toe. The
operation, which is at once more commonly required, and also gives
promise of a more satisfactory result, is the one performed for
cario-necrosis of the shaft only, and in the following manner:--
A straight incision through all the tissues, including the periosteum,
right down to the bone; then with nail or handle of the knife to
separate the periosteum from the bone; then with a pair of bone-pliers
or a fine saw to divide the shaft from both its extremities and remove
it entire.[79]
FOOTNOTES:
[52] _On Diseases and Injuries of Joints_, p. 121.
[53] For a very large amount of most interesting and valuable
information on the whole subject of excisions of joints, I would refer
to Dr. Hodge's most excellent work on this subject--_On Excisions of
Joints_. By Richard M. Hodge, M.D., Boston, Massachusetts.
[54] See Syme's _Observations on Clinical Surgery_, pp. 55, 57; Hodge
_on Excision of Joints_, p. 63.
[55] Maunder's _Operative Surgery_, 2d ed. p. 123.
[56] _Edin. Med. Journal_, May 1873.
[57] Quoted by Mr. Porter. _Dublin Quarterly Journal_ for May 1867, p.
264.
[58] A-A. Deep palmar arch; B. Trapezium; C. Articular surface of ulna;
Dotted lines include the amount removed in Lister's earlier operations;
Unshaded portions are those removed by Lister in cases where the disease
is limited to the carpus. (Reduced from Lister's diagram in _Lancet_,
1865.)
[59] Skey, _Op. Surg._, 2d ed. p. 438.
[60] Abridged from Butcher, _Op. and Con. Surgery_, p. 208.
[61] _Science and Art of Surgery_, 3d ed. p. 745.
[62] _On the Surgical Treatment of Children's Diseases_, pp. 454-6.
[63] _Clinical Society's Transactions_, vol. xiii. p. 71.
[64] Billroth of Vienna and Pelikan of St. Petersburg, quoted from
Heyfelder by Hodge _on Excision of Joints_, p. 161.
[65] _Operative and Conservative Surgery_, pp. 28, 138.
[66] _On Excision of Knee-Joint_, pp. 18, 20.
[67] _Operative and Conservative Surgery_, p. 169.
[68] Mr. Jones of Jersey, _Med. Chir. Trans._, vol. xxxvii. p. 68.
[69] _Lancet_, Oct. 1, 1859.
[70] Barwell _On Diseased Joints_, p. 464.
[71] Syme _On Excision of the Scapula_, pp. 13-26, 1864.
[72] Butcher's _Operative and Conservative Surgery_, p. 225.
[73] For an excellent case, see Annandale on _Diseases of the Finger and
Toes_, p. 261.
[74] Holmes's _Surgery_, 3d edition, vol. iii. p. 771.
[75] _Brit. and Foreign Med. Chir. Review_ for July 1853.
[76] Mr. Holmes in _Lancet_ for February 18, 1856.
[77] _Ibid._ for May 1865.
[78] Butcher, _Operative and Conservative Surgery_, p. 354.
[79] See Butcher, _Operative and Conservative Surgery_, p. 356.