knee in patients of sixteen years of age and under. Of these, one died at the end of thirty days, the other on the eleventh day. The numbers given here are not large, but may, perhaps, be taken as the average mortality after amputations in London hospitals, and with these the results of resection of joints in the foregoing table may be favorably compared. Out of 22 cases of excision of the larger joints, 2 only terminated fatally.

THE

RESULTS IN THIRTY-NINE CASES

OF

EXCISION OF THE KNEE.

BY

GEORGE MURRAY HUMPHRY, M.D., F.R.S., PROFESSOR OF ANATOMY, AND SURGEON TO ADDENBROOKE'S HOSPITAL, CAMBRIDGE.

Received Oct. 14th.-Read Nov. 10th, 1868.

THE following may be regarded as supplementary to a paper communicated by me to this Society and published in Vol. XLI of its Transactions.' The first thirteen of the cases are related there, and observations are offered respecting the cases most suited to the operation, &c., to which I will merely refer inasmuch as they have been, in almost every particular, fully confirmed by my subsequent experience.

In 39 cases in which I have performed the operation of excision of the knee, the result has been as follows:

28 recovered. 2 died. 9 underwent amputation; of these 5 recovered and 4 died.1

All the cases were treated in Addenbrooke's Hospital.

1 Since this paper was read I have performed the operation six times; five of the patients have recovered, and one is under treatment. This makes the number of operations 45, and the number of recoveries 33.-July, 1869.

Of the two patients who died without amputation, one (No. 8) was the girl, æt. 5, whose case is related at p. 203 of the volume just referred to. The operation was performed, perhaps rather unwisely, on account of acute suppuration in the joint, supervening upon chronic disease with an opening into the joint, and attended with violent fever. The condition was most unfavorable for any operation, and the child would probably have died whatever course was taken. In the other (a female, æt. 25, No. 31) death was caused by a violent attack of hæmatemesis commencing a few days after the operation, and having, apparently, no particular relation to it.

Of the four who died after amputation the excision was in one (No. 29) performed in consequence of an extensive contused wound of the thigh, caused by a wheel passing over it, laying open the knee-joint and admitting a quantity of gravel and dirt into it. The lad was restless and delirious after the operation, with slight discharge from the wound, but there was no swelling or other indication of inflammation. As he became worse, I amputated on the fourth day. The restlessness continued, mortification of the stump supervened, and he died three days after the amputation.

In the other three cases amputation was performed in consequence of continued suppuration undermining the health, and was, in each instance, delayed too long.

In the remaining five cases in which amputation was performed, the reason for the removal of the limb was the same as in the three last mentioned. In one case, at least, I thought the extensive and continued suppuration was caused by bleeding taking place into the wound after the patient was replaced in bed, and I have accordingly been very careful in the later cases to prevent this occurrence by securing all the vessels that were at all likely to bleed. In two, if not three, of the cases I judged, from examination of the part after amputation, that the limb might have been saved if I had made incisions in the course of the discharging sinuses, so as to expose or remove the carious edges of the bones.

In each of the cases of recovery the cut surfaces of

the tibia and femur united together, and a good, firm, sound limb was gained. In four, in consequence either of an accident or of the patient's bearing upon the limb before firm union of the bones had taken place, the part became more bent than is desirable; in one of these (No. 15) I subsequently straightened the limb by removing a V-shaped piece from the forepart of the angle, and the patient has now, I am told, a straight limb, and can walk well. The other three are too satisfied with their condition to assent to any further operation. One, with the aid of a wood and iron addition to his limb, says "he can walk and work with most of them." Another considers the flexure rather advantageous, and says he can walk and work as well as other people. The third patient also can walk and work very fairly.

Through the kindness of medical men, and in other ways, I have been able to obtain information respecting the condition of most of the patients at various periods since the operation, and the result is highly satisfactory. The limb is, of course, stiff at the knee, but there is no other inconvenience. The slight shortening caused by the removal of the articular surfaces is no disadvantage. On the contrary, it facilitates the swing of the foot forwards in walking and running. There has been no tendency to return of disease at the part in any that I have heard of.

In the majority of the cases the disease in consequence of which the operation was performed had commenced in the synovial membrane, and had made its way slowly through the cartilages, more or less deeply, into the bones, so as to leave little or no prospect of a useful joint or of the limb being preserved.

In some the disease had passed away and sinuses resulting from an ulcerated state of the bones had healed, but the joint was contracted and the articular surfaces were distorted beyond the hope of benefit from extension and mechanical appliance. In these two classes of cases, and in some others, excision offers the prospect of a very useful limb, a better prospect, so far as my experience goes, than does any other

procedure, and it does so with little risk. I say with little risk, because the operation, though extensive, is, as in the case of other operations in which osseous structures are chiefly concerned, not usually followed by much constitutional disturbance. No large vessels or nerves, and not much muscular tissue, are involved. The chief danger to be feared is a continuance of suppuration undermining the health and rendering amputation necessary. This may probably be lessened by improved treatment after the operation. It is most likely to occur in patients of strumous temperament. In such persons, as mentioned in my former paper, disease lingers long in the synovial membrane, causing thickening and other changes in it, and tedious suppuration is not unlikely to follow excision. This was the most frequent cause of failure in my cases.

There is no longer any doubt that the growth of a limb after excision of the knee, in a young subject, may keep pace with that of the opposite limb, provided the epiphysial or growing lines at the end of the femur and the tibia have not been removed or injured, and provided other circumstances are favorable. This is shown by Case 30 and others. Nevertheless, just as growth is commonly more or less impaired when muscular action in a limb is prevented by paralysis, by disease, or anchylosis of a joint, so some years after excision it is not unfrequently found that the limb is shorter than its fellow, to an amount which is scarcely to be accounted for by the loss of bone incurred in the operation. Thus, in Case 13, ten years after the operation, performed at the age of thirteen, the operated femur measured sixteen inches and the tibia fourteen; these bones in the opposite limb measuring respectively eighteen inches and fourteen and a half. The operated tibia had grown as fast as the other; but, for some reason not quite obvious, the operated femur had been less active in its growth than its uninjured compeer. In Case 22, six years after the operation, performed at the age of fourteen, the femur and tibia were each two inches shorter in the operated than in the other limb. In Case 15, three years after the operation, performed at the