with the view of removing a source of irritation and exhaustion
from the system, without sacrifice of a limb. When the operation
proves successful, the beneficial effect on the general health is
as remarkable and rapid as after removal of the hectic cause by
amputation; the pulse falls and grows firmer, diarrhœa and sweating
cease, the hectic flush leave the cheek; in short, the constitution
makes a complete and successful rally. It is had recourse to in order
to take away disease in the following situations,—in the cancellated
articulating extremity of a long bone, in part or the whole of a short
bone, and in part or the whole of long bones. Even a long bone, from
one articulating surface to the other, may be removed; the metacarpal
bone of the thumb, and the metatarsal bone supporting the great toe,
may, for example, be taken away in their whole extent. I have seen
these bones so treated, but the result was unsatisfactory. As has
already been observed, the part of the member that is left is without
support, and not under the influence of muscle; it is consequently
loose and useless.
Operation for the removal of necrosed, or softened and ulcerated
portions of the carpal and tarsal bones, is sometimes successful. But
operative interference, either with these, or with more extensive and
formidable articulations, is not advisable unless the soft parts are
not largely involved, and when the general health is tolerably good—the
patient either having suffered less than usual, or having rallied and
begun to gain strength after exhaustion by discharge and fever. If the
ligaments, bursæ, and cellular tissue are much affected, as is often
the case, there is no chance of discharge ceasing, and the patient
regaining health, even though the bone be removed to any extent—a
second operation will be required, namely, amputation above the
diseased parts. And when this becomes requisite, after failure of the
first to restore or even improve the health, the patient is apt, as has
too often been the case, to sink under the accumulation of suffering.
He might, even though much exhausted, have been able to bear up against
the shock of one and a successful operation, but he cannot endure that
of a second, or perhaps third, serious and protracted attack of the
knivesman. The disappointed hope of a cure from the first operation
is a secondary, though nevertheless a sure contributor towards the
unfortunate issue.
No particular rules can be laid down for the operative procedure.
By converting two or more natural openings into one, extending the
incisions as much as possible in the direction of the limb and of
the muscles and tendons, and avoiding the course of the larger
bloodvessels and nerves, room is made for an accurate examination of
the diseased parts. A strong and firmly pointed knife is required for
these incisions, for the soft parts are much consolidated, and are
cut with difficulty. The extent of disease is ascertained both by
the probe and by the finger, and farther measures, if necessary, are
then adopted for complete removal. Loose portions of bone are taken
away; and often large sequestra of the cancellated tissue are found
lying in the cavity, either loose or easily separable; for extraction,
forceps and the fingers, and sometimes a lever, are required. A firm
scoop is useful for removing such portions of diseased cancellated
tissue as are still continuous with the shaft of the bone. When an
opening in the cancellated tissue, leading to an internal sequestrum,
is minute, enlargement is effected by means of either the trephine or
the cutting pliers: afterwards, gouges, gravers, &c., may sometimes be
useful in operating on the soft texture underneath,—but they are seldom
requisite. The bleeding from the soft parts is free; the vessels do not
retract, and may require the application of a needle and ligature. That
from the bone is easily arrested by pressure: the cavity is filled with
charpie or with dossils of lint, and these are supported by a bandage.
Some days after, this dressing is removed, having been previously
softened and loosened by fomentation and poultice. The cavity should
now be examined carefully, to ascertain whether or not all the diseased
parts have been taken away; it is then dressed daily from the bottom.
If parts of the surface assume an unhealthy aspect, the granulations
being either backward or flabby, to these escharotics should be
applied—the most suitable is the red oxide of mercury. Gradually the
cavity fills up, and a depressed, firm, and permanent cicatrix is
obtained. It need not excite surprise, however, if, in not a few cases,
after matters have proceeded apparently very favourably for some time,
the surface become pale, soft, and glistening; the discharge thin,
acrid, and profuse; the integuments around tumid and discoloured,—if,
in short, the disease be in no long time fully reëstablished.
The tarsal and carpal bones are often the subjects of this operation.
In a few cases I have removed several, in others one or a portion of
one, with success. In one instance the greater part of the astragalus
was taken away, along with the ends of the tibia and fibula. There
remained, in consequence, a large opening across the joint, through
which a cord was passed, to facilitate gradual and piecemeal discharge
of remaining portions of diseased bone. The articulation could
actually be seen through. The seton was gradually diminished and the
aperture closed. The foot was thus preserved, and the leg was but
little shortened; the limb proved strong and extremely useful, but
the ankle-joint retained little or no power of motion. I have also
again and again trephined the os calcis, and removed large portions of
it; the cuboid likewise has been taken away, along with the base of
the metatarsal bone or bones in connection with it; in some of these
cases an excellent cure followed, in others amputation of the foot was
afterwards necessary.
Some have ventured to cut away the articulating ends of the bones
composing the _knee-joint_. This may be accomplished without much
difficulty. The patella is either removed entirely or turned to a
side, the ligamentous and tendinous attachments are divided, and the
ends of the bones thus exposed; by cutting close to and towards them,
little risk is incurred of wounding the bloodvessels and nerves in the
popliteal space. The saw is readily applied in a horizontal direction.
After tying the vessels, and approximating the edges of the wound,
the limb is placed in the straight position, and retained fixedly so
by the application of splints. Much constitutional disturbance is to
be expected, as well as profuse and tedious suppuration. There are
few surgeons so rash as to have recourse to this operation. One or
two patients, it is true, have lived in spite of it, retaining the
limb in a tolerably useful state. But in others,—and these constitute
the majority,—amputation was after all required, and that proved
insufficient to save the patient. In short, the results of excision of
the knee-joint do not justify its repetition.
The articulating ends of the bones composing the _shoulder-joint_ have
been removed; and this may be done with advantage on account either of
disease or of injury. This joint is, like others, liable to ulceration
of the cartilages, either primary, or in consequence of abscess
and degeneration of the soft parts around. The disease is attended
usually with painful feelings increased by motion, and the patient is
indisposed to attempt motion. Sometimes merely weakness of the limb
is complained of, and the attention is drawn to the wasted appearance
of the muscles, particularly of the upper arm; the deltoid seems
shrunk almost to nothing. The motions above the shoulder are lost; and
abduction is impracticable. Much pain is produced by pushing sharply
the articulating surfaces into contact, and is further increased by
rotation. The enforcement of strict and absolute rest of the joint, the
establishment of a drain in the soft parts immediately neighbouring,
and attention to the general health, often prove sufficient to arrest
the progress of this disease. If, however, it is neglected, abscess
forms sooner or later. On cutting into this, and introducing the
finger, the joint is discovered to be open; the head of the bone is
found detached from the soft parts, and unsupported. Or this state
of parts may be ascertained to exist by examination through a sinus,
either with a probe, or with the finger after dilatation. In these
circumstances, an attempt may be made to check disease, and preserve
the arm, by excision of the obnoxious parts of the bone. And this
kind of operation is also justifiable when the head of the humerus
has been shattered by musket-shot; or when it has been exposed and
injured by a splinter, or by a large shot, and the joint laid open. The
situation and course of the incisions will be so far regulated by the
openings or wounds already existing. They should always be made in the
direction of the fibres of the deltoid, and the posterior aspect of
the articulation is preferable to the anterior. One incision, from the
back of the acromion process to near the insertion of the muscle, is
sufficient to expose the head of the bone, to allow all its remaining
attachments to be separated, and to admit of its being turned out so as
to be conveniently acted on by the saw. The head of the bone merely is
taken away. In separating the soft parts from its neck, the edge of the
knife should be always directed to the bone, to avoid the nerves and
vessels on the inside. In some cases of injury, very little additional
wound may be requisite. The glenoid cavity may, in consequence of
being seriously involved in disease, also require removal; this is
best accomplished by large cross-cutting pliers. Few vessels require
ligature. The edges of the wound are brought together; the elbow is
supported, and the arm fixed to the trunk, in order to keep the bones
in apposition, and prevent motion. This position must be retained
during the rest of the cure; and when the wound is on the outside of
the shoulder, as recommended, the dressing of it does not interfere
with the retentive apparatus. The discharge gradually ceases, and
cicatrisation is obtained, though not till after a considerable time,
at least in general. The cut ends of the bones accommodate themselves
to each other, and a sort of new joint is formed—but never strong. The
motions of the forearm are perfect, though perhaps weakened; those of
the upper arm are very incomplete. I have both performed and assisted
in the operation repeatedly, and never experienced any difficulty; a
cure has not always followed, but in some cases the limb has become
very useful.
The _elbow-joint_, on account of its exposed condition, is generally
regarded as the most favourable for excision. The affections of the
joints of the upper extremity are much more manageable than those of
the lower, and may generally be prevented from proceeding so far as
to end in destruction of the apparatus. By care and good management,
disease will be arrested, and the functions and motions of the parts
restored and preserved; or the articulation may become stiff, and even
though the anchylosis be complete, the limb will be very useful if the
joint have been kept in a good position. The health, if previously
undermined, is renovated, so soon as the local disease is arrested.
But some bad cases are met with, in which all the parts surrounding
the articulation are involved, and the strength wasted; in these
amputation is the only safe and effectual procedure. It is only when
the soft parts are not much diseased, when it is ascertainable that
the affection of the bone is only to a limited extent, and when the
usual means of cure have had a fair trial and failed, that excision
is admissible. In determining on the operation, the time of life and
the worldly circumstances of the patient are to be considered: a poor
man requires his limb to be serviceable in labour; handsome appearance
without utility is to him of no value. The motion and usefulness of
the arm may be in a great measure preserved, if only a part of the
bone of the arm, or a part of those of the forearm, entering into
the articulation, be removed; but if large portions of all of these
be taken away, the muscles will lose their support, the motions will
never be restored to any extent, and the motion that is of it will be
weak and vacillating. The joint will remain loose and powerless, and
the limb will prove to be but a useless incumbrance. Such, at least,
is the result of my experience on this subject; and I am sorry to add,
that all which has been written on it is not deserving of unreserved
belief. Many patients have, after long and severe suffering, preserved
the arm to little purpose; others have been necessitated to submit
to another operation—amputation after all; some have died after the
first, others after the second mutilation. The operation is attended
with no difficulty in execution, and this in some measure accounts for
its frequent, and it is to be suspected, indiscriminate, performance
of late years. The incisions are made on the posterior aspect of the
joint. One is placed in the mesial line, extending from about two
inches above the olecranon to the same distance below it; and from this
flaps are raised, by making either a cross-cut in the middle, or one
at each extremity; in the one case the flaps are four, and triangular;
in the other two, and quadrangular; by either method the bones are
readily exposed. A more simple form of incision, as described in the
_Practical Surgery_, will often be found to suffice. The joint is
opened and dislocated, and the soft parts separated to the necessary
extent from the bones. The ulnar nerve is avoided by dissecting close
to the bone. The diseased portions are then sawn off. The wound is
closed, and the arm kept bent. This operation I have performed pretty
often, the cases being carefully chosen for it, and the success has
been highly satisfactory. By the sanguine supporters of this operation,
the after-treatment is advised to be conducted so as to secure motion
in the new articulation. From this I would dissent, for if the
articulating ends of the bones have been actually cut off, the motion
may be extensive enough certainly, but both joint and limb will be
almost altogether impotent. It would be better to procure anchylosis
in the bent position, than to have the arm dangling like a flail; in
the one case the limb will be useful; in the other, ornament, and that
too of an equivocal kind, is all that it can boast. Even anchylosis, in
most cases, can be brought about only after the lapse of a long period.
In the more severe affections of this joint, amputation of the limb is
the operation which must ultimately be had recourse to, if the patient
survive; and it is better to perform this at once, than after the
experiment of excision has been tried and found wanting. I know that
parents have too often had to regret and mourn bitterly their having
departed from sound advice, and lent themselves to such experimental
trials on their offspring.
FOOTNOTES:
[1] [In the cellular tissue the pain is acute and throbbing; in the
pleura, sharp and lancinating; in the lungs and glandular organs,
obtuse and heavy; in the skin, prurient and smarting; in the bones,
dull and gnawing. Sometimes it is persistent, sometimes intermittent,
sometimes periodical; and occasionally, again, it is felt at parts
very remote from the one originally and mainly affected. Of the latter
variety we have a familiar instance in the hip-joint disease of
children, in which the earliest symptom complained of is pain in the
corresponding knee. In hepatitis, the right shoulder is often the seat
of the suffering; in cystitis, the head of the penis.—ED.]
[2] [Mr. Hunter endeavoured to settle this point by experiments on the
inferior animals. With this view, he made a wound in the right side of
the chest of a dog, and placing the thermometer in contact with the
diaphragm, ascertained that the temperature was 101°. A large dossil
of lint was then thrust into the opening, when the edges were drawn
together with adhesive strips. On the following day, when the parts
were in a state of inflammation, the foreign substance was removed, and
the instrument being again introduced, no difference of heat was found
to exist. Similar experiments were made on the rectum and vagina of an
ass, with like results. Hence Hunter concluded that there was no real
increase of temperature. From more recent researches, however, it is
obvious that this inference of the great English surgeon is at variance
with facts. Thus, in erysipelas, furuncle, and anthrax, the thermometer
has been observed, in numerous instances, to rise as high even as 107°,
being an increase over the average heat of the blood of eleven degrees.
Results of a similar nature have been noticed in tetanus, acute
rheumatism, and other maladies.—ED.]
[3] [Leeches may be applied to almost any region of the body, excepting
such as are abundantly supplied with loose cellular substance, as the
eyelids and scrotum; or traversed by large subcutaneous veins. Parts in
a state of high inflammation must also be avoided, otherwise gangrene
may be induced, an effect which I have several times witnessed in
hospital practice: in a case of this kind they should be placed in the
immediate vicinity of the disease.
Previously to applying them, the skin should be thoroughly cleansed
with a wet sponge, and moistened with a few drops of milk, blood, or
sweetened water. Dipping the leeches in table beer is very effective in
rendering them lively and active. Having been withdrawn from the water
in which they are kept for a quarter of an hour before, they should be
held to the part by means of a glass tube, a roll of pasteboard, or
a piece of linen. When there is plenty of space, as on the abdomen,
chest, or back, and it is designed to use great number, they may be
confined by an inverted tumbler or a wire-gauze cage. They should not,
however, be crowded too closely together, as erysipelatous inflammation
is apt to arise when this is done; and they ought not to be touched
until they drop off of their own accord. If they remain on too long,
their separation may be facilitated by sprinkling them with a little
salt or vinegar: pulling them away is painful and liable to occasion
irritable sores. The subsequent flow of blood, which is generally
considerable, especially in children, is to be promoted by cloths wrung
out of warm water, and reapplied every ten or fifteen minutes for
several successive hours.
If the bleeding be profuse or continue longer than is desirable, it may
be arrested by some styptic powder or lotion, either alone or assisted
by a compress and roller. In obstinate cases, it may be necessary to
apply the nitrate of silver or chloride of zinc; or, what is better,
because more effective, to use the twisted suture made with a very fine
needle and ligature passed through the sides of the little wound.—ED.]
[4] [Scarification is a very efficient mode of abstracting blood, and
one which, in my own hands, has often been attended with the happiest
results. It is performed by drawing a sharp thumb-lancet rapidly and
lightly over the affected surface, in as many places as may be deemed
necessary, and afterwards encouraging the bleeding either by means of
a wet sponge or by immersing the part in warm water. Scarification
is mainly used in chronic ophthalmia, attended with great vascular
turgescence of the lower lid, in scrofulous swellings of the joints, in
chronic enlargement of the testicle and epididymis, in irritable ulcers
of the leg, in tonsilitis, and in erysipelas.—ED.]
[5] [All practitioners are aware how much the formation of the buffy
coat is influenced by extraneous circumstances. Of these the most
important are the shape and capacity of the receiving vessel, the
degree of motion to which the blood is subjected, and the size of
the orifice in the vein. Dr. Belhomme, of Paris, who has minutely
investigated this matter in a series of one hundred and fifty
experiments, has come to the conclusion that a narrow basin, a large
orifice, and a full, rapid stream, in the form of an arch, are the
external conditions most favourable for producing the buffy coat.
The results of these researches have since been verified by those of
Gendrin and other observers, and they are well worthy of recollection,
as they are calculated to exert an important bearing on the practice of
our profession. See my _Elements of Pathological Anatomy_, Vol. I., p.
207. A _cupped_ state of the blood most commonly occurs in association
with inflammation of the serous membranes and parenchymatous organs,
and may generally be regarded as evincive of a high degree of vascular
excitement. Still, not too much stress should be placed upon this
appearance, as it is sometimes present in states of the system the very
reverse from that just mentioned, in persons, for example, who have
been repeatedly bled or whose strength has been otherwise very much
reduced.—ED.]
[6] Throughout the Elements, the edition of Practical Surgery referred
to is that of 1842. Philadelphia.
[7] To prevent mortification blisters have long been a favourite means
with American surgeons. The practice originated, I believe, with the
late Dr. Physick, of Philadelphia, early in the present century. To do
good, they should be large enough to cover, not only the whole of the
inflamed part, but a considerable portion of the surrounding surface,
and to be kept on until they have produced thorough vesication.
Blisters are scarcely less serviceable to arrest mortification, after
it has made some progress, but in this case they should be placed in
contact with the sound skin, not with the dead, as they cannot, when
this is done, be productive of any good.
To expedite the sloughing process, allay the unpleasant fetor, and
promote the formation of healthy granulations, I know of no remedy
that will answer so well as the nitric acid lotion. It should vary in
strength, according to the exigency of the case, from four to twelve
drops of the acid to the ounce of water, and a cloth wet with it should
be constantly kept in contact with the affected part, taking care to
wash it occasionally to rid it of the foul discharges with which it
becomes from time to time impregnated. If necessary, a poultice can
be placed over the rag. Under this treatment, particularly when aided
by the liberal use of carbonate of ammonia, wine, brandy, and other
cordials, I have often been astonished to witness the rapid changes
that have taken place, in cases apparently of the most desperate
character.—ED.
[8] In this country no remedy is perhaps more frequently employed in
the treatment of erysipelas than blistering. In my own practice I
have constantly resorted to it for the last fourteen years, and in no
instance has it disappointed my expectations. Not only do I consider it
as perfectly free from danger, an objection which has sometimes been
alleged against it, but I know of no measure so well calculated to
afford prompt and effectual relief. My practice is to apply the blister
directly to the inflamed surface, together with a small portion of the
healthy skin, and to keep it on until it produces thorough vesication.
The vesicles are then opened with a needle, and the part covered with
a light emollient poultice or the warm-water dressings. In children,
and persons of a nervous delicate constitution, or whose health has
been previously much impaired, the blister must be removed in from
three to six hours, otherwise serious local mischief may be induced.
This treatment, although applicable to every species of erysipelas,
is particularly valuable in the phlegmonous form, no matter where
situated, whether in the face, eyelids, scalp, trunk, or extremities.
Another remedy which has been extensively employed in this country,
is the _mercurial ointment_, first recommended to the notice of the
profession by Dr. Dean and Dr. Little, of Chambersburgh, Pennsylvania.
My own experience, however, does not enable me to offer anything in
its favour. Indeed, if at all useful, it can only be so, it seems to
me, in the milder forms of the complaint: in the more severe grades
it should never be resorted to, as it is far inferior to blistering,
or scarification, as practised by Mr. Liston. The ointment should be
perfectly fresh, and be applied upon soft linen, at least twice a day.
Professor Velpeau has recently recommended methodical compression by
means of the roller, and from some cases which he has published in
illustration of his method it would seem to be entitled to further
trial.—ED.