The Knee-joint.—Mr. Butcher, the able and distinguished champion of resection of the knee-joint, by his valuable memoirs on the subject has left little to be desired, either in the collection of cases, or in the analysis of their results. Time only can add to our knowledge on this subject, by testing the permanency of the cure effected by the operation; and additional experience may guide us more correctly in our choice of cases, by teaching us the comparative advantages of the operation in the various affections of the joint.

The account of the first operation for resection of this joint is contained in a letter from Mr. Filkin of Northwich, to Mr. Park, in answer to an application made by Mr. Park for an account of the

case:

"The patient," says Mr. Filkin, was always of scrofulous habit, and had for many years a tumour on the knee, which gradually increased in size, and to which every topical application was made without effect. By accident falling from a horse, the patella was fractured, and from a small wound there was discharged a quantity of fetid, foul-coloured pus. Amputation was proposed, but the parents not consenting, my father was called in. Having frequently thought this method might sometimes succeed, and having performed it once on the dead body, he proposed it to the parents of the patient in this case, though it was an unfavourable one, the patient's general health being much impaired. The parents consenting, a day was fixed for the operation, which was performed August 23rd, 1762. The ligaments were found in a sloughy and suppurated state, with the cartilages greatly injured, and the heads of the bones much diseased, particularly the head of the tibia. The patella, head of the femur, and a portion of the tibia were removed; a good digestion came on; the limb was kept in a straight position; and on November 21st, 1762, the patient got so well as to require no further attention. The person is now living, and sometimes goes to Liverpool, where, if you will give me leave, I will direct him to call upon you."

In 1781, Mr. Park himself operated with success; not having heard of Mr. Filkin's case. In France and Germany it was, in a few instances, put into practice at the end of the last century; and again. at the commencement of the present it was performed by Sir P. Crampton and Mr. Syme; but since the year 1830 it had been abandoned, until re-introduced by Mr. Fergusson in 1850. Since then it has been fortunate in possessing good operators and successful surgeons to put it in practice, and an able advocate to sound its praises, and keep us in memory of its successes; and thus it is at the present time recommended and practised by most of the leading surgeons of the day. Even now some surgeons stand aloof, and prefer subjecting a patient to amputation of the thigh, to exposing him to the, to them, untried dangers of resection. Curiously enough, foremost among those who hesitate to perform resection of the knee-joint, stands one or more whose very watchword is "conservative surgery," and who deservedly have the reputation of never, without good reason, resorting to operative interference.

The operation is only recommended, even by its strongest supporters, as a substitute for amputation in certain cases, and not as an operation of expediency. It may be performed as a substitute for amputation in any disease of the cartilages, synovial capsule, or articular extre

mities, which either by its severity endangers the life of the patient, or is in its nature incurable. Thus it has been put into practice with success by Dr. Buck, of the New York Hospital, in a case of angular ankylosis of the knee. On the other hand, just as in the case of the other joints, the disease, if of the bones, must be limited to their articular extremities; while of course visceral disease, or extreme age, alike preclude the performance of the operation.

This proceeding has but rarely been put in practice for injuries of the joint; indeed, it is seldom that the knee is exposed to an accident sufliciently severe to justify resection, which is not at the same time so dangerous to life as to necessitate amputation. It may, and has been, performed for gun-shot injuries to the articular extremities of the bones forming the joints, or for wounds of the capsule where the articular surfaces of the bones are bruised or lacerated by the bullet. It has also been put in practice with success in a case where, from an old fracture of the patella, with great separation of the fragments, the leg became useless, and mechanical appliances could not be worn.

The object to be attained by this operation is to free the patient from an incurable and often fatal disease, and to restore to him the power of progression, by giving him a firm and unbending, though shortened, limb, which shall have its axis of motion at the hip-joint. In fact, this operation, if successful, effects all that amputation can do; and in addition, while it endeavours to save the patient's limb, it is said to expose the sufferer to no greater danger of his life than amputation.

The various modes of resecting the knee-joint resolve themselves into two principal methods: first, the H-shaped; and second, the

semilunar form of incision.

In the first operation, an incision three or more inches in length is made on either side of the joint, opposite the lateral ligaments, and these are joined by a transverse cut, extending across or below the patella, which bone is either thrown up in the flap, or removed, according to circumstances; forcible flexion is then used, and the lateral ligaments divided; the posterior part of the femur is carefully freed from its ligamentous covering; and with an ordinary saw the articular surface of the bone may be removed, first from the femur, and then from the tibia. The second mode of operating consists in forming a semilunar flap, with its convexity downwards, commencing just above one condyle of the femur, extending across the joint below the patella, and ending at the opposite condyle; the subsequent steps of these operations are the same in both cases.

There is yet another plan of excising the joint-ends at the knee, which was originated by Mr. Jones of Jersey, and has for its object the preservation of the ligamentum patellæ. It consists in forming two lateral longitudinal incisions, with a transverse connecting cut across the head of the tibia; the flap thus formed, of the integuments only, is thrown up, the synovial capsule cut through, and the patella with its ligament drawn to the inner side while the joint is in an extended condition; forcible flexion should now be used, the lateral ligaments divided, and the articular surfaces sawn off.

This operation, though admirable in its design, must at all times be difficult of execution, and in some cases impossible, though its performance may be much facilitated by the use of Mr. Butcher's ingenious saw. Indeed, Mr. Jones thus speaks of his operation:-"There are cases in which it is altogether inadmissible, and I feel persuaded that whoever adheres to one mode only, will often find himself wofully disappointed in the result."

To secure the general object in view-viz., bony ankylosis-it is in all cases necessary to remove the articular surfaces of both tibia and femur, whether diseased or not. The condition of the patella, as disclosed during the operation, will determine the course to be pursued with respect to this bone; any small and circumscribed spots of caries may advantageously be removed by the gouge, for in all cases healthy surfaces of bone should be left in contact.

In resecting joints, the seat of the particular affection known as "pulpy synovial disease," it is doubtless of great importance (as suggested by Mr. Humphry) to remove, if possible, all portions of the degenerated synovial membrane, as its presence in the wound cannot but prolong the subsequent suppuration and retard the healing processes. After removing the portions of bone from the articular extremities, much difficulty has occasionally been found in bringing the femur and tibia in apposition, and in maintaining the whole limb in a right line; to obviate this, Mr. Hutchinson has suggested the division of the hamstring tendons, a proceeding fully justified by the vital importance of the end in view. Heyfelder recommends, that even if the limb cannot at first be placed in a straight position, it should be put upon a splint, and a day or two afterwards straightened, when the muscles will be found to offer less resistance. In proof of this he quotes a case where, ten days after the operation, the limb could be straightened which had hitherto resisted the efforts made to place it in a proper position. Five days afterwards this patient died of pyæmia. We cannot but disagree with Heyfelder in this plan of practice, deeming it, as we do, of the highest importance that the limb be placed at the time of operation in a proper position, and there maintained until it no longer requires artificial support.

In no other resection is the after-treatment of such importance as in resection of the knee; on this point Mr. Butcher justly insists, and urges the personal superintendence of the surgeon in all the subsequent dressings and shifting, which should be few and far between.

A well padded McIntyre splint behind and a long Liston's thigh splint outside, are almost indispensable to the well-doing of the case. The former should be applied before the patient leaves the operatingtable, and the latter on his removal to bed. After no operation is the judicious administration of stimulants and opiates, together with a skilful management of diet, more necessary than after this; indeed, in reading over any number of cases of recovery from this operation, though a few patients seem to suffer but little from the immediate effects of the operation and subsequent suppuration, yet in the many cases one cannot but be struck with the fact, that where the event

was successful, the after-treatment showed a well-contested and hardlywon struggle between the surgeon on the one hand, and the flagging powers of the system on the other.

We pass on to consider the results of this operation, as furnished us by Mr. Butcher in his memoirs on the subject; omitting the records of cases he gives us operated upon prior to 1850, we find recorded the abstracts of 82 cases where the operation has been performed. Of the 82 cases subjected to operation, 57 have recovered with either useful limbs, or progressing rapidly towards the same result; 15 in all have died, and one of these after amputation; 8 have been subsequently subjected to amputation, with the one death above mentioned. Mr. Butcher relates that of the 57 recoveries, at the time his account ceases, 36 had regained "perfect use of limb”—i.e., a strong and unbending limb, fitted for all purposes of locomotion; the remaining 21 were in progress of perfect recovery. That recovery when established and complete, will (setting aside accidents) be found permanent, we have little doubt; though at present we have no living instances of cure extending over more than six years, yet we can see no reason why, when tibia and femur are firmly united, there should be any more risk of relapse than after the union of a fractured femur.

In addition to the well-known case of Mr. Park, where the patient followed his avocation as a seaman for many years after the operation, we have a case before us related by Heyfelder, where the knee-joint was resected, in 1830, by W. Jäger; the patient was twenty-eight years of age at the time of the operation, and was seen thirteen years afterwards by Heyfelder, who reports that at that time the limb was slightly bent laterally, but in a perfect state of extension, the patient enjoyed "complete" use of the limb, and could make pedestrian journeys without the support of a stick.

A year after this he died of phthisis, and the limb was examined by Reid, who found perfect osseous union between the femur and tibia. The tibio-fibular articulation was unchanged. In some cases, the symmetry of the lower extremity has been remarkably restored by the operation. Mr. Butcher's patient appears, by the drawing furnished us, to have recovered the normal appearance of his limb. The same gentleman also gives a woodcut, representing the altered appearance of the limb after the excision of the knee-joint. The patient was one of Mr. Jones's, and, says Mr. Butcher-

"This case affords such an admirable illustration of the powers of conservative surgery when directed by an able surgeon, that it is a pleasant and instructive thing to contemplate and dwell upon the great change, as represented in the annexed woodcuts of the limb, taken before and after the operation."*

The aforesaid cuts show indeed a change-the effect of the joint efforts of surgeon and artist; for not only has the "able surgeon" restored beauty and symmetry to the limb, but the change has been materially assisted by the artist, who has drawn a right limb before the operation, and a left after. It has been objected to this operation,

Dublin Quarterly Journal, Feb. 1857, p. 52.

that the period of recovery is long and tedious. This we by no means deny. But surely the object to be gained is well worth the time consumed in attaining it. How willingly do patients submit to two, three, or more years' treatment of a diseased knee-joint before abandoning it to amputation; and, after all, though a patient often quickly recovers from the immediate effect of amputation, yet we question if there is much difference in the time after operation when a patient can comfortably wear an artificial leg, and when he can walk upon the restored limb from which the knee-joint has been resected. Again, it has been urged against resection, that by performing this operation in the young, the growth and development of the limb are arrested. This objection has principally been put forward by Mr. Syme of Edinburgh, who himself met with a case which, so far as it went, fully justified this opinion. More recently, Mr. Jones of Jersey, Mr. Page, Mr. Keith, and others, have had cases where the same operation has been performed in youth without its affecting in any way the subsequent growth and development of the limb.

Mr. Jones operated on two boys in the years 1851 and 1852 respectively, who are now both possessed of useful limbs, and have in no way suffered as Mr. Syme threatened. Mr. Page of Carlisle,

reports a case where, during four years, the growth of the stiff limb has quite kept pace with that of its fellow, and there are not wanting other cases which tend to confirm our belief that, provided the line of epiphysis is uninjured by the operation, the subsequent growth of the bones will continue as before. Mr. Syme,* in his operation, sawed off the femur as high as the tuberosities, and afterwards removed half an inch more from the femur, as well as the head of the tibia. It is not unlikely that in this case the epiphysis was injured or removed.

The shortening-a necessary consequence of the removal of the articular surfaces of the bones-if slight, will be found rather advantageous than otherwise in a limb where the knee-joint is stiff, and any greater loss in length may be supplied by a piece of cork worn in the shoes.

Among the 82 cases subjected to operation, 15 died-3 from phlebitis and pyæmia; 2 from dysentery and diarrhoea; 2 from phthisis and organic disease; 6, more immediately from the operation; and 2 sank at a longer interval. Mr. Butcher separates from these fifteen, a case of Mr. Cutler's, where partial resection was performed, the articular end of the femur only being removed; thus the first principles of resection. were unfulfilled, and a successful result could scarcely be expected. Two of the fatal cases suffered from severe hæmorrhage, which carried one of them off on the fourth day, while the other lived to have his limb amputated, and died five days after the second operation.

Mr. Butcher labours hard to prove that the mortality after amputation in the thigh is greater than after resection of the knee-joint. That the success of the latter operation is abundantly sufficient to justify its performance in suitable cases, there is no question; but that amputation is a much more dangerous operation we hesitate to affirm, although we have no doubt but that the immediate effects of amputaSyme's Cases of Resection, p. 136.