[40] _Observations in Clin. Surgery_, p. 48.

[41] _Monthly Journal of Medical Science for 1849_, vol. ix. p. 951.

[42] _Med. Times and Gazette_, June 3, 1865.

[43] _Operative Surgery_, p. 170.

[44] _Annali Universali de Medicina_, Milano, 1857.

[45] _Med. Chir. Transactions of London_, vol. liii., p. 175.

[46] Carden's (of Worcester) Pamphlet, pp. 5, 6; and _British Medical Journal_, 1864.

[47] B. Bell's _Surgery_, 6th ed. vol. vii. pp. 336-339.

[48] In diagram the amputation is drawn as if for middle third of thigh.

[49] Teale, _op. cit._, pp. 34, 39.

[50] _Edin. Med. Journal_, for April 1863.

[51] _Edin. Medical Journal_, March 1879.

CHAPTER III.

EXCISION OF JOINTS.

_Historical._--Beyond a pa.s.sage ascribed to Hippocrates, but of very doubtful authenticity, and slight allusions in the works of Celsus and Paulus aegineta, 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 aegineta both advise the removal of protruding ends of bone in compound dislocations, but without giving any cases.

From the days of these cla.s.sic 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 a.s.sisted 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 cla.s.s 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 a.s.sociated 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 a.s.sistance.

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 ca.n.a.ls for large veins, tending on any irritation or inflammation to set up a diffuse suppuration, and to culminate in phlebitis, myelitis, and other pyaemic conditions.

Excisions are performed through degenerate or disorganised, amputations through healthy, tissue.