64.-CASE OF AMPUTATION OF THE HIP-JOINT.

Under the care of C. GUTHRIE, Esq.

[This patient, a man aged 50, noticed a swelling about the thigh eight years ago. A year before he was admitted, the pain began to be very severe, developed rapidly, and the man's health began to fail. As there could be no doubt of its malignant character, amputation was decided upon; but as several cases had happened where the disease had returned, if a portion of the shaft had been preserved, Mr. Guthrie decided upon amputation of the hip-joint. Considerable interest was excited by this operation, several of the most eminent surgeons being present.]

The patient was so placed that the ischia were a little beyond the margin of the table; and the sound leg (left) having been as widely separated from the affected limb as practicable, Mr. C. Guthrie placed himself on the man's right side, and prepared to use a knife, made for the purpose, about fourteen inches long and two inches wide at the handle. This knife was introduced horizontally from without inwards a little above the great trochanter, and the point made to emerge close to the scrotum, which was carefully held aside. By cutting horizontally along the anterior margin of the bone and then upwards, for about four inches, the knife was liberated, and the anterior flap formed. The latter was immediately raised by the assistants, and presented a rather unusual appearance, both from its size and the naturally considerable gush of blood which took place both from the flap itself and the lower traumatic surface. Mr. Guthrie now divided the capsular ligament, and run the point of his knife between the head of the bone and the cotyloid cavity, so as to divide the round ligament.

The limb at this time should have been strongly rotated outwards, but this could only be imperfectly done, as the rigid knee and the rather low table prevented the assistants from accomplishing their purpose. When the knife had separated the rotator muscles, the handle was close to the scrotum; and without changing its position, Mr. Guthrie made it glide along the posterior portion of the bone for about three inches and a half, and by cutting downwards made the posterior flap, thus completely separating in less than two minutes such a considerable portion of the patient's frame.

The assistants immediately covered the bleeding surfaces with sponges, and now began the very important business of securing the vessels. This was done first for the upper flap, whilst the lower was being compressed, and the hemorrhage became more and more feeble as the ligatures were successively and carefully placed on the arteries. The vessels of the lower flap were now secured in the same manner and with great rapidity, so as to render the loss of blood as inconsiderable as possible; and the two huge flaps soon presented an extensive, unequal, deep red, muscular surface, from which merely a little venous oozing was going on.

The patient became at this stage rather faint and pale, but a little cold water to the forehead sufficed to restore him. The flaps were now approximated, and their margins kept in contact by sutures, strips of adhesive plaster, and appropriate dressings. The patient's bed was brought into the theatre; he was gently placed on it, and seemed on opening his eyes to have retained a comparatively large amount of animation.

When the man had been removed, Mr. C. Guthrie addressed the gentlemen present, and stated that the method in which the operation had just been performed might be called Mr. Brownrigg's. He had been induced to remove the limb at the hipjoint, because the disease had returned in another patient likewise suffering from malignant disease of the femur, on whom he had performed amputation of the thigh close to the trochanter three years ago. This first patient had made a good recovery, and had married; but he unfortunately had a fall upon the stump; an abscess formed, the disease returned, and he died one year after the operation. The bone at the trochanter had at the time of the amputation been pronounced sound by very high authorities. No disease whatever of the viscera was found on a post-mortem examination. The limb just removed had been sent to the College of Surgeons to be injected and examined, and he (Mr. C. Guthrie) would be happy to acquaint his professional brethren with the actual pathological state of the part.

The patient remained very quiet and comfortable for the remainder of the day, and

spent a comparatively good night, sleeping for a couple of hours at a time. The next day was not marked by any untoward symptoms; the patient took sustenance, and was not complaining of any pain, when at two o'clock in the afternoon a gush of blood was noticed to take place from the dressings. Assistance was immediately procured, the dressings were taken off, but the hemorrhage had ceased, and when Mr. C. Guthrie arrived, no trace of bleeding was observed. A large and clean piece of lint was placed under the stump, so that the least amount of hemorrhage could be perceived, but it had completely stopped. It was not thought advisable to remove the sutures and separate the flaps, as it was apprehended that the shock might act very unfavourably upon the patient. But the latter was becoming more and more weak, and, in spite of ammonia, brandy, &c., he died at five o'clock.

A post-mortem examination was made on the following day, when all the viscera were found completely healthy, though in a very exsanguineous state. The stump contained a quantity of coagula which might have filled a large tumbler, and when these were removed, the vessel from which the hemorrhage had proceeded was looked for. No open mouth could be distinguished; but after water had been forced into the external iliac artery, the fluid was seen to come out from a vessel which was judged to be a branch of the circumflex artery. It is very probable that the hemorrhage from this vessel had stopped when the patient became faint, but that enough blood had been lost, as proved by the coagula, to lead to a fatal issue.

The unsuccessful results of this case indicate very clearly that it is advantageous to postpone the approximation of the flaps until reaction has taken place. Had the latter been immediately opened at the least sign of hemorrhage, the case might possibly have taken a more favourable turn. We consider this as an accident to be guarded against, but which does not throw any discredit on the operation itself. Many patients have been lost by secondary hemorrhage after comparatively trifling operations, and as the shock after amputation at the hip-joint is much diminished by the use of chloroform, the sources of danger are principally the loss of blood on the table and afterwards, and the subsequent profuse suppuration.-Lancet, April 30, 1853, p. 416.

65.-ON EXCISION OF THE KNEE-JOINT.

By R. J. MACKENZIE, Esq..

[Not only has an unfavourable impression been produced against this operation, but severe censures have also been passed upon the operators. Mr. Park, of Liverpool, in 1783, first prominently noticed the operation, but it had previously been performed successfully by Mr. Filkin of Northwich. After these, Moreau operated in three cases, two of which were fatal. In 1809, Mülder operated upon a pregnant female-she died some months after from tetanus.]

The next notice of the operation is by Mr. Crampton, in 1823. The operation in Mr. Crampton's first case can scarcely be said to bear on the question of excision of the knee-joint; not only were the patella and part of the tibia removed, but upwards of six inches of the thigh bone were taken away. The patient, however, lived upwards of three years after the operation, and then died from phthisis. Mr. Crampton, in his remarks on the case, says, that it "was one to which the operation of excision was not applicable." The disease had proceeded too far; for, even had it been possible to have removed the whole of the diseased bone, and that union had taken place between the femur and tibia, the limb, from its shortness, would have been useless. The operation was performed in the same year in a second case by Mr. Crampton. The girl, although a most unmanageable patient, made an excellent recovery. Six months after the operation, the femur and tibia were consolidated by a firm bony union. Eight months later, she is reported as being able to walk a distance of nearly five miles at once; and upwards of three years after the operation, Mr. Crampton says:-" I have examined the limb, and find that the femur and tibia are firmly consolidated; the leg and thigh are not in the slightest degree wasted, but the limb is considerably bowed outwards; she wears a shoe with a cork sole four inches thick; and, to use her own expression, 'is able to stand or walk the length of a day.""

The operation was next performed by Mr. Syme, who, in 1829 and 1830, excised the knee-joints of two children, of seven and eight years of age. Up to this time the operation had only been performed in adults. The result in the second case was unsuccessful, the child having died about ten days after the performance of the operation. Writing in 1831, Mr. Syme gives the following satisfactory account of his first case:"In the course of four weeks after the operation, the wound was all but healed, and the limb, before the expiration of three months, had regained so much strength that the patient could make some use of it in walking. It has been progressively improving since, and is still doing well. I have no doubt that ultimately it will be nearly as useful to him as ever; but even at present he would be very sorry to exchange it for a wooden one. He can walk and run, though with a halt, without the constrained appearance of a person with an artificial leg, and merely requires the heel of the shoe to be two inches higher than the other. The limb is stout and well nourished, and though slightly bowed outwards, does not occasion any disagreeable deformity; it allows a slight degree of flexion and extension." Seventeen years later, however, a much less satisfactory account of the same patient is given. In speaking of excision of the knee-joint, in 1848, Mr. Syme says: "I tried the operation nearly twenty years ago on a boy, who recovered perfectly from it, and seemed at first to possess a limb little inferior to its fellow, except in so far as it was stiff at the knee. But in the course of time it was found that the growth of the two limbs was not equal, and that the one which had been the subject of operation gradually diminished in respective length, until it wanted several inches of reaching the ground, when the patient stood erect."

After Mr. Syme's experience in 1830, the operation seems, as far as I can ascertain, to have been abandoned till within the last three years. The results of the operation on the whole had been decidedly unsatisfactory.

In 1850, the operation was revived by Mr. Fergusson; and within the last three years the operation has, as far as I can ascertain, been performed thirteen times: in three cases by Mr. Fergusson, in six cases by Mr. Jones of the Island of Jersey, in one case by Mr. Page of Carlisle, in one case by Dr. H. Stewart of Belfast, and in two cases by myself. Of the results of these cases I shall give some details immediately. Of the thirteen three have died, two directly from the effects of the operation and one from dysentery. The remaining ten are, as far as I know, at present alive. In five the limb is already used freely in progression; in one the result, as regards the usefulness of the limb, is yet uncertain; in one, I am ignorant as to the result; in the remaining three, sufficient time has not yet elapsed to render the result certain, but of each the most favourable expectations may be entertained.

Such is a brief outline of the history of all the cases in which, as far as I can ascertain, the operation has hitherto been performed, and I think I am justified in saying, that an impartial review of these cases, especially of the later series, at least proves that the propriety of the operation is yet an open question.

[Dr. Mackenzie, after cursorily examining the cases of this operation occurring within the last three years, proceeds to defend those who have been censured for reviving the operation. He says:]

The propriety of attempting to save a limb by excision of the knee-joint, seems to depend on the three following considerations:-1st. Is the operation of excision attended by greater or less danger to life than amputation of the thigh? 2nd. In the event of recovery after excision of the knee-joint, is the limb more or less useful and seemly than a wooden leg? 3rd. Does the long confinement to the horizontal posture, which is necessary after excision of the knee-joint, in any measure counterbalance the benefits of the operation (if such benefits are proved) as compared with amputation of the limb?

A careful consideration of these questions and of the recorded results of the operation, led me several years ago to doubt the propriety of the operation having been rejected from surgical practice. I satisfied myself, by repeated trials on the dead body, that the operation could be performed without difficulty, and without the risk of wounding any important parts; and, as a teacher of surgery, I have been in the habit of mentioning to my pupils my impression that the operation had been rejected from practice on insufficient grounds. Knowing, however, the objection of my hospital colleagues to the operation, I never requested their sanction in carrying it into execution, till the late experience of Mr. Fergusson and Mr. Jones appeared to me

to warrant my urging the question more closely on their attention, and my performing the operation in the cases which I have related.

With regard to the considerations which I have suggested as principally bearing on the merits of the operation, I would submit,-1st. That the danger of the operation may be reasonably expected to be less than that attending amputation of the thigh. The wound necessary for the removal of the diseased bones is less extensive than the wound of amputation of the thigh, whether performed by the circular or flat operation. The large vessels and nerves are not divided in the operation, the parts involved in the incisions being principally the integuments and ligamentous apparatus of the joint; the medullary canal of the bone is not laid open, a point which has of late years been suggested as of some consequence in diminishing the dangers of amputation; the shock, which always attends, to a greater or less degree, the sudden removal of a large part of the body, is avoided.

Time and experience, however, can alone determine the comparative danger of the two operations. In the mean time, the results of the limited number of cases in which the operation has been recently practised, prove, as far as they go, that the danger to life is not great; and, unless some unforeseen accident should occur to the cases which are at present in progress of convalescence, that the danger is inferior to that of amputation.

2nd. With regard to the usefulness and the seemliness of the limb, I need only refer to the account I have given of the results of the operation in Mr. Jones's hands, to show that the limb may retain a degree of usefulness which can never be attained by the wooden leg in common use, nor yet by the most expensive and efficient artificial limb which I have ever seen; and if, in the days of Mr. Park, such a result could be obtained as that a man, whose knee-joint had been excised, could run up the rigging and perform all the duties of a seaman, surely, with all the resources of modern surgery, we ought to obtain an equally satisfactory result now.

3rd. The remaining objection to the operation is the tediousness of the conva lescence. This, I think, unquestionably detracts, to a certain extent, from the benefits of the operation. I am doubtful, however, after all, whether the recovery can be proved to be on the whole more tedious than the recovery from compound fracture of the leg; in some cases even the limb seems to have been restored to usefulness as soon as the patient would have been able to walk on a wooden leg, had the limb been amputated. In Mr. Syme's case, for instance, "in the course of four weeks after the operation the wound was all but healed, and the limb, before the expiration of three months, had regained so much strength, that the patient could make some use of it in walking."

Mr. Syme, in another place, says, "It ought to be recollected, too, that, though recovery from amputation of the thigh is usually completed in three or four weeks, it is generally at least as many months before the patient can rest the weight of his body on the face of the stump, so as to use it in standing or walking."

Another objection has been brought forward against the operation which requires to be noticed, viz., that, when the operation has been performed on children, the growth of the limb has been checked, and that, consequently, from the unequal growth of the two limbs, that on which the operation has been performed becomes so disproportioned to the other as to be ultimately useless. The only practical proof of this being so, which I can find, is Mr. Syme's case; and I think it is possible that it might be attributed in this instance to anchylosis not having taken place. Experiments have been performed on animals to show that bones do not grow when deprived of their heads, but the results do not appear to be conclusive. A few years will be required to confirm this as a valid objection to the operation. Mr. Jones has, in the mean time, made accurate measurements of the limbs of the three boys on whom the operation has been performed, and will have an opportunity of giving farther information on the subject hereafter. I have, in an earlier part of this paper, mentioned the fact, that the limb in one of Mr. Jones's cases had already, since the operation, grown considerably, and presented now no appearance of checked growth. As bearing on this question, I would be glad to know if the growth of the upper extremity is checked by excision of the elbow-joint. It is so, as far as I remember to have observed, only in a slight degree. Surely the numerous children who have undergone this operation at the age of six or seven, have not grown to adult age with the stunted arm and hand of little more than an infant. Supposing, however,

that the fact is so-t that the limb is so much respectively shortened in after yearsthe objection applies only to the operation being performed on children, and has nothing to do with the question of the propriety of excision in the adult.

I have suggested that an error has, till lately, been committed in the performanee of the operation, which has been allowed to interfere most seriously with its result. I refer to the removal of the patella. It is said that the patella is generally extensively diseased in affections of the knee-joint demanding excision or amputation : this, I have no doubt, is an error. The amount of disease to which it is liable is very limited-in the great majority of cases consisting only in its being more or less deprived of its cartilage, and of a rough, or perhaps carious condition of its articular aspect. The patella is rarely, if ever, the primary seat of the disease in affections of the knee-joint. When the disease commences in the bones, it invariably does so in the cancellated texture of the head of the tibia, or condyles of the femur. It is extremely rare that there is such extent of disease in the patella as to prevent its easy and effectual removal by the gouge, the body of the bone being left uninterfered with. The advantage of leaving the patella cannot fail, I think, to be very great. The natural form of the joint is preserved; the attachment of the extensor muscles is left undivided; the wound is less extensive; the annoying tendency to displacement forwards of the end of the femur seems, in a great measure, to be done away with; and there is every reason to believe that the consolidation of the bones will proceed more rapidly, and the limb ultimately be found both more useful and more seemly than when that bone is taken away. This is a point, however, which remains to be proved. In the two last cases, however, in which the operation has been performed by Mr. Jones and myself, the patella has been left, and the advantages of its having been retained are already apparent in each case.

I shall not lengthen this paper by describing what appears to me the best mode of performing the operation, but merely mention that the semilunar incision seems to me the most advantageous, as being the smallest by which the joint can be satisfactorily exposed, and as giving rise to less bleeding than the H-shaped incision. There is one point, however, to which I wish to direct attention. It has been recommended that a considerable portion of integuments should be removed by a double lunated incision, to prevent the redundancy of skin which might be expected from the large amount of bone removed in the operation. I believe that this advice, if followed, will lead to great annoyance. I have not removed any portion of integuments in the cases in which I have performed the operation, notwithstanding which, the retraction of the skin was such as to cause, in each case, more or less gaping of part of the wound. Mr. Fergusson mentioned to me that he had removed a small portion of integuments in the operation, in the case now in King's College Hospital, and that, during the patient's convalescence, he had much reason to regret having done so, as the retraction of the integuments was such as to leave part of the end of the femur uncovered, and a thin cicatrix only now covers this point of bone.—Monthly Journal of Med. Science, June, 1853, p. 526.

[At a meeting of the Edinburgh Medico-Chirurgical Society, after a paper had been read on this subject by Dr. Mackenzie,]

Mr. SYME said that nothing could be more praiseworthy than trying to extend the means of affording relief by surgery, but as every step in advance was necessarily experimental, it should be understood that there were two sorts of experimentsthe experientia erudita and the experientia vulgaris. In the former, a process of reasoning led to the expectation that certain causes would be followed by certain effects; but in the latter there was no such foundation for the procedure, which was executed simply with the view of obtaining results. He thought it needless to detain the Society by showing that the only warrantable experiments on the living bodies of human beings were those of the former kind; and would endeavour to explain the considerations which induced him to regard excision of the knee-joint as a dangerous and unprofitable proceeding. The large size of the wound, which was just double that of amputation, and the want of a dependent opening for the matter to escape, must be apt to occasion a profuse and protracted discharge-dangerous directly from its exhausting effects, and indirectly from lighting up disease in the pulmonary or intestinal textures, especially in subjects predisposed to such derangements, as most patients requiring the operation were. The strong and irregular action of the muscles must render it difficult to prevent displacement of the bones,