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Lectures ON DISEASES OF THE JOINTS.
SEPTEMBER
1, 1855.
the absolute rest which is This is the error into which The case appears slight, because it has commenced in a very chronic manner ; there is little pain, ON a slight degree of swelling, and an insignificant halt in the gait. Hence the patient is allowed to walk about occasionally, or at the most is directed to repose the limb on a chair or couch. The Delivered at St. Mary’s Hospital. consequence is, that, as every motion of the limb brings an increased flow of blood to the affected tissues, the inflammaBY WILLIAM COULSON, ESQ. tory action is kept up, and the development of accidental SURGEON TO THE HOSPITAL. tissues is promoted until the disease becomes fully established. But I shall not say any more about keeping the limb in a state of absolute rest, because in my opinion repose should LECTURE XIII. always be combined with another powerful means-viz., comCHRONIC INFLAMMATION OF THE KNEE-JOINT. pression of the limb. The means employed for effecting this compression will serve, at the same time, to keep the limb in (Concluded from p. 162.) a state of rest. Observe that I say the limb and not the joint, for it is essential that the whole, or, at least, the greater part of the affected limb should be kept in a state of rest, and LET us now see what means we haveat command during submitted to compression. The utility of these two means is the first period of the disease. Antiphlogistics naturally occur admitted by all practitioners* What I would insist on is, that to you. These must not be neglected, but they will be of little they should be employed more extensively than is commonthat is to say, that the pressure should extend over a consideror no use unless seconded by means which are still more efficainstead of being confined, as often able of the cious, and these are, absolute rest of the inflamed joint, and a takesportion to a few limb, inches above and below the inflamed join, places, of the limb. But, to proceed methodically, The favourable position advantages of compression have been fully established we may divide the treatment into local and general: this latter by experience ; they may also be rationally explained. Comcomprehending remedies which act on the general health of pression of the tissues diminishes the flow of blood; this is a the patient, without reference to ths diseased part, and reme- mechanical effect. It also produces an active physiological clies which are supposed to act more particularly on the affected effect in promoting absorption of effused fluids, and preventing the organization of accidental products. The influence of compart, although admitted through the system. Of local remedies, pression in promoting absorption is well seen in the treatment of during the first stage, the first we have to notice is bloodletting. cancerous tumours by pressure. This has such an effect in Blood may be abstracted by cupping or by leeches. I prefer dissipating that portion of the tumour which depends on serous the latter. To produce any decided effect on the disease, the and plastic effusions around the malignant muscles, that some local bleeding must be repeated frequently; and hence due at- practitioners have been deceived into believing they have cured cancer by its means. For attaining the desired objects through tention must be paid to the general health of the patient, and rest and compression, a great variety of methods have been to the degree of inflammatory symptoms present. Asageneral employed. I can only notice the principal. Some surgeons rule, the leeches should be applied above the knee, and re- prefer using pressure, in such a manner that absolute rest of the peated three or four times, according to circumstances. When limb shall be ensured at the same time; others employ mere the patient is strong, and the inflammation subacute, the simple bandages, and keep the limb at rest by the use of one method, number of leeches, and their repetition will be regulated splints. Sir B. Brodie recommends sometimes sometimes another, according to the severity of the case. In .accordingly. milder cases he employs a calico bandage, with strips of adhesive Surgeons are generally agreed that bloodletting is little, if plaster in alternate layers. Another convenient bandage is at all, applicable to the numerous class of cases which occur in made of stiff leather and small spiral wires, secured by a lace. weakly or scrofulous children. From such subjects I would In cases of longer standing, when the joint is more seriously be cautious in abstracting blood more than once ; anything implicated, a greater degree of support will be required. Gutta which increases their natural debility should be avoided. percha splints may then be applied, or a broad leathern splint M. Leuret, however, remarks that antiphlogistics have been may be placed on each side of the limb. This splint is made of too generally condemned, in the treatment of scrofulous dis- stiff cow-hide, softened in warm vinegar and moulded on the eases of the joints. If we see the case at an early period, and limb, where it is allowed to dry. To these methods it has been if any active symptoms be present, he recommends leeches. objected that they do not exercise a sufficient degree of presTheir repetition will be determined by the effect produced on sure, and that they do not ensure perfect immobility of the the general health of the patient; when no bad effect results, affected parts. The same objections apply to the hollow then blood may be abstracted locally several times. splints, and to those made of gutta percha. The method employed by the late Mr. Scott I have already But, as I have many times warned you during these Lectures, neither bloodletting nor blisters nor any other remedy, described to you. The principle on which he acted was to whether local or general, will have much effect in chronic in- exercise long-continued pressure by means of bandages and flammation of the joints, unless the articulation be kept in a strips of adhesive plaster. In his hands this method perfect state of repose. This condition is absolutely necessary ; many remarkable results, chiefly, I believe, because he followed and if we see so many cases prolonged for months and years in it up with unwearied perseverance. Any degree of pressure a state of what may be called semi-cure, it is because absolute may be thus obtained; but the bandages do not fix the limb rest of the joint has been attained in an imperfect manner or for sufficiently, and a great deal of trouble is caused whenever it limited periods. This state of rest is procurable by the use of becomes necessary to removethem. When bandages are emartificial means, but as it is highly desirable that the joint ployed, flannel, I may observe to you, is a better material than should be placed at rest in a good position, this must not be calico, because it is not so liable to become loose. The common neglected. You know already what I consider a good position, starch bandage I cannot recommend. It gives strong support, generally speaking, for inflamed joints. It is one which pro- but it is very stiff and disagreeable to the patient, and cannot duces the least distension of the inflamed capsule-the least be adapted to the decreasing size of the limb as inflammation pressure on the articular surfaces; it is one which will be the subsides. For my own part I prefer exercising compression by most useful should anchylosis ensue. means of bandages or plaster strips, and rendering the limb For the knee-joint, this position consists in a very moderate immovable by properly adjusted splints. The bandages should degree of flexion, the foot remaining in its normal position. extend from the foot to the lower third of the thigh, and the No matter what the stage of the disease, we should always splints should in all cases pass down to the foot, being furnished endeavour to get the limb into this position. At the early with foot-boards, to prevent rotation of the foot. This is period of which I now speak, it is easy to bring the limb into essential. Bearing in mind these principles, the surgeon may the extended posture by mere traction with the hands : a few exercise his ingenuity with respect to the best materials to be attempts may be required, and if the muscles are strongly re- used. The degree of pressure, I need hardly remind you, must tracted, as sometimes happens, chloroform should be employed be graduated according to the condition of the affected joint. to relax them. Great benefit will be derived from fixing the It should never produce much pain ; and if it becomes painful, limb in this extended position as early as possible. But how the bandage should be removed at once. To prevent an unequal is the limb to be fixed ? Repose in bed, or on a couch, even at degree of pressure, it will be prudent to fill up all the concathe earliest
Lectures
DISEASES OF THE
period,
will not
required to promote the many practitioners fall.
ensure
cure.
JOINTS.
produced
No. 1670.
vities of the limb with thin cotton pads ; and when immovable active symptoms are present, where the joint is much swollen bandages are employed, the prominent osseous surfaces should and the swelling firm, where the patient’s health, without also be protected in a similar manner. Increased attention to being broken down, is not exactly what we could wish it to the state of the limb is required towards the close of the first be. It may be used in frictions, and given internally, under ’stage, when abscesses may be expected ; and if any discharge the form of iodine of potassium, in doses of from three to five should have taken place, the splint should be lined with oiled grains twice a day. To produce any effect, the indine must be continued for a considerable time-say a month; after which we skin. Next to the remedies just mentioned, counter-irritation must suspend its use for some days, and then resume it. Prepatake rank. This means has been employed from time imme- rations of iodine are more efficacious in scrofulous than in other morial in the treatment of chronic inflammation of the joints. cases; and the same may be said of another powerful remedyIt is used in various degrees. Sometimes the skin is merely cod-liver oil, the value of which, in the treatment of articular reddened; we then call the means employed rubefacients. diseases, has been fully established within the last few years. Sometimes a higher degree of stimulus is had recourse to; the The cod-liver oil is to be preferred to iodine in all scrofulous skin is broken; under this head we may range blisters, tartar cases, and in those in which the general health is much deteemetic ointment, &c. Finally, the extreme degree is produced riorated. M. Leuret thinks that it has more effect in cases by the use of cauteries, either the actual or potential, with where the disease begins in the bones than when the synovial which I would class setons and issues. Various kinds of rube- membrane is primarily attacked. However this may be, facients have been employed-ammonia in oil, turpentine, there is no single remedy from which so much benefit may be camphorated spirits, &c., the acids. Sir B. Brodie recoiu- expected in protracted cases of the disease as from cod-liver mends a stimulating liniment, composed of one drachm of oil. Lil-eiodine, its action seems to be somewhat transient; iodine in one ounce of alcohol, ox an acid liniment, composed and hence we should administer it for many months together. of one drachm and a half of sulphuric acid, half an ounce of Sir B. Brodie strongly recommends the preparations of iron in the spirits of turpentine, and one ounce and a half of olive oil. scrofulous form, and the syrup of iodide of iron will be found an These stimulating liniments are only applicable in very chronic excellent preparation in these cases. The other general remecases, when the swelling and pains are slight. Blisters act dies are chiefly such as act by improving the patient’s health In cases where the disease is chiefly con- and invigorating his constitution. It is particularly necessary more efficaciously. fined to the synovial membrane, they promote the absorption to improve the health by every means in our power in cases of£ of effused fluids in a remarkable manner. The blister should scrofulous affection, and when the patient’s constitution has be applied just above the joint, and be repeated frequently; been debilitated by previous disorders. The particular remedies they should not be kept open. Other substances may be em- to be selected will depend on the constitutional state with ployed in such a way as to break the skin and imitate the which the disease of the joint seems to be affected. Debilitated action of blisters; these are croton oil and tartar emetic, which subjects in large cities may require, besides a generous diet, Exposure ’to fresh air produce pustular eruptions, and tincture of iodine, which makes some moderate stimulus, as porter, &c. The tartar-emetic ointment should is necessary, and still more so gentle exercise, for scrofulous the epidermis peel off. Croton oil, patients. I have already insisted on this most essential point never be used for weakly or scrofulous children. Tinc- in the treatment. There is little use in remedies so long as in liniment or plaster, is much more manageable. ture of iodine is generally preferred. The joint may be scrofulous and debilitated subjects are shut up in our crowded painted over with this substance until the epidermis is entirely wards, breathing a vitiated air, and deprived of the healthful detached in brown scales. Counter-irritation to any great influence of the solar rays. Like flowers, they continue to extent should not be employed in scrofulous cases; but as these droop, and at length sink. Hence, whenever circumstances will admit of it, the patient should enjoy gentle exercise in cases are often characterized by effusions into the cellular tissue outside the joints, by the development of cellulo-vascular the open air, and in a sunny situation. If the limb has been tissue, and by effusions into the sub synovial cellular tissue, or properly fixed by an immovable apparatus, or by splints, underneath the periosteum, mild counter-irritation is useful. gentle exercise will not disturb the joint. Even simple expoThe plan which I adopt consists in applying a blister for a few sure to the snn, and without exercise, is preferable to remain* hours over the affected joint, and repeating its application from ing constantly in the same atmosphere within doors. time to time. In chronic cases unconnected with the scrofulous Amongst the means of invigorating the constitution, bathing diathesis, or when the disease appears to assume a tendency must not be overlooked. You are well aware of the salutary towards reparation, stimulating applications may be employed influence of sea-bathing in cases of scrofula; it may be recomwith advantage. Cauterization of the skin acts in the same mended when the active symptoms have passed away. On theway as blisters, but it is much more energetic; hence cauteries continent, artificial baths of various kinds are employed, but are not to be recommended except in very chronic cases, and in this country we prefer bathing in the sea, which is much when milder revulsives have failed to produce any effect. The more efficacious. The poor from this town we send to the actual and potential cautery has been employed; Rust was Infirmary at Margate, where every means, local and constituconstantly in the habit of using it. The actual cautery, how- tional, are employed by the surgeons of the institution for ever, is not applicable to superficial joints like the knee, and I their recovery. In the treatment of the second period of the shall not notice it here. The same remark applies to caustic disease the same indications are to be fulfilled, with the addipotass. When the use of caustic is thought advisable, it will tion of such as are connected with the formation and discharge be better to employ the Vienna paste, which is more manage- of purulent matter. Rest and pressure are to be con=nued, able than any other. Moxas and issues are sometimes useful; the apparatus being so arranged that the state of the joint can but they should not be kept open too long, else they lose their be conveniently examined from time to time, and the matter revulsive effect, and only weaken or irritate the patient. be discharged without impediment. In the long intervals The general treatment of chronic inflammation of the joints which take place between the formation of successive abscesses is of as much importance as the local treatment, and in counter-irritation is to be employed. The patient’s strength is scrofulous cases it is much more so. Indeed it is difficult to be supported by a more generous diet and increased attento understand why a disease so apparently mild in its nature tion paid to constitutional remedies. If the patient has not this often is should be so obstinate and so difficult of It is not we regard it as a mere local inflammation. always easy to discover what the nature of the general disturbance is. Many patients are attacked by disease of the knee, who seem to be of good constitution, and who tell you that they have always enjoyed good health; still I cannot help always suspecting something more than a local malady, and I would advise you in all cases to inquire most particularly about the general health of the patient, and endeavour to restore the several functions to a natural condition. The most activegeneral remedies are mercury, iodine, and cod-liver oil. Mercurial preparations are administered with most advantage in cases of synovitis, when the inflammatory symptoms are rather active, and when they have become so during one of the exacerbations to which I haveso often referred. It is unnecessary to insist on the circumstance that the general health of the patient must be such as will admit of the use of mercury. Iodine seems to be indicated rather in chronic cases, where no as
cure, if
184
until now, the contraction of the muscles will be found to be great, and the limb firmly fixed in the bent position. Repeated efforts will be required to, extend it. With the aid of chloroform these will commonly succeed; if not, an apparatus must be employed to extend the limb gradually. But the principal point to be considered during this period is the treatment of the abscesses which form around the joint. These are almost invariably derived from the matter secreted within the joint, and which has made its way out by perforation of the articular capsule. The question then arises, what are we to do when pus forms ? Some surgeons, amongst whom I may mention the celebrated Dupuytren, advise us to leave the case to Nature. I cannot recommend this practice. The abscesses which form have already a great tendency to become sinuous, and open at a distance from the joint. The local inflammation developed round these sinuses disorganizes the soft parts and keeps up irritation. The abscesses should therefore be opened; and next comes the question, in been
seen
probably
what manner should the openings be made ? Some practitioners the deformity; the tendinous sheaths of the muscles contract, advise small punctures: for many reasons, this method is become thick, and are also bound down; in short, the various inadmissible. Others open them freely in a depending situa- tissues around the joint are united into firm, resisting masses, tion : this is the method which I prefer myself. On the Con- and the limb is almost as firmly fixed in its abnormal position tinent the method proposed by M. Guerin is frequently adopted, as if the opposite surfaces of the bones were united together. and it presents some advantages. This has been called the In this country, we are not in the habit of interfering with unsubcutaneous incision, and it consists in what may be called promising cases of this kind, but Dieffenbach and other German tapping the abscesses. A small flat trocar, the extremity of surgeons have shown that they are not altogether beyond the which is furnished with eyes for the discharge of the matter, resources of our art. The method which they adopt is as while the other is closely adapted to a syringe, is passed follows :-The patient is placed on his belly on a table, the into the abscesses at a little distance from its circumference. pelvis is firmly fixed by two assistants, another holds the The trocar is then withdrawn, the canula being of course left sound limb on one side, while a fourth seizes the lower part of in; the syringe is screwed on, and the matter evacuated by the diseased limb, and keeps the parts to be divided in a state repeated strokes of the piston. When the abscesses are large, of tension. Subcutaneous division of the contracted and adthis is a good method, but the end of the canula is apt to get herent tendons &c. is now effected. The operator commences blocked up by the solid débris mixed with the pus. Towards’ with the tendon which appears most prominent and tense. the end of this stage, the ease, as I have said, may either This is sometimes the tendon of the biceps, sometimes of the exhibit a tendency to reparation and cure, or it may go on from semimembranosus or semitendinosus muscles. The operation bad to worse, tending to destroy life. These circumstances itself is quick, and very easily performed: the skin is raised, characterize the third stage of the disease, the treatment of the tenotome is passed underneath the tendon, and this latter which will naturally vary according as the disease has a is divided from within outwards. The most convenient point for dividing the tendons is about an inch above the angle tendency to cure or to kill. Let us consider the reparative tendency first. The general formed by the flexed joint. When the cutting instrument has. and local treatment, with rest of the joint, compressions, &c., been withdrawn, some force is used to extend the joint; this must be continued as before; sea-bathing and revulsives are makes certain tendinous bands salient and tense. The operation now particularly indicated; the strength must be supported by is now repeated, extension employed as before, and the several bands are divided so long as they oppose any considerable regood diet, &c. You have been informed of the condition of the joint in those sistance to the extension of the limb. A strong, folded napkin cases where reparation is taking place, and you can therefore is then passed round the knee, and held by the assistants in understand what morbid effects are to be counteracted. Your such a way as to prevent laceration of the integuments. This chief object will now be, to preserve as much motion in the done, the surgeon flexes and extends the limb with a certain limb as possible, taking, at the same time, the greatest care degree of force, in order to lacerate any cellular adhesions that your attempts in this direction do not excite inflamma- which may have been formed; if any resistance is offered by tion, and reproduce those injuries which Nature has been re- tense fibrous bands, these are likewise divided in the manner pairing. In some cases, the joint remains merely stiff, from described. This plan has been adopted here by my colleague contraction of muscles and fibrous organizations outside the Mr. Ure, with complete success. The after-treatment is joint, without anchylosis. Here we must not defer employing simple: water-dressing is applied over the points where the the necessary means too long, or we run the risk of seeing the cutting instrument has been introduced, the knee is enveloped joint become anchylosed from long inaction. Frictions with with lint, the whole limb is covered with a flannel bandage, the hand, and douches, are very useful in removing the stiffness and a strong concave splint, also lined with flannel, is applied now alluded to. But passive motion must also be employed; from the middle of the thigh to the middle of the leg. Care is and the most important question we have to settle is-When taken to fill the space between the ham and splint with pads may passive motion be commenced without danger? The of lint, and the splint is kept firmly in its place by a bandage, safest answer we can give is this: Do not commence passive or which is particularly well secured above and below the patella. active motion so long as movement of the joint occasions any If the patient do not suffer much, the splint is allowed to pain. The first movement should be made by the surgeon remain on for several weeks. When any tendency to retrachimself, who will observe the effect produced, and after some tion manifests itself during the after-treatment, the screwtime the patient may be allowed to move the joint himself. It splint must be applied, and extension made from time to time. may, however, happen that the contraction of the muscles is This may appear to you a severe operation, but it is much less so great as to require means of a special kind to overcome it. so, in reality, than it would seem to be from the description I mentioned how they were sometimes converted into fibrous of it. True anchylosis of the joint is also frequently observed after cords, while the tendons were bound down by firm adhesions to the surrounding tissues. Here, if you can ascertain, by chronic disease of the knee. If the surgeon has taken care examination of the joint, that osseous anchylosis has not taken during the course of the disease to bring the limb into a good. place, benefit may often arise from dividing the tendons of the position, the patient preserves a tolerably good use of the limb, contracted muscles. The division should be effected by sub- which is nearly straight; but in many cases the limb is bent, cutaneous incision-that is to say, by passing the point of the and the patella adheres to the femur, while a certain degree of knife through the skin, and then dividing the teudon from motion exists between this bone and the tibia. In these cases, within outwards, without cutting the integuments at the same and likewise in those where .more or less osseous union has time. Some of you may remember an operation of this kind taken place between the opposite surfaces of the joint, nothing which I performed in this hospital on a boy named Mortimer can be done for the relief of the patient; for I never would Smith, twelve years of age. He had laboured under scrofulous advise you to imitate the barbarous practice of M. Louvrier,. disease of the knee, followed by great stiffness of the joint, and endeavour to straighten the limb suddenly by violent exfrom permanent contraction of the muscles. I divided the tensions. It is true that the effects of this violence are often tendons ofthe biceps and semitendinosus and semimembranosus much less than one would be disposed to conclude that they muscles in the way I have mentioned, and then applied one of should be; but death has been the immediate result in some M’lntyre’s splints with a screw. The limb was extended by cases, while even in the most favourable the result has been these means. In other cases, the stiffness and contraction may little better than if the patient wore a wooden leg. 1M overcome by mechanical apparatus, without division of the Another effect of the disease is secondary dislocation of the muscles. The most simple means is the screw-splint just men- tibia. When this occurs, an attempt may be made to keep tioned. This treatment is only applicable to cases in which the bone in its place by means of splints. It is often easy to the rigidity and flexion of the joint are chiefly produced by reduce the displacement, but it is extremely difficult to keep muscular contraction. In many cases, where disease of the the head of the tibia from slipping back behind the external knee has been neglected, or when, from its natural progress, condyle of the femur. This tendency depends on the destruccertain changes have taken place within the joint, the treat- tion of the cartilages and end of the femur, and no effectual ment now spoken of will be unavailing. You are aware that means of counteracting it have been discovered. the complaint has often a tendency to terminate in false anchyThe treatment of the third stage of chronic disease of the losis. Here the limb presents various degrees of flexion, from knee is entirely palliative. I have described to you the various an obtuse to a right angle; sometimes, indeed, the heel is symptoms of a secondary nature, which may appear when the drawn up so far as almost to touch the buttock. This, of constitution of the patient begins to suffer under the continucourse, cannot take place without considerable retraction of ance of incurable disease. An operation is now the only rethe flexor muscles. But this is not all; the tendons of the source left, and the only questions you have to decide on are, contracted muscles become fixed to the subjacent parts by whether amputation or excision of the joint should be selected, chronic inflammation; fibrous bands of new formation increase and at what time the operationshould be performed. The
185
latter is a most important point, and one that will require very serious deliberation. We have, on the one hand, to avoid the error of removing a limb which might perhaps be saved; on the other, we have to avoid the still more serious error of sacrificing the patient’s life in an attempt to preserve his limb. The general rule which I would lay down is this: If the case has been under treatment for some time, and you are convinced that your remedies have failed to check it, then operate as soon as the general health begins to suffer from the progress of the disease. If the case has not come under your care until a late period, or if the constitutional symptoms do not make much progress, the effects of treatment may be tried for a short time, the operation being held in reserve as a last reIn scrofulous cases the rule now laid down will admit source. of some relaxation; although these cases are slow, unpromising in appearance, and often attended with considerable disorganization of the joint, yet experience proves that recoveries may take place under very discouraging circumstances. The general health of scrofulous patients is visibly improved by remedies and hygienic means; any amelioration of the health soon acts on the local disease, and hence operations on scrofulous patients of tender age may be deferred for a longer time than in other cases; in a word, until the effect of the disease on the general health is such as to render an operation indispensable. I have also insisted on the necessity of not deferring an operation too long, from remarking a circumstance connected with operations for articular disease, which appears to have escaped the notice of all writers on diseases of the joints. Numbers of patients, whose limbs have been amputated or whose joints have been excised from chronic articular disease, die of purulent infection of the blood. This is not an epidemic accident, or one confined to the hospitals of London ; it occurs in provincial practice as well as in London, abroad as well as at home. It is a very remarkable fact, which requires further investigation. In looking over the pages of THE LANCET, for example, for 1852-3, in which a mass of valuable matter connected with this subject is to be found, I observe seventeen cases reported of amputations or excision of the knee-joint for chronic disease; of these seventeen cases, eight proved fatal; and of the eight deaths, no less than five occurred from purulent infection of the blood. In the reports from provincial hospitals, published in the Medical Times, I find thirteen amputations and excisions for diseases of joints, (not including the ankle,) and of these operations four proved fatal, one-half of the mortality being occasioned by purulent infection of the blood, or pyaemia. I am not in possession of sufficient data to explain this unusual tendency to pyæmia after operations for articular disease, but I have ascertained one fact which may lead the way. In many cases I have observed that the medullary membrane of the bones or the periosteum have been inflamed in consequence of the extension of inflammation from the disorganized joint. Underneath the inflamed membranes were certain points where suppuration had taken place. Now we know that operations on debilitated subjects, performed through tissues which are the seat of suppuration, are extremely likely to be followed by purulent infection of the blood; and I am inclined to conjecture that this may be the cause of the pyaemia, in many cases, at least, after operations for diseased joints. I may also inform vou that I am acquainted with one case in which death occurred from purulent infection, though no operation had been performed. Before concluding the subject of treatment, it remains for me to notice excision of the knee-joint as a substitute for amputation of the thigh. Is excision of the ends of the bones to be recommended as a general rule ? Is excision admissible under any circumstances, or should it be rejected for the kneejoint ? If admissible, what are the particular circumstances in any given case which should lead us to prefer it to amputation ? in other respects, what are the special indications of excision ?-These, gentlemen, are interesting questions which I should like to discuss with you, but to do justice to them at the conclusion of a long lecture would be impossible. Some surgeons affirm that we should always prefer excision to amputation; others, again, condemn excision. Mr. Syme, in a recent lecture, which has excited a great deal of discussion in the medical world here, argues with considerable force against the propriety of our ever excising the knee-joint. Although I agree with Mr. Syme in a great deal that he has said, yet I cannot go so far as to condemn this operation altogether. It has its defects, but the preservation of a limb is often an object, even though the limb may not turn out a very serviceable one. The principal objections which may be raised against excision of the knee-joint are two: in the first place, a considerable time is required to ensure a cure, and
186
effect the
of the wound
of aftersix and twelve or eighteen months); in the second place, the limb, though preserved, is sometimes of little or no use to the patient. Hence the chief indications of the operation are to be derived from the general condition of the patient and from the state of the joint. In order that excision becomes admissible, the general health of the patient must not have suffered much from the disease of the joint; he must be in a condition to bear up against the long confinement and other influences to which a protracted convalescence must expose him. On the other hand, the local disease must not have proceeded too far, or destroyed the soft and hard tissues of the joint in too extensive a manner. If this be the case, and, above all, if any considerable portion of the femur be implicated, the extensive removal of parts will not only require a very protracted aftertreatment, but will leave a limb of little or no use whatever to the patient. These remarks, however, rather apply to the indications and contra-indications of the operation, and not to its results, when it is performed at a proper time and in a The results of the operation, thus perscientific manner. formed, seem to be more favourable than has been commonly supposed, and they have been very clearly set forth in an excellent memoir recently published by Mr. Butcher, of Mercers’ Hospital, Dublin. Mr. Butcher has collected no less’ than thirty-one cases of excision of the knee-joint, performed between July, 1850, and December, 1854. Of these thirty-one operations, five terminated in death; in sixteen the result is stated to have been perfect use of the limb; one produced an useful limb; the result of one is given as encouraging; one was followed by recovery, one by perfect anchylosis, while six cases were under treatment and recovering at the time of Mr. Butcher’s publication. These results are certainly very encouraging, and Mr. Butcher deserves much praise for the industry which he has shown in collecting the cases, and for his careful investigation of them. I would strongly recommend his paper to you, as likewise the reports on excision of diseased joints contained in the last two volumes of THx LANCET. Next to seeing cases yourself, the greatest advantage will be derived from meditating on these faithful portraits of,
complete healing
treatment, in fact, generally extending
disease and
(the period
over
practice. CONTRIBUTIONS TO
THE
PHILOSOPHY
OF
ZOOLOGY,
WITH SPECIAL REFERENCE TO
THE NATURAL HISTORY OF MAN.
BY ROBERT
KNOX, M.D., F.R.S. EDIN.,
LECTURER ON ANATOMY, AND
CORRESPONDING MEMBER OF THE ACADEMY
OF MEDICINE OF FRANCE.
"A magnificent temple is a laudable monument of national taste and religion ; and the enthusiast who entered the dome of St. Sophia might be tempted to suppose that it was the residence, or even the workmanship, of the Deity. Yet how dull is the artifice, how insignificant is the labour, if it be compared with the formation ot the vilest insect that crawls upon the’ surface of the temple !"-GIBBON. Decline and Fall.
PART I. CHAPTER
V.
-
ON THE DENTITION AS A NATURAL HISTORY CHARACTER, AND AS AN EVIDENCE OF THE EXISTENCE OF A TYPE; CERTAIN BUT UNKNOWN.
The Dentition
of
the Vertebrata.-The hard
parts, termed
teeth, besides forming valuable characteristics in zoology, assist,
by their durability, in detecting the signification of the fossil world. They furnish, moreover, a valuable illustration of the doctrine of Type; and, with this double view, I have introduced into this section an inquiry into the dentition of a single natural family to which I happen to have paid much attention - the Salmonidas. The inquiry, moreover, is based on a class of animals whose structure, more than that of any other, has contributed to the advancement of philosophic anatomy. The principles resulting from this inquiry, if rightly conducted, must be universally applicable; if not, they cannot be true: there must be something wrong in the generalization, or some error in the details leading to the generalization. But neither circumstance affects the laws of unity and of type, which apply to all or none. But in this chapter I aim at something more than a mere sketch of the philosophy of the teeth in a particular class of the
1, 1855.
the absolute rest which is This is the error into which The case appears slight, because it has commenced in a very chronic manner ; there is little pain, ON a slight degree of swelling, and an insignificant halt in the gait. Hence the patient is allowed to walk about occasionally, or at the most is directed to repose the limb on a chair or couch. The Delivered at St. Mary’s Hospital. consequence is, that, as every motion of the limb brings an increased flow of blood to the affected tissues, the inflammaBY WILLIAM COULSON, ESQ. tory action is kept up, and the development of accidental SURGEON TO THE HOSPITAL. tissues is promoted until the disease becomes fully established. But I shall not say any more about keeping the limb in a state of absolute rest, because in my opinion repose should LECTURE XIII. always be combined with another powerful means-viz., comCHRONIC INFLAMMATION OF THE KNEE-JOINT. pression of the limb. The means employed for effecting this compression will serve, at the same time, to keep the limb in (Concluded from p. 162.) a state of rest. Observe that I say the limb and not the joint, for it is essential that the whole, or, at least, the greater part of the affected limb should be kept in a state of rest, and LET us now see what means we haveat command during submitted to compression. The utility of these two means is the first period of the disease. Antiphlogistics naturally occur admitted by all practitioners* What I would insist on is, that to you. These must not be neglected, but they will be of little they should be employed more extensively than is commonthat is to say, that the pressure should extend over a consideror no use unless seconded by means which are still more efficainstead of being confined, as often able of the cious, and these are, absolute rest of the inflamed joint, and a takesportion to a few limb, inches above and below the inflamed join, places, of the limb. But, to proceed methodically, The favourable position advantages of compression have been fully established we may divide the treatment into local and general: this latter by experience ; they may also be rationally explained. Comcomprehending remedies which act on the general health of pression of the tissues diminishes the flow of blood; this is a the patient, without reference to ths diseased part, and reme- mechanical effect. It also produces an active physiological clies which are supposed to act more particularly on the affected effect in promoting absorption of effused fluids, and preventing the organization of accidental products. The influence of compart, although admitted through the system. Of local remedies, pression in promoting absorption is well seen in the treatment of during the first stage, the first we have to notice is bloodletting. cancerous tumours by pressure. This has such an effect in Blood may be abstracted by cupping or by leeches. I prefer dissipating that portion of the tumour which depends on serous the latter. To produce any decided effect on the disease, the and plastic effusions around the malignant muscles, that some local bleeding must be repeated frequently; and hence due at- practitioners have been deceived into believing they have cured cancer by its means. For attaining the desired objects through tention must be paid to the general health of the patient, and rest and compression, a great variety of methods have been to the degree of inflammatory symptoms present. Asageneral employed. I can only notice the principal. Some surgeons rule, the leeches should be applied above the knee, and re- prefer using pressure, in such a manner that absolute rest of the peated three or four times, according to circumstances. When limb shall be ensured at the same time; others employ mere the patient is strong, and the inflammation subacute, the simple bandages, and keep the limb at rest by the use of one method, number of leeches, and their repetition will be regulated splints. Sir B. Brodie recommends sometimes sometimes another, according to the severity of the case. In .accordingly. milder cases he employs a calico bandage, with strips of adhesive Surgeons are generally agreed that bloodletting is little, if plaster in alternate layers. Another convenient bandage is at all, applicable to the numerous class of cases which occur in made of stiff leather and small spiral wires, secured by a lace. weakly or scrofulous children. From such subjects I would In cases of longer standing, when the joint is more seriously be cautious in abstracting blood more than once ; anything implicated, a greater degree of support will be required. Gutta which increases their natural debility should be avoided. percha splints may then be applied, or a broad leathern splint M. Leuret, however, remarks that antiphlogistics have been may be placed on each side of the limb. This splint is made of too generally condemned, in the treatment of scrofulous dis- stiff cow-hide, softened in warm vinegar and moulded on the eases of the joints. If we see the case at an early period, and limb, where it is allowed to dry. To these methods it has been if any active symptoms be present, he recommends leeches. objected that they do not exercise a sufficient degree of presTheir repetition will be determined by the effect produced on sure, and that they do not ensure perfect immobility of the the general health of the patient; when no bad effect results, affected parts. The same objections apply to the hollow then blood may be abstracted locally several times. splints, and to those made of gutta percha. The method employed by the late Mr. Scott I have already But, as I have many times warned you during these Lectures, neither bloodletting nor blisters nor any other remedy, described to you. The principle on which he acted was to whether local or general, will have much effect in chronic in- exercise long-continued pressure by means of bandages and flammation of the joints, unless the articulation be kept in a strips of adhesive plaster. In his hands this method perfect state of repose. This condition is absolutely necessary ; many remarkable results, chiefly, I believe, because he followed and if we see so many cases prolonged for months and years in it up with unwearied perseverance. Any degree of pressure a state of what may be called semi-cure, it is because absolute may be thus obtained; but the bandages do not fix the limb rest of the joint has been attained in an imperfect manner or for sufficiently, and a great deal of trouble is caused whenever it limited periods. This state of rest is procurable by the use of becomes necessary to removethem. When bandages are emartificial means, but as it is highly desirable that the joint ployed, flannel, I may observe to you, is a better material than should be placed at rest in a good position, this must not be calico, because it is not so liable to become loose. The common neglected. You know already what I consider a good position, starch bandage I cannot recommend. It gives strong support, generally speaking, for inflamed joints. It is one which pro- but it is very stiff and disagreeable to the patient, and cannot duces the least distension of the inflamed capsule-the least be adapted to the decreasing size of the limb as inflammation pressure on the articular surfaces; it is one which will be the subsides. For my own part I prefer exercising compression by most useful should anchylosis ensue. means of bandages or plaster strips, and rendering the limb For the knee-joint, this position consists in a very moderate immovable by properly adjusted splints. The bandages should degree of flexion, the foot remaining in its normal position. extend from the foot to the lower third of the thigh, and the No matter what the stage of the disease, we should always splints should in all cases pass down to the foot, being furnished endeavour to get the limb into this position. At the early with foot-boards, to prevent rotation of the foot. This is period of which I now speak, it is easy to bring the limb into essential. Bearing in mind these principles, the surgeon may the extended posture by mere traction with the hands : a few exercise his ingenuity with respect to the best materials to be attempts may be required, and if the muscles are strongly re- used. The degree of pressure, I need hardly remind you, must tracted, as sometimes happens, chloroform should be employed be graduated according to the condition of the affected joint. to relax them. Great benefit will be derived from fixing the It should never produce much pain ; and if it becomes painful, limb in this extended position as early as possible. But how the bandage should be removed at once. To prevent an unequal is the limb to be fixed ? Repose in bed, or on a couch, even at degree of pressure, it will be prudent to fill up all the concathe earliest
Lectures
DISEASES OF THE
period,
will not
required to promote the many practitioners fall.
ensure
cure.
JOINTS.
produced
No. 1670.
vities of the limb with thin cotton pads ; and when immovable active symptoms are present, where the joint is much swollen bandages are employed, the prominent osseous surfaces should and the swelling firm, where the patient’s health, without also be protected in a similar manner. Increased attention to being broken down, is not exactly what we could wish it to the state of the limb is required towards the close of the first be. It may be used in frictions, and given internally, under ’stage, when abscesses may be expected ; and if any discharge the form of iodine of potassium, in doses of from three to five should have taken place, the splint should be lined with oiled grains twice a day. To produce any effect, the indine must be continued for a considerable time-say a month; after which we skin. Next to the remedies just mentioned, counter-irritation must suspend its use for some days, and then resume it. Prepatake rank. This means has been employed from time imme- rations of iodine are more efficacious in scrofulous than in other morial in the treatment of chronic inflammation of the joints. cases; and the same may be said of another powerful remedyIt is used in various degrees. Sometimes the skin is merely cod-liver oil, the value of which, in the treatment of articular reddened; we then call the means employed rubefacients. diseases, has been fully established within the last few years. Sometimes a higher degree of stimulus is had recourse to; the The cod-liver oil is to be preferred to iodine in all scrofulous skin is broken; under this head we may range blisters, tartar cases, and in those in which the general health is much deteemetic ointment, &c. Finally, the extreme degree is produced riorated. M. Leuret thinks that it has more effect in cases by the use of cauteries, either the actual or potential, with where the disease begins in the bones than when the synovial which I would class setons and issues. Various kinds of rube- membrane is primarily attacked. However this may be, facients have been employed-ammonia in oil, turpentine, there is no single remedy from which so much benefit may be camphorated spirits, &c., the acids. Sir B. Brodie recoiu- expected in protracted cases of the disease as from cod-liver mends a stimulating liniment, composed of one drachm of oil. Lil-eiodine, its action seems to be somewhat transient; iodine in one ounce of alcohol, ox an acid liniment, composed and hence we should administer it for many months together. of one drachm and a half of sulphuric acid, half an ounce of Sir B. Brodie strongly recommends the preparations of iron in the spirits of turpentine, and one ounce and a half of olive oil. scrofulous form, and the syrup of iodide of iron will be found an These stimulating liniments are only applicable in very chronic excellent preparation in these cases. The other general remecases, when the swelling and pains are slight. Blisters act dies are chiefly such as act by improving the patient’s health In cases where the disease is chiefly con- and invigorating his constitution. It is particularly necessary more efficaciously. fined to the synovial membrane, they promote the absorption to improve the health by every means in our power in cases of£ of effused fluids in a remarkable manner. The blister should scrofulous affection, and when the patient’s constitution has be applied just above the joint, and be repeated frequently; been debilitated by previous disorders. The particular remedies they should not be kept open. Other substances may be em- to be selected will depend on the constitutional state with ployed in such a way as to break the skin and imitate the which the disease of the joint seems to be affected. Debilitated action of blisters; these are croton oil and tartar emetic, which subjects in large cities may require, besides a generous diet, Exposure ’to fresh air produce pustular eruptions, and tincture of iodine, which makes some moderate stimulus, as porter, &c. The tartar-emetic ointment should is necessary, and still more so gentle exercise, for scrofulous the epidermis peel off. Croton oil, patients. I have already insisted on this most essential point never be used for weakly or scrofulous children. Tinc- in the treatment. There is little use in remedies so long as in liniment or plaster, is much more manageable. ture of iodine is generally preferred. The joint may be scrofulous and debilitated subjects are shut up in our crowded painted over with this substance until the epidermis is entirely wards, breathing a vitiated air, and deprived of the healthful detached in brown scales. Counter-irritation to any great influence of the solar rays. Like flowers, they continue to extent should not be employed in scrofulous cases; but as these droop, and at length sink. Hence, whenever circumstances will admit of it, the patient should enjoy gentle exercise in cases are often characterized by effusions into the cellular tissue outside the joints, by the development of cellulo-vascular the open air, and in a sunny situation. If the limb has been tissue, and by effusions into the sub synovial cellular tissue, or properly fixed by an immovable apparatus, or by splints, underneath the periosteum, mild counter-irritation is useful. gentle exercise will not disturb the joint. Even simple expoThe plan which I adopt consists in applying a blister for a few sure to the snn, and without exercise, is preferable to remain* hours over the affected joint, and repeating its application from ing constantly in the same atmosphere within doors. time to time. In chronic cases unconnected with the scrofulous Amongst the means of invigorating the constitution, bathing diathesis, or when the disease appears to assume a tendency must not be overlooked. You are well aware of the salutary towards reparation, stimulating applications may be employed influence of sea-bathing in cases of scrofula; it may be recomwith advantage. Cauterization of the skin acts in the same mended when the active symptoms have passed away. On theway as blisters, but it is much more energetic; hence cauteries continent, artificial baths of various kinds are employed, but are not to be recommended except in very chronic cases, and in this country we prefer bathing in the sea, which is much when milder revulsives have failed to produce any effect. The more efficacious. The poor from this town we send to the actual and potential cautery has been employed; Rust was Infirmary at Margate, where every means, local and constituconstantly in the habit of using it. The actual cautery, how- tional, are employed by the surgeons of the institution for ever, is not applicable to superficial joints like the knee, and I their recovery. In the treatment of the second period of the shall not notice it here. The same remark applies to caustic disease the same indications are to be fulfilled, with the addipotass. When the use of caustic is thought advisable, it will tion of such as are connected with the formation and discharge be better to employ the Vienna paste, which is more manage- of purulent matter. Rest and pressure are to be con=nued, able than any other. Moxas and issues are sometimes useful; the apparatus being so arranged that the state of the joint can but they should not be kept open too long, else they lose their be conveniently examined from time to time, and the matter revulsive effect, and only weaken or irritate the patient. be discharged without impediment. In the long intervals The general treatment of chronic inflammation of the joints which take place between the formation of successive abscesses is of as much importance as the local treatment, and in counter-irritation is to be employed. The patient’s strength is scrofulous cases it is much more so. Indeed it is difficult to be supported by a more generous diet and increased attento understand why a disease so apparently mild in its nature tion paid to constitutional remedies. If the patient has not this often is should be so obstinate and so difficult of It is not we regard it as a mere local inflammation. always easy to discover what the nature of the general disturbance is. Many patients are attacked by disease of the knee, who seem to be of good constitution, and who tell you that they have always enjoyed good health; still I cannot help always suspecting something more than a local malady, and I would advise you in all cases to inquire most particularly about the general health of the patient, and endeavour to restore the several functions to a natural condition. The most activegeneral remedies are mercury, iodine, and cod-liver oil. Mercurial preparations are administered with most advantage in cases of synovitis, when the inflammatory symptoms are rather active, and when they have become so during one of the exacerbations to which I haveso often referred. It is unnecessary to insist on the circumstance that the general health of the patient must be such as will admit of the use of mercury. Iodine seems to be indicated rather in chronic cases, where no as
cure, if
184
until now, the contraction of the muscles will be found to be great, and the limb firmly fixed in the bent position. Repeated efforts will be required to, extend it. With the aid of chloroform these will commonly succeed; if not, an apparatus must be employed to extend the limb gradually. But the principal point to be considered during this period is the treatment of the abscesses which form around the joint. These are almost invariably derived from the matter secreted within the joint, and which has made its way out by perforation of the articular capsule. The question then arises, what are we to do when pus forms ? Some surgeons, amongst whom I may mention the celebrated Dupuytren, advise us to leave the case to Nature. I cannot recommend this practice. The abscesses which form have already a great tendency to become sinuous, and open at a distance from the joint. The local inflammation developed round these sinuses disorganizes the soft parts and keeps up irritation. The abscesses should therefore be opened; and next comes the question, in been
seen
probably
what manner should the openings be made ? Some practitioners the deformity; the tendinous sheaths of the muscles contract, advise small punctures: for many reasons, this method is become thick, and are also bound down; in short, the various inadmissible. Others open them freely in a depending situa- tissues around the joint are united into firm, resisting masses, tion : this is the method which I prefer myself. On the Con- and the limb is almost as firmly fixed in its abnormal position tinent the method proposed by M. Guerin is frequently adopted, as if the opposite surfaces of the bones were united together. and it presents some advantages. This has been called the In this country, we are not in the habit of interfering with unsubcutaneous incision, and it consists in what may be called promising cases of this kind, but Dieffenbach and other German tapping the abscesses. A small flat trocar, the extremity of surgeons have shown that they are not altogether beyond the which is furnished with eyes for the discharge of the matter, resources of our art. The method which they adopt is as while the other is closely adapted to a syringe, is passed follows :-The patient is placed on his belly on a table, the into the abscesses at a little distance from its circumference. pelvis is firmly fixed by two assistants, another holds the The trocar is then withdrawn, the canula being of course left sound limb on one side, while a fourth seizes the lower part of in; the syringe is screwed on, and the matter evacuated by the diseased limb, and keeps the parts to be divided in a state repeated strokes of the piston. When the abscesses are large, of tension. Subcutaneous division of the contracted and adthis is a good method, but the end of the canula is apt to get herent tendons &c. is now effected. The operator commences blocked up by the solid débris mixed with the pus. Towards’ with the tendon which appears most prominent and tense. the end of this stage, the ease, as I have said, may either This is sometimes the tendon of the biceps, sometimes of the exhibit a tendency to reparation and cure, or it may go on from semimembranosus or semitendinosus muscles. The operation bad to worse, tending to destroy life. These circumstances itself is quick, and very easily performed: the skin is raised, characterize the third stage of the disease, the treatment of the tenotome is passed underneath the tendon, and this latter which will naturally vary according as the disease has a is divided from within outwards. The most convenient point for dividing the tendons is about an inch above the angle tendency to cure or to kill. Let us consider the reparative tendency first. The general formed by the flexed joint. When the cutting instrument has. and local treatment, with rest of the joint, compressions, &c., been withdrawn, some force is used to extend the joint; this must be continued as before; sea-bathing and revulsives are makes certain tendinous bands salient and tense. The operation now particularly indicated; the strength must be supported by is now repeated, extension employed as before, and the several bands are divided so long as they oppose any considerable regood diet, &c. You have been informed of the condition of the joint in those sistance to the extension of the limb. A strong, folded napkin cases where reparation is taking place, and you can therefore is then passed round the knee, and held by the assistants in understand what morbid effects are to be counteracted. Your such a way as to prevent laceration of the integuments. This chief object will now be, to preserve as much motion in the done, the surgeon flexes and extends the limb with a certain limb as possible, taking, at the same time, the greatest care degree of force, in order to lacerate any cellular adhesions that your attempts in this direction do not excite inflamma- which may have been formed; if any resistance is offered by tion, and reproduce those injuries which Nature has been re- tense fibrous bands, these are likewise divided in the manner pairing. In some cases, the joint remains merely stiff, from described. This plan has been adopted here by my colleague contraction of muscles and fibrous organizations outside the Mr. Ure, with complete success. The after-treatment is joint, without anchylosis. Here we must not defer employing simple: water-dressing is applied over the points where the the necessary means too long, or we run the risk of seeing the cutting instrument has been introduced, the knee is enveloped joint become anchylosed from long inaction. Frictions with with lint, the whole limb is covered with a flannel bandage, the hand, and douches, are very useful in removing the stiffness and a strong concave splint, also lined with flannel, is applied now alluded to. But passive motion must also be employed; from the middle of the thigh to the middle of the leg. Care is and the most important question we have to settle is-When taken to fill the space between the ham and splint with pads may passive motion be commenced without danger? The of lint, and the splint is kept firmly in its place by a bandage, safest answer we can give is this: Do not commence passive or which is particularly well secured above and below the patella. active motion so long as movement of the joint occasions any If the patient do not suffer much, the splint is allowed to pain. The first movement should be made by the surgeon remain on for several weeks. When any tendency to retrachimself, who will observe the effect produced, and after some tion manifests itself during the after-treatment, the screwtime the patient may be allowed to move the joint himself. It splint must be applied, and extension made from time to time. may, however, happen that the contraction of the muscles is This may appear to you a severe operation, but it is much less so great as to require means of a special kind to overcome it. so, in reality, than it would seem to be from the description I mentioned how they were sometimes converted into fibrous of it. True anchylosis of the joint is also frequently observed after cords, while the tendons were bound down by firm adhesions to the surrounding tissues. Here, if you can ascertain, by chronic disease of the knee. If the surgeon has taken care examination of the joint, that osseous anchylosis has not taken during the course of the disease to bring the limb into a good. place, benefit may often arise from dividing the tendons of the position, the patient preserves a tolerably good use of the limb, contracted muscles. The division should be effected by sub- which is nearly straight; but in many cases the limb is bent, cutaneous incision-that is to say, by passing the point of the and the patella adheres to the femur, while a certain degree of knife through the skin, and then dividing the teudon from motion exists between this bone and the tibia. In these cases, within outwards, without cutting the integuments at the same and likewise in those where .more or less osseous union has time. Some of you may remember an operation of this kind taken place between the opposite surfaces of the joint, nothing which I performed in this hospital on a boy named Mortimer can be done for the relief of the patient; for I never would Smith, twelve years of age. He had laboured under scrofulous advise you to imitate the barbarous practice of M. Louvrier,. disease of the knee, followed by great stiffness of the joint, and endeavour to straighten the limb suddenly by violent exfrom permanent contraction of the muscles. I divided the tensions. It is true that the effects of this violence are often tendons ofthe biceps and semitendinosus and semimembranosus much less than one would be disposed to conclude that they muscles in the way I have mentioned, and then applied one of should be; but death has been the immediate result in some M’lntyre’s splints with a screw. The limb was extended by cases, while even in the most favourable the result has been these means. In other cases, the stiffness and contraction may little better than if the patient wore a wooden leg. 1M overcome by mechanical apparatus, without division of the Another effect of the disease is secondary dislocation of the muscles. The most simple means is the screw-splint just men- tibia. When this occurs, an attempt may be made to keep tioned. This treatment is only applicable to cases in which the bone in its place by means of splints. It is often easy to the rigidity and flexion of the joint are chiefly produced by reduce the displacement, but it is extremely difficult to keep muscular contraction. In many cases, where disease of the the head of the tibia from slipping back behind the external knee has been neglected, or when, from its natural progress, condyle of the femur. This tendency depends on the destruccertain changes have taken place within the joint, the treat- tion of the cartilages and end of the femur, and no effectual ment now spoken of will be unavailing. You are aware that means of counteracting it have been discovered. the complaint has often a tendency to terminate in false anchyThe treatment of the third stage of chronic disease of the losis. Here the limb presents various degrees of flexion, from knee is entirely palliative. I have described to you the various an obtuse to a right angle; sometimes, indeed, the heel is symptoms of a secondary nature, which may appear when the drawn up so far as almost to touch the buttock. This, of constitution of the patient begins to suffer under the continucourse, cannot take place without considerable retraction of ance of incurable disease. An operation is now the only rethe flexor muscles. But this is not all; the tendons of the source left, and the only questions you have to decide on are, contracted muscles become fixed to the subjacent parts by whether amputation or excision of the joint should be selected, chronic inflammation; fibrous bands of new formation increase and at what time the operationshould be performed. The
185
latter is a most important point, and one that will require very serious deliberation. We have, on the one hand, to avoid the error of removing a limb which might perhaps be saved; on the other, we have to avoid the still more serious error of sacrificing the patient’s life in an attempt to preserve his limb. The general rule which I would lay down is this: If the case has been under treatment for some time, and you are convinced that your remedies have failed to check it, then operate as soon as the general health begins to suffer from the progress of the disease. If the case has not come under your care until a late period, or if the constitutional symptoms do not make much progress, the effects of treatment may be tried for a short time, the operation being held in reserve as a last reIn scrofulous cases the rule now laid down will admit source. of some relaxation; although these cases are slow, unpromising in appearance, and often attended with considerable disorganization of the joint, yet experience proves that recoveries may take place under very discouraging circumstances. The general health of scrofulous patients is visibly improved by remedies and hygienic means; any amelioration of the health soon acts on the local disease, and hence operations on scrofulous patients of tender age may be deferred for a longer time than in other cases; in a word, until the effect of the disease on the general health is such as to render an operation indispensable. I have also insisted on the necessity of not deferring an operation too long, from remarking a circumstance connected with operations for articular disease, which appears to have escaped the notice of all writers on diseases of the joints. Numbers of patients, whose limbs have been amputated or whose joints have been excised from chronic articular disease, die of purulent infection of the blood. This is not an epidemic accident, or one confined to the hospitals of London ; it occurs in provincial practice as well as in London, abroad as well as at home. It is a very remarkable fact, which requires further investigation. In looking over the pages of THE LANCET, for example, for 1852-3, in which a mass of valuable matter connected with this subject is to be found, I observe seventeen cases reported of amputations or excision of the knee-joint for chronic disease; of these seventeen cases, eight proved fatal; and of the eight deaths, no less than five occurred from purulent infection of the blood. In the reports from provincial hospitals, published in the Medical Times, I find thirteen amputations and excisions for diseases of joints, (not including the ankle,) and of these operations four proved fatal, one-half of the mortality being occasioned by purulent infection of the blood, or pyaemia. I am not in possession of sufficient data to explain this unusual tendency to pyæmia after operations for articular disease, but I have ascertained one fact which may lead the way. In many cases I have observed that the medullary membrane of the bones or the periosteum have been inflamed in consequence of the extension of inflammation from the disorganized joint. Underneath the inflamed membranes were certain points where suppuration had taken place. Now we know that operations on debilitated subjects, performed through tissues which are the seat of suppuration, are extremely likely to be followed by purulent infection of the blood; and I am inclined to conjecture that this may be the cause of the pyaemia, in many cases, at least, after operations for diseased joints. I may also inform vou that I am acquainted with one case in which death occurred from purulent infection, though no operation had been performed. Before concluding the subject of treatment, it remains for me to notice excision of the knee-joint as a substitute for amputation of the thigh. Is excision of the ends of the bones to be recommended as a general rule ? Is excision admissible under any circumstances, or should it be rejected for the kneejoint ? If admissible, what are the particular circumstances in any given case which should lead us to prefer it to amputation ? in other respects, what are the special indications of excision ?-These, gentlemen, are interesting questions which I should like to discuss with you, but to do justice to them at the conclusion of a long lecture would be impossible. Some surgeons affirm that we should always prefer excision to amputation; others, again, condemn excision. Mr. Syme, in a recent lecture, which has excited a great deal of discussion in the medical world here, argues with considerable force against the propriety of our ever excising the knee-joint. Although I agree with Mr. Syme in a great deal that he has said, yet I cannot go so far as to condemn this operation altogether. It has its defects, but the preservation of a limb is often an object, even though the limb may not turn out a very serviceable one. The principal objections which may be raised against excision of the knee-joint are two: in the first place, a considerable time is required to ensure a cure, and
186
effect the
of the wound
of aftersix and twelve or eighteen months); in the second place, the limb, though preserved, is sometimes of little or no use to the patient. Hence the chief indications of the operation are to be derived from the general condition of the patient and from the state of the joint. In order that excision becomes admissible, the general health of the patient must not have suffered much from the disease of the joint; he must be in a condition to bear up against the long confinement and other influences to which a protracted convalescence must expose him. On the other hand, the local disease must not have proceeded too far, or destroyed the soft and hard tissues of the joint in too extensive a manner. If this be the case, and, above all, if any considerable portion of the femur be implicated, the extensive removal of parts will not only require a very protracted aftertreatment, but will leave a limb of little or no use whatever to the patient. These remarks, however, rather apply to the indications and contra-indications of the operation, and not to its results, when it is performed at a proper time and in a The results of the operation, thus perscientific manner. formed, seem to be more favourable than has been commonly supposed, and they have been very clearly set forth in an excellent memoir recently published by Mr. Butcher, of Mercers’ Hospital, Dublin. Mr. Butcher has collected no less’ than thirty-one cases of excision of the knee-joint, performed between July, 1850, and December, 1854. Of these thirty-one operations, five terminated in death; in sixteen the result is stated to have been perfect use of the limb; one produced an useful limb; the result of one is given as encouraging; one was followed by recovery, one by perfect anchylosis, while six cases were under treatment and recovering at the time of Mr. Butcher’s publication. These results are certainly very encouraging, and Mr. Butcher deserves much praise for the industry which he has shown in collecting the cases, and for his careful investigation of them. I would strongly recommend his paper to you, as likewise the reports on excision of diseased joints contained in the last two volumes of THx LANCET. Next to seeing cases yourself, the greatest advantage will be derived from meditating on these faithful portraits of,
complete healing
treatment, in fact, generally extending
disease and
(the period
over
practice. CONTRIBUTIONS TO
THE
PHILOSOPHY
OF
ZOOLOGY,
WITH SPECIAL REFERENCE TO
THE NATURAL HISTORY OF MAN.
BY ROBERT
KNOX, M.D., F.R.S. EDIN.,
LECTURER ON ANATOMY, AND
CORRESPONDING MEMBER OF THE ACADEMY
OF MEDICINE OF FRANCE.
"A magnificent temple is a laudable monument of national taste and religion ; and the enthusiast who entered the dome of St. Sophia might be tempted to suppose that it was the residence, or even the workmanship, of the Deity. Yet how dull is the artifice, how insignificant is the labour, if it be compared with the formation ot the vilest insect that crawls upon the’ surface of the temple !"-GIBBON. Decline and Fall.
PART I. CHAPTER
V.
-
ON THE DENTITION AS A NATURAL HISTORY CHARACTER, AND AS AN EVIDENCE OF THE EXISTENCE OF A TYPE; CERTAIN BUT UNKNOWN.
The Dentition
of
the Vertebrata.-The hard
parts, termed
teeth, besides forming valuable characteristics in zoology, assist,
by their durability, in detecting the signification of the fossil world. They furnish, moreover, a valuable illustration of the doctrine of Type; and, with this double view, I have introduced into this section an inquiry into the dentition of a single natural family to which I happen to have paid much attention - the Salmonidas. The inquiry, moreover, is based on a class of animals whose structure, more than that of any other, has contributed to the advancement of philosophic anatomy. The principles resulting from this inquiry, if rightly conducted, must be universally applicable; if not, they cannot be true: there must be something wrong in the generalization, or some error in the details leading to the generalization. But neither circumstance affects the laws of unity and of type, which apply to all or none. But in this chapter I aim at something more than a mere sketch of the philosophy of the teeth in a particular class of the