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Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, APRIL 12TH, 1870.DR. BURROWS, F.R.S., PRESIDENT, IN THE CHAIR.

ON EXCISION OF THE JOINTS FOR DISEASE, AND SPECIALLYOF THE KNEE, HIP, AND ELBOW.

BY FREDERICK JAMES GANT, F.R.C.S.,SURGEON TO THE ROYAL FREE HOSPITAL.

THE primary object of this paper is to lay before theSociety the conditions of disease which, in the author’s expe-rience, seem to be appropriate for excision of the joints ingeneral ; and those conditions also which specially pertainto the knee, hip, and elbow, severally, with relation to thisoperation, as illustrated by the accompanying cases.

So far as the appropriate nature of these conditions ofdisease may be established by the typical character of thecases adduced, and confirmed by an increased number, theywill represent principles whereby to determine the proprietyof performing the operation of excision in diseases of thejoints.With this view the author has appended a careful analysis

of each series of cases in regard to their pathology and theoperation itself, and its results; and also of the generalresults of excision in the cases taken collectively, and the relation of these results to the pathology of the joints sub- Ijected to operation.The necessity either for excision or for- amputation in

joint disease implies incurability by non-operative treat- Iment. As regards excision, incurability is defined to signify I,,that condition of the local disease wherein the joint has become functionally useless by destruction of the articularcartilages, without the supervention of anchylosis, but IIIwhile the constitution still retains the reserve power requi-site for the long process of reparative union-averagingthree months after removal of the diseased bone. Anyother cases-namely, of advanced local disease; if not falling within the provision of the latter clause of the defi- Inition as to the requisite constitutional reserve power, but ’,which are accompanied with prolonged hectic and exhaus- ’,tion, will be proportionately unfavourable or unfitted for ’,excision, and must be submitted to the alternative opera- ition-amputation. IAs compared with the natural cure by anchylosis, as a ’’,

possible result in joint-disease, excision would seem to bepreferable in proportion to the more prolonged period of recovery when unaided by surgical removal of the diseasedbone, a probation which entails long-continued suffering, IIand ultimately leaves the constitutional vigour reduced and Iinadequate to sustain the contingencies of disease in after-life.

Failures of the natural cure are then considered with re-gard to excision. This comprises two results: defectivekind of anchylosis for the functional use of the limb, asfibrous anchylosis in knee-joint disease, and osseous anchy-losis in elbow-joint disease; or malposition of the limb, ac-companied, perhaps, with defective anchylosis.The author then proceeds to state in extenso the patholo-

gical conditions, or those of disease, and their results fromfailures of reparation, which severally justify the operationof joint excision, and those also which specially pertain tothe knee, hip, and elbow. The histories of the illustrativecases are narrated, and their analyses appended.The following general results may be enumerated in this

abstract :-1. Excision proved successful, by one operation, in 16 out

of 20 cases of the joints referred to.2. Of the 4 unsuccessful cases, by one operation, 3 were

cases of scrofulous disease, and of the knee-joint, out of a:

total of 9 cases; the remaining one being chronic synovitis,and of the elbow-joint, out of 5 cases.

3. Re-excision was resorted to in 2 of the 4 cases ; 1 knee-

joint and 1 elbow-joint, the latter with a successful result.4. Secondary artiptttatioit in 3 of the 4 cases. All 3 were

knee-joint cases, and of scrofulous disease; 1 of which hadbeen subjected to re-excision. The 3 amputations made Irapid recoveries. These results tend to show that if the at- tempt to preserve a limb by excision, and even by re-excision, I,

of a large joint, as the knee, should fail, the operation isnot unfavourable to secondary amputation for the preserva-tion of life.

5. No death ensued in any of the 20 cases of the knee, hip,or elbow-joints, whatever had been the condition of disease,or the operation,-excision, re-excision, or secondary ampu-tation.The paper was accompanied by drawings and by specimens

of bone.Mr. SOLLY expressed his acknowledgments to Mr. Gant,

and spoke of the change which had been wrought in thefeelings of the profession with regard to excisions. Such

operations were now performed, and their value fully recog-nised, in all great hospitals; but he believed the advantagesattending them were not sufficiently recognised in thecountry; and that many limbs which might be saved wereeven now sacrificed by amputation. In cases of failure ofunion, re-excision was almost always practicable; and hebelieved the chief cause of failure of union was that the-bones were not kept perfectly still, and that the method ofputting up the limb was more likely to be at fault than theconstitution of the patient.Mr. PARTRIDGE related a case in which he excised the

knee-joint fourteen years ago, with excellent results. Quitelately the part sustained some injury, a superficial abscessformed, and was followed by caries of bone. He re-excisedthe joint, and the patient again made a good recovery.Mr. JOHN WOOD said that the full value of excision of

joints had only lately been admitted. The chief difficulty ofthe surgeon now was to know when to interfere, or ratherthe earliest period of time at which he was called upon todo so. The author of the paper had laid down one rulewhich might be of great value if we could only determinewhen its conditions were fulfilled. It was to operate whenthe cartilages were removed by ulceration. He believed,.however, independently of the difficulty of determining-when this had happened, that joints would recover not onlyafter the removal of cartilage, but after the removal of’bone itself ; and that such removal would be effected byabsorption, without there being necessity for any externalopening. While fully recognising the merits of Mr. Gant’S’,paper, he was surprised to hear in it no mention of thegreatest modern improvement in the practice of excision,-the method of gouging away the diseased bone, and leavingits periosteum, and the attachments of its muscles, undis-turbed. He also thought it important that the surgeonshould confine his incisions within the limits of induration,so as to avoid the burrowing of matter. He did not concurwith Mr. Gant in his employment of the elliptical incision.At King’s College Hospital it was now the custom to em-ploy a single straight incision across the front of the joint,-level with the head of the tibia ; and it was found that thisincision very much facilitated the application of the saw.Mr. BARWELL expressed his belief that neither the re-

moval of cartilage nor the gelatiniform degeneration of thesynovial membrane rendered excision necessary. He hadtreated such cases successfully by ordinary means, togetherwith firm pressure. With regard to the subperiosteal re-moval of bone, he referred to Dr. Sayer, of New York, bywhom that practice had been long ago advocated. He re-gretted that the author had given no particulars about thedegree of shortening of the limbs in his cases. He couldnot approve of leaving the limb to assume its own positionafter removal of the head of the femur, for he believed thatshortening was much increased by adduction. It was hisown practice in such cases always to use an interrupted-splint applied in such a manner as to abduct the limb.Mr. JOHN WOOD explained that he had not claimed

originality for the practice of leaving the periosteum, butonly for the practice of removing the bone piecemealthrough a small opening.Mr. TIMOTHY HOLMES said that the cases given by the-

author, and the principles laid down by him, were suchthat his results threw no light upon the general question ofmortality after excision. The cases were selected ones;:and in such there was an almost entire absence of risk inamputation. To have had twenty cases of excision withouta death was in itself a very gratifying fact; but he wishedto know what became of the rejected cases. Did they dieor did they undergo amputation ? He believed that, withall necessary care, many of these cases of joint diseasemight be guided to good recovery, andthat the joints would

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be more solid after spontaneous cure than after excision.He was not himself an advocate for subperiosteal resection,and believed some of those surgeons who had at one timeperformed had now seen reason to abandon it. He saw nobenefit from not severing the attachments of the muscles.In ordinary excision of the elbow, muscular attachmentswere severed very freely, and the muscles recovered fullpower and usefulness.

Mr. WILLIAM ADAMS thought we should compare ampu-tation and excision rather by considering the latter a re-source for saving limb, the former for saving life. He re-ferred to the value of persistent pain, in addition to othersymptoms of joint disease in the knee, as a symptom that- the bones were extensively implicated; and briefly describedhis own case of subcutaneous division of the neck of thefemur, with an intimation that he hoped to bring it before the Society. !

Mr. CALLENDER moved the adjournment of the debate tothe next meeting.Mr. BARWELL seconded the motion.The PRESIDENT appealed to the two ex-Presidents among

the audience with regard to the custom of the Society.Mr. PARTRIDGE said that debates had been adjourned, but

that they always languished on the second occasion, andthat the practice was not desirable.

Mr. SOLLY expressed an opposite opinion on the generalquestion, and a particular wish that the adjournment mightbe carried.On being put to the vote, it was carried almost unani-

mously, and the meeting was then rendered special for thepurpose of confirming the previous resolutions upon theamalgamation scheme.

Reviews and Notices of Books.Nouveau Dictionnaire de Médecine et de Chirurgie Pratiques.

Tome xii. DYSM-EM. Paris: Bailliere. 1870.

THIS great work is brought out with commendable punc-tuality, and the present volume is no whit behind its pre-,decessors in the importance of the subjects discussed in it,which happen to be principally obstetrical, and the treat-ment they have received. There are thirty-eight articles init, of which the following are the chief :-Dysmenorrhœa,’by M. Siredey; Dyspepsia, by M. Luton ; Dystocia, by M.Stoltz; Eau and Eaux Medecinales, and Electricity, by M.H. Buignet; Eclampsia, by Emile Bailly; Eczema and Ec-thyma, by M. Hardy; Therapeutical Action of Electricity,’by M. Jaccoud ; Embolie, by Hirtz and Strauss; Embryo-tomy, by M. Tarnier; and Empoisonnement, by M. Tar-,dieu. It is difficult, with the space at our disposal, to domore than indicate the principal points of one or two of thearticles, which must serve as an indication of the mode inwhich the others are discussed. We select that of Embolia,by MM. Hirtz and Strauss. This term, though invented byVirchow, only gives expression to an old idea, the facthaving been known to Bonet, a pathologist of the seven-teenth century, and to Van Swieten. The sources of em-bolia are very various, and may be arranged in three groups- namely, (1) substances derived from the blood itself; (2)substances derived from the vascular walls; and (3) sub-stances which have traversed the walls of the vessels, andare derived either from the adjoining tissues, or altogetherfrom without the body. In the first place, as regardsfibrinous embolism. This is produced by the transport ofolots or thrombi formed within the vessels. To form these,however, it is not sufficient that the energy of the cardiacaction should be diminished, but the walls of the vesselsmust also be diseased, either by calcareous or atheromatousdegeneration, or by aneurismal dilatation of the arteries,or by some valvular lesion in the heart, or by varicose dis-tension or phlebitis in the veins. To distinguish between aclot or thrombus formed during life and a post-mortem

coagulum, it is essential in every instance to ascertain bymicroscopical examination the presence of the old formationin the middle of the new coagulum bywhich it is surrounded;the old clot being always recognised by its stratified struc-

ture and dry character, whilst the recent clot is soft, homo-geneous, and contains red and white corpuscles in about thesame proportion as in the blood.The changes which the thrombus is capable of under-

going are, first, organisation into a solid cord, and, secondly,molecular disintegration, the essential parts breaking downinto a puriform mass. Direct experiments, which consistedin the introduction of fragments of muscle, &c., into the

jugular veins, have clearly demonstrated the power of thecurrent of blood to sweep such fragments along till theybecome impacted in the healthy pulmonary artery; andusually, by reason of their specific gravity, one of thebranches distributed to the lower lobes of the lung. In theaorta the clots usually follow the axis of the current, andhence rarely enter the carotids. The order of frequencywith which the branches of the aorta are attacked is

splenic, renal, iliac (especially the left, which is not, likethe right, crossed by the iliac vein), the carotids, subclavian,mesenteric, and cæliac axis. When the obstruction occursin the internal organs, the abolition or diminution of thefunctions is the only means by which it can be recognised.As a general rule, the nearer the heart the less serious arethe results of the occlusion of a vessel, because the collateralcirculation is in most instances so readily established ;hence it is still doubtful whether death has ever ensuedfrom the obstruction of a cerebral artery. Speaking gene-rally again, the result of an embolia is dry gangrene of thepart previously supplied by the artery. The effects of theinfarction of a pulmonary and of a splenic artery are wellgiven, and are illustrated. Certain special forms of embo-lism are described, including (1) gangrenous embolism, (2)pigmentary, (3) gaseous, and (4) fatty embolism, of which.last the occluding material seems to be derived from themedulla of bones affected with necrosis, articular suppu-ration, and complicated fractures. The pathological im-portance of embolism is then treated of, and the articleconcludes with a brief section on the general therapeuticsof embolism.The articles on Dystocia and Embryotomy appear to us

to be remarkably well worked up, containing a full accountof all the modern views, and, in the latter case, of all theinstruments that have recently been suggested in relationto their subjects. ‘

The subject of Eclampsia, by M. Emile Bailly, is also

very fully discussed. He does not, as usual, limit it to

puerperal convulsions, but considers that it may occur inboth sexes, and at all ages; and defines it to consist in thesudden supervention of convulsions, accompanied by totalloss of consciousness, and constantly associated with patho-logical conditions of the urinary function and kidneys. Stillit is common in the female during gestation, and the orderof frequency he considers to be (1) pregnancy, (2) duringlabour, and (3) in the puerperal state. Headache, mistyvision, and epigastric pain are the chief premonitory sym-ptoms. The attack resembles the fit of an epileptic, andusually lasts only one or two days, terminating then eitherin recovery, some other malady induced by the convulsions,or death. The prognosis is bad both for mother andchild. The chief morbid post-mortem changes that havebeen discovered are the so-called forms of Bright’s disease,into which the author enters at considerable length. In

regard to treatment, he approves of moderate bleeding,purgatives, diuretics, sudorifics, and nauseating doses oftartar emetic, together with acceleration of the process ofdelivery, if imminent or proceeding, as constituting the