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There can be no surprise, then, that a joint so treated, which depends for its subsequent stability upon the healing of its divided ligaments and the establishment of fibrous ankylosis. should disappoint our expectations. There being no true osseous union. the tendency to flexion is considerable, for the soft structures inevitably yield to the force of the flexor muscles. So serious is this tendency that Mr. Watson Cheyne says that “a back splint should be worn for a long time, sometimes for years ” (Tuberculous Disease of Bones and Joints, p. 189). Here the danger is that when the child has passed from direct surgical treatment, the deformity may go on increasing owing to the neglect of the parents, and the patient may returu to us with a limb bent almost at right angles, demanding excision of the bones.
Now there is no exaggeration about this picture. Professor Wright stated at the Oxford meeting of the British Medical Association, in 1903, that, of the ninety-seven cases which he analysed, twelve had "slight” flexion, and twenty-six
considerable " flexion—or more than one-third in all. I think I may say that a child with considerable flexion needs a crutch, and, although there may be no more active disease, for purposes of progression the patient is in no way improved.
In the second place, the procedure has a limited application. That is, it is specially reserved for children in whom the membrane only-or little more--is affected. There can be no objection whatever to adapting our operation to varying developments of disease. We do it every day. But we must be sure as to what the condition is.
Now I need hardly say that we cannot always be sure that the disease is absolutely confined to the membrane. Opening a knee joint may reveal entirely unexpected conditions. There may be erosion of cartilages, pus pockets, and caries of the bone ends. Clearly, removal of the synovial structure will not suffice. The surgeon must develop his procedure. He must scrape out the caseous foci of disease; must deal thoroughly with the caries, and gouge out all dead or dying bone. It may be that he must use the saw, and his operation passes into the category of " modified " arthrectomy. When he does this, it is difficult to discern the line
which divides the proceeding from excision, so far as immediate shock or ultimate mobility of the joint go.
In the third place, let me notice the question of permanent shortening due to interference with the epiphyses in excision. My own experience does not support the allegation that this is one of the results of the radical operation. In the large number of children on whom I have operated, and examined subsequently at various periods, I have not noticed this defect, and I believe it seldom occurs. If a neighbouring lesion has this effect as a necessity upon the epiphysary line, we should see it more frequently than we do. In the violence inflicted near the ends of young bones by fractures-even when there is a separation along the line of the epiphysiswe do not look for a stoppage of development. It may occur, and it is wise to take all chances into consideration in such circumstances, but I hold that we do not look for this as a matter of course. If the epiphysis were always as sensitive as undoubtedly it sometimes is, then we should expect to find this lack of development in many of the modified arthrectomies. For there the bone is entered, and the surgeon does not hesitate to use his gouge freely in clearing out carious masses, even if doing this carries him into the epiphysary line at more than one point. This invasion of a region of great physiological activity may be followed by all the dangers which are held by some to be inherent in the operation of excision. On the other hand, I wish to emphasise the fact that in the thorough operation we do not necessarily encroach upon the growing line at all, and that therefore we are not accustomed to see the disastrous shortening which we are told ought to follow.
I have now brought before you what I conceive to be the defects of the methods which I have enumerated, and I have no doubt whatever that all these ways of dealing with tuberculous joints are inferior in all respects to the radical operation of excision. In my own experience the mortality is not two per cent., and is at least as low as that of the simpler operations. The results are certainly better, for, having removed the joint and cleared away the infected soft
parts, we in the end have a limb which is free of disease, firm, stable, useful. We are not haunted by the perpetual suspicion that some day or other, in a joint that we supposed to be saved, a destructive outburst may occur. In cases of erasion we are dealing with children who do not realise what are the limits of use of the weakened joint. Some day there is perhaps an over-strain, and the whole trouble is set up again, to follow the weary road of rest and rigid splints, or perhaps to pass on to further palliative operations, or to removal of the limb altogether. All these conditions of prolonged liability to mischief which is only quiescent, and of close guardianship against possible movement and accident, are unsatisfactory. We certainly cannot get the protection among the poor, and these children are always running risks which are often realised in failure of the surgeon's efforts.
I have already said that in England excision of the knee does not stand in high favour. The recent text-books relegate it to a position of secondary importance, and seem to place it in competition with amputation only. One surgeon has declared it to be "a comparatively rare operation.' Another says “ that the old classical excision is a thing of the
Well, let me assure you that in Dublin it is not rare, and that it is very much a thing of the present. And this is not because erasion has not been tried, but because experience and judgment have led us to adhere to what we believe to be more satisfactory.
There can be no doubt that at one time excision was a very fatal operation ; but so was any procedure which involved opening of the large synovial sac. The revolution in the treatment of wounds affected the results in a remarkable way. Ollier's mortality fell from 80 to 14 per cent. Another group of cases by Meusing shows a reduction from 35 to 5 per cent., and later on to 2 per cent. My personal experience as to mortality is that no major operation could show a much better record. I have lost two cases out of seventy-eight excisions-one after amputation, and one from acute mania in a patient who I then learned had already been in a lunatic asylum. My colleagues—Sir Thornley Stoker and Sir T.
Myles-inform me that they have had no deaths. Mr. Tobin, of St. Vincent's Hospital, has just reported fifty cases with one death.
My first excision of the knee dates back just thirty years. It was done within a few weeks of my joining the visiting staff of my hospital. I remember very well the views of my senior colleagues. They had been there for thirty years before that, and some of them seemed to be still under the influence of that terrible Lancet picture of the sufferings of an unchloroformed patient. They had also seen in later times some of Butcher's cases, concerning which there were still horrible tales related in the schools and hospitals. They shook their heads deprecatingly, and foretold inevitable disaster. But I was young and full of zeal, and I had the support of my younger colleagues. The excision was done, and the patient recovered. She was able to walk in three months, and many years afterwards I saw her in excellent health-the limb never having given any further trouble. This success gave me encouragement, and from that time I have steadfastly adhered to the operation because, in my opinion, nothing so good in advanced cases has yet been devised. My patients have ranged in age from four years to forty-seven, and I have, of course, met with all degrees of severity—cases in which only the synovial membrane was engaged, and others in which the bones were severely affected. But I have applied the same remedy alwaysthorough removal of the diseased parts, and of sections from the femur and tibia, whether these were infected or not.
Here let me say that I never use Butcher's saw for this purpose. The best instrument is an amputation saw with movable back. It gives a flat surface, which is not easy to secure with the narrow blade of Butcher's saw.
In the early days I used Heron Watson's splint, but I found that there were two objections to it. As the muscles shrank under the unyielding plaster of Paris casing, the patient suffered from jarring of the divided bone ends, and it was difficult to keep the discharges from getting beneath the covering and causing much uncleanness. I then tried a simple
hoop-iron splint, from one and a half to two inches wideposteriorly extending down from the buttock-fold to the foot ; bent to receive the heel, and then carried forwards along the sole. In front I used the same material, and fashioned it after the shape of Heron Watson's anterior splint. I found that with little padding this served very well, although I still used plaster of Paris. But the disadvantages of this material persisted, and I determined to rely entirely upon bandages to secure the limb on the splint, and for twenty years I have never used plaster of Paris. Next in our progress at the Richmond Hospital was the introduction of dowel-pins by Sir Thornley Stoker. These are used as soon as the cut bone surfaces are placed in position. One pin is passed through the tibia three-quarters of an inch below the cut surface, and on one side--is carried across obliquely into the cut surface of the femur at the opposite side, and pushed into the bone for one and a half inches or more until it meets compact tissue. Another is introduced in the same way froin the other side of the tibia, and also pushed obliquely into the femur. The two pins thus cross each other, and the result is perfect fixity, so that the leg can be lifted from the table by the foot as one rigid piece. This great advance, in conjunction with the light hoop-iron splint, removed our difficulty in the painful movement of the bones, and enabled us to dress the wound with great facility. In bed the leg is swung from a strong cradle, and so easy and secure is the whole limb that a patient is able to sit up against a bed-rest, or even without back support, on the third day.
It is absolutely essential that every visible portion of diseased soft tissue shall be removed, and this is particularly the case in reference to the long pouch under the quadriceps tendon. This must be carefully dealt with. Further, I always made a two-inch longitudinal incision through it, including the skin, so as to give direct exit to any oozing. The main wound, made as dry as possible, having been thoroughly swabbed with pure carbolic acid and then washed out with absolute alcohol, is drained on either side by openings carried through to the popliteal surface, and the tubes are removed