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 past." 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 always— thorough 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 from 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

in forty-eight hours. Esmarch's bandage is no longer employed.

In three or four weeks the pins, which project from the points of insertion about two inches, are withdrawn without any pain. The bony surfaces are now well advanced in their adhesion; the limb is firm, and complete osseous union is assured.

But all do not run so smooth a course as the weeks go by. Remember that, as elsewhere, we see these patients when usually the disease is well advanced and they are driven by pain, or discharging sinuses, or lameness due to flexion, to seek relief. The membrane is very thick; often there are points of caseation and suppuration; the bone is diseased, and the capsule and other ligaments are infected. Then there may follow the formation of sinuses. But these we attack early and vigorously, time after time if necessary, until at last we have the satisfaction of sending our patient out with a saved limb.

I may be asked where I draw the line between excision and amputation. Well, I say that in every knee case which is only fit for radical operation the question that presents itself first to my mind is, “Is this a case for excision?" I have not done ten amputations of the thigh for diseased knee joint. Unless amputation is quite obviously indicated, I begin with an excision exploration, always with permission to amputate if I find it necessary. But I wish to say that cases that I thought the most unpromising have turned out in the end quite satisfactory. Twice only I have amputated in the early days for failure of union. I have always felt, even in the worst cases, that it was fair to give the patient the chance of a sound limb, no matter what the trouble. In subsequent treatment one can always easily take off a leg; but no wooden substitute can effectually take the place of a support of bone and muscle, even although we shorten and stiffen it.

This matter of shortening seems to me to have weighed unduly against the operation. There are two kinds-that which follows of necessity from the removal of portions of

bone, and that which is the result of premature ossification of the epiphyses. This last can only occur in children; and I am inclined to think that in practice it is met with far less frequently than the books would lead us to expect. In the case of the child we may find that the disease has not yet deeply implicated the bones. Then the surgeon's purpose is to limit his bone incisions in such a way as to provide flat surfaces which will lie easily against each other and become united in a few weeks. In such circumstances the epiphysary lines can be avoided, and the dreaded secondary shortening does not necessarily follow. When it does, it can always be dealt with by some simple appliance. Some primary shortening there must be-the result of the removal of bone-but we must not forget that it is more easy to walk with such a leg than one in which erasion has produced ankylosis, but has had no effect on the activity of the epiphyses. Therefore I cannot admit that the advocates of erasion as opposed to excision have a good case, when, the knee being stiffened, they claim a special advantage in the absence of any shortening.

But more serious is exaggerated flexion which undoubtedly used to occur occasionally in the earlier cases of excision in children, when the patients had passed out of surgical care for long periods. I am glad to say that I have not seen such a case for many years. The reason is that I invariably apply a well-made poroplastic splint, when the patient is allowed to move about. The splint is moulded closely to the limb so as to encase it, and extends from an inch below the trochanter to two inches above the malleoli. This should be worn for

a year, and it can then be removed with safety. I believethat it might be taken off in a few months, but many of these patients are from distant country parts, and cannot be seen. regularly. Let me add that the plaster of Paris is inadvisable then as a support. It is heavier and does not last so long, and when it cracks it loses its efficacy and is apt to be removed and not replaced.

In these remarks I have endeavoured to put before you the claims of the two important methods of treating advanced.