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happy-go-lucky lives as usual-perhaps they only appear at long intervals at the out-patient department, or not at all. But very surely the trouble goes on, and in the end, sooner or later, they come to us with a joint whose treatment has passed out of the region of simpler non-operative remedieswith greatly thickened synovial membrane, often with sinuses, sometimes permanently flexed and deformed.
Up to fifty years ago it may be said that all such joints had a uniform fate at the surgeon's hands. The thigh was promptly amputated, if only the patient would consent, and the sufferer was submitted to the risk of a 30 per cent. operative mortality. It came about, however, that limbs as well as life had an increasing value; and there arose among surgeons, influenced by the wonderful development of their art, in response to the lessons of science, a desire to preserve what it had been the habit to condemn.
But long before this period—in 1782—Park, of Liverpool, had the honour of trying to place the treatment of these cases on a rational basis. He successfully excised the knee joint, and seven years later he did the operation a second time with a fatal result. Filkin, of Northwich, had, however, anticipated Park by just twenty years, although he modestly withheld publication, and to him belongs the distinction of having performed the first operation of this kind. Up to 1816 only six cases are recorded. Then came a couple of Irish cases operated upon by Sir Philip Crampton. The procedure was one of the surgical curiosities of the time. No British surgeon other than Filkin and Park had ventured upon it, and naturally in Dublin, where Crampton operated in 1823, there was intense excitement in the profession. The theatre of the Meath Hospital was crowded by medical men and students. I have already put on record an account of the proceedings as described in the Lancet of 1825, but the story will bear repetition now.
The writer says :
It was the first time, we believe, that the removal of the knee joint was attempted here. We earnestly hope it will be the last. The operator, of course, accomplished his purpose with his usual dexterity. But could he have beheld, as we did, the contorted countenances of the spectators, the knife would have
fallen from his hand, never to be used where it was not more
But as to knee joint excision, the experiment was repeated in spite of much hostility. Butcher, in Dublin, and Heron Watson, in Edinburgh, laboured on, and Butcher—although his cases were few compared with present-day statistics—did succeed in establishing the operation in his own country. In England, however, the operation has never been a popular
It takes a long time to overcome the opposition of men of accepted eminence; but in Ireland we have not been so reverent to authority, and the results we have obtained justify our position.
It is a sound principle that we should take the easiest and the simplest road to attain a good result in our treatment. But it must be clear beyond dispute that the plan we adopt is as effective as any rival one in regard to efficiency of the limb; that it has less risk to life; and that it occupies less time in reaching the final stage of success. Experiment in surgery has led us to very remarkable achievements, and it is essential to progress that all legitimate efforts in this line
should not be hindered. The motive has been to cure, but I am not satisfied that the expectations which have been time after time excited in this department of surgery have been fulfilled. I have only to point to the variety of plans which have been submitted to the profession during the past few years to justify my view.
The serum treatment has been abandoned, and in its place we have had the direct introduction of chemicals into the joint and the diseased synovial membrane.
Lannelongue's injections of chloride of zinc have not justified the claims made for them by that distinguished surgeon. Kolischer has admitted disappointment in the results obtained from his efforts to calcify the tuberculous structures by injecting neutral phosphate of calcium. Arsenious acid, tincture of iodine, and other substances have also had a trial. Iodoform is extensively used in Germany as a germicide. Krause reports twenty-three cures of various diseased joints out of sixty treated. I have had the most satisfactory results from the use of iodoform injections in cases of chronic tuberculous abscess. But this is an entirely different thing from injection into the substance of a greatly thickened tuberculous synovial membrane. Apart from the fact that many of these substances produce great pain, it is to be remembered that the injections must be repeated frequently at long intervals, and that the patient on these occasions has to endure some days of irritative fever, which in itself has a depressing influence on his general condition. Furthermore, the effect of the injection is limited to a small area around the point to which the needle has reached, and it is necessary to visit the already untouched parts at successive operations. At least two dangers seem to attend these proceedings. We can have no assurance that the diseased membrane has in every part been subjected to the claimed curative effects of the injection. If, then, certain portions have not been beneficially affected, they still remain as foci from which the disease will progress. The second danger is that outside the sphere of direct influence there must be an area of disturbance which may, and often does, advance to inflammation. In that area there are all the
conditions which encourage mischief. In other words, the already diseased tissue in that zone beyond the reach of the
germicide is stimulated into increased activity. So, as we -, should expect, in spite of all aseptic precautions, spots here and there inflame, caseate, and suppurate after the injections, and surely make the last condition worse than the first.
Meanwhile, what of the ligaments of the joint? One of the characteristics of this affection is the persistency and subtlety of the infective process. If we could say that disease is strictly limited to the synovial membrane, we should perhaps be encouraged in our efforts. But everyone knows that this is not so.
Every ligament in the articulation is tainted or infiltrated. Even the skin gives evidence of it, as we see so often as the result of an incision, in the unhealthy unhealing granulations that follow. Unless, then, we begin the injections at a very early stage, supposing them to be as potent as is alleged, they are not likely to do good; on the contrary, by their interrupted character, and the limited portion of tissue which each can affect, they are more likely to create a false security, while the disease is in truth making dangerous headway.
The opinion of German surgeons is in favour of this method. British surgeons have certainly not accepted it, although occasionally the results may be satisfactory; but the experience in these countries appears to be that it is an unreliable form of treatment, and that disappointment usually follows the practice of it.
But this having been tried and found wanting, we have gone a step further in England. Professor Wright, of Manchester, some twenty years ago led the way in what was deemed a further advance which would give better results than excision in the case of children. The suggestion that we might remove the disease, and at the same time preserve the mobility of the joint, is a very attractive one; and there have been many followers of his practice in all parts of the world.
Let us examine this method. It was believed at first that not only could the disease be extirpated, but that a movable
joint could be secured, and that shortening would not follow because the epiphyses were not interfered with. But experience has not found the promises fulfilled. What is the position to-day? It is quite true that movement is preserved in some cases, but the effort to secure it as a routine practice has been abandoned. We know that shortening does take place, as reported in eight of Professor Wright's cases, and that there are other drawbacks which, I believe, give the operation a secondary position when compared with excision. In erasion the surgeon removes the synovial membrane, say through two lateral incisions or one of horse-shoe outline ; probably divides the ligaments to secure better access ; perhaps takes away the semilunar cartilages; brings the articular surfaces of the tibia and the femur into apposition ; fixes the limb, and awaits-not mobility, but rigidity. For, those who are most experienced in this operation do not make attempts at systematic passive movements, because they have learned that they are attended by undesirable results. Now if we want to obtain union which will be solid and reliable, I do not think the best media for securing it are two articular cartilages. Mr. Howard Marsh has emphasised this by declaring that “the practical difficulty is that often no firm synostosis, but only fibrous ankylosis, can be obtained.” And he says further, “While the hip, the ankle, and the elbow owe their security to the modelling of the articular ends, in the knee this security is entirely dependent on the presence of powerful ligaments. These ligaments, while they connect the bones firmly together, yet allow flexion and extension, sliding and rotation, as well as these movements in constantly varying forms of combination. By arthrectomy, not only is the largest of the synovial membranes completely removed, but the ligaments are divided. In fact, all the essential components of the joint, except the articular ends themselves, are sacrificed, and the bones are henceforth connected merely by cicatricial tissue. One is almost tempted to remark that if, after this, a useful joint remains, the original structures would appear to have been a needless arrangement” (Diseases of the Joints and Spine, pp. 335 and 337).