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The patient will rejoice in an unwonted freedom from pain and in the return of a long-lost ability to use his leg when sitting. From a chronic invalid dependent upon external support he will be transformed into an independent, well and active man. This kind of case is the typical case for excision, and for it the operation is, in my judgment, imperatively indicated.

When both knees are affected, but all other joints are free from disease, the matter becomes more complicated. It is evident that a man with two stiff knees is in a very different condition from one who has one only in this state. In the latter case he can rise unaided, by the use of the well knee; in the former it would be very difficult to get on his feet without assistance. It would, too, be more difficult to sit comfortably, and he would in every way be in a much more helpless condition. The question would arise in such a case whether the man were not better off in a wheel-chair with his knees bent. In deciding the matter in an individual case, we would have to consider the amount of pain inore or less constantly suffered. In some cases the serious involvement of one joint may be associated with a mild affection of the other, and an excision of that most diseased might add to the patient's comfort and efficiency. Where many joints are involved the gain to be derived from operative procedures becomes more and more problematical, and yet even then the great relief of pain achieved by the excision of diseased structures may justify the surgeon in removing them.

I will relate three cases, each differing from the other, which will illustrate the course of events after operation of this kind on the knee.

The first case, Miss T., aged twenty-two years, had a severe attack of rheumatic inflammation of the right knee in May, 1899, which left the joint partially anchylosed and flexed at an angle of about one hundred and thirty degrees. She entered Saint Mary's Hospital, Detroit, in May, 1900. On examination the knee was found to be flexed, varying from ninety to one hundred thirty degrees. This variation was due to a certain limited mobility. It was, however, not possible to flex the joint to a lesser angle than a right angle nor to extend it beyond one hundred thirty degrees. The tibia was partially dislocated on the femur. There was not much pain in the joint excepting when motion was carried beyond the limits mentioned. Her general health was good. She was put to bed and a double extension applied to the leg in such a way that while one weight pulled in a line with the long axis of the body, another attached to the upper part of the tibia pulled that bone forward. During the six weeks of her stay in the hospital under this treatment there was a slight progressive improvement in the position of the limb, and the angle of greatest extension was increased about ten degrees. She went away, however, as she came, on crutches, and was advised to have an operation for the relief of her trouble.

On November 12, 1900, she came back, and on November 14 submitted to excision of the joint. The joint when opened was found to be filled with inflammatory deposit. The surfaces were attached by a new tissue of fibrous character, which permitted a certain degree of motion. The contraction, however, of the posterior ligamentous struc

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tures was so great that even after complete section of the lateral ligaments it was impossible to overcome the pathological dislocation. This was eventually accomplished by excising a sufficient amount of bone from the femur and tibia. Healing was by first intention, and when she left the hospital on January 13, 1901, she was able to walk without cane or crutch, but continued to wear the plaster bandage. When she presented herself to me six months later she was quite well. The limb was strong, and she was able to walk miles without artificial support. She walked without any perceptible limp, and it was only when she sat that the stiff projection of the limb rendered her trouble apparent.

The second case, Dr. M., had been rendered incapable for business during a period of more than two years by a rheumatic partial anchylosis of the left knee. He entered Saint Mary's Hospital, Detroit, on August 7, 1901, for treatment. The leg was then extended on the thigh and straightened, and when supported by splints could be made of limited use in walking. There was a slight motion in the joint, and this motion was the cause of constant pain. A slight touch on the foot would cause pain in the knee, and walking without the splints was practically impossible. The joint was swollen and tender, and sometimes hot. On August 8, 1901, I excised the knee. I found the ligaments thick and swollen, the cartilages eroded, and between the joint surfaces a mass of new fibrous tissue in which there were multitudes of minute bony particles. Healing was uneventful, and on September 26, 1901, he left the hospital. His leg is now strong, he walks with hardly any limp, has no pain, and attends to all of his business without inconvenience.

The third case illustrates a different and somewhat rare type of rheumatic joint disease. Mr. R., aged forty-five, has suffered for several years with a rheumatic disease affecting nearly all of his joints. When I first saw him, early in May, 1902, I found him suffering from pain in his shoulders, hips, knees, ankles and wrists. Both wrists were swollen, slightly flexed, and partially anchylosed. He walked with the aid of canes, but, in doing so, had great pain in his left knee. He was worn and haggard and showed in his countenance and carriage the effects of long suffering.

On examining the joint carefully I was puzzled at the discrepancy between the severity of his pain and the lack of objective symptoms. He complained of great agony when he rose to his feet; the knee became then the seat of such pain that he was unable for a moment to bear any pressure on it. There would then be a subsidence of this great anguish and he could hobble on it for a short distance, though never without pain. The joint was not more swollen than its neighbor, and there was, if anything, a mobility that was rather abnormally great than impaired. Sitting, he could swing the leg freely in every direction without inconvenience, but pressure on the articular cartilages could not be endured. I hesitated in this case to operate, on account of the general character of the disease, and it was only after long consideration that I came to the conclusion that a malady which had resisted all kinds of treatment,

including the baths at Mount Clemens, and which, during a period of more than two years, had rendered the patient miserable, justified an attempt at operative relief, even though the possible disablement of other joints should in the future complicate the conditions.

I excised the joint on May 19, 1902. The wound healed nearly by first intention. At the end of six weeks he was up on crutches bearing some weight upon the foot. He has no pain at the seat of operation and can walk without support, although, as a matter of precaution, he will use splints and crutches for another month.

The technique of excision of the knee varies with every operation. That which has proved most satisfactory in my hands is as follows: I make an incision across the knee from condyle to condyle just below the patella. For purposes of drainage this extends on the external surface to a point behind the condyle. The patella is removed, and the bursa under the quadriceps extirpated. The leg is now flexed to the utmost, breaking up all interarticular adhesions and new formations, and the joint exposed. For this purpose it is necessary to divide the lateral ligaments. All newly formed tissue is now cut away and the crucial ligaments and semilunar cartilages removed. From now on the technique for children and that for adults differs. In children the utmost care should be taken not to injure the cartilages of the epiphyses. I accordingly remove the surface cartilages of the joints with a sharp chisel, avoiding any more cutting than is necessary to denude the bones, while in adults I saw off the bones with attached cartilages. The joint is now cleansed and the hemorrhage checked.

Some surgeons bring the bones together in a slightly flexed position. This is a great mistake and one which is responsible for many failures in knee-joint incision. The object for so doing is to elevate the heel slightly and thus facilitate walking and to give a better attitude while sitting. Its disadvantages are, a lessened stability and a tendency with some patients to a dislocation backward of the head of the tibia. When the weight of the body is borne on the flexed knee it exerts a leverage on the joint which will inevitably force it apart if applied before the formation of a strong bony union.

The bones should, therefore, be brought together in a position of complete extension. This gives strength and stability and does not interfere with walking, as the patient learns to elevate the limb at the hip and to flex the ankle-joint, and thus carry the foot free from the ground. It is remarkable how little limp is shown by these patients. I have women whose skirts hide the stiff knee who will walk so well that they never betray any lameness to the casual observer.

I have given up the practice of fastening the bones together with nails or wire. It is altogether unnecessary, if a splint is properly applied. I have an assistant hold the limb up in extension while I sew the cut ligaments together with large chromacized catgut. Before doing so, however, I pass a rubber drain through from the inside to the outside of the joint. In order to do this properly it may be necessary to cut a groove in the bones at the back of the joint, in which the drain

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can lie. This drain is necessary for the discharge of blood, which continues for several hours to ooze from the cut bony surfaces. This drain is carried out of the joint from its external surface and should be so formed as not to discharge within the dressings. I always apply a plaster bandage to these cases from the navel to the toes of the affected side. Such a bandage may be left on a month if only the blood is not allowed to discharge into it, in which case it will soon become septic and foul. In forming the drain a medium sized rubber tube should be selected. The portion within the joint should have holes cut in it, but no holes except that at the end should be in that part which is outside. The joint should be enveloped in oiled muslin and the drain passed through a very small opening in it. The bandage should now be applied in such a way as to avoid the drain, and another piece of oiled muslin, through which the drain passes, should protect its outer surface. In this way the plaster is protected within and without from all discharges.

An important feature to consider in applying a plaster bandage, which is to remain in place three or four weeks, is the padding. This should be made of layers of cotton wadding aggregating an inch in thickness and quilted between two sheets of gauze. When the bandage is completed the inner layer of gauze next the skin should be turned over and attached on every edge to the gauze bandage, which protects, thus preventing any fraying of edges and escape of wadding. If the padding is not sufficiently thick the patient will suffer great discomfort from the pressure of the hard plaster on the bony prominences. At the end of three or four days if all discharge has ceased the drain should be removed. After three or four weeks the plaster should be removed and the joint examined and a new plaster bandage applied to the leg and thigh, but not to the body. At the end of six weeks usually the patient may walk on crutches and begin to bear some weight on the leg. He should, however, in rheumatic cases, wear splints of some kind for at least three months after the operation. In tuberculous cases, however, in which the bone is always more seriously affected, and in which the foci of disease may remain undiscovered in the bone, care should be taken for many months to protect the new tissue from severe strain, by the habitual use of splints.

THE SURGICAL TREATMENT OF PROCIDENTIA UTERI.* BY REUBEN PETERSON, A. B., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

At the outset let me relieve your minds by a frank statement of the purposes of this paper. Otherwise, you may look forward with dread. to the usual deluge of drawings and diagrams of a new operative procedure for the relief of a very common disability. Such descriptions, while no doubt interesting to the essayists and endured with resignation * Read by invitation January 7 and 8 before the IONIA AND INGHAM COUNTY MEDICAL SOCIETIES.

by an audience composed of specialists, are entirely out of place on occasions such as this. My purpose will be rather to discuss briefly the causes giving rise to marked degrees of uterine prolapse and to consider certain fundamental principles underlying any form of cure of the condition by surgical means. Finally, I shall emphasize the futility of any form of treatment except surgical, and try to explain the reasons therefor.

Literally procidentia uteri means a prolapse of the uterus, a pathologic descent of the organ so that it comes to lie permanently in a lower position than normal. But by common consent the term has come to be applied to marked degrees of prolapsus uteri, where a part or the whole of the organ lies outside the vulva. The procidentia is spoken of as partial when only a portion of the uterus protrudes and complete. where the entire organ lies outside the vulva, when the patient strains down or assumes the erect posture.

Procidentia uteri is not an uncommon condition, and either the complete or incomplete form has probably been seen and recognized by each of my audience. It is usually seen in women near or past the menopause. In my experience the more marked forms of the disability will be found in patients past the menopause, for reasons which will be explained later.

ETIOLOGY.-Normally the uterus is maintained in position by various pelvic structures which act together, not separately. The principal support may be said to come from the various muscles and connective tissue making up the pelvic floor. These muscles run from various portions of the bony pelvis and are so inserted as to hold upward the rectum and vagina. The uterine ligaments, the round, broad and vesico-uterine and utero-sacral do not hold the uterus upward but simply act as guy ropes, keeping it from going too far in one direction. In order to insure the normal position of a uterus we must have all these factors acting together, and any failure so to act is liable to result in a malposition. In this, then, lies the explanation why almost without exception procidentia uteri is met with in women who have borne one or more children. Here the integrity of the pelvic floor has become impaired either through a direct tear of the pelvic muscles and fascia or overdistention of the same. The child's head in its passage through the vaginal tract tears the muscles at either side of the median line, the levator ani muscles. The external perineum may or may not be involved in the tear. From the standpoint of pelvic and uterine support the integrity of the external perineum is of slight importance. If the internal perineum be torn either on one or both sides, unless the torn edges of the muscles be sutured properly and primary union take place, the results of such tears are shown very soon after the woman begins to walk about. The posterior vaginal wall no longer hugs the anterior wall of the vagina, but falls away from it, making the axis of the vagina horizontal and not downward and backward, as it should be normally. Then may follow more or less rapidly, according to the extent of the perineal tear, a bulging forward

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