"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 ma.s.s. 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 a.s.sistant.

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 pa.s.sive 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 anaesthesia.

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, pa.s.ses 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 pa.s.ses 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.

[Ill.u.s.tration: 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 st.i.tched 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 princ.i.p.al specialities being--(1.) early and free movement of the fingers; (2.) secure fixing of the wrist to procure consolidation. (1.) By pa.s.sive 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 pa.s.sive 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 Jager on the dead body, and operations by Hanc.o.c.k, 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.