CANADA

MEDICAL JOURNAL.

ORIGINAL COMMUNICATIONS.

Two Cases of Excision of the Knee Joint. By GEORGE E. FENWICK, M.D., one of the Governors of the College of Physicians and Surgions, C.E.; Physician to the Montreal General Hospital, &c.

IN the present day, Conservative Surgery has so far advanced, that the surgeon does not consider himself justified in sacrificing one inch of substance unattacked by disease, and, where a fair probability exists of the part becoming of some use to his patient. Considerable difference of opinion exists among surgeons, as to the advisability of excision as applied to the knee joint; the formidable nature of the procedure, the high rate of mortality, shock to the system, the chances of a useless limb, and the time required before a perfect cure is obtained, are all reasons which have been urged against the operation. Excision of the knee joint is more formidable in appearance than in reality; it certainly is not more so than amputation. The removal of a limb is always a cause of great anxiety to both surgeon and patient, the results not being more promising in the one than in the other; provided always, that in excision, the case is carefully selected, and that by delay, the bony structures are not found in such a state of disease, as to preclude the possibility of cure. Excision is not to be practised as a last resource, as is frequently the case in amputation; and I think, the success of the operation of excision of the knee joint, will be found to depend mainly on its early performance. Surgeons are fully alive to the unsatisfactory nature of synovitis affecting the knee joint; the attacks are frequent in their recurrence-each one leading to further mischief. From the synovial membrane the disease extends to the other structures, the ligaments, cartilages and bones, become altered in structure and appearance, and the disease steadily advances. These changes are by no means rapid in their advance. Years may elapse from the commencement up

to that period in which, from the formation of pus, little hope remains of saving the joint. The attempt at procuring anchylosis in disease of the knee joint is not always attended with success; in this disease it appears to me to be the exception and not the rule, indeed, when there is disease of the cartilages, and caries of the bones, little hope need be entertained of a successful issue. What, then, becomes the surgeon's duty in a case of this nature ?-manifestly to remove the diseased structures, and by securing a comparitively healthy surface, place his patient in the very best possible position of saving a useful limb, which, although shorter than its fellow, is at least of greater benefit than a stump, which as Sir W. Fergusson aptly says, "becomes a peg whereon to hang an artificial leg." From the successful results of cases operated on by Sir W. Ferguson, Mr. Jones, Mr. Butcher, and others, it does appear that excision of the knee joint is a justifiable procedure, and the opinion of hospital Surgeons is growing in its favour. It is hardly fair, at this period of the history of this operation, to examine critically the results of the cases of excision of the knee joint, and compare them with the results obtained after amputation at the lower third of the thigh. When the operation of excision numbers its thousands as does amputation, I firmly believe, that the favourable results will be found somewhat different from those given by Dr. Hodges, so that the question of the rate of mortality cannot be considered as definitely settled. If, in comparison, we take the operation of ovariotomy, which, at the present day, is considered by most surgeons as justifiable, and compare the results as first given by Mr. Clay, at the early period of the history of that operation, with the statistics of the present day, a wide difference will be found to exist, and one in every way favourable to the procedure. Shock to the system, after excision of the knee joint, does not appear to me to be at all greater than after amputation at the lower third of the thigh.

With regard to the time required to elapse after excision, before a perfect cure is obtained, it is not more than that after amputation. From eight to twelve weeks must elapse before union is sufficient to permit of the use of the limb, but I would ask, where is the stump that is capable of bearing the weight of the body, on a well-padded and wellfitted artificial leg, even at the end of that period of time after amputa

tion. From these facts, I think, that in every way excision compares favourably with amputation, and, in some respects, is superior. The security and comfort with which a patient stands and walks on his own. leg, although shorter than its fellow, and, with a stiff knee, is far greater than that with any artificial contrivance applied at the end of a well-healed

stump. The operation of excision of the knee joint, so far as I can ascertain, has been performed four times in Canada. The first case, that of a young woman suffering from scrofulous disease of the knee joint, excision was performed by Dr. Hingston, at the Hotel Dieu Hospital, in the spring of 1862; every hope was entertained of success, as the case progressed favourably, until about the twelfth or thirteenth day, when diarrhoea set in, which carried her off on the seventeenth day after the operation. The second case was that of Dr. Grant, of Ottawa, C.W., the notes of which are to be found in the first volume of this journal. The results were most encouraging the patient recovered with a sound and useful limb, two and a quarter inches shorter than the other leg. I may observe, that in a recent letter received from Dr. Grant, he states, that his patient had perfectly recovered, and was capable of enduring the labour of working his farm, and following the plough. In the other two cases, the operation was performed by myself, and they are of sufficient interest to warrant their record.

John Keenan, aged 18 years, a native of Canada, by trade a confectioner, of small stature, regular conformation, delicate appearance, fair complexion, light-coloured hair and eyes, and is of a happy, cheerful disposition. His family history was good, his maternal grandfather still living at an advanced age, and all members of his family strong and robust. He was admitted into the Montreal General Hospital on 11th April, 1865, suffering from an acute attack of synovitis.

History.-Seven years since he received a kick on the knee from a cow; at the time it became inflamed and very painful. He was confined to his bed for several weeks, during which period the knee was leeched several times, and various local applications made. This attack was attended with considerable constitutional disturbance, which, after some time, subsided, and he was enabled to get about, but the joint remained a little swollen, and was rather stiff. He was able, however, to go about his usual avocations, but the knee gave him much uneasiness; it was easily hurt, and he could not enter into the play of boys of his age. Slight blows, or twists in running would oblige him to remain at rest for days; these accidents were of frequent occurrence.

rest.

Two years ago the knee joint began to pain him at night, and occasionally would start, giving him much agony and interfering with his Still he continued on at his work, with occasional intermissions; these attacks became more frequent, until worn out by their annoyance, he sought admission to the Hospital. At the time of admission he presented a careworn look. There was loss of appetite; he was pale and anxious, and the affected limb presented a marked contrast with its fellow

-the muscles on the affected side were not as well developed as on the sound limb, and the joint was much enlarged, being, by measurement, an inch and a halflarger than the other knee. Active treatment was adopted, and the limb put on a double inclined plane, this afforded temporary relief.

On the 1st May, the patient came under my care. I continued the treatment up to the 15th, but finding that the man's health was beginning to suffer from the confinement and pain, consequent on the starting of the limb, and want of rest, I removed all bandages and made a careful inspection of the joint. The condyles of the femur were found expanded the synovial membrane felt thickened and pulpy, and on moving the patella in lateral, or rotatory motion of the joint, a distinct roughness was found to exist. This examination was accompanied with considerable pain which continued for some hours. In consultation with the medical staff of the Hospital, it was decided to excise the joint, which operation was performed on 17th May. The disease being on the left side, the operation consisted in making a U shaped incision from the outer side of the leg commencing a little above the head of the fibula, and with a semi-circular sweep, the joint was opened, the flap was dissected upwards and the heads of the bones, being turned out about 1 inches of their anticulating surfaces were removed, a second slice had to be removed from the head of the tibia as that bone was found diseased. The femur was also found in a diseased condition, but not extensivley so; the cartilages were eroded and gone, and the articular surface of the patella being also diseased it was removed. Several small vessels had to be ligatured; the bones were placed in apposition, the flap turned down, and secured by eight silver sutures, the leg placed in a box splint, similar to that recommended by Mr. Butcher, carefully padded, and the patient removed to bed; 3j of tinc. opii. was ordered to be given as soon as he recovered thoroughly from the chloroform, as much vomiting and nausea existed; however the anodyne was not taken until about six in the evening, when I saw him myself. He was still suffering from a sense of nausea; said he had no pain in the knee, but a feeling of soreness in the vicinity of the wound; had not taken any nourishment, but experienced thirst; was allowed weak brandy and water, of which he partook sparingly; pulse 100, and weak; appeared rather dull, somewhat like a person recovering from intoxication. Cold water dressings were applied to the wound, and the anodyne was ordered to be repeated during the night, if necessary.

May 18.-Slept a little during the night; feels squeamish; has taken beef tea at intervals; pulse full 110. Complains of pain in the wound; the anodyne to be repeated at night.

May 19. Slept well during the night; had slight starting of the limb; has taken freely of beef tea; the surface of the wound was hot and slightly inflamed, skin moist, tongue slightly furred, pulse full 100 per minute. Complains of fulness; as the bowels had not moved was ordered 3 ii. of castor oil, and if necessary, the anodyne to be repeated at night.

May 20. The oil acted gently, and gave him relief this morning; is cheerful and easy, a sense of tingling in the wound but no pain, slept well, and felt refreshed, the anodyne was not needed, healthy pus is exuding from the wound, and granulations are observable at several points. The thigh bone was displaced forward, which necessitated the removal of the dressings.

It was put up afresh, and an anterior splint applied. He bore the removal of the splints well, and after the limb was done up stated he felt more comfortable. Tongue moist and clean, appetite returning, takes freely of beef tea, pulse 90 full and soft. From this date he steadily improved, the ligatures and sutures were all removed by the 14th day. On July 1st, it is stated, the wound all but healed; slight discharge from the outer side, the bones are firmly united, but it was not thought advisable to remove the splints. The diet throughout was nourishing, and he was allowed a pint of porter daily.

On the 25.-July, the limb was put in a starch bandage; all discharge