A Manual of the Operations of Surgery, Joseph Bell [suggested reading .txt] 📗

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