The statistics seem to be favourable: out of 55 cases, Continental, American, and English, 21 died, a mortality of 38 per cent., while in a table of 1055 cases of amputation of the thigh, 464 died, being a mortality of 44 per cent. In some of the American cases the articulating extremity of the femur seems to have been removed, as in the following operation:—
The statistics seem to be favourable: out of 55 cases, Continental, American, and English, 21 died, a mortality of 38 per cent., while in a table of 1055 cases of amputation of the thigh, 464 died, being a mortality of 44 per cent. In some of the American cases the articulating extremity of the femur seems to have been removed, as in the following operation:—
Amputation through the Condyles of the Femur.—In theLondon and Edinburgh Journal of Medical Sciencefor 1845, Mr. Syme advocated a method of amputation through the condyles of the femur as specially suitable in case of diseased knee-joint. Amputation at this spot has certain advantages:—1. The shaft of the bone being untouched, there is no injury of the medullary cavity, and hence no fear of inflammation of its lining membrane. 2. There is less risk of exfoliation, the cancellated texture of the epiphysis not being liable to it. 3. Being close to the joint, the muscles are cut through where they are tendinous, thus very much diminishing the risk of retraction and consequent protrusion of the bone. 4. A large broad surface of bone is left to bear the weight of the body, and one which, like the ankle-joint stump, will round off andafford a comfortable pad over which the skin of the flap will freely play.
One objection used to be urged against this mode of operating, the fear lest the thickened, brawny, and often ulcerated textures in the neighbourhood of a diseased knee-joint, would not make a good covering. This, however, is no longer a bugbear, as we see in cases of resection, where the diseased joint alone is taken away, how very soon all swelling and disease departs, once its cause is removed.
Mr. Syme's original operation was briefly as follows:—With an ordinary amputating-knife make a lunated incision (Plate I.fig. 19) from one condyle to the other, across the front of the joint, on a level with the middle of the patella, divide the tissues down to the bones, and then draw the flap upwards, then cut the quadriceps extensor immediately above the patella. The point of the blade should then be pushed in at one end of the wound, thrust behind the femur, and made to appear at the other end; it should then be carried downwards (Plate III.fig. 5), so as to make a flap from the calf of the leg, about six or eight inches in length, in proportion to the thickness of the limb; the flap should then be slightly retracted, and the knife carried round the bone a little above the condyles to clear a way for the saw, which should be applied so as to leave the section as horizontal as possible.
This method is now hardly ever used, as the following seems a much better one:—
Gritti's[44]Amputation.—In this two flaps are formed—an anterior long one rectangular and a posterior short one. The condyles of the femur are divided through their base, and the lower surface of patella is removed by a small saw, and then the surfaces of bone approximated.
Stokes's[45]modification of Gritti's amputation.—In this "supracondyloid" amputation, the femur is sawn just above the condyles, without going into the medullary canal. The anterior flap is oval, twice as long as posterior, and the patella is brought up after denudation against end of femur.
Carden's Amputation at the Condyles of the Femur.[46]—The operation consists in reflecting a rounded or semi-oval flap of skin and fat from the front of the knee-joint, dividing everything else straight down to the bone, and sawing the bone slightly above the plane of the muscles, thus forming a flat-faced stump, with a bonnet of integument to fall over it.
The operator standing on the right side of the limb, seizes it between his left forefinger and thumb at the spot selected for the base of the flap, and enters (Plate II.fig. 8) the point of the knife close to his finger, bringing it round through skin and fat below the patella to the spot pressed by his thumb; then turning the edge downwards at a right angle with the line of the limb, he passes it through to the spot where it first entered, cutting outwards through everything behind the bone (Plate IV.fig. 16). The flap is then reflected, and the remainder of the soft parts divided straight down to the bone; the muscles are then slightly cleared upwards, and I saw it applied.
I have ventured to make a slight change in the method of performing this most excellent operation, for having found the posterior flap, as cut in the method above described, rather scanty in the earlier cases in which I have had occasion to perform it, after dissecting back the anterior flap and cutting into the knee-joint, I shape a slightly convex posterior flap of skinonly, at least one and a half inches in length in adult, and allow it to retract before dividing the muscles by a circular cut to the bone, and have had every reason to be satisfied with the change.
Amputation of the Thigh.—Amputation of the thigh has been the favourite battle-ground where flap and circular, antero-posterior and lateral, long and short flaps, double, triple, and conical incisions, have striven with each other; so were I to attempt to describe one quarter of the various methods employed, I should need to rewrite the history of Amputation.
It will suffice merely to describe thebestmodes of amputating the thigh through its lower, middle, and upper thirds respectively, and at the hip-joint.
In one word, it may be stated that, with the exception of those amputations performed through the lower third of the bone, the flap method is to be preferred, and the flaps should in almost every case be made by transfixion.
In the lower third, however, the flap method, though exceedingly easy, and capable of very rapid performance, has certain defects; the chief of these being the tendency which the muscular flaps (the necessary result of transfixion) have to cause undue retraction, and hence protrusion of the bone. This is seen specially in the hamstrings, which from the great distance of their origin, and the purely longitudinal direction of their fibres, retract to a very great extent, much more than the anterior muscles can do from the pennate direction of their fibres, and the manner in which they are mutually bound down to each other and to the bone.
Even in this one position, the lower third of the thigh, the methods that may be needed are various, and require separate notice;—for operations here are extremely frequent from the frequency of strumous disease of the knee-joint in our variable climate, and from thefact that compound fractures or dislocations of the knee-joint so very often necessitate amputation.
In cases where the skin over the patella is uninjured and available, the operation by long anterior flap (either by Teale's method, or by Mr. Spence's modification of it, which curiously is almost exactly similar to the amputation of Benjamin Bell by a single flap) is suitable enough. But, I believe, preferable to either of these is the operation of Mr. Carden, already described. In cases where the knee-joint is injured, and the skin over the patella unavailable, and yet where it is not necessary to go higher up the limb, the modified circular amputation of Mr. Syme will be found very suitable.
As it is in this lower third of the thigh that a very large proportion of the cases requiring a long anterior flap is to be found, it affords the best opportunity for comparing in their detail the three almost similar plans of B. Bell, Teale, and Spence—after which Mr. Syme's modified circular may be described.
Benjamin Bell's Flap Operation above the Knee(reported in his own words, slightly abbreviated).—"When this operation is to be performed above the knee, it may be done either with one or two flaps, but it will commonly succeed best with one. The flap answers best on the fore part of the thigh, for here there is a sufficiency of the parts for covering the bones, and the matter passes more freely off than when the flap is formed behind.... The extreme point of the flap should reach to the end of the limb, unless the teguments are in any part diseased, in which case it must terminate where the disease begins, and its base should be where the bone is to be sawn. This will determine the length of the flap, and we should be directed with respect to the breadth of it by the circumference of the limb, for the diameter of a circle being somewhat less than a third of its circumference,although a limb may not be exactly circular, yet by attention to this we may ascertain with sufficient exactness the size of a flap for covering a stump (Plate IV.fig. 17). Thus a flap of four inches and a quarter in length will reach completely across a stump whose circumference is twelve inches; but as some allowance must be made for the quantity of skin and muscles that may be saved on the opposite side of the limb, by cutting them in the manner I have directed, and drawing them up before sawing the bone, and as it is a point of importance to leave the limb as long as possible, instead of four inches and a quarter, a limb of this size, when the first incision is managed in this manner, will not require a flap longer than three inches and a quarter, and so in proportion, according to the size of the limb. The flap at its base should be as broad as the breadth of the limb will permit, and should be continued nearly, although not altogether, of the same breadth till within a little of its termination, where it should be rounded off so as to correspond as exactly as may be with the figure of the sore on the back part of the limb. This being marked out, the surgeon, standing on the outside of the limb, should push a straight double-edged knife with a sharp point to the depth of the bone, by entering the point of it at the outside of the base of the intended flap; and carrying the point close to the bone, it must here be pushed through the teguments at the mark on the opposite side. The edge of the knife must now be carried downwards in such a direction as to form the flap, according to the figure marked out; and as it draws toward the end, the edge of it should be somewhat raised from the bone, so as to make the extremity of the flap thinner than the base, by which it will apply with more neatness to the surface of the sore. The flap being supported by an assistant, the teguments and muscles of the other parts of the limb should, by one stroke of the knife, be cutdown to the bone, about an inch beneath where the bone is to be sawn; and the muscles being separated to this height from the bone with the point of a knife, the soft parts must all be supported with the leather retractors till the bone is sawn," etc., arteries tied, and dressings applied.[47]
Amputation of Thigh by Rectangular Flap—(Teale's).—I take the opportunity here of describing fully, and as far as possible in his own words, Mr. Teale's method of amputating, this being the situation where his method is most frequently available. The same principle may be applied to amputations at almost any other part of the body.
After advising the surgeon to mark out the proposed line of incision with ink before the operation, he gives the following directions for fixing the exact size of the flap:—"Supposing the amputation to take place (Plate II.figs. 9, 10) at the lower part of the middle third of the thigh, the circumference of the limb is to be measured at the point where the bone is to be divided.[48]Assuming this to be sixteen inches, the long flap is to have its length and breadth each equal to half the circumference, namely, eight inches. Two longitudinal lines of this extent are then traced on the limb, and are met at their lower points by a transverse line of the same length. The inner longitudinal line should be first traced in ink as near as practicable to the femoral vessels, without including them within the range of the long flap. The outer longitudinal line, which is somewhat posterior, is next marked eight inches distant from the former and parallel to it. These two lines are then joined by a transverse line of the same extent, which falls upon the upper border of the patella, or upon some lower portion of this bone. The short flap is indicated by a transverse line passing behind thethigh, the length of this flap being one-fourth that of the long one; or, assuming the circumference of the limb to be sixteen inches, and the length of the long flap eight inches, the length of the short flap is two inches. The operator begins by making the two lateral incisions of the long flap through theinteguments only. The transverse incision of this flap, supposing it to run along the upper edge of the patella, is made by a free sweep of the knife through the skin and tendinous structures down to the femur. Should the lower transverse line of the flap fall across the middle or lower part of the patella, the transverse incision can extend through the skin only, which must be dissected up as far as the upper border of the patella, at which place the tendinous structures are to be cut direct to the thigh-bone. The flap is completed by cutting the fleshy structures from below upwards close to the bone. The posterior short flap, containing the large vessels and nerves, is made byone sweepof the knife down to the bone, the soft parts being afterwards separated from the bone close to the periosteum, as far upwards as the intended place of sawing.... In adjusting the flaps, the long one is folded over the end of the bone, and brought, by its transverse line, into union with the short flap, the two corresponding free angles of each being first united by suture. One or two additional stitches complete the transverse line of union. Care is now required in arranging the two lateral lines of union. As the long flap is folded upon itself so as to form a kind of pouch for the end of the bone, it is requisite that it should be held in its folded state by a point of suture on each side. Another stitch on each side secures the lateral line of the short flap to the corresponding part of the long one. A longitudinal line of union thus passes at right angles each end of the transverse line."[49]
Mr. Teale's account of the resulting stumps is too long to quote entire, but in a few words, we find that by retraction of the short posterior flap, the cicatrix is drawn up quite behind and out of the way of the bone, that a soft mass without any large nerves or vessels is the result of the partial atrophy of the long flap, and that the patient is able to bear one-half, two-thirds, or even in some cases the entire weight of his body on the face of the stump. Such a power of support is to be found in no other flap except in Mr. Syme's amputation at the ankle-joint.
Spence's Amputation by a long Anterior Flap.[50]—The method used by Mr. Spence in amputations just above the knee-joint obtains the advantages of Teale's method, and avoids many of its disadvantages. He makes two flaps. The anterior one, which is to fall loosely over and cover in the posterior segment of the stump, must have a breadth fully equal to one-half of the circumference of the limb, and must be gently rounded at its extremity, so as to adjust itself readily to the curve of the cut margin of the posterior half of the stump. He begins the anterior incision below, or on a level with, the lower margin of the patella, and when the skin is retracted to a little above the patella, cuts downobliquelyto the bone, so as to divide the soft parts up to the base of the flap. For the posterior incision, he begins about two fingers'-breadth below the base of the anterior flap, and the assistant retracting the skin, the edge of the knife is carried obliquely up to the bone (in Alanson's manner) and the posterior soft parts divided, the bone is sawn through—or immediately above—the condyloid portion. Mr. Spence does not advise or practise this method high up. The results are good, for by these means the end of the bone has a thick covering, including muscular fibres,over it, and the cicatrix is not pressed upon in walking. The stump remains full, mobile, and fleshy, as in Mr. Teale's method, without the disadvantage which it has, in requiring the bone to be divided so far above the seat of injury or disease. This is an exceedingly good method of operating in the lower third of the thigh, in muscular patients the very best, and in all cases only equalled in value by Carden's method.
The next is now hardly ever used here, except in cases where the skin over the patella is destroyed.
Modified Circular at Lower Third of Thigh(Syme's).—Two equal semilunar flaps of skin should be cut (Plate I.fig. 20,Plate III.fig. 6), one anterior, the other posterior, their convexities being towards the knee. The skin and subcutaneous cellular tissue should be raised from the fascia, and then retracted to a further distance of at least two inches; the muscles should then be divided right down to the bone, on a level as high as they are exposed in front, and as low as they are exposed behind. This allows for the different amount of retraction at the two sides of the limb, and leaves the muscles cut on a level; the whole mass of muscles should then be drawn well up, and the bone exposed, and sawn through at a level about two inches higher than where it was first exposed by the anterior incision through the muscles.
In very weak thin flabby limbs this process may be simplified by just at once including the muscles in the skin flaps, and carefully exposing the bone higher up. In performing the retraction the assistant should be cautioned not to overdo it, lest he strip the periosteum from the bone higher than is necessary. This is very easy to do in the weak limbs of strumous patients, and may cause exfoliation, and greatly delay cure.
Amputation in the middle third of the Thigh.—A very short notice will suffice here. The exact position, shape, and size of the flaps must in every case be modified by the nature of the injury for which the operation is performed, taking the flaps where they can be obtained. As a general rule, a long anterior flap with a short posterior, on the principle described above, should be preferred. In cases where the long anterior cannot be obtained, two equal flaps should be made by transfixion. The flaps should always be antero-posterior, the lateral flaps introduced by Vermale, and indorsed by Chelius and Erichsen, having the great disadvantage of allowing the bone, which is drawn up by the psoas and iliacus, to project at the upper angle.
Supposing the right thigh is to be amputated, the surgeon, standing on the inside of the leg, should raise the skin and muscles of the front of the limb in his left hand, and entering the knife just in front of the vessels, should transfix the limb, the knife passing in front of the bone, and including as nearly as possible an exact half of the limb (Plate IV.fig. 19); having by a sawing motion brought out the knife and cut a flap of the required length, the knife is re-entered at the same place, and passing behind the bone, the point must be brought out at the angle on the other side. Both flaps being then held back by an assistant, the bone is cleared by a circular turn of the knife, and the saw applied, the vessels are found cut high up in the inner angle of the posterior flap.
In muscular patients it is often better to make the incision through the skin first and allow it to retract before transfixing; this is slower and not so brilliant looking, but avoids redundancy of muscle.
Amputation at the Hip-Joint.—This operation, exceedingly dangerous from the amount of the body removed, the great hæmorrhage, and the risk ofpyæmia, is of comparatively modern invention. Though the proportion of recoveries is at present to that of deaths about one to two or two and a half, it is still a perfectly justifiable operation in many cases of disease and injury.
Like amputation at the shoulder, amputation at the hip has given rise to very many various methods of performance. Under the heads of single flap, double flap, oval, circular, and mixed flap and circular, at least twenty distinct methods have been put on record, and, including modifications, there are thirty-seven or thirty-eight different surgeons who have each their own plan of operation.
The reason of this fearful complexity in its literature depends on this fact, that this amputation has generally been performed for cases of such severe injury of the limb, that no milder amputation was possible, and thus the flaps had to be taken just where the surgeon could get them best. And this will have to be the guiding principle in most amputations at this joint; the surgeon must just cut his coat according to his cloth—get his flaps where and how he can.
In cases, however, where it is possible to have a choice, and to select the flaps, the following is, I believe, both the best and quickest method:—
This is one of the very few operations in which quickness of performance is a desideratum; the use of anæsthetics has, in most other cases, given time for elaboration of flaps, and careful dissection; here the risk of loss of blood, specially from the posterior flap, renders rapid disarticulation imperative.
Amputation by double flap, anterior the longer.—In hip-joint amputations, besides the ordinary sponge-squeezers, two assistants are necessary, whose duties are exceedingly important.
The first is to check hæmorrhage. Pressing with a firm pad on the external iliac just as it passes the bone,he must be prepared, the instant the anterior flap is cut, to follow the knife and seize flap and artery in his hand, and he is to hold it there till all the vessels in the posterior flap are first tied.
The second has to manage the limb, and on the manner in which he performs his duty much of the success and nearly all the celerity of the operation depend. While the surgeon is transfixing the anterior flap, this assistant is to support the limb in a slightly flexed position, so as to relax the muscles; the instant the flap is cut he is to extend the limb forcibly, and at the same time be careful not to abduct it in the least, but to turn the toes inward so as to bring the great trochanter well forwards on a level with the joint; if this precaution is neglected, the operator in making the posterior flap is almost certain to lock his knife in the hollow between the head of the bone and the great trochanter.
If it is the left side, the operator, standing on the outside of the limb, enters the point of a long straight knife midway between the anterior superior spinous process of the ilium and the great trochanter, and passes it as close to the front of the joint as possible, making the point emerge close to the tuberosity of the ischium (Plate IV.fig. 20-20). With a rapid sawing movement he then cuts a long anterior flap, avoiding any pointing of it, and endeavouring to make the curve equal. The fingers of the assistant must be inserted so as to follow the knife and seize the vessel even before it is divided. The flap being raised out of the way, the surgeon, without changing his knife (as used to be advised), opens the joint, divides the ligaments as they start up on the limb being extended and adducted, the round ligament, and the posterior part of the capsule; and then getting the knife fairly behind both the head of the bone and the trochanter, cuts the posterior flap as rapidly as possible. Instantly on the limb being separated, assistantsshould be ready with large dry sponges or pads of dry lint to press against the surface of the posterior flap, till the large branches, chiefly of the internal iliac, which are cut in it, are tied one by one.
The lever invented by Mr. Richard Davy, by which the common iliac is compressed from the rectum, has in many cases proved of great service in preventing hæmorrhage, but has dangers of its own in cases of abnormal position of rectum, or even in sudden movements of the patient.
In every case the abdominal tourniquet will be found of great service in checking hæmorrhage, during the operation of amputation at the hip-joint. It consists of an arch of steel fitted with a pad behind, which rests against the vertebral column, and a pad in front playing on a very fine and long screw, through an opening in the arch. When screwed down tightly on the aorta just before the incisions are commenced, it checks hæmorrhage admirably without injuring the viscera. When this is applied, a method of amputation once practised by Mr. Syme, though not so rapid as the double-flap method by transfixion, will be found very easy, and to result in most excellent flaps. He cut an anterior flap in the usual manner by transfixion, then made a straight incision from its outer edge down to about two inches below the great trochanter, thus exposing it fully, and from the lower end of this incision transfixed again, cutting a posterior flap nearly equal in size to the anterior; a few strokes of the knife round the joint finished the disarticulation. The resulting flaps came together with great accuracy, and were not burdened with the great unequal masses of muscles so often noticed in the posterior flaps which are made by cutting from within outwardsafterdisarticulation.
In some cases of amputation where the femur has been badly shattered, it is a good plan to amputate through the upper third of thigh, tie all the vessels, andthen, aided by an incision at outer side, dissect out the head of the bone.
Mr. Furneaux Jordan of Birmingham carries out this principle by first dividing the soft parts in circular direction low down the thigh, and then dissecting out the head of the bone from the muscles by a long incision on the outer aspect of the limb.
Note.—In severe cases of smash when both lower limbs have required amputation, the author has derived much assistance from the method of managing the operation detailed below:—Double Primary Amputation of (both) Thighs from railway smash—Rapid recovery.—G., a healthy-looking man, aged twenty-seven, but looking much older, while driving a horse near Granton, caught his foot on the edge of a rail at a point, fell, and both his legs were run over by several loaded wagons. A special engine was procured, his thighs tightly tied up, and he was sent up to hospital at once.I was in hospital at the time, so with as little delay as possible he was placed on the operating table, and the necessity for amputation being too evident, I obtained his leave to remove both his legs above the knee; but his pulse was very feeble, and he was intensely nervous, throwing his arms wildly about, panting for breath, and looking very ill, cold, and exhausted.I determined that by great rapidity he might be got off the table alive, so operated in the following manner:—Fixing the tourniquet firmly near both groins, I first amputated the right leg by Carden's method, and tied the femoral only, wrapped up the stump in a towel wrung out of carbolic solution 1-20, then took off the other limb by Mr. Spence's method,—it had been injured higher than the right, so that I could not save the condyles of the femur,—then tied the femoral there, and fixed it up with another towel; then returning to the first, I tied one or two large branches which spouted, and rolled it up again, then back to the left one, doing the same, and getting the tourniquet off both limbs. On going back to the right the surface was nearly dry and glazed, so, asking Dr. Maclaren, who assisted me, to stitch it up and insert a drainage-tube, I did the same for the left, so rapidly that the patient was in his bed with his limbs dressed and bandaged in 24½ minutes from the time he entered the hospital gate.The strictest antiseptic precautions were observed, two engines being used to furnish spray. Of course this great rapidity was due to the fact that everything was ready, theassistants all in hospital, admirably disciplined, and steam had been up in the spray engines. Shock was comparatively trivial; his temperature once, and only once, reached 100°. His stumps healed by first intention, and he was in the garden on the seventh day after the operation.I have now in three cases found the benefit of this mode of dealing with double primary amputation in avoiding shock, lessening the time needed, and greatly diminishing the number of vessels requiring to be tied. In a previous case of double amputation for railway smash at the knees, the patient was almost pulseless, and had he been kept many minutes more on the table would not have left it alive. He also rapidly recovered.The case is interesting also as showing that, when the assistants know their work, the strictest adherence to antiseptic precautions need not in itself make either the operation or the dressing tedious, though it can easily be made an excuse for much fussing and many delays.[51]
Note.—In severe cases of smash when both lower limbs have required amputation, the author has derived much assistance from the method of managing the operation detailed below:—
Double Primary Amputation of (both) Thighs from railway smash—Rapid recovery.—G., a healthy-looking man, aged twenty-seven, but looking much older, while driving a horse near Granton, caught his foot on the edge of a rail at a point, fell, and both his legs were run over by several loaded wagons. A special engine was procured, his thighs tightly tied up, and he was sent up to hospital at once.
I was in hospital at the time, so with as little delay as possible he was placed on the operating table, and the necessity for amputation being too evident, I obtained his leave to remove both his legs above the knee; but his pulse was very feeble, and he was intensely nervous, throwing his arms wildly about, panting for breath, and looking very ill, cold, and exhausted.
I determined that by great rapidity he might be got off the table alive, so operated in the following manner:—Fixing the tourniquet firmly near both groins, I first amputated the right leg by Carden's method, and tied the femoral only, wrapped up the stump in a towel wrung out of carbolic solution 1-20, then took off the other limb by Mr. Spence's method,—it had been injured higher than the right, so that I could not save the condyles of the femur,—then tied the femoral there, and fixed it up with another towel; then returning to the first, I tied one or two large branches which spouted, and rolled it up again, then back to the left one, doing the same, and getting the tourniquet off both limbs. On going back to the right the surface was nearly dry and glazed, so, asking Dr. Maclaren, who assisted me, to stitch it up and insert a drainage-tube, I did the same for the left, so rapidly that the patient was in his bed with his limbs dressed and bandaged in 24½ minutes from the time he entered the hospital gate.
The strictest antiseptic precautions were observed, two engines being used to furnish spray. Of course this great rapidity was due to the fact that everything was ready, theassistants all in hospital, admirably disciplined, and steam had been up in the spray engines. Shock was comparatively trivial; his temperature once, and only once, reached 100°. His stumps healed by first intention, and he was in the garden on the seventh day after the operation.
I have now in three cases found the benefit of this mode of dealing with double primary amputation in avoiding shock, lessening the time needed, and greatly diminishing the number of vessels requiring to be tied. In a previous case of double amputation for railway smash at the knees, the patient was almost pulseless, and had he been kept many minutes more on the table would not have left it alive. He also rapidly recovered.
The case is interesting also as showing that, when the assistants know their work, the strictest adherence to antiseptic precautions need not in itself make either the operation or the dressing tedious, though it can easily be made an excuse for much fussing and many delays.[51]
Historical.—Beyond a passage ascribed to Hippocrates, but of very doubtful authenticity, and slight allusions in the works of Celsus and Paulus Ægineta, 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 Ægineta both advise the removal of protruding ends of bone in compound dislocations, but without giving any cases.
From the days of these classic 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 assisted 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 improvementof 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 class 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 associated 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, havefollowedup 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 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 necessarilynearer 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 wartyexcrescences. 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 foldof 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 head of the bone, or other reason, the straight incision may be deemed insufficient for the purpose (and we may remark that there are comparatively few cases in which it is insufficient), access may be obtained to the joint by raising a flap from the deltoid (Plate III.fig.a). Its shape—V-shaped, semilunar, or ovoid—is not of much consequence, for there are no great nerves or vessels to wound on the outside of the joint, and the surgeon should be guided, as in all other operations on the joint, very much by the position of any pre-existing sinuses. This flap being raised upwards towards its base, very free access is gained to the joint.
In these cases, fortunately comparatively rare, in which there is reason to believe that the glenoid is chiefly involved in disease, and yet that the disease can be removed without amputation, access will be gained most easily by an incision (Plate III.fig.b.) on the posterior surface of the joint, corresponding in size and direction to the linear incision in front. This gives a much easier mode of access to the glenoid. I have seen this practised in one very remarkable case by Mr. Syme, in which the glenoid cavity and neck of thescapula were extensively diseased, while the head of the bone was quite sound.
After-treatmentis exceedingly simple; for the first day or two the shoulder is to be supported on a pillow with a simple pad in the axilla, if there is any tendency for the arm to drag inwards; after this the patient should be encouraged to sit up and move about with his arm in a sling, the elbow hanging freely down.
Results.—Hodge records ninety-six cases in which this excision was performed for gunshot injury, of which twenty-five proved fatal, and fifty for disease, of which only eight died,—results which are more encouraging than those of amputation at the shoulder-joint for disease; though for injury the mortality is much greater than Larrey's famous Statistics of Amputation,q.v.p. 65.
Spence had thirty-three cases, with three deaths. He generally made a counter-opening behind to get rid of discharges, and inserted a drainage-tube.
Gurlt's statistics of excision for gunshot injury give of 1661 cases 1067 recoveries, 27 doubtful results, and 567 deaths, the mortality being 34.70 per cent.
Excision of the Elbow-Joint—In what cases should it be performed?—1. For disease of the elbow-joint which has resisted ordinary remedies, and is wearing down the patient's strength, including caries, ulceration of cartilages, and gelatinous synovial degeneration.
2. For wounds of the elbow penetrating the joint, the prognosis both as to the patient's life and the usefulness of his arm is much better after excision than after endeavours to save the joint without excision. This is especially the case when the wound of the joint is small and punctured, but if the case is seen early and treated by free drainage, with antiseptic precautions, excision may not be required.
3. For anchylosis, in cases where after disease or injury the limb has stiffened in a bad position, especiallywhen, with a straight elbow, the hand is rendered almost perfectly useless.
How much should be removed?—In the elbow-joint, more than any other joint in the body, complete excision is absolutely necessary; any portion of the articular surface being left proves a source of unfavourable result.
The surgeon is apt to err rather in removing too little than too much. For the removal of too little bone is, on the one hand, apt to result in long-standing sinuses, on the other, to induce anchylosis.
In making the section of the bones, the saw ought to be applied to the humerus transversely just at the commencement of its condyloid projections, and to the radius and ulna, at least at a level with the base of the coronoid process of the ulna.
But while removing enough, we must not be led into the error of removing too much. If this is done, as was done by Sir Philip Crampton in his first case, and as happens occasionally of necessity in cases of excision for gunshot wounds or other accidents, much of the power of the arm is lost as a consequence of the shortening and excessive mobility.
A mistaken pathology sometimes deceives in the examination of the state of the bones, and causes an unnecessary amount to be removed. For in many cases of disease the bones in the neighbourhood of the joint are stimulated to an excessive amount of what is in reality Nature's effort at repair, and while the cartilaginous surfaces are denuded of cartilage, soft, and porous, the bones close by are roughened with a stalactitic-looking growth, projecting in knobs and angles. Now, if this be mistaken for disease and removed, too much will almost certainly be taken away, and the result will be unsatisfactory.
Much less care need be taken exactly to discriminate and remove the diseased soft parts; indeed they may be left alone; the synovial membrane in a state ofgelatinous degeneration sometimes presents a very formidable appearance of disease, but if the bones be properly removed, all this swelling will soon go down, and a healthy condition of parts succeed, without any clipping or paring on the surgeon's part.
Operation.—The back of the joint is of course chosen for the seat of the incisions, both because the bones are there just under the skin, and because the great vessels and nerves lie in front of the joint. The form and number of the incisions vary considerably, and ought to vary according to the nature of the case and the amount of disease or injury.
Though it is now little used, for historical interest I retain the description of the H-shaped incision (Plate III.fig.c.), used first by Moreau, and re-introduced by Mr. Syme, and used by him for most of his very numerous cases.
The posterior surface of the joint being exposed, the surgeon, with a strong straight bistoury, makes a transverse incision into the joint just above the olecranon. It should begin just far enough outside of the internal condyle to avoid the ulnar nerve, which the surgeon should protect by the forefinger of his left hand, and should extend transversely across to the outer condyle. From each end of this incision the surgeon should next make at a right angle two incisions, each about one inch and a half or two inches long, right down to the bone, thus marking out two quadrilateral flaps. These should next be raised from the bones, up and down, as much of the soft parts being retained in them as possible, so as to add to their thickness. The olecranon is thus exposed, and should be removed by saw or pliers by cutting into the greater sigmoid notch; the lateral ligaments must then be cut, if they are not already destroyed by the disease, and the humerus protruded, a proper amount of which is then to be sawn off in a transverse direction. The head of the radius is theneasily removed by the bone-pliers, and the ulna also protruded, the attachment of the brachialis anticus to the coronoid process divided, and the bone sawn across just at the base of that process.
Few vessels, if any, will require ligature, and the arm being bent to nearly a right angle, the transverse incision must be very carefully sewed up with silver sutures closely set and deeply placed, as much of the future success of the joint depends on the completeness of the primary union of this incision. The external incision may also be accurately adjusted, the internal one not so completely, to allow free vent for the discharge, which is aided by the ligatures, if any are required, being brought out at its lower angle. A figure-of-8 bandage should be applied over pads of dry lint, and the limb laid on a pillow. No splint is necessary; in a few days the patient will be able to rise and walk about.
Passive motion should be begun so soon as the first inflammatory symptoms have passed off.
If properly performed, in a tolerably healthy subject, the surgeon should not be satisfied with any results short of almost perfect restoration of motion in the joint. Flexion and extension to their full extent, with a very considerable amount of pronation and supination, are to be expected, with proper care, in a patient of average intelligence.
Numerous cases are now on record where almost perfect performance of all the duties of life was retained after excision of the elbow-joint.[54]
In most cases it is possible, and in nearly all advisable, to excise the joint by means of a less complicated incision. Thus one long vertical incision at the posterior surface, with its centre about midway between the ulna and the external condyle, with a transverseincision at right angles to it, and reaching almost to the internal condyle, has been often practised with a very good result.
By nearly universal consent this single straight incision is now used, and when it is properly dressed anddrainedgives admirable results.
A single vertical incision (Plate III.fig.d.) without any transverse one, as long ago recommended by Chassaignac, is, in most cases, quite sufficient to give access. It is most suitable in cases of anchylosis, where there is little deposit of new bone, or in cases of disease of the joint, accompanied with little swelling or thickening of surrounding tissues. It has the advantage of avoiding the cicatrix of a transverse incision, which doubtless may, if at all a broad one, somewhat interfere with the future flexion of the limb, but, on the other hand, unless care is taken, it doesnotgive such free egress for the discharge, and when there is much delay in healing, the vertical incision may leave a cicatrix nearly as troublesome as the other.