Excision of the Elbow-joint; Recovery, with a useful arm

520

Luxation of the Elbow-joint of seven year’s date; Anchylosisof the Humero- Ulnar articulation; Excision of the Joint;Recovery, with satisfactory motion in the articulation.

(Under the care of Mr. FERGUSSON.)George G-, aged thirty-four, and a sailor, was admitted

Sept. 30, 1852, under the care of Mr. Fergusson. The historyof the case runs as follows :-Seven years before admission the patient fell from the

mast-head of a ship, and dislocated his left elbow-joint; he waseen four days afterwards by a surgeon at Valparaiso, whotold him it was a strain, and gave him an embrocation.Nine months after the accident the patient went into St.

Bartholomew’s Hospital, where efforts were made, underchloroform, to straighten and loosen the joint, and he wasordered to pull a weight by a cord over a pulley. No decidedbenefit was obtained.The man now went to Liverpool to a bone-setter, who

brought the fore-arm, which was nearly on a line with thearm, to a considerable degree of flexion. The limb became,however, fixed, and the patient being discontented with thefigure of the arm after he came home from the bone-setter,he got three men to pull the limb straight. In this theysucceeded, and for a short time the fore-arm could be flexedand extended to a slight degree.The patient now returned to the bone-setter, who employed

great violence in forcibly endeavouring to bend the fore-armon the arm, and, during the attempt, the ulna was brokenabout the junction of the middle with the upper third.A year after this rough dealing, he went to a surgeon at

Ash, who pulled at the arm every day for fourteen monthswith two men. Seven months after the termination of thistreatment the man was admitted into Guy’s Hospital, whereMr. Cock divided the triceps, and ordered the arm to be wornin a slana. But the fore-arm could not be brought to a rightangle with the arm.The patient now repaired to the Royal Free Hospital, in

April, and also in September, 1852, where he placed himself- amdeT the care of Mr. Wakley. Incisions were now made:across the back of the joint, and the ulna was found adheringto the humerus. Mr. Wakley also carried the knife alongthe inner side and front of the fore-arm, so as to divide theflexor tendons. By these means some improvement waseffected, and the patient obtained a little power of flexion.On admission into King’s College Hospital, under the care

of Mr. Fergusson, the state of the arm was noted as follows :-There is flatness behind the elbow-joint, across the condylesef the humerus; below this the olecranon is unusually promi-rent; the ulna and humerus are anchylosed, and the formerbone seems to have been luxated backwards. The head ofthe radius rotates freely, and is farther than natural from theouter condyle.As the patient was very pressing as to something being

done to make him regain a partial use of the joint, Mr.Fergusson consented to the resection of the articulation,which operation took place October 9, 1852.The patient having been completely narcotized with chlo-

roform, Mr. Fergusson made an incision in the shape of an Hat the posterior aspect of the elbow. The tissues covering thebones were reflected. and the uluar nerve dissected out, andheld raside with a blunt hook. The articular end of thehumerus was sawn nearly through, and then divided with thebone-forceps; the upper extremity of the ulna and the headof the oaa2izas were removed in the same manner.The anchylosis was found complete, the ulna and humerus

having thoroughly united. The bones were very much en-larged and indurated, and to such a degree that they offeredconsiderable resistance to the saw. A few ligatures wereapplied, the arm placed in a flexed position, the wound closed-with stitches, and covered with water-dressing.

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Mr. Fergusson, in entering a few remarks, said that the casepresented unusual interest,, since the operation had been per-fomied upon a joint already anchylosed. Still the arm was ofso little use to the patient, that the latter had been verydesirous that some procedure should be adopted to improvethe state of the joint. He (Mr. Fergusson) had performed, inthis instance, an operation somewhat similar to that adoptedby Burton, in the United States of America. The operationconsisted in taking off a wedge of bone from the articulation,the thin portion of it lying posteriorly. Burton had done thisfor the knee-joint. The patient was prepared to lose his arm,’bnt Mr. Fergusson preferred trying the operation which hadjust been performed; it would very probably give the man atolerably useful limb. The hardness of the bone, which

rendered the sawing somewhat more laborious than usual,was probably owing to the great excitement which the parthad been subjected to by the numerous operations which hadbeen performed upon it.Three days after the operation, the arm was placed in a

rectangular splint.On the fifth day, the pain, which for the first two days had

been very severe, considerably abated. There was somenumbness of the little finger and the contiguous side of thering-finger.The patient progressed extremely well; the wound was

almost healed on the thirty-third day; there was then a slightpower of flexion of the fore-arm upon the arm; and when theman was discharged, six weeks after admission, the action ofthe joint was sufficient for most ordinary purposes.The following case is the more remarkable, as the patient

was beyond forty years of age. The result has also beenfavourable.

Excision of the Elbow-joint; Recovery, with a useful arm.(Under the care of Mr. FERGUSSON.)

Mary B-, aged forty-four years, was admitted April 9,1852, under the care of Mr. Fergusson, with inflammation andabscesses around the elbow. Seven years before admission thepatient was seized with severe pain in the joint ; this was followedby the usual symptoms of inflamed articulations, and afterundergoing the ordinary treatment, anchylosis was established.About six weeks before her reception into this hospital, thepatient, without any assignable cause, again experienced painin the joint, deep-seated, and of a lancinating character.Matter formed at the posterior aspect, the abscess was opened,and the part has continued to discharge up to the time ofadmission.A week after this examination, Mr. Fergusson made a

counter-opening in front of the joint, and gave exit to a con-siderable collection of pus. The joint continued very painful,the discharge increased, and no anchylosis seemed about to beformed.On May 29, 1852, about six weeks after admission, Mr.

Fergussonproceeded to excise the joint, by making as usualan H incision at the posterior part, and reflecting the flaps.The olecranon and lower end of the humerus were then sawnoff, and the head of the radius removed with the bone forceps.The haemorrhage was more considerable than usual, severalvessels were tied, and the medullary cavity of the radius bledso obstinately, that Mr. Fergusson was obliged to introduce awooden peg into it, which measure effectually stopped thebleeding. The wound was secured by sutures, and the patient,who had all the while been under the influence of chloroform,removed to bed.Mr. Fergusson said that in the present case the question

lay between amputation and excision of the joint; as to thelatter proceeding, it was less frequently performed uponadults, and sufficient data had not yet been obtained in thisrespect. He had, however, preferred excision, as the preser-vation of the limb was a matter of great importance. Thebones entering into the joint were found carious, partlynecrosed, and the synovial membrane in a state of gelatinousdegeneration, so that the operation was perfectly justified.The upper portion of the radius was found soft and pulpy, andby scooping out the medullary cavity, the haemorrhage hadbeen considerable. This, as the pupils had seen, was stoppedby a measure which they should recollect, and use in case ofneed-namely, the use of a wooden peg. He (Mr. Fergusson)preferred this means of stopping haemorrhage to the actualcautery; for by using the latter, necrosis of the bone mighthave been induced.

This patient remained about two months in the hospital;she progressed remarkably well, and when discharged, withthe wound almost cicatrized, the motions of the joint weregradually returning, and would probably with time becomevery useful.The next case which we have to bring before our readers

was operated upon only a few days ago, and we shall justattempt a slight sketch of it, in order to complete the seriesof excisions which Mr. Fergusson has lately performed, re-serving to ourselves the pleasure of referring to these cases ona further occasion.

Chronic disease of the Elbow-joint ; Excision of the articulation.(Under the care of Mr. FERGUSSON.)

The patient is a woman about thirty years of age, who hasbeen suffering from the usual symptoms of diseased elbow-joint for the last two years. No apertures of sinuses were,