A Case of Excision of the Knee-Joint: Recovery. \

Cases Reported by Assistant-Surgeon Mahendra

I Nath Ohdedar, L. M. S.

Ajodhya, a Hindu lad, aged 1-1 years, born at Dhampore, was admitted into the Srinagar Dispensary on the 29th of November. 1879. He was weak and emaciated. The right knee was hard, considerably swollen and tender to touch. The leg was slightly flexed on the thigh, and the motion of the joint very limited. There was an opening close to the anterior tubercle of the tibia, leading right into the joint. Suppuration was rather profuse. Fever came on almost every night, and there was constant pain in the joint. The commencement of the disease dated as far back as the

middle of the year 1878. He was under the treatment of a

jorah at Najibabad, but, the disease gradually increasing, he was brought to Srinagar, and was under the care of Native Doctor Pooran Singh and myself for sometime before admis- sion. All ordinary means having failed to do any good, I proposed excision, and he was admitted as an in-patient.

Consultation.?Revd. P. T. Wilson, M. D., Superintendent of Dispensaries in Gurhwal and Kumaon, happening to be present at Srinagar at that time, I consulted with him on the propriety of excising the joint, and he agreed with me in thinking the case a fair one for excision. I excised the

joint on the 29th of November?the day of admission. Operation.?I need not describe the operation, suffice it to

say that a tourniquet was applied at Scarpa's triangle (there is no Esmarch's bandage in the dispensary), and as a

further precaution, an assistant commanded the artery with his thumbs on it ; the usual horse-shoe incision was made ; a portion of the tibia about three-quarters of an inch, and a

portion of the femur about one and a quarter of an inch in length, were removed ; the patella was not removed : hemor-

rhage was rather free, and three arterial twigs required ligature ; the flap was brought down and iron-wire sutures were applied ; the limb was placed in a Mclntyre's splint well padded and screwed out to the fullest extent, and the wound was dressed antiseptically. The following is a brief account of the progress of the

case :?

30th November? Dressing was not changed. The patient had fever : pulse was 120 : temperature could not be taken as

the thermometer was out of order. The following mixture was prescribed:?

B/ Quinine Disulph. ... ... grs.ij. Acid Sulph. Dil. ... ... 1TI v.

Liqr. Morphias ... ... TH, xv. Aquas ... ??? Ji- M. ft. Mist- T. D. Rice and milk for diet.

1st December.?Fever less : pulse 108 : dressing changed ; slight union on the outer side. Continue mixture.

2nd.?Pulse 100. Good deal of suppuration. Continue mixture. 3rd.?No fever : one suture has cut through, the rest are put

to great stretch owing to contraction of the quadriceps ex-

tensor cruris muscle : good deal of suppuration. 4th.?Much suppuration : sutures removed and the wound

well washed out with carbolic lotion. The edges were sup- ported with strips of sticking plaster. Cod Liver oil 3 i. after each meal and Liqr. Morphite JT]_ 20 at bed-time were

prescribed. 7th.?Suppuration less : wound granulating. Cod Liver oil

twice and the quinine mixture without morphia three times a day.

13th.?Patient improving in every respect. 28th.?I was congratulating myself on the fair progress

the patient made, but on the morning of the 28th I was sur-

prised to find a bulging of the skin and cicatricial tissue on the inner end of the incision. There was distinct fluc- tuation. An opening was made and more than half an

ounce of pus came out. One end of an India rubber drain-

age tube was put in, and the cavity washed out with carbolic

lotion.

31.fi.?Drainage tube taken out: cavity filling up, though slowly : wound granulating.

15th January.?The outer half of the incision is quite healed, the inner is granulating.

16th February.?Complains of tormina : stools contain

mucus and blood. The following powder to be taken every 6th hour

Bismuth Trisnitratis ... grs. iv. Pulv. Ipecac. ... gr. i.

Pulv. Opii ... gr. Pulv. Acaciae ... grs. v. Pulv. Bael ... grs. x. M. ft. pulv.; ... Sago and milk for diet.

23rd.?Motions quite healthy; the line of incision ig

completely closed; there is sufficient consolidation to lift up the leg by grasping the thigh.

4th March.?I was about to put up the leg in a starch

bandage, but on the morning of the 4th of March I found a small opening on the inner side of the joint, and on pressing the sides a little pus came out. I passed a probe, but could

not make out anything. Carbolic lotion was injected and a bit of lint soaked in carbolic oil was put into the opening.

I0i/i.?There is yet some flow of pus. Continue injection and dressing.

loth.?Two small bits of bone came away, and rough bone was felt with a probe. 23rd.?Opening not closing : no more bone came away since

the last Inject a lotion made of acid sulphuric strong n\i. and water ?l( 100. 27th.?Opening closing : slight flow of pus. April 3rd.?Opening quite closed : stop dressing. 14th.?Apply starch bandage. After this date the patient was allowed to get up and

move about in the hospital compound with the aid of crutch- es, and on the 6th of May 1880 he was discharged. The right leg was one and three-fourths of an inch shorter than the left. Remarks.?Excision of the knee joint is a comparatively

rare operative proceeding, more so in cases of chronic

1S6 THE INDIAN MEDICAL GAZETTE. [July 1, 288a

disease. Erichsen in liis book, Vol. II., 7th Edition, page 273, says :?" On the whole I think it may be fairly said that, although excision of the knee joint may in some cases leave an excellent result, and thus be preferable to amputation, yet, when we consider the uncertainty of the result, the greater mortality attendant on excision than on amputation of the thigh for chronic disease of the knee-joint, especially in the two earlier decennial periods of life, we should practice exci- sion as the exceptional operation, and I would still feel

disposed to give the preference to amputation in the majority of cases." The opinion of such a justly esteemed surgeon raised considerable misgivings in my mind, but as I could not cure my patient by ordinary means, and did not consider him a fit subject for amputation, I was obliged to have recourse to excision. My patient made a very slow and interrupted progress. Complete osseous anchylosis took place, and the tibia, femur and patella formed one solid mass of bone in an almost perfect straight line. The average duration of treatment in cases in which the patella is left, is said to be 255 days. My patient was discharged 180 days after the operation. Holmes in his book, page 907, says, that in some exceptional cases the recovery is very rapid. As an example of this, is the case reported by Assistant-Surgeon Annada Charan Kastagir of the North Suburban Hospital, in the

September number of the Indian Medical Gazette for the year 1878.

A Case of Urethrotomy for Impacted Calculus.

Ram Singh, a Hindu child, aged 7 years, was admitted into hospital on the 14tli January 1880. He complained of difficulty in micturition, the urine could only be passed in drops. On examination a calculus was found impacted in the

penis, a little further off its junction with the scrotum. It was large in size, and the skin over it on the under-surface of the penis was red and much stretched. Were the stone al- lowed to continue fixed for a few days more, ulceration of the urethra with its consequences would have resulted. The left testicle was at the external abdominal ring, the right could not be felt at all. An attempt was made to push the stone, first towards the

orifice and secondly towards the perinseum. It could not be moved cither way. I then decided to cut down on it, though many surgeons are very much against any interference with the spongy portion of the urethra. I raised the penis, and stretching the skin, made a longitudinal incision, and intro- ducing a pair of ordinary dressing forceps, extracted the stone. It was placed transversely : was somewhat of an hour-glass shape and- 70 grains in weight. I made repeated efforts to put in a catheter, but it only went as far as the bed of the stone, and cotdd not be made to go any further. I tried to see

through the incision the distal opening of the lower portion of the urethra, but failed. With considerable misgivings in my mind, I carefully brought together the edges of the inci-

sion with iron wire sutures and applied cold water dressing. On the 16th the patient passed all urine through the na-

tural orifice. On the 19tli one suture cut its way out and some urine passed through the incision in drops. A little

pus was also noticed on the lips of the wound. Carbolic^ oil dressing was applied. On the 25th the patient passed all urine through the meatus, and on the 26th the remaining suture was removed. On the 29th (16th day after operation) he was discharged with the wound perfectly healed. Remarks.?I consider this case worth recording, as urethral

calculus, of this size and weight, is rather rare. I do not

claim for this case more than that it proves that the spongy portion of the urethra might be cut and yet no fistula be

left?in some cases even if no catheter be passed into the bladder.