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: EXCISION

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' 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.)

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PRlNTIfiD BYJiOVBLL Pmi^TING AND PUBLISHING CO.

1877.

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EXCISION

OV THK

KNEE JOINT.

GEORGE E. FENWICK, M.D.,
Proftssor of Surgery, MoGill University, Montreal.

{Fr(ym. the TVamactions of the Canada Medical Association.)

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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

EXCISION or THE KNEE JOINT.

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.

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 :

Case I, — Fig. i.

{

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.

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

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.

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to t

EXCISION OF THE KNEE JOINT.

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

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

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.

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

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.

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*

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.

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

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

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

P<
bi

8l
W

EXCISION OF THE KNEE JOINT.

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 *<ras admitted into the
hospital. The leg was put up on a Mclntyre's splint, and as he
was somewhat run down tonics were given. Towards the middle
of May an abscess was found to exist in the vicinity of the joint,
this was freely opened and a drainage tube inserted. Subsequently
pus formed at other points, both above and bolow the joint ; these
were treated in the usual way, free openings being made, and the
boy was given nutritious diet, and ale, the quinine and iron mix-
ture on which he had been placed being continued.

The patient came under my charge on the 1st July, 1875, and I
found the joint open and sinuses leading to bare bone at the
extremity of the femur. The boy was in a very unsatisfactory con-
dition ; however, I proposed excision and, if the disease was too
extensive, determined to proceed to amputation at the lower third ;
this was agreed to, and the operation performed on the 13th July,
1875. At the end of eight weeks union between the bones was
tolerably firm. There were one or two points still discharg-
ing a small quantity of pus, in fact, the amount of the discharge
was so trifling that it did not more than moisten a piece of lint in
the twenty-foiir hours. The rest of the wound was firmly united.
As the patient was anxious to leave his bed a back splint of gutta
percha was moulded to the limb, and it was put up in a glue
bandage, openings being made in the bandage opposite the points
still discharging for the purpose of changing the dressings, and he
was allowed to get up and go about on crutches. He gradually
acquired confidence in the strength of his limb, and, by the middle
of January, could lim*p about with a stick. He returned home on
the 2nd February, 1876. The following October he again presented
himself for admission to the hospital, as there existed a somewhat
indolent ulcer, five inches in length, situated on the outer side of
the thigh, which had been treated with red wash and a band-
age, but without much benefit. Simple water-dressing was at
first employed, and cod liver oil with tonics and good diet. This
had the effect of improving the character of the sore, when it
rapidly healed by skin grafting. At this time the patient could
walk without a stick, and stated that he felt perfectly secure on
that leg. At the present time he is able to walk any reasonable
distance without fatigue ; the shortening is about 2 inches. This

CANADA, MEDICAL ASSOCIATION.

patient was in the room at the time of the reading of this paper,
and his leg was examined by the members of the association
present. The appearance of the leg in this case is well shown in
Fig. 6.

Case XL — M. McG., a delicate looking girl, set. 12 years, was
admitted into hospital on 15th July, 1875, with disease of the right
knee joint of several years' duration. The joint was flexed at a right
angle with the thigh ; there was dislocation backwards of the
bones of the leg from contraction of the hamstring muscles. There
were sinuses communicating with the joint which led into its
cavity and reached bare bone. The muscles of the leg and thigh
were very much wasted, soft and flabby, and the joint itself was
tender, so that she would not permit examination, except while
under chloroform. Excision was performed on the 10th August,
1875. In order to secure the after-growth oi' the bones the entire
epiphyses were not removed from either the femur or tibia. The
end of the femur was rounded off, mt&ing it convex, and the end of
the tibia was treated the reverse of this, rendering it concave. There
was much difficulty in straightening the log in consequence ot
contraction of the muscles, so that, in order to prevent crushing ot
the ends of the bones, a second thin slice had to be removed from the
end of the femur and the ham-string tendons had to be divided; the
bones then came into position, but the tissues in the popliteal space
appeared to be put on the stretch, this, in all likelihood, led to after
difficulty in the management of the case, probably from stretching
of the popliteal nerve. There was, throughout, great tendency to
the formation of sloughs from pressure, so that, after the end of the
first ten days, the splint had to be removed and the parts retained
in position by means of a weight keeping up extension, and sand
bags placed on either side of the limb ; sloughs formed over the
tibia, on the dorsum of the foot, and over the heel. The patient
complained of a sense of tingling in the leg, but of no urgent
pain. She progressed slowly, the sloughs separated, and healthy
granulation followed with closure of the sores. The wound, the
result of the operation, took on healthy action, and almost entirely
closed, and, at the expiration of the fourth month, she was allowed
to leave her bed and go about on crutches; bony union, however,
was not complete, as, owing to the difficulty of retaining the parts
atrest, some motion, though limited, existed. There was still slight
discharge from the wound, but the patient was improving in
general health. The following June she left the hospital, and
rtturned to her friends. At this time she walked about on crutches

EXCISION

THE KNT JOINT.

and was tolerably active. This patient was seor 4grtB is
1877, when the following condition was found : er gener health
was very good ; union of the bones was firm ill dischu ^e had
ceased ; the leg was slightly bent, and she could suHtuin Uk weight
of the body on the leg; muscular development was markedly in
abeyance, apparently because the little girl was disinclined to use
the limb, and she was very active on crutches. The limb was by
measurement two inches shorter than its fellow.

Case XII. — J. B., set. 38, farmer, was admitted into hospital April
5th, 1877, with chronic disease of left knee-joint. Family history
good. No history of tubercular, 8crofulou8,or rheumatic taint, up to
commencement of present affection. Seven years ago enjoyed per-
fect health. At that time after working in cold water, the left knee
became swelled and painful, particularly at night. The swelling
was evidently synovial. Was not confined to bed, but has gone
about ever since that time, though somewhat lame. At times after
any slight injury the joint would become more painful. It was
more swollen than it is now. Since last spring he has been unable
to walk without crutches. He has had starting pains in the joint
at night for the last year, and the same pain was produced by any
jarring of the joint. There is great thickening about the joint.
Circumference of the leg over the middle of the patella is 14|
inches, of the sound knee 13J. The patella is fixed. There is very
little motion of the joint possible. The limb cannot be
straightened entirel}^ and scarcely flexed beyond its constant
position. By flexion a grating sensation can bo got. There is no
pain when the joint is at rest. The muscles of the thigh are
much wasted. The patient's general condition is good. No
disease can be detected in any of the organs. Urine is clear
and of normal appearance, acid in reaction sp. gr. 1020. No
albumen or sugar. Excision of the joint was performed by Dr.
Fenwick on April 11th. The limb was put up on a gutter splint
moulded around the buttock so as to fix the pelvis as much as
possible. A drainage tube was put through the wound. The
incision healed by the first intention. The stitches were removed
on the 9th day. There was a moderate degree of inflammatory
fever with a rapid pulse, ranging from 108 to 124 tjU the I5th day,
when the temperature became normal and the pulse 92. The
temperature remained normal for three days, when after a chill it
ran up to 102°. After this till the Ist of June there were fluctua-
tions from high to low temperatures with occasional chills, and a

22 CANA.IA MEDICAL ASSOCIATION.

good deal of sweating. During this time there was evidence of
much cellular inflammation around the joint, with the forma-
tion of some collections of pus. June 9th, the splint was removed
and there was found to be tolerably firm union of the bones. A
moulded leather back splint was applied with a narrow piece of
wood at the back to strengthen it. Patient's condition now
rapidly improved. June 20th. — Patient got out of bed on a
wheeled chair, and in a few days he began to go about on crutches.
At this time his temperature would run up in the evenings to IOC
and even 102". July 20th— The leather splint was removed. Union
now is quite firm. The wound is still open at the two angles of the
incision. The discharge is very slight. The shape of the leg is
good. The patient was discharged August, 1877, went to the
country, being instructed to return when the wound had altogether
ceased discharging. He can now bear a considerable weight
on the limb, and goes about well on his crutches. He was thus
four months in hospital after the operation. Since this report I
heard from the patient, and he informed me that he was progres-
sing fairly well, was able to get about, but lacks confidence, as he
is always fearful of injury resulting from extra exertion or from
falling down.

Case XIII. — F. P., set. 17, a former's son, was admitted into the
Montreal General Hospital on July 5th, 1877, with a chronic
disease of the right knee. There is a history of scrofula on the
father's side of the family. Patient says he was perfectly healthy
until two years ago. At that time a swelling began in the
right knee, which increased and diminished alternately, and was
unattended by pain for about a year. He felt only a stiffness
and numbness of the joint. He attributes the affection to over-
work, especially mowing hay. About a year after the first
appearance of these symptoms pain began to be felt, not very
severe at first, without any increase in the swelling, until last
Christmas. He could walk without much lameness. The pain
and consequent lameness increased till in April he began to use
crutches. Since then the knee has become fixed in a flexed position.
The measurements of the diseased joint as compared with the
other are as follows :

Right Leg. Left Leg.

Over the patella 16f in. 14J in.

4 in. above " 16^" 14 •*

4 "below " 15 " 12^ "

EXCISION OF THE KNEE JOINT.

There is much heat and tenderness about the joint. It is red
and bulging on the inner side near the border of the patella.
Fluctuation here is evident. There is partial anchylosis of the
right elbow. He cannot extend the forearm completely. There
is no displacement of the bones; some swelling and Hlight tender-
tiess between the olecranon and external condyle. This condition
began a year ago. Has felt neuralgic pains at times darting
through the joint, and suffered from sciatica at the same time. The
patient is a good deal emaciated. Appetite is good. Heart, lungs,
and liver are normal. Examination of urine gives a negative
result.

July 7th. — Excision performed. Much pulpy degeneration of
the joint, not much pus. Spots of ulcerated cartilage on no ;.
condyles of femur. Considerable degeneration of the u con-
dyloid notch. The semilunar cartilages of the tibia \avt' ' ii
tirely destroyed, and several diseased spots were found « m b/..
articular surfaces of the tibia. The excision produces biion-v.;. ..^
of the limb by about IJ inches. The limb was put up on a gutter
splint, cut out at the knee, and extending up the side so as to fix the
pelvis.

July 11th.— Patient feels comfortable. Wound looks clear and
healthy. Urine and other excretions normal. Appetite poor.
Tongue heavily coated. Vomits occasionally. Bed sores appearing
ovei the sacrum.

July 21st. — Eemoved stitches, wound looking well, united super-
ficially, drainage tube still in. There are frequent spasms of the
flexors of the thigh which cause great pain. General condition
seems to be improving. No night sweats. Tongue clear. Pulse 132,
temperature 100.^°. Sleeps well after morph. gr. ^ hypodermically.
Appetite very good.

July 25th. — Temperature last night lO-l". Ordered quin. grs. xv.
Morning temperature 98". Passed a good night. Gets M. grs. J
hypodermically night and morning. Pulse 124, it has been
very rapid throughout. Knee dressed once a day, and lightly
bandaged with a many tailed bandage.

July 29th. — Diarrhoea for last two days. Increase stimulant,
brandy 6 ounces. Ordered pill plumbi c opio. Tongue dry.
Large slough over sacrum.

July 30th. — Diarrhoea persists. Lost appetite. Tongue dry. Pulv-
kino. CO. and starch and opium enemata given. Patient getting
very weak. Some dusky red blotches on back of left forearm and

CANADA. MEDICAL ASSOCIATION.

one over styloid process of right ulna. Diet of boiled milk. Pa-
tient sweats considerably, no chills.

July 31st. — A large collection of pus on outside of leg below
tho knee was discovered and opened. The pus was very fetid.
Introduced a drainage tube. Ordered frequent syringing of open-
ing with carbolic lotion. Discharge from wound of operation
ticanty.

Aug. Ist. — Bowels moved five times during night. Slept pretty
well, did not sweat. Pulse 120, temperature 98^°. Tongue moister.
Ordered a mixture of ac. sulph. co., spt. chloroform, and decoc.
heematox. Red blushes on left forearm disappeared.

Aug. 3rd. — Diarrhoea less, slept well. Tongue clean and moist.
Wound improved in appearance, discharge more healthy looking
and more copious. No sweating. Pulse 128, temperature 98^^ in
morning.

Aug. 5th. — Pulse 124, temperature 99J°. Diarrhoea continues. A
blush with oedema on forehead. Felt chilly yesterday. Patient very
weak. Tongue clean but glazed.

Aug. 6th. — Patient continued to get weaker and died at 9 p.m.
No autopsy was allowed, but the leg was examined. There was
found to be no union between the bones. There was a collection of
unhealthy pus anmnd the lower end of the femur, which was
partly stripped of periosteum and necrosed superficially.

I am indebted for tho reports of cases Nos. XI. and XIII. to
the late Dr. J. D. Clino, who was my House Surgeon during the
period that they were under observation. Case XIII. is from the
record taken at the time by the Clinical Clerk, Mr. D. F. Smith,
and is very carefully and accurately reported.

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