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.]