^ vr ^ > IMAGE EVALUATION TEST TARGET (MT-3) 1.0 £1^ 1^ !tf lift ■" 1 1.1 r-^Ka IliSi iJ4 U4 4VV Photographic Sciences Corporalion 33 WHT MAIN ITMIt WIMTII.N.V. I4SM (7l*)l7a-4S03 CIHM/ICMH Microfiche Series. CIHM/ICMH Collection de m Canadian Inttituta for Historical IMicroraproductiona / Institut Canadian da microraproductiona hiatoriqu« / Taehnical and Bibliographic Notaa/Notas tacliniquaa at bibliograpliiquaa Tha Inatituta liaa anamptad to obtain tha baat original copy availabia for filming. Faaturaa of tCiia copy which may ba bibliographicaHy uniqua. which may altar any of tha imagaa in tha raproduction, or which may algnificantly changa tha uaual mathod of filming, ara chackad balow. 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All othar original copiaa ara filmad baginning on tha firat paga with a printad or llluatratad impraa- alon, and anding on tha laat paga with a printad or llluatratad Impraaaton. Laa aicamplalraa originaux dont la couvartura an papiar aat ImprimAa aont fllmAa an commanpant par la pramiar plit at an tarmlnant aoit par la damlAfo paga qui comporta una amprainta dimpraaaion ou dllluatratlon. aoit par la aacond plat, aalon la oaa. Toua laa autraa axamplairaa originaux aont fUmAa an commanpant par la pramlAra paga qui comporta una amprainta dimpraaaion ou dllluatratlon at an tarmlnant par la damlAra paga qui comporta una taiia amprainta. Tha laat racordad frama on aach mieroficha ahail contain tha aymbd -^ {moaning "CON- TINUED"), or tha aymbol ▼ (moaning "END"), whichavar appilaa. Un daa aymbolaa auivanta apparaltra aur la damlAra imaga da chaqua mieroficha. aalon la caa: la aymbola — ^ aignifia "A 8UIVRE". la aymbola ▼ aignifia "RN". Mapa, plataa. eliarta, ate., may be filmed at different reduction retloe. Thoee too ierge to be entirely Included In one expoeure ere filmed beginning In the upper left hend comer, left to rigirt and top to bottom, aa many framee ee required. The following diagrama llluatrete the method: Lee oartee. plenchee, taMeeux. etc.. peuvent Atre fllmAe A dee taux da rAductlon diff Aranta. Loraque la document eet trop grend pour Atre reprodult en un aaul clichA, 11 eet fllmA A partir da i'angle aupArieur gauche, do gauclte A droKe. et do haut en bee. en prenent ie nombre d'Imagee nAceeaaira. Lee diegremmee auivanta iliuatrent ie mAthode. 1 2 3 1 2 3 4 8 6 ■.. ..iX..-,: :^^y, '^■^^ ■? i^- ;- 'SI .' »,•".■■■> ".■.-■ ^ ■ J* • I--' ■ f. [•ff'iii'^i V.J ...<,,■• : EXCISION m^'^ ' 0» THE , >;i.i.''-v KNEE JOIHX ' ■ 'by GEORGE E. FfijTWICK, M.D., Profflsaor of ourgery, tfcQill UaiversUjr, Montreal. {Prom th4 TranaactioM of the Canada Medical Association.) -^:^. iWontreah PRlNTIfiD BYJiOVBLL Pmi^TING AND PUBLISHING CO. 1877. ■>'.■ , ;> ■■'a., , •- ' IT- ' I'd . f , < '- ■- I ..K^J ■^'', ' .1 '.'■■' ' , ii^ \'^^. A,- :"%.! , ^ — V- 1, »j 5^ I? > ■i' '' '1 f*" >- - 1 r * f A T ,- J- ■ EXCISION OV THK KNEE JOINT. BY GEORGE E. FENWICK, M.D., Proftssor of Surgery, MoGill University, Montreal. {Fr(ym. the TVamactions of the Canada Medical Association.) » T -r *'CA Tv'^'' JVotitreal t PRINTED BY LOVBLL PRINTING AND PUBLISHING CO. 1877. EXCISION OF THE KNEE JOINT. GEORGE E. PENWIOK, M.D., Professor of Surgery, McGill University, Montreal. Considerable diversity of opinion exists at the present time as to the justifiableness of the operation of excision of the knee joint, and there are those who do not hesitate to condemn the operation as " one which will sooner or later fall into deserved desuetude." With a view of attracting more prominently the attention of Can- adian surgeons to the subject of excision of the knee joint, t have prepared this paper, based mainly on the results of that operation as practiced in the Montreal General Hospital during the past twelve years. It must not be considered a reflection on the sur- gical experience or practical skill of the staff of our Hospital that the performance of the operation of excision should have been so long delayed after the published results of Sir W. Fergusson, Price and others, rather be it looked upon as an evidence of caution, in that the surgeons of our Hospital failed to recognise in cases sub- mitted to their care those suitable for an operation of such mag- nitude. Let it be remembered that excision of the knee joint is an operation of greater magnitude than that of amputation at the lower third of the thigh. It is I're difficult of performance, and the consequent shock is far great*, c ; indeed, if we take the latest published statistics on this point, based on the results of 472 cases of excision of the knee joint, as compared with 431 cases of am- putation at the thigh for disease of the knee joint, it will be found that, in the former case, excision of the knee joint, the mortality equals 27 percent., against 22 percent, of amputation at the thigh. This is taking an average of all cases, independent of age. Mr. Bryant, however, calls special attention to the greatly increased fatality of excision in young subjects, as compared with amputa- tion. In his table he gives the results of excision in 97 cases, the patients being under twenty years of age; of this number 27 died. On the other hand, out of 69 amputations for chronic disease of the knee joint performed on patients under 20 years, he lost but turee by death ; which would make excision, when practiced on the young, CANADA MEDICAL ASSOCIATION. nearly seven times a» fatal as amputation in the same class of patients. This result, although favourable to amputation, cannot be wondered at, when it is considered that many of the cases of excision, probably all of them, were submitted to the major op- eration after a long and exhausting siege of pain, suffering, and prostration of strength, from disease in which the bones entering - into the formation of the joint had been implicated. In considering the various diseased conditions in which the operation of excision may be practiced, we must affirm that much of the success attending this operation will depend on the judicious selection of cases. Sir W. Fergusson makes the following statement : " I myself have been too zealous, and resorted to the operation of excision when I should have selected amputa- tion." In deciding this question we must regard the patient's age, his constitutional condition, and the extent and character of the disease present. Although excisioi of the knee joint has been practiced with success at all ages, yet it cannot be de- nied that the most favourable period is during young adult life. Statistics point to the fact that excision in children is seven times as fatal as amputation at the thigh. But in children there is a prominent objection to excision. I refer to the removal of the epiphyses, and the consequent loss of growth in the length of the limb. We must, however, remember that disease of the knee joint in children is commonly attended by arrest of development and that, although the disease may terminate in bony anchylosis, we frequently find the growth of the limb stunted. We may have, after the lapse of years of suffering, a limb very much shorter than its fellow. In proof of this I may cite the case of W. H., published in the January number, 1871, of the Canada Medical Journal. In tliat case, an illustration of which is subjoined, the patient, at the age of 12 years, had suf- fered from an attack of rheumatic arthritis. The joint became disorganized and pseudo-anchylosis occurred, the limb being bent at a right angle. At the time he came under my observation, he was 23 years of age. There was very slight motion in the joint. The patella was firmly attached to the external condyle of the femur. The limb was perfectly useless for progression, and for his relief I excised the joint, and he made a good recovery with a useful limb. Accurate measurement of the limb before performing excision showed a shortening of two inches in the length of the femur and one inch in the length of the tibia. I am by no means satisfied I EXCISION or THE KNEE JOINT. 5 I that excision is not a perfectly justifiable measure in disease of the knee joint in children. I have, however, very limited experience to offer on this point, not sufScient at least to influence the judg- ment in this class. In December, 1870, I excised a knee joint in a boy, aged 14 years, for chronic disease of ten years standing ; and, with the view of saving portions of the epiphyses, in dividing the bones I made use of an ordinary fretwork saw, adjusted in Mr. Butcher's frame. A thin slice of the femur was removed, the end of the bone was rounded off, the entire diseased structure being taken away. The tibia was next attended to, and a thin slice re- moved, the reverse of that on the thigh bone, so that the two bones titted quite accurately. For the ensuing six week« the case pro- gressed favourably, when symptoms of osteo-myelitis set in, for which amputation was proposed. The parents of the boy, however, insisted on taking him home, and he left the Hospital. Since then I have lost all clue to the ease, except that I was informed some time back that the boy had recovered with a useful leg, and that he could walk without a stick, but this I cannot affirm from any per- sonal knowledge, as the family live some distance up thi Ottawa. During the summer of 1874, while on a visit to Edinburgh, I re- lated this case to Mr. Annandale of the Eoyal Infirmary, and he in- formed me that his practice was to excise the knee joint in childi*en, and that in so doing he removed all the diseased structures with a strong knife, paring off the face of the bones, his object being to save as much of the epiphyses as possible. I have followed the method practised in the first case, as described above, in one other instance — the case being that of a little girl aged 10 years, whose knee joint I excised in 1875. There had been disease of the joint, implicat- ing the bones, of some four or five years standing. The limb was bent at a right angle, and, from softening and relaxation of the ligaments, together with constant traction of the ham-string muscles, dislocation backwards of the bones of the leg had taken place. There was great difficulty after section of the bones and division of the ham-string tendons, in placing the bones in position, so that, to avoid bruising of the ends of the femur and tibia, a second slice had to be removed. This encroached very much on the epiphysis of the femur, and there was only a very small portion of it left behind. We had a great deal of trouble in the after treatment of this case, constant watching and attention being required to carry the child through a long siege of sup- puration and threatened pyaemia, but she ultimately recovered. 6 CANADA MEDICAL ASSOCIATION. and is now able to set the foot to the ground, and bear her whole weight on the limb. She has grown considerably, but the limb does not increase in length in the same proportion as its fellow. This result I do not think is entirely due to removal of the epiphyses or their injury by the operation, since the previously existing disease must have had much influence in arresting the development of the limb. However, the patient has a limb, such as it is, with an ankle joint and foot, both of which, as time advances, will increase in efficiency and usefulness; whereas, had she merely a stump, the result of amputation, her condition would remain over the same. So much, then, for the influence of age in the results of this operation ; not only is it admitted to be moHt fatal in children, but the other considera- tions are of the highest consequence, as affecting the after useful- ness of the limb in its arrest of development. Constitutional condition. — I have already stated my conviction that excision of the knee joint id an operation of greater magni. tude than that of amputation. From this I fancy there are few that will dissent. It is attended with a much longer conflnement to bed, a longer period of absolute restraint in one position (on the back), which is very irksome; besides, we have the long con- tinued suppuration and sometimes the burrowing of matter and for- mation of sinuses, in all instances requiring constant attention, and being also a great drain on the patient's powers of repair. Hence, in the selection of cases for excision, the surgeon should be careful to ascertain that he has no slumbering evil, no incipient or deve- loped disease of the lungs, kidneys, or other viscera. After excision, the condition of the patient is such, that greater demands are made upon his reparative powers, and upon his ability to resist the long-continued suppuration which so frequently accom- panies these cases. " It should be a golden rule," writes Swain, '* one of the few without exceptions, that tubercle of the lung contra-indicates excision of the knee." It is true that Mr. Price reports a case of successful excision of the knee in a phthisical patient. This, however, must be regarded, as Mr. Swain truly observes, " as an exceptional case, one of those solitary instances of good luck, and good management as well, because the patient made a rapid recovery." In another case, also reported by Price, the patient developed acute phthisis and died. The condition of the heart and kidneys should always be ascertained before decid- ing on an operation for excision of the knee. Mr. Savory, on this EXCISION OF THE KNEE JOINT. point, remarks, " that damaged kidneys have, as a rule, much more influence upon the result of an operation of any kind, or an injury of any kind, than a damaged heart, although the action of the kidneys is not so immediately necessary to life as that of the heart." It may be looked upon as a rule that recovery from excision is more tedious than from amputation of the thigh. There are some very exceptional instances on record of marvellously rapid recovery after excision of the knee-joint. Therefore, it follows in cases where some of the important viscera are engaged in diseases, and the constitutional ability of the patient is enfeebled, that when, from in'itation in the joint itself, the constitutional disease is apparently increased, then indeed should the local malady be removed, and in doing so, the surgeon should select the operation that holds out the best chance for rapid recovery. ^. Again, in deciding the question of excision of the knee joint, the extent and character of the disease present must seri- ously engage our attention. While the disease is confined to the soft tissues, no operative measures should be entertained. If the synovial membrane alone is implicated, it would be highly improper to excise the joint. On this point Mr. Cadge of Nor- wich observes : " It will generally be found useless to remove the ends of the bones when the synovial membrane is the primary and chief seat of the disease." Mr. Price records twenty-one cases of excision of the knee for the removal of diseased synovial membrane, and they were all unsuccessful. In performing exci- sion under such circumstances the surgeon opens a joint in which the principle tissues entering into its formation are unaffected by disease. The shock of such an operation would be very much greater, as it has been found that shock to the general system is greater in proportion to the integrity of the joint. If the synovial membrane is alone implicated, the bony structures are compara- tively healthy. The bone tissue with their cancelli are not con- densed by disease, and by opening this healthy bone tissue the risk of purulent absorption is greatly augmented. Acute suppuration is not a favourable condition for excisions. This is conceded by most surgeons. Exceptions, however, do occur, and successful results have followed excision in this condition. Mr. Holmes, in his work on the Surgical Diseases of Children, observes on this head, " Exci- sion usually much increases the amount of suppuration, and gener- ally excites a very great degree of surgical fever. Hence I should fear that it would very generally hasten the fatal event instead of 8 CANADA MEDICAL ASSOCIATION. averting it ; so that I have always preferred to amputate, though I do not deny that excision might sncceed in occasional cases of acute abscess of joints." Disease attacking the cartilage of the joint simplifies the question for operative interference. The implication of the car- tilage, erosion, or so-called ulceration is soon attended with implication of the osseous structures, if, indeed, the bone is not the first structure implicated, and then follows a train of most distressing symptoms. In these cases we may believe that the integrity of the joint is destroyed. Here the surgeon may seek to secure anchylosis in a favorable position, and no doubt, in time, his labors may be crowned with success; but, in his success, the surgeon cannot restore a perfect knee ; at best, he can alone have a stiff knee, and if in a child, most likely a dwarfed limb. But if, as so frequently occurs, a patient is brought to you with a limb fiexed at a right angle, with a knee swollen, tender to the touch, with agonizing night start- ings, so that he awakes from sound repose to utter a cry of pain, all attempts at palliation in such a case will fail. Pro- bably we may have sinuses leading into the joint, or reaching diseased bone ; even in such a case anchylosis may sometimes be secured, but in the attempt, after many months of suffering, the patient will most likely be reduced to such a condition that oper- ative measures of any kind will be very haisardous. But let us take the most favourable resultsi when anchylosis has followed after what we may term the expectant treatment, and it will be observed in very many cases that, after years of misery and con- stant attention, a hollow peace, so to speak, will have been entered into between the surgeon and the disease, which may at any time be broken. On this point I may quote Mr. Solly, who remarked in a clinical lecture delivered at St. Thomas' Hospital, in compar- ing the results of anchylosis fVom what he is pleased to term medicnl as distinguished from operative surgery : *' I must confess that I have been disappointed in some of my cases of natural, as distinguished from artiJcial anchylosis, by their return to the hospital after I had hoped a complete cure had been affected." From the records of many British surgeons it would appear that in acutely painfViI articular disease, those cases in which the oarti- lages and bones are affected are most favourable for excision, and in selecting this operation its advocates recommena its early performance. This would appear to be one element of success : k Case I, — Fig. i. ti { I — IXCISION OP THK KNII JOINT. Operation performed 17th Mnyi IMS. Photograph taken iinth Ootobor, \mr>, tlve monthe »fter the operation. EXCISION OF THE KNEE JOINT. f \ to wait long enough to be certain that the disease present is beyond all chance of amendment except by operative inter- ference. Dr. Sayre, of New York, in discussing this subject, re- commends that if the disease of the joint is not sufficently exten- sive to warrant complete excision, you may remove all the dead bone by drilling and gouging ; passing^ setons of oakum or perfor- ated rubber tubing through the joint for the purpose of securing complete drainage, &c." Dr. Sayre is not very warm in his advocacy of excision, though he by no means condemns it. Excision of the knee joint has been practiced for trauinatio injury, gunshot wounds, both in civil and military practice. In this latter it is not advocated, in fact by many condemned. The chief reason appears to be the danger of pyaemia, which is the military surgeon's most formidable enemy. But more than this, one of the most difficult problems to the practical surgeon is the retention of the bones in apposition in absolute rest to secure union. Hence the surgeon in the field in the face of an enemy, with no permanent hospital establishment, is loath to attempt an operation which requires weeks, if not months oi absolute rest to ensure success. On this head I may cite the record given in circular No. 6 from the Surgeon General's department during the American war. There is a table containing the results of eleven cases of ex- cision of the knee for gunshot wounds of that joint with only two recoveries, the others were fatal. This is fkr from encouraging. In the Montreal General Hospital the operation of excision has been performed thirteen times with the following results : No. of cases, 13 ; cured, 9 ; doubtf\il, 1 ; died, 1 ; amputated, 2. Some of these cases have already been published in the Canada Medical and Surgical Journal, and, without repeating over the details of each case, I shall select as much as will add interest to this paper, and shall call attention to any special feature which may appear of importance. Case I. — Excision of the knee joint performed at the Mont- real General Hospital on 17th May, 1865. The patient was a young man, cet. 18, who had suffered for some years iVom frequent attacks of synovitis. The disease first developed after the receipt of an injury to the joint from a severe kick. The joint became acutely inflamed, and ho was energetically treated by leeching, local applications, and rest in bed. The attack was attended with some constitutional disturbance, and, at the end of eix or eight weeks, he was able to go out, but the joint remained 10 CANADA MEDICAL ASSOCIATION. stiff and enlarged ; he was able, however, to get about, but could not join in play with boys of his age, as the slightest blow or twist would light up fresh inflammatory action, necessitating rest for days or weeks. Two years before he came under my observation he began to experience pain in the joint at night, and would suffer from severe startings, which occasioned much agony and inter- fered with his rest. At the time of his admission into the Mon- treal General Hospital he presented a care-worn appearance ; there was loss of appetite, he was pale and anxious, and the affected limb presented a marked contrast to its fellow. The muscles of the affected leg were flabby and wasted, and the joint was by measurement an inch and a half larger than the other knee. On careful examination the condyles of the femur appeared to be expanded, there was evident pulpy thickening of the synovial membrane, and on motion, rotatory or lateral, of the joint, or on moving the patella, distinct roughness was found to exist. I have thus given a general view of the clinical features observed in this characteristic case, one by no means uncommon. In ten weeks after the operation all discharge had ceased, the bones were firmly united, the limb was supported by a gutta- percha back splint, and the patient was going about the ward on crutches. He rapidly gained strength, and, at the end of the fifth month, he could walk about the street with the aid of a stick. The photograph from which the engraving marked Fig. 1 iu copied, was taken five months after the operation, and the patient walked down to the photographic gallery and returned, which was something over a mile from the Hospital. Figure 2 is from a photograph of this man taken in 1870 — or five years after his recovery — it will be noticed that the growth of the leg operated upon has been quite equal to that of its fel low, the muscular development of the calf is remarkable. The man has grown in stature some two inches, and the leg has grown in length in proportion to its fellow. There was one inch and three quarters of shortening after recovery from the operation, and the same amount of shortening was found to exist at the last examination made in 1870. Case II. — This case was somewhat different in the character of the disease present, and in its mode of attack. The patient was a healthy, robust, well-developed man of 22 years of age. Nine years previously he had suffered from acute articular rhou- matism, and, after three months' confinement to bed, he was able Case I. — Fig-. 2. IXeitlON or THt KNII JOINT. Phologr*ph Ukfn Sth Dooember, 1870, flv« yean after th« opantloa. t( ri A V) t\ C( joir and cici at the disc to e alio did oft of a to t EXCISION OF THE KNEE JOINT. 11 to get about, but the disease appeared to have located itself in the right knee joint, which remained very stiff, swollen and painful* At the time he came under my observation the right knee joint was partially anchylosed, the limb was bent at a right angle, and the patella was fixed, being attached by bony union to the outer condyle of the femur. At the inner side of the thigh, close to the joint, there existed a sinus which led downwards to denuded bone, and on the outer side of the thigh there were the remains of the cicatrices, through which several pieces of bone had come away at different times. The operation of excision was performed on the 21st June, 1866, and about two inches 6f bone removed. All discharge had ceased on the.9th August, and firm union was found to exist. The limb was put up with a glue bandage, and the patient allowed to leave his bed ; he rapidly gained strength, although I did not permit him to leave the Elospital for some weeks. Figure 3 is from a photograph which was taken in December of that year. The patient at that time could walk without the aid of a stick. Case III. — This was very similar in origin and general history to the one just related. It occurred in the person of a young 12 CANADA MEDICAL ASSOCUTION. man, 23 years of age, not over robust, and whose history was as follQ;i^s. At the age of 11 years he was attacked with acute synovitis, which had apparently followed a lengthened exposure to cold, as he had the previous day remained in the water bathing for several hours. When he came under my observation I found the leg flexed at right angles to the thigh. The bones of the leg were dislocated backwards, the condyles of the femur projected, and the patella was firmly attached to the external condyle. The whole limb presented a dwarfed appearance, and there was found to be shortening in the length of the thigh of two inches, and of the leg of one inch. The foot was very much arched, which gave to the heel a peculiar prominence, and the toes were semi-flexed. He could not use his leg in walking, his gait was very awkward, and to himself very wearisome, as he was forced to use a stout stick. There were no sinuses, nor had the joint been opened. Here was a case in which some surgeons would have practised subcutaneous division of the ham string muscles, and hrisement force. I believe from the condition in which the bones were found subsequently that such an operation would have been attended with disaster and loss of the limb. Excision of the joint, however, was advised, and the operation performed on the 28th May, 1870. The ham string muscles had to be divided before the bones could be brought into position, unless indeed an extra slice of bono had been removed ; this I was desirous of avoiding on account of the already shortened state of the limb. The bones when examined presented the following appearance. There existed caries of the head of the tibia and also of the extremity of the femur, the inter-articular fibro-cartilages were gone, the patella displaced outwards and firmly attached by bone to the external condyle of the femur. The case progressed slowly, as suppuration and burrowing of pus gave much trouble and constant employment, slitting up sinuses and using drainage tubes. The poor fellow sometimes became wearied, and requested that amputation should be performed. This, however, was not acceded to, and on the 14th November the report states : "He has been going out for a walk for the last ten days, and with a crutch and stick gets along very well. It was found that from the arching of the foot and the flexed state of the toes that he sustained his weight on the point of the heel and ends of the toes. To remedy this state I divided the plantar fascia and short flexor subcutaneously and straightened 1 Case II. — Fig. 3. IXCISION OF THE KNEE JOINT. OperBtton performed 21st June, 1866. Photograph taken January, 1867, seven months aft^r. EXCISION OF THE KNEE JOINT. 13 the foot. This enabled him to bring the foot well down, and gave . greater freedom to the motions of the foot. He left the Hospital some time in the month of February following, at which time he was uble to use the leg freely. There was shortening to over four inches, which was made up by an addition to his boot. General health good. I have heard from this man once since he left Mon- treal and he stated that he was progressing favourably. Fig. 4 is from a photograph taken in February, 1871, and gives a fair idea of the condition of this patient at that time. Case IV. — This was in a boy aged 14 years. He had been a sufferer from a bad knee since his fourth year. He was admitted into the Montreal General Hospital in October, 1870. The leg on examination was found semi-flexed, it was exquisitely tender, he would cry out with agony or fear if even the bed was touched. He presented an anxious and care-worn appearance. The knee was very much larger than its fellow, and when handled gave great pain which persisted for hours. There was effusion into the sub- crural pouch, and his sleep was disturbed by frequent startings. Under chloroform the limb was placed in an extended position on a gutter splint, and while under the influence ot the anaesthetic I examined the joint, when it was found that there was much thickening of the tissues around the joint and marked roughness, as though from erosion of the cartilages, between the ends of the bones as well as on the under surface of the patella. The treat- ment was chiefly palliative : absolute rest, good nourishment and locally hot fomentations over the joint. Morphia was given hypo- dermically, which secured refreshing sleep. By these means the acute inflammatory symptoms gradually subsided. Subsequently 1 tapped the joint at the inner side of the thigh with a small aspirator needle, and drew off a quantity of serous fluid tinged with blood. This gave him conside^^able relief and the startings subsided. Belief, however, was only temporary, and a fresh attack of acute inflammation followed, which was relieved as before. As soon as he was in a favourable condition, I recommended excision of the joint, which operation was performed on the 21 st December, 1870. As the patient was a growing lad I determined to save as much of the epiphyses as possible, and with this end in view I adjusted to Mr. Butcher's frame a carpenter's whip saw, somewhat coarser than those used for fret-work. A semicircular sweep of the saw was applied to the end of the femur, thereby remov- ing all the diseased bone so that the extremity of the femur after re- moval of the condyles presented a convexity. The head of the tibia 14 CANADA MEDICAL ASSOCIATION. was next attended to and the surface was removed, rendering it con- cave. The patella was then removed, as its surface was found diseased. The leg was bandaged in the usual way and placed in a gutter splint with a vacancy on either side opposite the joint, the popliteal space being supported by a connecting shelf After adjustment of the bones the flaps of the wound were brought together by interrupted metallic sutures. The shock after the opera- tion was very marked, his pulse, which was weak, ranged from 160 to 180 per minute. His condition, however, improved, and at the end of a week suppuration and granulation of the wound progressed slowly, but he took nourishment well. The advantages in this method of section of the bones are two-fold. In the first place the smallest quantity of bone is removed, portions of the epiphyses are left, which to a growing individual is a great gain, and secures the after-growth of the limb ; and, secondly, a larger extent of surface is secured, and from the shape of the cut surfaces there is less risk of displacement of the bones and forcing forwards of the ond of the femur from contraction of the ham-string muscles unop- posed by the quadriceps extensor which had been divided. In all the cases reported the bones were with diflBculty retained in position. In all there was a tendency (in the thigh bone) to rise out of position. The accompanying woodcut is an accurate repre- sentation of the portions of bones removed. The case progressed favourably at first, though the progress was very slow. The wound in the soft tissues closed with the exception of two or three points, sinuses, which led down to bare bone. At the end of six weeks he had a severe rigor, and symptoms of osteo- myelitis set in, for which amputation was proposed, as his general health was failing and the discharge was considerable. His friends, however, refused to permit amputation, and determined to remove him to his home in the country. This was some time in the follow- ing March, and he left the Hospital. Since then I have lost all trace of this case, but have heard that the boy recovered with a useful leg. However, I have no positive evidence to oflfer on this head, and therefore record the result as doubtful. Case IH.—Fig. 4. ' EXCISION OF THE KNEE JOINT. Operation performed aWh May, 1870. PhotOKrapli taken February, 1871. EXCISION OF THE KNEE JOINT. 15 Case V. — ^This was a case of bony anchylosis at a right angle of the knee joint, which was admitted under the care of my colleague, Dr. VVright. For the relief of this deformity Barton's operation was proposed, but it was found necessary to remove the entire mass of what had been the knee joint. This was rendered necessary in consequence of the contraction of the muscles. The case progressed favourably and the patient made a good recovery with a useful limb. Case VI. — Under the care of Dr. MacCallum was operated on a month or two after the one just reported. It was in an adult 8Bt. 42. The patient progressed favourably for the first few weeks, the soft parts united and all discharge had ceased, but bony union was not secured. The limb was put up in a permanent apparatus, and he was allowed to go about on crutches. Subse- quently the wound opened at several points. The man was desirous of having amputation performed, as time was to him an object, so that his wishes were complied with. The limb was removed and he made a good recovery. The bones were found in excellent position, but no attempt at bony union had occurred. It was in my opinion a case in which re-excision would in all likelihood have succeeded. A somewhat similar instance is re- corded by Sir William Fergusson, in which that surgeon perform- ed re-excision and secured a good result. Case VII. — This was in a man aged 36, who had suffered for years from chronic synovitis resulting from injury, with ultimate disorganization of the joint and perfect inability to use his limb. He came from the country, and was brought to the Hospital for the purpose of having his limb amputated. His health was not seriously impaired, he was strong, robust and well nourished. Excision was performed 20 September, 1872, and everything pro- gressed favourably .or the first eight weeks, partial union had taken place, when unfortunately the poor fellow contracted small-pox, and he was removed to the small-pox department. He recovered from the attack, but when returned to me, I found the bones wore lyina; in a huge collection of pus. Whatever union had existed before, there was cprtainly none at this period, so that I did what was deemed necessary, drained off the pus, built up his general health, and subsequently amputated the limb. He made a good recovery and loft the Hospital. " Case VIII. — 8. C, aged 23, had suffered for the past four years from a sore knee. Had always enjoyed good health up to the summer of 1868. She was u norvous, hysterical girl, rather dolicate in appear* / 16 CANADA MEDICAL ASSOCIATION. ance, with florid complexion, blue eyes and fair hair. Her diges- tive organs were in good order, and she was regular. The attack appeared to come on from some over-exertion or twist of the joint while walking. This was in the summer of 1868. The knee gave her much pain, more especially at night, which deprived her of rest. There was swelling of the joint, and it was tender to the touch of in bending it. She was admitted to the Hospital in February, 1869, and was then treated for hysterical knee joint. Eelief was given, and she was discharged, but again returned in a few months. On this occasion the joint was by measurement found larger than the other. There was considerable pulpy thickening of the tissues, and various means were resorted to for her relief, such as leeching, blistering, hot stupes, and putting the leg up with Scott's dressing Towards the close of 1871 she was again admitted to the Hospital, and remained under treatment, but no permanent relief was given. In October, 1872, she sufieredfrora night startings,the knee was ex- ceedingly tender, and measurements showed the affected joint an inch larger than its fellow. Examination under chloroform revealed distinct roughness, and in consultation it was deemed advisable to excise the joint. The operation was performed on the 11th October, 1872. Erosion of the cartilages existed, and was tolerably exten- Blve. About an inch and a half of the femur was removed, and a very thin slice of the head of the tibia. The bones, after the application of the saw, were found tolerably healthy. The patella was removed, as its free surface was implicated in the disease. The limb was placed on a padded posterior iron splint, being carefully bandaged from the foot to within half an inch of the lower margin of the wound. The thigh was secured to the upper part of the splint by straps well padded. The bones being accurately adjusted, the wound in the soft tissues was closed, and a lotion of carbolic acid applied with lint and oil silk. On the sixth da}^ the patient was com« fortable, temperature normal, and slight discharge from the edges of the flap. The wound in front was well united, and several stitches were removed. The first removal of the splint was effected on the 9th November, when It was found that the wound had almost entirely closed — leg washed, and again adjusted in the splint. December 1st. — The leg again taken down. A small portion of the wound was discharging at the innerslde, but tirm bony union was found to exist. The splint was, however, re-appi led, and the leg retained in the same position up to the 17th December, / Case VI II.— Fig. 5. EXCISION OF THE KNEE JOINT. Operation performod llth ncfobcr, 1879. PUotoifrapli taken antli March, 187S. EXCISION OF THE KNEE JOINT. 17 when it was entirely removed, and the limb, supported by sand bags placed on either side, was laid on a soft pilltfw. The follow- ing day it was noticed that the limb was slightly swollen, so that a bandage was applied from the toes up to the groin. The bandage was removed each day and gentle friction practiced, when the limb was again bandaged. On January 2nd, 1873, or twelve weeks from the date of the operation, she walked the full length of the ward supported by two persons, one on each side. From this time she progressed rapidly, and soon acquired suflScient confidence to walk with crutches. The photograph from which the engraving Fig. 5 is made was taken on the 20th March, 1873, and she walked unas- sisted into the photograph gallery from the vehicle which brought her from the Hospital. By the most accurate measurement the amount of shortening in this case was found to be one inch and a half. This patient was discharged from the Hospital in April at which time she could walk with tolerable freedom. Her friends sent her to the country during the summer months, and the following October she returned to her family in Ireland. Short- ly before leaving this country I examined the leg, and found it straight, well proportioned, the muscles of the leg and thigh being firm and well developed. She could sustain any amount of ex- ercise, and walked with perfect freedom of motion. Case IX. — I am indebted to my friend Dr. Drake for the particulars in this case and permission to include them in the series. J. G., aged 22, came under Liie care of Dr. Drake, Sept. 15th, 1873, suffering from painful swelling in the right knee joint. The joint had been repeatedly injured by sprains, falls, &c., and for the past two years had been more or less swelled and painful. For the past three weeks the pain has been excessive, and he uses largo quantities of morphia to alleviate it. Rest and palliative measures were resorted to till October 16th, when, the patient being fully otherizodjthe joint was excised. The semilunar incision was adopted, the patella removed, together with about 2 inches of the lower end of the femur, and J an inch of the tibia. The cortilages of both sur- faces were considerably eroded, and the synovial membranes much thickened. The limb was put up firmly in a straight trough splint, attached by rivets to a pelvic belt made of wire and covered with leather, moulded carefully to the shape of the patient's body. The limb remained undisturbed for 73 days, was then drosnod, and returned to the splint for 20 days. At this time, owing to a defect B 18 CANADA MEDICAL ASSOCIATION. ^ in the splint, a superficial sore of some three inches in length was observed on the outer side of the thigh. The splint was removed altogether, and the limb steadied by means of sand bags. He remained in bed 43 days longer, and was then allowed to sit up, union being apparently complete. He left the hospital in March, 1873, with two or three small fistulous openings in the neighbour- hood of the wound, which did not close completely for four or five months. Nevertheless, he was able to get about with the aid of a crutch, and came repeatedly to my office. It is worth recording that, on the evening of the day on which the operation was per- formed, a considerable hemorrhage occurred from the bowels, and this continued for three consecutive days and nights. The urino also was smoky, and contained albumen in considerable quantity. The albuminuria continued for upwards of twelve months, and was present when I last examined the urine, fifteen months after the operation. The limb is now (Jan., 1875) perfectly strong, the wound and fistula6 completely healed, shortening to 2J inches. He expresses himself perfectly satisfied with the result, and says he walks as well as ever he did without a cane or support of any kind. Case X. R. E., aged 20, was admitted into hospital in April, 1875, suffering from an attack of acute synovitis. The history is as follows: In October, 1871, he slipped while running, fell, and struck his knee a severe blow. The leg became swollen and pain- ful; the pain, however, was not sufficient to oblige him to keep in the house, so that he continued to walk about. He experienced a sense of fatigue and also a creaking sensation in the joint while walking, — this sense of uneasiness obliged him to sit in the house after returning from school. Towards the end of the month of October he consulted Dr. Roger, who enjoined absolute rest, put the leg on a splint, and painted the knee with tincture of iodine. The leg was also blistered several times, which gave him relief In February, 1872, he left Montreal and returned to his home in St. John's, P. Q., when he became the patient of Dr. Wight of that place. The same treatment of rest was followed out, and, at the end of a week or two, belladonna plaster spread on leather strapping, and a bandage, were applied over the knee. While under treatment an abscess formed, which was freely opened, and discharged for some five or six weeks. After the closure of this abscess he noticed th«t motion in the joint was less free, still he was able to go about with comparative comfort. In March, 1873, ho again slipped while running, and twisted or sprained his If L* (f Case X.— Fig. 6, EXCISION OF THE KNEE JOINT. Operation performed 13th July, 1878. Phototfraph taken Jiittn,.l877, knee; recov as b( short hosp wa8 of :^ thiB pus wer boy tur( fou ext dit ex1 thi 18' tol inj W5 th Ai P< bi 8l W a t i 1 EXCISION OF THE KNEE JOINT. 19 knee; this accident obliged him to keep his bed for six weeks. After recovery from this injury freedom of motion was much the same as before. Again in April, 1875, he m*^* with a severe fall, and shortly afterwards, on the 29th April, he *7;vw V-K^ ■^^'r- ri;^^' .^^' 1;^ ■'.:". ;-';'! ,- V. 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