flexor muscles, with a view of straightening the limb. It proved, as predicted, impossible to straighten the leg, owing to the tension of the soft parts in the popliteal region. This condition is generally found to exist in children who have long suffered from that flexion of the knee by which the head of the tibia is removed from direct pressure upon the extremity of the femur; and it has been explained by some writers, that the femur becomes overgrown by the removal of the pressure of the tibia from its extremity. It seems much more rational, however, to explain the tension of the tissues of the ham in these cases by the long-continued contraction which has existed. It is certain that, by the most accurate measurement made in this case of the two femurs, no difference in length could be detected.

Failing in my effort, a consultation was held with Dr. James R. Wood, as to the propriety either of excision of the knee, thus straightening the leg and ankylosing the knee, or amputation at the knee-joint. Dr. Wood emphatically favored amputation. Excision of a healthy knee-joint he regarded as full of danger, however antiseptics might be employed, and he would not give his consent to the operation under any such circumstances. After a few weeks' delay, excision was determined upon and was performed with antiseptic precautions. At that time, the details of antiseptic dressings differed much from those now relied on and so rigidly enforced. The small room in which the operation was performed was subjected to disinfection with a spray-apparatus, loaned by Dr. Sass, which threw two jets of vapor. This vapor created a mist so tempered with carbolic acid that, while the odor of the disinfectant was perceptible, no inconvenience was experienced. The whole room appeared as if filled with a light fog. All the attendants were subjected to this atmosphere for ten minutes before the operation was begun. No spray was used directly on the wound, but it was continued in the room during the operation. An incision was made directly over the center of the patella, and this bone was divided. A section of the extremity of the condyles was then made, inclining from below upward, so as to give the requisite angle to the ankylosed knee. A sufficient extent of bone was not, however, removed, and a second, a third, and a fourth section was made, before the femur was so shortened as to admit of proper extension of the leg. The tissues covering the head of

the tibia were not disturbed, nor were the crucial ligaments divided. Two silver-wire sutures were employed to maintain the bones in apposition. The two halves of the patella lay in easy apposition, but, to prevent displacement, a wire suture was inserted. The limb was fixed in position by a light plaster-ofParis bandage, and was placed in a suspension-apparatus.

The wound healed without suppuration, and at the end of four weeks the patient was again moving about on crutches. There was still considerable movement at the knee. In eight weeks he began to bear some weight on the foot, and the consolidation was then firmer, but not complete. At the end of twelve weeks he was walking without crutch or cane, but with some imperfection of gait, owing to the ankylosis, which was not yet so perfect but that some motion, though very slight, could be obtained. In four months the consolidation, though fibrous, was so firm that motion could not be detected. He had now acquired an elasticity in his movements which so concealed the imperfection of the leg, due to stiffening of the knee, that it was difficult to detect his infirmity. About this time I exhibited him to Dr. Wood as a boy who had an affection of one of his legs which impaired his gait, and asked his advice as to the proper procedure to remedy the defect. He did not recognize the lad as the patient whom he had formerly seen, and, after directing him first to walk and then to run, declared that he saw nothing wrong in his movements.

The boy continued under observation for a year or more, during which time the left leg enlarged considerably, and his gait was nearly perfect.

CASE II. This patient was not unlike the former as to the condition of the leg. She had suffered from infantile paralysis, and the position of the leg was such that she could touch the toes to the floor, but could not bear any weight upon the limb. The head of the tibia was displaced backward on the femur, the leg was flexed, and the foot was everted. The entire limb was greatly atrophied, but not more than half an inch of shortening of the bones of the leg could be made out. The knee was not affected, but the leg could not be straightened from its flexed position without great tension of the soft parts. She had always walked with a crutch upon the affected side, simply touching the toes of that foot to the ground. The question of excision or amputation was

sharply discussed in consultation in this case, and was decided by the older surgeons in favor of the latter, if any operation were to be performed. Excision was, however, adopted. It was not found difficult to place the head of the tibia at a proper angle with the excised extremity of the femur. Under antiseptic treatment, recovery was prompt, and at the end of four months the patient was able to dispense with all artificial aids in walking. When last seen, the limb had increased in size markedly, and was in every respect thoroughly useful. The gait betrayed a slight halt due to the fixation of the joint at the knee.

Remarks.-The results of excision in these cases were very gratifying. The operation itself was attended with no unfavorable symptoms whatever in either case. Consolidation pro

gressed rapidly, but, as the head of the tibia was not excised, the union was fibrous for a long time, if, indeed, it did not remain so permanently. Motion could have been preserved at the joint by manipulation if it had been required, but, owing to the feebleness of the limb, firm union was considered essential to its future usefulness. Limited motion continued long after the patients began to walk, but finally the union became firm and unyielding.

The absolute value of these limbs after successful excision is surprisingly great. Sustained and strengthened by a firmly consolidated knee-joint, the limb bears its part in locomotion, with increasing vigor and power. In both cases, the longatrophied limbs developed markedly in size from use, and they became more and more useful while the patients were under observation.

In both instances an effort was made to impair as little as possible the normal structures of the joint. For this reason the cartilage of the tibia and the inter-articular cartilages were uninjured. In excising the extremity of the femur, thin sections were made with a fine, butcher's saw until the requisite quantity of bone was removed. The entire epiphysis was not excised, and hence the conditions for the future growth of the femur were, as far as possible, preserved. What will be the final re

sult on the growth of the affected limb by preserving the tissues of the joint and bringing the limb into active use, remains to be determined.

The question of excision or of amputation in this class of deformities was fully discussed in these cases, and the decision was either to perform no operation or to resort to amputation. Against excision it was alleged that, as compared with amputation, it was, first, the more dangerous operation, and second, that the resulting limb would be weak and useless. In favor of amputation, it was decided that the resulting stump would be useful for an artificial limb, whether the point of operation were below or at the knee. It should be stated that the influence of antiseptics, as modifying agents in the operation, had no weight with those declaring in favor of amputation.

Excision was preferred by the operator for the following reasons: First. It was believed that, by the use of antiseptics, the operation of excision would be quite as free from danger as amputation. The result warranted the conclusion. Second. The straightened limb, ankylosed at the knee, would be more serviceable than any form of stump at or near the knee. In this respect the result fully sustained the conclusion.

The following statement is submitted:

Excision is to be preferred to amputation in deformities of the leg resulting from infantile paralysis, which so displace the bones of the knee as to prevent their being brought into position for locomotion.

There are many cases of flexion of the knee, and others of partial displacement of the bones, due to affections of the joint, rendering the limb quite useless, which are frequently subjected to amputation, but which would result in far more useful limbs if excision were performed. The mortality from excision in chronic diseases of the knee which cripple the limb is, in our time, with the thorough use of antiseptic appliances, no greater than from amputation at the joint or in its vicinity. As to the comparative usefulness of a leg ankylosed at the knee and of a stump in that region, perhaps no better authority can be cited than that of Dr. E. D. Hudson, who had a very large experi

war.

ence in supplying artificial limbs to soldiers during and after the Much as he valued amputation at the knee, as furnishing the best form of stump for an artificial limb, he always preferred an ankylosed knee; and he gave his advice accordingly, when the question of excision or of amputation was under consideration.

DISCUSSION.

DR. S. W. GROSS, of Philadelphia.-There can be no difference of opinion with regard to the relative advantage to be derived from amputations above and below the knee-joint; but I take it that excision of the knee-joint is not a proper operation in all cases of deformity. When we have to deal, for example, with an angular bony ankylosis or synosteosis, I see no necessity, in the great majority of cases, for resorting to excision at all. There is an extremely simple and safe operation, which originated with my father, Dr. S. D. Gross, many years ago, and is described in his work on surgery, but which seems to have escaped the attention of the majority of the profession. Suppose a case to be one in which the adhesions between the articulating surfaces are completely osseous, the leg being bent at an angle interfering with progression; the surgeon should feel for the line of division between the tibia and the external condyle, there make an incision not more than half an inch in length, introduce a chisel into the opening, and break up the osseous adhesions; then place a towel over the patella and separate it from its connection with the external condyle by blows with the mallet. My father did six operations of this kind; and I performed one upon a medical student three years ago, who got up and walked about in three weeks. All the patients upon whom this operation was performed recovered without any untoward symptoms. The position of the limb should not be entirely corrected at one sitting, as this might endanger the popliteal vessels; but the bending process should be repeated after two or three days, the patient being under the influence of ether. I am of the opinion that this operation should be more