CONTENTS:

XLII. Resection of the Knee-joint. Wm. Tod Helmuth, M. D.

XLIII. Lupus. Wm. Tod Helmuth, M. D.

XLIV. A Very Rare Case of Extrophy of the Bladder; One Kidney and One

Ureter. Wm. Tod Helmuth, M. D.

XLV. Cases of Tumors of the Eye. T. F. Allen, M. D.

XLVI. Case of Anthrax of the Face. F. L. Vincent, M. D.

XLVII. Case of Fungoid Tumor of the Hand. H. G. Preston, M. D.

XLVIII. Report of Surgical Cases Treated at the Albany City Dispensary; with Remarks on the Treatment of Ulcers. H. G. Preston, M. D.

XLIX. Case of Cancer of the Rectum. H. M. Paine, M. D.

L. Trephining the Tibia. L. Pratt, M. D.

LI. Dry Cupping the Bowels for the Removal of Strangulated Inguinal Hernia. Ralph Blakelock, M. D.

XLII.

Resection of the Knee-Joint.

By WM. TOD HELMUTH, M. D.

To Mr. Henry Park, of Liverpool, belongs the credit of having originated the operation of resection of the knee-joint. He, how ́ever, gives the credit of the first actual performance of the operation to Percival Pott, the date of which was July, 1781. Soon after the publication of the Park pamphlet, Mr. Filkin, of Norwich, declared that he had performed the operation as early as 1762. On the fifth day of November, 1789, Dr. Simmons performed a similar operation. M. Moreau, in 1792, excised the whole of a carion's knee-joint; in 1809, Mülder removed it; in the year 1823, Sir Philip Crampton, and in 1829 and 1830, Mr. Syme resected the articulation. These latter operations were not successful, and the procedure gradually fell into disrepute until it was revived by Mr. Fergusson.

In the following table, altered a little from Butcher, the names of the surgeons, the dates of the operations, and the results are shown, embracing a period of eighty-seven years:

We find in the Edinburgh Monthly Journal and Medical Times and Gazette for 1853, the record of thirteen cases performed by the continental surgeons since 1850. Thus: Three times by Mr. Fergusson, six times by Mr. Jones, once by Mr. Page, once by Dr. Stewart, and twice by Dr. Mackensie. Of these cases two died from the operations, one from dysentery, and the remaining ten recovered, with limbs not very serviceable, but all of them in better condition than though amputation had been performed. Butcher gives a second table of fifty-one cases operated on from 1854 to 1856. Of these there were twenty-two cured-fifteen recovering when the table was made, one relieved, and one in a precarious state. The deaths only numbered ten.

Since that period the operation has been performed many times, and with good success, both in this country and in Europe. In America we have the record of an operation performed by Guerdon Buck, at the New York Hospital, in the month of October, 1844. The operation was resorted to in order to straighten a limb, which was bent at right angles.* Dr. Bauer, formerly of Brooklyn, now of St. Louis, records an interesting case in which the operation was performed for genu valgus †, with traumatic diastases of the lower ephiphysis of the left femur.

The disease, which probably directs to resection of the knee, is most generally a strumous inflammation of the joint. This may either commence in the synovial membrane of the knee, or in the spongy structure of the long bones, which become filled with strumous deposit, and very much degenerated, enlarged and softened. The inflammatory action is generally of the sub-acute character; there is increase of temperature of the parts involved; the cancellated structure of the bone becomes filled with a reddish grumous deposit; the patients waste in flesh, have feverish exacerbations at night, and become sallow and cachectic in appearance. If this process is not arrested in due time, then the pain increases, and there takes place within the bone cells a lardaceous or oily deposit, and, the disease increasing, a chemical change is effected in the constituents of the bone. The calcareous matter lessens, or, even in severe cases, may be entirely deficient, and the compact structure is reduced to a mere shell. The periosteum also becomes very much thickened, and is less adherent to the bone than normal. Suppuration then

* Velpeau Operative Surgery, vol. 1, p. 810.

+ Bauer's Orthopedic Surgery, p. 193.

may follow, and the debris is cast out with an ill-conditioned and at sanious pus. This disease, no doubt, has been often mistaken for caries of the ends of the bone; but there is a considerable difference between them, the one belonging more especially to the simple ulcerative process, the disintegration, molecule by molecule; the other, being accompanied by, or essentially consisting in, an absolute degeneration of the spongy structure, and a deposit and infiltration of strumous matter in the cancellated structure of the bone itself. In such an affection, after suppuration has occurred, the joint should be excised.

Other affections which may lead to resection are, white swelling, degeneration of the cartilages, caries of the extremities of the bones, deformity of the legs, injuries of the joint, etc.

There is a question of some import in relation to the removal of the patella in this operation. If the bone is diseased, remove it; if it is not, refresh its under surface, that it may adhere to the parts below. I am quite certain that the rule adopted by some surgeons, that the patella, whether implicated or otherwise, should be removed, is not a good one. The excision requires considerable dissection; it leaves a cavity which has to fill by granulation; it increases the suppuration, and prevents the application of an anterior splint, if such be necessary. In resection of the knee-joint, I have divided the ham-string tendons before the operation was performed, with the idea of preventing muscular contractions from separating the extremities of the bones, but I found that the spasmodic action still would occur and occasion great pain. I should hereafter rely on the internal administration of ignatia or cuprum, which will have a much more beneficial action. Again, surgeons have recommended that after the extremities of the bones have been sawn off, that an opening be made in the popliteal space, in order to allow drainage. I should think that this would be an excellent suggestion in some cases, but would much prefer to wait until the fact of very extensive suppuration was established, because, with calendula, carbolic acid, and glycerin, or carbolated glycerin, I believe we have very great control over the suppurative process, especially with the internal use of silicea and hepar. The latter I always use in the third decimal trituration, and the former in the two-hundredth potency. I have positive evidence, in my own mind, of the reliability of these two agents, but, with the exception of mercurius, cannot speak, that is, from my own individual experience, of the efficacy of other medicines.

The best incisions, as a general rule, are those which will most freely expose the joint, and allow the removal of the bones with greater facility. The sweep of the knife may be semi-circular, commencing at a point opposite the inner condyle, and extending below the tubercle of the tibia to a point opposite the external condyle.

Mr. Park preferred the crucial cut, as did also Mülder. Moreau operated by two lateral incisions in front of the ham, which are united by a horizontal cut below the patella. The H incision for many cases is the most desirable. The incisions should be about four inches in length on each side, beginning at the condyles, and extending downward; they should be crossed by a second cut, which will open the joint; the flaps are then turned aside, and the condyles rapidly freed with careful strokes of the knife, the leg is then forcibly flexed, and the crucial ligaments divided; retractors of metal, should then be slid behind the head of the tibia, which must be removed first. The condyles of the femur are treated in like manner. Butcher's saw can be used with advantage in the operation, as it cuts from behind, forward, and by the screw the blade can be made to assume any angle that may be necessary.

The after treatment is very essential, and requires great care in its management. I have no hesitation in recommending the swinging splint of Dr. Hodgen; the modification of that, by Dr. E. A. Clark or Smith's anterior splint. Sometimes, however, a fracture box filled with bran, to absorb the discharge, is very useful in many particulars. To illustrate the operation, the accidents which may be expected, the beneficial effects of treatment and good recovery with a straight limb, shortened but one-eighth of an inch, I give here a case of my own.

F. B., aged thirty, came from Minnesota, with a deformity of the leg, which was daily growing worse, was giving him considerable pain, and rendering him incompetent for any business. He had suffered when about fourteen years of age, with a softening and disintegration of the cartilages of the knee, which had finally left him, but in the condition as shown by the plate. (Fig. 1.) I first endeavored to relieve the deformity by the application of an iron splint, with screws, having previously divided the ham-string tendons. This produced no effect whatever, and he begged that an operation might be performed. The accompanying plate, taken from a photograph, illustrates the amount of deformity and the peculiarity of the anklejoint, the patient being able to set the foot flat upon the ground. (Fig. 2.)