Part 84

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.