Clinical Lecture Delivered at the Second Annual 
Meeting of the Association of Military 
Surgeons of the United States. 
BY 
N. SENN, M.D., Pli.D., 
OF CHICAGO. 
PRESIDENT ASS’N MIL. SURGEONS OF THE NATIONAL GUARD OF THE UNITED 
STATES, SURGEON-GENERAL W. N. G., PRESIDENT ASS’N MIL. SURGEONS 
OF W. N. G., HONORARY MEMBER MILITARY ORDER OF NEW JERSEY, 
MEMBER SOCIETE DES CHEVALIERS SAUVETEURS DES ALPES 
MARITIMES, PROF. OF SURGERY RUSH MEDICAL COLLEGE. 
Reprinted from the Second Annual Proceedings held at St. Louis, 
on the 19th, 20tli and 21st of April, 1892. 
ST. LOUIS! 
NIXON-JONES PRINTING CO. 
1892. Clinical Lecture Delivered at the Second Annual 
Meeting of the Association of Military 
Surgeons of the United States. 
Gentlemen of the Association of Military Surgeons of the 
National Guard of the United States : 
I show you here a case that presents all the characteristic 
features of tumor-albus, white swelling, with the typical spindle- 
shaped enlargement of the joint, the largest diameter corre- 
sponding exactly to the line of the joint and tapering gradually 
towards both sides. The swelling here (indicating the point) 
can be directly traced, not to an effusion into the joint, but 
to the presence of masses of granulation tissue, as the catarrhal 
stage of inflammation has subsided long ago, either in conse- 
quence of the treatment employed or spontaneously. A catarrhal 
synovitis is very often the first indication of the existence of 
tubercular inflammation of the synovial membrane, but often, 
if left to nature’s resources, it gradually disappears and the 
swelling which assumes a different aspect is then no longer due 
to an effusion into the joint, but to a thickening of the synovial 
membrane and the capsule of the joint. 
I am told when these incisions were made into the joint, conditions 
were found that corroborate the diagnosis that I have ventured. 
I can show you now, if the patient is thoroughly relaxed by the 
anaesthetic, that the affection has given rise to serious textural 
changes of the joint; that the tubercular inflammation no longer is 
limited to the synovial membrane, but has already attacked the 
deeper structures of the joint, resulting in a weakening of the 
capsule, so that now, when the patient makes an attempt to walk, 4 
the knee joint bends under the weight of the body, rendering 
locomotion exceedingly difficult, and the following of his occu- 
pation, impossible. I find on examination that the patella rests 
directly upon the condjdes of the femur, that there is but moderate 
fluctuation in the upper recess of the synovial sac which is 
a characteristic feature, either in cases of copious effusion into 
the joint, or the existence of immense masses of granulation 
tissue filling this portion of the synovial sac. You notice 
that the lateral movements are very well marked, showing a 
decided elongation, and a weakening of the capsule of the 
joint. I find here, over the outer and inner aspect of the 
patella, a condition that might be mistaken for a slight effusion 
into the joint, a puffiness, which extends past the normal 
depression on each side of the patella, a swelling that 
presents on palpation, a sensation of fluctuation. It is not 
a true fluctuation, it is simply a sensation imparted to the 
finger by a mass of granulation tissue within the joint, a pseudo 
fluctuation, that so often gives rise to serious mistakes, not only 
in diagnosis, but in treatment. I believe that the most expedient 
and most conservative treatment that we can suggest in this case 
is the removal of the diseased synovial membrane, and if neces- 
sary, the capsule of the joint. Although the patient is fifty 3rears 
of age I feel that I am justified in making a conservative effort in 
saving his limb. At the same time, I wish to choose an operation 
which will remove all the diseased tissue. I propose to make, in 
this case, an or resection of the joint. 
Arthrectomy was devised by Volkmann, and recommended 
by him in all cases in which the synovial membrane is either 
primarily or secondarily involved in the tubercular process, 
and where the pathological lesions in the extremities of 
the bones, are such that a typical resection can be avoided. It 
is becoming more and more the favorite operation, to limit 
our efforts to the removal only of diseased tissue, and save 
as much as possible of the other joint structures, hence, I think 
in the treatment of tubercular j oints, the operation now almost in- 
variably selected, where the disease is not very extensive, is either 
arthrectomy or atjqncal resection. I am quite confident, that in 
this case the disease does not seriously implicate the articular ends of the bones involved in the formation of the knee joint. 
The first thing that we do is, to mechanically empty the blood 
vessels of the affected limb, not by an elastic bandage, be- 
cause I would be fearful that by making an elastic compression 
from the periphery of the extremity up to the diseased joint and 
beyond it, that with this means of rendering it bloodless, it might 
become the direct cause of the dissemination of the tubercular 
process. The mechanical compression may result in furthering 
the work of the disease in the joint, and force the tubercular 
process into the circulation, hence it might become the direct 
source of a general or a disseminated tuberculosis. I believe 
that the elastic compression of the extremities is not only super- 
fluous, but exceedingly dangerous. All that is necessary is simply 
to elevate the limb and keep it in this position for a few minutes. 
Lister's experiments on the lower animals show, that even in a 
large animal like the horse, by elevating the limb you can cut the 
tibial artery without much hemorrhage occurring. We have 
drained the limb of the venous blood by elevating the limb, we 
have diminished the arterial force of the circulation by the same 
means and are now ready to at once cut off the circulation 
of the limb to be operated upon by the elastic constrictor. 
I wish to call your attention incidentally to this means of 
preventing hemorrhage, that even elastic constriction must 
be practiced carefully in order to prevent remote, and often 
serious, consequences. It has happened to me on two occa- 
sions, perhaps, by my own carelessness, in resorting to this 
simple surgical measure, that I have produced in one instance 
paralysis of the musculo-spiral nerve, that gave me great 
anxiety for three or four months, and in a second case, in operat- 
ing upon the leg, making constriction immediately above the 
knee joint, paralysis of the peroneal nerve followed, from 
which the patient has, even now, not fully recovered. I 
therefore insist that in using the elastic constrictor, it 
should be applied invariably at a point at which the principal 
nerves of the extremity are safely protected by a cushion 
of muscular tissue. (Constrictor applied.) Never apply the 
elastic constrictor, if you can avoid it, for instance, to the part 
where the musculo-spiral nerve passes almost sub-cutaneously 6 
over the shaft of the humerus; when this has to be done on 
account of the location of the disease, interpose between the 
constrictor and limb a thick layer of gauze. The next thing to 
avoid is linear compression of the deep important structures. I 
am very sorry indeed that I have now an elastic constrictor 
that is not very well adapted to avoid linear compression. I 
should much prefer to use a bandage instead of a tube, to make 
the compression as diffuse as possible. An elastic constrictor 
should be at least an inch or an inch and a half in width. We 
will use in this case the ordinary elastic roller. (The constrictor 
broke, whilst the doctor was making the constriction.) The con- 
strictor has lost its intrinsic elasticity, I therefore shall have to 
use a rubber tube, but I will apply the tube in such a manner as to 
diffuse the compression as widely as possible. Apply the tube 
at several points in this manner (indicating), so as to obtain a 
wide surface pressure. One other matter to be considered in 
applying an elastic constrictor, is, to make the compression sud- 
denly, so as to interrupt the circulation at once. A slight applica- 
tion of pressure, or a slow application results in venous stasis. 
I believe that we have a comparatively bloodless condition of the 
limb in this case, and are now ready to proceed with the operation. 
One of three incisions is usually selected now, in making a typical 
arthrectomy or an atypical resection. There are few surgeons 
who make the old horseshoe incision with the convexity of the 
flap directed downwards. There are two serious objections to this 
incision. The resulting scar of such a resection wound, falls in a 
place where it is later most exposed to injury. Volkmann’s trans- 
patellar incision is an improvement upon the old incision, but is 
again open to objections, because the lines of the incision of the 
soft parts and the sawn surfaces of the patella correspond. The 
result is an adherent scar, sealing the soft tissues to the anterior 
sux'face of the patella, hence, I select the semi-lunar incision, with 
the convexity not directed downwards, but upwards, making the 
trans-patellar section in the same manner as Volkmann, thus we 
have a large flap, which, after suturing, renders the line of 
the suturing of the patella sub-cutaneous. 
before we make the incision, I will call your 
attention to these three scars that I have pointed out to you before; they are characteristic tubercular scars, scars that are 
even now manifest, long after the operation was made, still remain 
exceedingly vascular, scars showing only too plainly that the 
primary cause of the joint affection has reached the scar tissue, 
interfering with the normal avascularization of scar tissue. In 
some cases, where there is some doubt about the nature of the 
primary affection, the condition of the scar will often lead you in 
the right direction, in making a correct diagnosis. I will now com- 
mence the incision over the inner aspect of the knee joint, exactly 
over the most prominent point of the internal condyle, and 
extend it in a gentle curve from this point to about an inch above 
the upper border of the patella. I select as my landmark for 
the termination of the external incision, the most prominent portion 
of the external condyle, and carry the incision in a second gentle 
curve across the swollen synovial sac, near its upper recess 
carrying it again downwards, terminating it on the opposite side 
of the knee at about the same level. I have now completed 
the semi-lunar incision with the convexity of the flap directed 
upward. Its upper border reaches about an inch above the upper 
margin of the patella. I now reflect this flap, turn it down- 
wards, being careful to take with it the other tissues down to the 
deep aponeurosis so as to preserve as many of the sub-cutaneous 
blood vessels as possible. I will separate the flap downwards to 
a point just below the lower border of the patella, exposing the 
patella. I am ready to make a trans-patellar incision, dividing 
first the soft tissues on either side. I saw through the patella 
transversely, about the middle. I now divide the ligaments of 
the knee joint on each side, and am ready to give the joint 
a very careful inspection in order to make a positive pathological 
diagnosis. You now look into a typical tubercular joint, with 
very slight affection of the articular ends of the bones, but quite 
an extensive destruction of the articular cartilage. Our diagnosis 
has therefore been corroborated by direct inspection of the joint. 
I must now make two additional incisions one on each side of 
the upper fragment of the patella, in order to expose fully the 
upper recess of the joint, to enable me to remove the diseased 
capsule, thoroughly. Notice how much the capsule of the joint 
has become thickened, the disease, as I predicted, is no longer limited to the synovial membrane, it has extended to 
the capsule, which accounts for the preternatural mobility of 
the knee joint laterally, as we ascertained before the operation. 
I must, therefore, make a typical arthrectomy of the soft 
structures of the joint, an operation which is always some- 
what tedious, but which, in order to be successful, must be 
thorough. As the patella presents no evidence of disease, I 
believe it is safe to leave this structure, and limit our opera- 
tion to the soft tissues of the joint. You notice a most in- 
teresting pathological condition at this point, a mass of 
cicatricial tissue which seals down the anterior wall of the 
synovial sac to the posterior; it is an intra-articular scar, pre- 
senting an unmistakable evidence of the recuperative power of 
nature’s resources, an attempt not only in the arrest of the 
disease, but even a well marked indication of a curative process. 
Tubercular joints occasionally will get well spontaneously, but 
only too often, the best result that can be expected, as you 
well know, is either a partial or complete ankylosis caused by 
such an intra-articular scar. 
I now dissect out carefully the upper recess of the joint, 
which I can do very readily by lifting up this central flap that I have 
made. In making this dissection I am exceedingly careful to 
carry my incision as far as I can determine through healthy 
tissue. It is the clearing out of the upper recess of the synovial 
sac, that in the old operation with the convexity of the flap 
directed downwards, is so imperfectly done, and that accounts 
for the many local relapses after such operations. I show you 
here a typical tubercular capsule. Haste in this part of the 
operation should be made slow, as the removal of the capsule 
requires a tedious dissection. The prime indication in this part 
of the operation is, to remove all of the diseased tissue and to 
preserve as much as possible of the healthy structure of the 
joint. As we predicted, the capsule is very extensively diseased, 
making its complete removal a matter of necessity and not of 
choice. I reached this copious cushion, of what appears as 
healthy, para-articular fat. As I have no use for this structure, 
and as it may be the seat of an incipient infection, I have no 
hesitation in removing it with the diseased capsule. I wish to clear the condyles of the femur thoroughly as though I were 
to make an anatomical preparation, hugging the bone very 
closely, as I remove the tissues from the intercondyloid 
notch and all around the condyles. We have now cleared out 
the upper recess of the synovial sac, very thoroughly, and are 
ready to attack the joint surface. I now proceed to remove 
the synovial membrane, and the diseased capsule over the 
outer aspect of the joint, and clearing at the same time the 
articular surface of the tibia, taking again the same precaution to 
hug the lower surface of the patella and to reach the remote corners 
of the joint. You notice that here between the condyles, what 
remains of the crucial ligament presents about the same appear- 
ance as the diseased capsule, necessitating the complete removal of 
this structure. It is here on the sides of the joint where I have to 
make the arthrectomy again very thorough. The capsule here 
again is thickened enormously. I have so far made no use of the 
sharp spoon. I am not making what English surgeons are pleased 
to call an erasion, I prefer to make a typical arthrectomy in- 
cluding the removal of the synovial membrane and the capsule. 
To make a typical arthrectomy, it is unsafe to allow any part of 
the lateral portion of the capsule to remain. I now reach a part 
of the joint, presenting the greatest difficulty in making an 
arthrectomy, the space behind the condyles and the head of the 
tibia. We will use the arm of one of our assistants as a 
fulcrum in the popliteal space, over which I will now bend the 
knee, so as to render this part of the joint more accessible. 
I am reaching now, as you all are aware, a dangerous neighbor- 
hood. The large blood vessels are alwa}7s a bugbear to the 
operating surgeon, a hair’s-breadth of tissue between them and 
the operation wound often will make a great difference as to the 
immediate and remote outcome of an operation. I remove 
every vestige of the crucial ligament and the posterior part of 
the capsule without endangering the popliteal vessels which I 
am very anxious to avoid. As I have removed the entire capsule 
very thoroughly, the best result that I can expect in this case will 
be ankylosis with the limb in a good position. The articular car- 
tilage has been worn away, destroyed by the extension of the 
disease from the synovial membrane, to this structure. In clear- ing the articular surfaces I have to abandon the use of the knife ; 
I cannot dissect away the cartilage in the same manner that I 
dissected away the capsule of the joint, I do not wish to use the 
saw, as I promised you not to make an atypical resection, and 
yet, I must clear out of the joint all of the tubercular tissue; I 
will now make an erasion of the articular surface of the knee 
joint; I will scrape away the articular cartilage. Unfortunately 
the spoon I am working with is better adapted for scraping 
sinuses than to remove the articular surface of the femur and 
tibia. The instrument I prefer for this purpose is a large shallow 
spoon. I can do this part of the operation well with this spoon, 
but its use necessitates a little unnecessary loss of time. Never 
rely upon the spoon in removing a tubercular capsule, this part 
of the operation must be done with a more thorough instrument — 
the knife. I have not used as yet, as you have observed, another 
instrument that is so frequently used in this operation, scissors. I 
prefer the knife to the scissors, because I can with it make my in- 
cisions with more precision and thoroughness. I now wish to flush 
the joint with a strong aqueous solution of iodine, a solution that 
I invariably employ in operating on tubercular lesions. The 
effect of iodine on tubercle bacilli is a decided one, and can be 
relied upon much more than corrosive sublimate or carbolic acid 
in operations for tubercular lesions as both of these antiseptics 
have no decided antibacillary effect. At the same time, the iodine 
solution produces another effect on the tissues that is of great 
use in operating for tubercular lesions. It has a decidedly 
stimulating effect on the tissues exposed by the operation, ini- 
tiating at once an active process of repair so useful in the pre- 
vention of a local recurrence. There are still remaining on the 
wound surfaces small fragments of tissue that may still harbor the 
essential cause of the disease that a stream of water will not 
remove. I wish to rub awray with a small antiseptic compress, 
preferably iodoform gauze, the fragments of tissue entirely or 
partly detached, so as to supplement the means which we 
have resorted to in the mechanical removal of the diseased tis- 
sues, by this simple and yet exceedingly important measure. 
I now wish to iodoformize thoroughly the wound surfaces, 
by sprinkling them with iodoform; most of which of course will again be removed by rubbing with the small compress of gauze. 
I wish to bring this valuable antibacillary agent in immediate 
contact with the tissues that have been so close to the infective 
process, adding to the mechanical measures a chemical means of 
destroying, or rendering harmless, all that still possibly might 
remain of the tubercular disease. We have now completed the 
arthrectomy. I now ask for a large compress with which to 
make surface pressure, in order to reduce to a minimum the 
amount of parenchymatous oozing, which will follow the removal 
of the elastic constrictor. I believe it is a mistake in theory and in 
practice, after operating on such a large joint, and so extensively 
as in this case, to rely upon suturing in arresting the hemor- 
rhage. I will ask one of the assistants to remove the constrictor 
while I am making surface pressure. You are all aware that 
valuable as the elastic constriction is in the prevention of hem- 
orrhage or its treatment, that the very means which we resort to 
in diminishing hemorrhage during an operation, unfortunately 
often gives rise to serious parenchymatous oozing after the 
removal of the constriction, on account of a temporary paretic 
condition of the capillary vessels caused by the constriction. 
It is a well-known clinical fact that parenchymatous oozing is 
much more marked and more difficult to manage after elastic 
constriction than by operating without taking this precau- 
tion. Compressing the surface for a few minutes, I resort to the 
best known measure to prevent this undue amount of parenchy- 
matous oozing. I desire in this case, to obtain, if I can, per- 
fect hemostasis, I wish to arrest the hemorrhage thoroughly 
and completely before I suture the operation wound. I hardly 
believe that it will become necessary to apply more than one or 
two ligatures, to some of the articular branches, as I have been 
careful not to injure any of the important blood vessels in the 
immediate surroundings of the knee joint, and while the assistants 
are now taking care of the bleeding points, I will utilize the time 
in drilling the fragments of the patella, in order to enable me 
to approximate the fragments by suturing. The only suture 
necessary to keep the parts in apposition until union by a bony 
callus takes place, is catgut. I am satisfied that any fracture 
of the patella can invariably be brought together, and success- fully united, by relying on the catgut suture. I am exceedingly 
anxious in a case of this kind, that no foreign material shall 
be allowed to remain, because I am operating for a pathological 
condition, and any foreign substance being allowed to remain 
within the immediate vicinity of the knee joint, might become 
the means of lighting up a latent tubercular process at any time 
in the future. I therefore desire to use a suture that will be 
absorbed, after its presence has been made unnecessary. 
Evidently St. Louis favors the use of an artificial finger, the 
assistant here has handed me a needle threaded with a catgut 
suture in a needle holder. I simply wish to enter my protest 
against the use of this occasionally very useful instrument, 
wherever it can be avoided. I believe the best needle holder, 
and one that never is out of order, one that can be rendered 
aseptic, and should be asepticized before a wound is touched, 
is the hand. I wish to make a double suture, with one thread. 
I therefore have proceeded by passing the suture through the 
outer side of the patella. I now drill the second opening in 
the lower fragment, about an inch from the first. The assistant 
will now watch his chance to follow the perforation as I remove 
the drill. I make a small opening in the upper fragment, and 
I hope that we will not lose quite so much time. I have now a 
double suture of durable cliromacised catgut in place, and I am 
ready to bring the sawn surfaces in accurate apposition by tying 
the suture. 
In operating for tubercular affections of joints, it is exceed- 
ingly important to classify the cases according to the pathological 
conditions — pure tubercular affections, and tubercular affec- 
tions complicated by secondary infection with pus microbes. I 
maintain that this classification is important, because in oper- 
ating for mixed infections, with few exceptions, we fail in 
obtaining a union by primary intention. On the other hand, in 
operating for purely tubercular affections, we are brought face to 
face with a condition which, if we eradicate thoroughly, we can 
confidently expect what we should aim at, primary union of the 
wound throughout. I make this distinction simply to introduce my 
remarks on drainage in operation wounds made for tubercular 
lesions. If I had here a joint communicating with the outer surface by means of suppurating fistulous tract, I should 
certainly feel that I should not do justice to the case, if I closed 
the wound throughout, because in all probability, I should be 
unable to remove the primary pathological conditions of both 
forms of infection. I believe, that in this case, even if tuber- 
cular tissue has remained, there is absolutely no indication 
for securing drainage. Open tubercular lesions are always more 
dangerous than sub-cutaneous lesions. The sooner, therefore, 
this wound heals, the better for the patient, it is therefore my 
intention to close the wound throughout, but to establish a drain- 
age for a few days only, in order to avoid tension upon the flaps, 
by inserting a few strands of-catgut at the lower angle of the 
wound a drain that will not necessitate an early removal of the 
dressing, which can never be accomplished without some dis- 
turbance of the wound surfaces, a drain that will be removed 
in the course of five or six days, after its presence is no longer 
desirable, after it has fulfilled its object. This drain will lead 
away from the wound surface into the absorbent antiseptic 
dressings the excessive primary wound secretion, which of 
course will place this wound in a condition of absolute rest, 
so much to be desired in operating upon tubercular patients, 
that invariably are not only suffering from this apparent direful 
pathological condition, but are tubercular patients in every sense 
that that word implies. We have now arrested the hemorrhage, 
as you notice, but I am anxious that the limb should be kept 
in an elevated position, in order to bring the blood vessels in the 
most favorable condition for the establishment of a collateral 
circulation, adequate to the requirements in this case. Now by 
drawing upon the ends of this double suture, you will notice 
how gradually the sawn surfaces are brought into approximation, 
no need of silver wire, no need of any other form of durable 
suture, the absorbable catgut suture here, will keep the parts in 
apposition, until its further use has been made unnecessary by the 
plastic process that will be initiated at once and terminate in 
bony union. We have now the patella in place, we have here a 
double bridge composed of absolutely healthy tissue, a bridge 
that will add strength to the weakened member at the site of 
operation, a bridge that will prevent the retraction of one of the most important muscles of the lower extremity, the quadriceps 
extensor femoris muscle, a bridge that will add its part to the 
process of repair at the site of operation. We will now suture 
what remains of the capsule over the joint on each side, in other 
words, we are ready to close the deep wound with buried catgut 
sutures. I am ready now to close the deeper portion of the wound 
which embraces all that it was deemed safe to preserve of the 
deeper, para-articular structures. What I wish to call your special 
attention to, is the relative position of the external incision to 
the line of section of the patella, the first occupying a level about 
two inches higher than the other, hence the section through the 
patella is covered by the flap; it has been rendered sub-cu- 
taneous by this method of making the incision. I have to enter- 
tain no fear that the skin covering will become permanently at- 
tached to the line of bone suture. I have secured for the 
anterior surface of the patella perfectly healthy tissue. The 
scar that will necessarily result from the operation, will be in a 
well protected place, it will not be exposed to prolonged, con- 
tinuous irritation, incident to locations previously selected. 
Witness with what ease the assistant is suturing the external 
wound, with a facility never within reach if you make the 
old-fashioned incision with the convexity directed downward; 
hence, I would advise in all operative treatment, requiring 
full exposure of the knee joint, a semi-lunar incision with the 
convexity directed upwards, the margin of the flap about an 
inch above the upper border of the patella. You are aware 
that the advice is given, even at the present time, the assertion 
that in operations for tubercular knee joints, it is not only 
desirable, but necessary to remove the patella; we have no reason 
to exempt the patella from the general rule that is becoming, 
or has become an axiom in general surgery, to remove only 
diseased, never healthy tissue. I have pointed out to you the 
uses of this long bridge in resection of this joint. It is 
necessary in such an extensive operation, to apply over this 
large wound a very copious hygroscopic antiseptic dressing. 
We have, I hope, guarded sufficiently against primary wound 
infection, it is now our duty to protect the patient against 
such an occurrence in the future, and the less the wound is disturbed, and the least number of times it becomes 
necessary to remove the dressing, the greater the possibility of 
obtaining an ideal wound healing, in fact, I hope that we have 
left the parts in such a favorable condition, that this wound will 
heal under one dressing. It is my hope that no indications will 
arise, necessitating the removal of the first dressing, for at least 
three or four weeks. We can hardly expect with a man of his 
age, although we have been exceedingly conservative in the 
removal of the joint structures, that we can obtain anything else 
but healing by partial ankylosis, in fact, it is my intention, rather, 
to favor this termination. If the patient were only 15, 20 
or 25 years of age, I should make a faithful effort after such an 
operation to restore motion after the external wound is healed, 
but in a man at his age, anxious again to follow his occupation, to 
support himself and family, it is our duty to initiate such a course 
of treatment as will enable him to leave the hospital in the 
shortest space of time, with a limb in a condition to render 
himself again useful in the community, hence the limb will be 
placed in a slightly flexed position, in fact, the patient is intelli- 
gent enough to have called my attention to the fact that he did 
not desire a perfectly straight limb, he desires a limb slightly 
flexed, a wish which meets with my hearty approval. We will 
now secure for this limb then, a desirable angle, and at once im- 
mobilize it in a permanent, fixed dressing of plaster-of-Paris. 
The assistants will now envelop the limb in a thick layer of 
aseptic cotton from the periphery up to the groin, which will pro- 
vide a soft, yielding cushion to protect the soft tissues, and which 
will guard against harmful compression in the event that 
we should have failed in obtaining all the essential con- 
ditions for primary wound healing. I hardly believe, gen- 
tlemen, that we have as yet found a desirable substitute 
for the old plaster-of-Paris dressing, that is the dressing that 
will be used in the wars of the future. It is the dressing that 
fulfills all the indications, securing to perfection immobilization 
of the injured parts, a dressing that can be so readily applied, a 
splint that adapts itself to all irregular surfaces. It is therefore 
a splint that if properly applied, is the best and the safest safe- 
guard against peripheral gangrene and localized pressure necrosis. The limb will be kept in an elevated position, at about this 
angle (indicating), for at least six or twelve hours, an exceed- 
ingly important precaution in preventing unnecessary parenclty- 
matous hemorrhage after such an extensive operation. 
AMPUTATION OF RIGHT THIGH, LOWER THIRD, BY GENERAL 
SENN. 
Gentlemen: We have just finished, what you will all admit to 
have been a very conservative operation, for a life-destroying 
serious joint affection in a man 50 years of age. I am very sorry 
indeed that the conditions presented in this our next patient, 
although he is younger in years, render it necessary this morning to 
make a mutilating operation, for the same pathological conditions, 
but affecting two great joints instead of one. It is not necessary 
for me to make any extensive remarks to justify my diagnosis in 
this case, as tubercular disease of the ankle and knee joints. The 
case is an exceedingly interesting one from an setiological stand- 
point, illustrating over and over again what we have claimed 
for }rears, the infectiousness of tuberculosis, the disease com- 
mencing in this instance in the same insidious manner as in the 
one which has just left the arena. The disease of the ankle 
joint, commenced after a simple innocent sprain, followed, 
however, by an insidious tubercular affection, which has now 
reached its maximum destructive effect, having resulted in 
complete destruction of the soft structures of the joint, and as is 
evident by exploration of the joint with a probe, it has extended 
beyond the cartilage, into the articular extremities of the bones 
entering into the formation of the ankle joint. In fact, here is a 
case of so-called caries, which is in reality an effect of disease, not 
a disease per se. Caries of bone is produced by molecular 
destruction of bone tissue by granulations and is in ninety-nine 
out of a hundred cases, the result of a tubercular inflammation. I 
was encouraged when I was asked to examine this patient, to make 
for you this morning a conservative operation on the ankle joint, 
I had already decided to make a typical resection of this joint, when my attention was called to the knee joint, where I found all 
of the pathological conditions which warranted me in claiming for 
it a similar origin and character, as the affection of the ankle 
joint. To us, it is an exceedingly important matter to discuss 
the aetiological relationship existing between the disease of the 
ankle and the knee joints. I believe that in this case, there is 
absolutely no direct setiological connection between the ankle and 
between the knee joint affections, but the infection of the knee 
joint can in all probability be traced to the same focus that 
primarily produced the disease of the ankle joint. There is great 
danger that in this case, with two tubercular joints, the seat 
of secondary infection with pus microbes, the patient would 
soon become the victim of pulmonary tuberculosis, tubercular 
meningitis, or even of disseminated miliary tuberculosis, if the 
peripheral lesions wTere allowed to pursue their own course, 
hence, in order to meet the pathological conditions, it becomes 
necessary for us to sacrifice the lower limb and make the 
amputation through the thigh, eliminating by the same opera- 
tion the two tubercular joints. It has been my custom for years, 
never to burden the student’s brain with names attached to 
operations immortalizing distinguished surgeons, important as 
these things may be from a historical stand-point, they are useless 
in practice. There are only a very few essential principles that 
become necessary to memorize and to carry into effect in ampu- 
tating through any part of the lower or upper extremities. If 
you will remember that it is very important to make the incision 
in such a manner as to bring the resulting scar away from pressure 
in wearing an artificial limb ; if you will remember that it is quite 
essential in order to secure an ideal result in all amputations to 
preserve the periosteum and in order to prevent a common and 
very painful affection, neuroma, that the principal nerve trunks 
should be cut off at least an inch above the level of the incision 
through the deep soft part; and if you will not forget that it is 
important under all circumstances to secure complete haemostasis, 
you have all the essential rules that should guide you in making 
an amputation anywhere. Hence the names so frequently 
attached to the many different operations, names that have made the student’s life a misery and their practice often a 
failure, do not deserve as much attention as they have received 
in the past. 
The operation that I am just about to make, through the thigh, 
may be regarded as a type for any amputations of the upper or 
lower extremities. In order to throw the scar away from where it 
will do harm, it will be necessary to make one long and one short 
flap, whether you take a long flap from the front, from the side 
or from behind is immaterial, you will take tissue where you can 
obtain it, you will make the amputation as far away from the body 
as possible. 
It makes my blood curdle and my hair stand on end when in 
the 19th century, during this progressive age, men are held 
up in courts of justice to answer a malpractice suit for hav- 
ing made perhaps a posterior long or a lateral flap, but old text- 
books are still revered by lawyers, but they are of little use to the 
surgeon. If called upon, under such circumstances, do not hesi- 
tate for a moment in supporting your colleague, whether he has 
made a long anterior or a long posterior flap. Rest assured that 
if he is a progressive man he has taken the flap from the region 
best adapted to serve as a covering for the stump. (Applause.) 
Here, fortunately, we are in a position where I can take the flap 
from where it is most desirable to take it. I wish here *o 
make a long anterior flap, which is the ideal flap, of course, 
or drainage to the wound, and as you will notice, the flap by its 
own weight will seek and maintain its proper position, at the 
same time securing the best conditions for efficient drainage. 
If the knee joint had formed sinuses I should have found the 
tissues over the anterior aspect of the knee joint in a favorable 
condition for a flap than on the opposite sides, I would have no 
hesitation in transgressing public opinion and would make a long 
posterior and a short anterior flap, I should then come to the 
rescue of the flap and instead of relying too much on gravitation 
in keeping the flap in place, I would furnish it with proper 
mechanical support by suturing splints and careful bandaging 
and establish drainage by making a button-hole in the center of 
its base. Here then, if I am to use names that will for all time to come be associated with an amputation that will yield 
an ideal and useful stump, I must mention one man above 
all others, Bruns, the late distinguished professor of surgery at 
Tubingen, who advocated a long anterior and a short posterior 
flap in amputation for trauma or pathological conditions wherever 
his rule can be applied without violating the laws of pathology, 
f wish I could make here a lower amputation, and demonstrate to 
you Carden’s transcondyloid amputation, but unfortunately we 
have to remove not only the knee joint but the tissues some 
distance above . it, we must, therefore, necessarily amputate 
above the condyles. I have carefully examined the cutaneous 
covering, and believe I can make an anterior flap reaching 
down at least to the upper border of the patella, without running 
any risk of including in the flap any of the tubercular tissue, 
and I will therefore follow the rule that should never be 
violated, the same as in resection, of not removing, unneces- 
sarily, healthy tissue, even in making a mutilating operation. 
We will use the same means to control hemorrhage during 
the operation as in the last case, and will again resort to elastic 
constriction which here must be applied very high up. 
Having made a long anterior and a short posterior flap I will 
divide the remaining soft tissues with a long knife, and make 
the incision a little conical, the apex of the cone directed up- 
wards. I now make the last cut, a circular incision through 
the periosteum about two inches below the circular incision 
through the muscles, in order to enable me to obtain, 
not only for the soft tissues, but for the bone itself, its 
normal envelope. I will reflect here, as you notice, the cuff 
of periosteum with the same care as I would make the flap 
for the soft parts, because as far as the immediate risks of 
traumatic infection are concerned, this material is of more im- 
portance than the remaining deep structures of the limb. 
I will now saw the bone through in such a way that the sawn 
surface will be on a higher level than the section through the 
soft tissues in order to prevent undue prominence of the bones in 
the stump so that the patient can wear an artificial limb, with 
comfort. The end of the bone as you observe, is even, but there are sharp edges left, and if these were allowed to remain they 
would become the cause of much trouble, consequently I chip 
away these sharp margins with bone forceps in order to protect 
the periosteal cuff against the harmful effect of linear pressure. 
You notice the periosteal cuff will be abundantly long to supply 
the cut end of the bone with its normal covering. I wish to 
isolate and tie the arteries and in a second ligature 
about one-third of an inch higher up I shall include the accom- 
panying veins. I believe it is very important for us to place the 
vessels in a condition best adapted for closure by cicatriza- 
tion in the shortest space of time. In ligating a large vessel, 
it is important always to use ligature material that will be removed 
by absorption, an absorbable ligature cannot be excelled, and I 
believe we have overdone the last few years in the way of using 
silk ligatures, which to me, have often become a source of great 
annoj'ance, and more so to my patients. A silk ligature that 
fails to become encysted in a suppurating wound, is always a 
source of mischief. 1 have now applied one ligature, the next liga- 
ture shall include not only the artery but also the accompanying 
veins. I am tying with a double ligature the second one of which 
includes also the veins. The bloodless space in the artery, 4 to 
7 days, becomes closed permanently by granulation tissue. We 
will now seek for additional vessels, muscular branches, if any of 
them can be found and tie them before the constrictor is removed. 
I am now looking for the sciatic nerve, -which I find here, 
buried in this mass of fat. It is extremely important for to 
remove at least an inch or two of this nerve in order to pre- 
vent the development of a painful neuroma later a frequent 
sequela of amputations unless neurectomy is practiced, a source 
of much pain to the patient and chagrin to the surgeon. Such 
a complication seldom or never sets in if the nerve end does not 
remain in the scar of the amputation wound. You will always 
find the neuroma involved in the cicatricial tissue. We have 
ligated the large vessels, we have resected the nerve, and we 
will resort to some means of arresting unnecessary parenchj'ma- 
tous oozing. I will see, however, whether the flaps are as they 
should be before we go any further, because now would be the time to correct any mistakes as to the length of the flaps. You 
see the anterior flap falls down into its natural position, there 
will be no tension, I have made the flap about right as far as 
the length is concerned. I will compress the surface of the 
wound firmly with a gauze sponge for a number of minutes, 
after removal of Esmarch’s constrictor, in order to prevent un- 
necessary loss of bipod. In patients debilitated by such an 
extensive tubercular disease, as in this case, not a drop of blood 
should be wasted unnecessarily. The assistant should be ready 
with hamostacs forceps, as I am about to remove the compress, 
to catch any spurting points that ma}’’ be seen, all of which should 
be ligated, after which compression is resumed if necessary. 
Now we have all had cases, in which the arrest of parenchy- 
matous oozing proved a most serious task. I remember one 
case of amputation through the leg, where I almost despaired; 
the more I ligated the more it bled, surface pressure was of 
little avail. I hardly knew what to do; douches with boil- 
ing water, scalded the surface, but bleeding proceeded. Only 
after a long siege, by surface pressure and with irrigation of 
hot water, we were able to control the bleeding, in fact we 
had to resort to permanent compression by compress bandage 
that we finally succeeded in controlling the hemorrhage. I was 
anxious afterward to ascertain the condition of the tissues, that 
would satisfactorily account for this obstinate parenchymatous 
oozing. I found in the tissue subjected to microscopic exam- 
ination, numerous encapsulated trichina that had wrought seri- 
ous changes in the structure of the vessels and other tissues, and 
I am firmly convinced, that in many of these cases that will tax 
your patience and skill in this most important part of your oper- 
ative work, you will find some tissue lesions that will account 
satisfactorily for the obstinacy of the parenchymatous oozing. 
Remember the important tissues concerned on the line of section 
made through the limb. I have attended to the nerve, I have lig- 
ated the arteries, I have ligated at the same time the large veins; the 
parenchymatous oozing has ceased, now I wish to protect as far as 
I can the most important anatomical constituents of the line of sec- 
tion, the vessels and the medullary tissue against the deleterious effects of suppuration, should such a complication arise in thi& 
case. I will ask for a catgut suture, in order to take special 
care in protecting the ends of the blood vessels, because in the 
event of suppuration the ligated stump of the artery might sep- 
arate and secondary hemorrhage would be almost sure to follow. 
I wish to bury, from the surface of the wound, the ligated blood 
vessels with a buried suture. I do not pl3.ce very much stress 
on this being carried out in practice, but where time permits, and 
in debilitated patients, this is an excellent precaution. You 
notice that I am taking a deep suture, which entirely buries the 
arterial stump; I have protected the end of these blood vessels 
against the immediate effects of traumatic infection, and sec- 
ondary infection from the surface of the wound that might occur 
later. I now wish to protect that most sensitive of all structures, 
to infection with pus microbe, the medullary tissue. It is for- 
tunate for pathologists and surgeons that we are now in posses- 
sion as a nation, of the rich pathological collection of necrosed 
bone from amputated stumps, harvested during the last war of 
the rebellion. Such specimens after amputation are now rarely 
obtained owing to the effective wound treatment that is now 
almost universally adopted. It is this traumatic osteomyelitis 
which so frequently resulted in pyaemia and death, it is this trau- 
matic osteomyelitis that yielded the large collection of specimens 
of necrosed bone I close the medullary canal by bringing over 
it the periosteal flap which is again stitched with catgut sutures. 
Preservation of the periosteum and securing and maintaining an 
aseptic condition of the wound furnish the most reliable safe- 
guards against osteomyelitis, necrosis and pyaemia. One of the 
trying conditions after an amputation through the thigh, is the 
tendency of the bone to project through the soft parts, giving a 
painful and often useless stump and often making re-amputation 
necessary. This follows either in consequence of the flaps having 
been made short or as the result of violent and prolonged course 
of muscular contractions. We have divided here, some of the 
strongest muscles in the body, the muscles that have lost their 
anchorage below, they seek a point of attachment above, con- 
sequently there is a tendency for the bone to project. In order to guard, as far as vve can,, against this condition, I now resort 
to the second row of buried sutures, the muscles will be supplied 
with a temporary point of anchorage. We will make for them 
for the time being, a point of attachment below. I now make 
a rowr of muscle sutures not expecting that these sutures will 
bring the muscles over the sawn surface of the bone and keep 
them there permanently, that is not my intention-, I could net do 
so if I wished, because nature’s resources here will step in later 
and undo what I have done. You will always find in an old 
stump, all the muscles covering it that are placed over the bone 
intentionally, at the time of the operation, have wasted away by 
a gradual process, by inactivity and pressure atrophy. But what 
I do wish to secure for the next three or four weeks, until the 
process of healing has been completed, is to supply the muscles 
with a support below, a support that later will be removed 
spontaneously. The external wound will be closed throughout 
with silk sutures, that after the process of healing has been 
completed and the stump has become conical, that the scar will 
be above and behind the point of pressure. We are dealing now 
with a very large wound, there will be considerable primary wound 
secretion ; the hospital surroundings here are not the very best, the 
patient is debilitated by disease and it will become necessary 
to establish tubular drainage, in the other case we attempt to gain 
this object by a capillary drain. Here I .will drain by making a 
small button-hole in the middle of the base of the posterior 
flap, I prefer to do this, rather than drain from the angles 
of the wounds as I desire to obtain healing of the 
amputation wound throughout, at the same time the drainage 
will be at the most dependent point where it will prove most 
effective. The flaps will be stitched in the usual manner 
and the operation wound closed throughout. In the dressing it is 
important to again make use of compression as a means of 
guarding against subsequent parenchymatous oozing during the 
period of reaction, by making the antiseptic hygroscopic dressing 
copious, so that it will not only prove useful in absorbing and 
disinfecting the primary wound secretions but will prove bene- 
ficial by exerting a continuous equable elastic compression, which not only guards against hemorrhage, but constitutes at the same 
time the best known means in securing accurate apposition 
between the wound surfaces. The stump will be supported by 
a hollow posterior splint and will be kept in an elevated position 
for at least twelve hours.