Original Articles. It was to meet this condition that Dr. E. H. Bradford devised the instrument pictured in Figure 3. Its construction and mechanical principles are apparent. THE FORCIBLE STRAIGHTENING OF ANGU- The plate C is forced forwards, LAR DEFORMITIES OF THE KNEE BY MEANS BY JOEL E. GOLDTHWAIT, M.D., OF BOSTON. THE angular deformities resulting from disease in, or about, the knee-joint, may be corrected in four ways: Gradual traction with fixation. Rapid forcible correction (brisement forcé). Osteotomy, usually above the condyles of the femur. Excision, either of the whole joint, or of a wedgeshaped piece from the lower end of the femur. The first method applies to the deformities occurring in, and presenting for, treatment, during the acute or sub-acute stages of the disease. At this time the condition is due, chiefly, to a spasmodic contraction of the posterior muscles, and immobilization combined with light extension, will, in the majority of cases, be all that is required. The third and fourth, or the bone operations, are reserved for those cases in which there is firm bony anchylosis. Rapid forcible straightening is to be tried in those cases in which, after the acute symptoms have subsided, the joint is held in the malposition by fibrous adhesions. If these be slight they can be broken up with the hands, and the leg straightened with comparatively little difficulty. In a certain number of cases, however, in which the deformity has lasted for a considerable length of time, the adhesions become so firm that more force must be applied, and the force applied in such a way that the hands alone are not sufficient. carrying the head of the tibia This appliance was first used collected them and offer them for FIG. 1. Two deformities are almost invariably present, that is, flexion, and luxation backwards of the head of the tibia upon the femur (Fig. 1). The correction of both of these is important. The former can be rectified with comparative ease, but in order to throw the head of the tibia forwards, mechanical appliances become necessary. (Fig. 2 shows the faulty apposition of the bones after the flexion alone has been overcome.) 1 Read before the Surgical Section of the Suffolk District Medical Society, November 2, 1892. the tibia was subluxated. There was very little, if any, motion possible, and the bony change was comparatively slight. On the outer side was an old cicatrix, evidently the remains of an old sinus. There was no local heat, pain or tenderness. On August 12, under ether, the leg was straightened with the apparatus figured above. Much force was necessary, and the instrument had to be reapplied several times, gaining a little with each application, before the position was satisfactory. As the leg straightened, quite a marked genu-valgum was developed, so much that it was thought a McEwen operation or supra-condyloid osteotomy would be required later on. This, however, has entirely corrected itself, showing that it was probably due to an old inflammatory deposit on one side, which has been absorbed or has readjusted itself. forced forwards and the leg straightened. With the leg straight there was a marked knock-knee, which was corrected a few weeks later by osteotomy above the condyles of the femur. The patient was in the hospital for three months, and at the time of discharge could bear her whole weight upon the leg, but walked with the aid of one crutch. A year later she was walking about without any assistance, with the leg perfectly straight. CASE III. A patient of Dr. E. H. Bradford and Dr. Abner Post, at the Boston City Hospital. A man thirty-four years of age, with the left knee flexed to a right angle, the tibia subluxated, and the foot rotated outwards, as the result of Gonorrhoeal Rheumatism. The deformity had existed for five years, and during that time he had suffered almost constant pain, which prevented him from doing any regular work. After the operation the leg was done up in a circular plaster-of-Paris bandage, from the toes to the groin. One-sixteenth of a grain of morphia was given by suppository, after the anaesthesia, and this was repeated once in a few hours, for pain. The salicylate of soda, in five-grain doses, three times daily, was given for a few days, because of its effect in controlling joint pain, although I doubt if it was necessary in this case. Otherwise, no drugs were used. The convalescence was uninterruptedly good. She was up in a chair in one week, and about on crutches a few days later. In four weeks from the time of the operation she was walking about upon a Thomas caliper knee-splint, without crutches, and two weeks later she was discharged from the hospital with a perfectly straight leg, and with a few degrees of motion in the knee-joint, which has increased somewhat since then. Figure 5 represents her condition at about that time. At present the patient is wearing the knee-splint, and walks about comfortably without other assistance. The other cases which have been treated in this way are as follows: FIG. 4. The patient was operated upon twice, and the case is of interest as showing the necessity of correcting the position of the head of the tibia, as well as the angular deformity. At the first operation the flexion alone was corrected, by manual force, and up to the time of the second operation the patient was in constant pain, which required large doses of morphia for its control. At the second operation the correcting apparatus was used, and the head of the tibia brought forwards into its proper place. After that only one dose of morphia was given, and in ten days of the time of operation, he left the hospital, walking with the aid of crutches, which were discarded a few months later, and a Thomas caliper knee-splint substi tuted to protect the joint. He still wears the splint, two and one-half years later, as a precaution, although without it he is able to walk perfectly well. The leg is straight, there is some motion at the knee, the mus cular development of the leg and thigh is very good, in marked contrast to the condition before the operation, and he is entirely free from pain. CASE IV. A patient of Dr. E. H. Bradford, at the CASE II. A patient of Dr. E. H. Bradford, at Boston City Hospital. A boy nine years old, with the Boston City Hospital. A young woman twenty-right-angled contraction of the right knee, resulting four years of age, with a right-angled contraction of one knee, as the result of Tumor Albus eighteen years before. The head of the tibia was dislocated back wards. With the same appliance (Fig. 3) the tibia was from Tumor Albus, which had lasted for about five years. The leg was straightened by means of the correcting appliance, but before the deformity could be fully overcome it was necessary to divide the ham string tendons which were firmly contracted. In six weeks he was discharged from the hospital, wearing a Thomas knee-splint and using crutches. There have been no unpleasant symptoms since the operation, and, at the present time, three years later, he is running about, wearing no apparatus, with a straight leg, and with some motion at the knee. CASE V. A patient of Dr. Abner Post, at the Boston City Hospital. A young girl, eighteen years old, straightened in the same manner as with the other cases and a very satisfactory result obtained. I am indebted to Dr. E. H. Bradford, Dr. Abner Post, and Dr. C. L. Scudder, for permission to report these cases. The results obtained in these cases are of interest as contrasted with the results of other operations, which are performed in the same class of cases and for the same purpose, that is, to relieve pain and to enable the patient to be about, and at work, if need be. In the first place, at least three of the six cases had been strongly urged to have the leg amputated, and that by surgeons of ability. It needs no argument to show that from the present condition of the patients they are better off than with wooden legs. Excision, which is done more commonly in these cases mutilates the leg. It causes noticeable shortening, invariably leaves a stiff leg, and furthermore, is an operation having a mortality rate, in young persons of 9.42%, or a per cent. that is much higher where FIG. 5. with the right knee flexed to nearly a right angle as the result of an attack of Acute Articular Rheumatism a number of months before. After a trial of several weeks in bed, with constant extension, without improvement, the leg was straightened with the same appliance as was used in the other cases. At the present time, about seven months after the operation, there is considerable motion in the joint, and she is able to go about with very little difficulty. CASE VI. A patient of Dr. C. L. Scudder. A woman about thirty years of age, in which the deformity was due to articular rheumatism. The leg was adult cases are included. Culbertson, in an analysis of from 600 to 700 operations done upon patients ranging in age from five to forty years, found a mortality rate of 29.8%. This is in marked contrast to rapid forcible straightening, which is a much more conservative treatment, and not only have there been no fatal cases thus far, but the amount of constitutional disturbance as a result of the operation, has been surprisingly slight, considering the amount of force that is required to accomplish the result. There has been but a slight elevation of temperature in any of the cases, and the pain has not been at all severe. The leg is not shortened as a result of the operation, and recovery usually takes place with a somewhat moveable joint. Three objections to the operation have been offered: the danger of starting up a severe acute arthritis; the liability of fracture of some of the bones about the joint; and the danger of injuring the vessels and nerve in the popliteal space. The first should be avoided by the selection of the cases, and by the judicious application of the force. The second should not occur if the apparatus is properly applied and due caution observed in its use. The third, or the danger of injuring the vessels and nerve, is not apt to occur because of the anatomical relations of the structures behind the joint. Through 2 A. M. Phelps: New York State Society Transactions, 1886, p. 586. 3 Bradford and Lovett: Orthopedic Surgery, p. 389. the kindness of Dr. Dwight of the Harvard Medical is applied, nearer to, or farther from, the knee, it can School, I have been able to study the relations of these be used upon a child or an adult. The application of structures from frozen sections and Figure 6 was drawn the power in front instead of behind, is more convenfrom a section made through the head of the tibia. ient and more easily managed. The screw b, working This shows very clearly the way in which the tibia and in the arch a, raises the cross-bar c, to which the posfibula, at A and B act as buttresses to protect the ves- terior band d, is attached by means of the steel loops e. sels from pressure even though the force be applied The counter-pressure comes upon the end of the femur with a straight band as is represented by the dotted by means of the leather pad f, and to a less extent line x-y. The actual curved band of the apparatus, upon the strap g. The apparatus as applied is shown still further protects these structures from injury, as is in Figure 8. shown by the line n - m. FIG. 8. Conclusions. The angular deformities of the knee, with fibrous anchylosis, resulting from chronic inflam matory conditions, whether tubercular or otherwise, can be corrected by means of such mechanical appliances as are here described. The results, judging from six cases, are better than can be obtained by other operations. The leg is not mutilated or shortened, and the joint recovers with more or less motion. There is no mortality and the constitutional disturbance is slight. The danger of injuring the structures in the popliteal space is slight, because of the anatomical relations of the parts, as is shown by dissections. FIG. 7. TOTAL EXTIRPATION OF THE UTERUS: BY CHARLES P. STRONG, M.D. In the case of former extensive destruction of the tissues at the back of the joint with all of the parts more or less adherent, the vessels might be torn, were the apparatus used, but in the majority of these cases the operation would. be contraindicated, because with It is not my intention to discuss the relative value this amount of destruction of tissue, and adherent soft of different operations of removal of the uterus by parts, the joint is apt to be anchylosed, which would high amputation as against total extirpation, but rather demand another operation. If this is not the case, the to point out the merits which may attend the use of a leg should be straightened at several sittings, gaining Trendelenburg posture, and removal of the uterus in a little each time, and the operations done at long that position by means of abdominal incision instead enough intervals for the contracted parts to have time of the more commonly used vaginal extirpation. to relax, so that there is comparatively little danger of injuring the important structures. This precaution should also be taken in elderly persons where an atheromatous change in the vessels is to be considered. A modification of the original apparatus is pictured in Figure 7, which has the advantage of being adjustable, so that by moving the arch a, upon which the power The extension of the disease into the broad ligaments, the presence of adhesions, the binding of the uterus backward, and of the ovaries and tubes, together in one mass, render extremely difficult the possibility of a thorough and complete eradication of the disease, Society, November 2, 1892. or a removal of the whole organ by simple vaginal incision. The operation also leaves, as commonly practised, a free opening from the vagina into the abdominal cavity, which is closed, perhaps by stuffing the vagina with iodoform gauze, or some such method. The operation which I wish to present to your notice is one which I believe occupies the position of combining the advantages to be gained by the ordinary vaginal form, that is, the complete removal of the organ; it also enables the complete closure of the wound between the vagina and the abdominal cavity by its natural covering, that is, the peritoneum, and leaves less risk of infection, less chance for septic absorption of any kind than any other operation. of sepsis in this case, yet I feel the patient's chances would have been much better could I have closed the wound in my usual manner. I thoroughly disinfect the vagina by soap and corrosive sublimate, scrape away all disease possible, and at the same time employ the Pacquelin cautery and pack with iodoform gauze. This secures as much asepsis as is possible in a vaginal operation. Opening the abdomen, the fundus of the uterus is seen snugly reposing against the back of the pelvis away from the bladder. With double hooks I draw the fundus as closely as possible to the abdominal wound, pass a ligature of silk with aneurism needles to include the ovarian artery and as much as possible of the broad ligament, pass the second suture including the remainder of the broad ligament and the uterine artery. I similarly secure the vessels of the It is not in any one of its particulars essentially new; but the combination of them all is, I think, re-opposite side, and control any bleeding from the uterus cognized to be of advantage by few, if any operaters. by compression-forceps. Then dissect away all the I think Frennd's operation, which was that of total extirpation of the uterus through the abdominal cavity, was rendered so difficult by the position of the patient, such as would be assumed in the case of an ordinary laparotomy, that it has fallen practically into disuse. By the Trendelenburg posture, however, this is obviated. The field of view is so extended and broadened that the operative technique becomes a comparity. atively easy matter. Since the first of May I have performed this operation seven times. In only one of these cases do I think the removal of the organ would have been possible by the ordinary vaginal method of operating. My mortality has been two out of the seven. Both of these were desperate cases and were unpromising from the start, but the election was made by the patient to have the operation performed rather than to suffer death from the cancer. I should never have undertaken the cases had I been obliged to rely upon the vaginal method alone. The entire success of the operation, I think, depends upon securing the arteries of the broad ligament before removing the uterus, dissecting off from the anterior and posterior walls of the uterus a good layer of the peritoneal investment, so that the closure of the vaginal-abdominal wound may be made complete; with this is also stripped back the bladder and rectum. With this done there is no danger of hæmorrhage, there is no danger of infection; and malignant outcroppings into the broad ligament and along adhesions between the uterus and the intestines are easily felt, seen and secured. The cases reported in detail will afford a certain similarity; so that, after describing the various steps of the operation, I shall merely give in the individual cases the particular point that made me elect this operation in preference to the more common one. In none of these, I may say, would the operation of high amputation have afforded any prospect of removal of the disease. The sutures employed have been uniformly silk, the single exception is the continuous suture which unites the peritoneal surfaces at the completion of the operation, which is of catgut carefully prepared; and I have never seen septic absorption from it. One death of the two came in a patient in whom the investing peritoneum was so thick, and also evidently the seat of malignant disease, that I did not dare to leave any behind, and so removed it entirely and adopted the usual method of abdominal drainage by iodoform gauze. Although there was no evidence Believing that the tendency of the disease is greater to return if the tubes and ovaries are left behind, it has been my rule to remove these. The operation is accompanied by very little hæmorrhage, because the uterine ends of the vessels, as severed, are held by compression-forceps. A single large flat piece of gauze laid across the intestines at the upper end of the abdominal wound is sufficient to protect the general abdominal cavity from any fluid or from blood, which forms a pool in the retro uterine pouch exactly as with the patient in her ordinary posi tion. The toilet of the peritoneum by this means, therefore, becomes very simple. A continuous suture of catgut closes in the peritoneum, placing peritoneal surface against peritoneal surface, thus securing a very speedy obliteration of any possibility of infectiou extending from the vagina into the abdominal cavity. In my first operations with long ligatures I drained through the vagina as suggest by Dr. Krught in his operation for removal of fibroids. Without going into details of separate cases, I will briefly indicate what advantage I gain by this method of operating over the more common one. In the first case, the disease invaded the right broad ligament to such an extent that after removal of the uterus, I extirpated the ligament out to its junction with the pelvic wall. I also removed all the vaginal wall, anteriorly, and posteriorly to within about one inch of the vulva. In the second case, there were adhesions connecting the uterus with the intestines, with the bladder, and with the ovaries and tubes, which adhesions also were in part the site of malignant disease. These bands I was able to sever entirely from the intestinal end, thus preventing a possible return through disease there. Also, in this case, both the vagina and the broad ligaments had to a certain extent become affected, and these were also removed. The third case, along the top of the broad ligament there ran a single piece of small intestine, which lay exactly parallel with the top of the ligament, and which was collapsed, and could not have failed to have |