442 OX A CASE OF EXCISION OF THE KXEE-JOIXT 



Here no portions of bone at all had been taken away, no active disease had been 

 present for several ^^ears, and the only abnormal circumstance was that the 

 limb had been in a condition incapable of being used like the other. In con- 

 sequence of this want of use, not only had the muscles atrophied, a thing which 

 you would all have anticipated, as the converse of the hypertrophy- that occurs 

 in the blacksmith's arm, but all the textures, including the bones, had grown 

 in a less degree than in the healthy limb. Similarly, after excision, although 

 the operation be successful, and perfect anchylosis between the femur and tibia 

 be attained, the limb is not so vigorous as the other, and in proportion to its 

 diminished activit\- may its growth be interfered with. I lately saw a case 

 in private practice which illustrates this point still more strikingly. The patient 

 was a boy who had experienced fracture of both bones of the leg in the lower 

 third when a child. The fracture had been overlooked, and the bones had 

 united in a faulty position, so that the foot was considerably inverted. The 

 boy therefore could only walk upon the outer edge of his foot, and that with 

 a very limping gait, except by the aid of an apparatus which, though it enabled 

 him to tread fairly on the sole of his foot, was in itself necessarily cumbrous ; 

 and the result had been a shortening of the limb, as compared with the other, 

 altogether out of proportion to the effect of the curved position in which the 

 bones had united ; and, just as in the case before you, the foot also was smaller 

 than its fellow. There the interference with full development induced b}* 

 imperfect action of the limb was still more plainly illustrated than in this little 

 girl, because in the former there had been no disease at all from first to last, 

 but merely the crippling influence of an injury. 



To return to the case of the little girl. We had to deal with a limb which 

 was not only useless from its bent position, but which had been so retarded in 

 its growth that, even if perfectly extended, it must be shorter than the other. ' 



Hence it was a matter of the utmost importance that the means which should 

 be used to produce extension should add as little as possible to the existing ] 



deficiency in length. The joint was not anchylosed, but the hamstrings became j 



extremely tight on any attempt at extension. We therefore proposed to divide 

 the hamstrings b\^ subcutaneous tenotomy, but I led you to fear that this step I 



might not be sufficient to enable us to restore the straight position ; for I men- 

 tioned to you the fact first brought prominently forward bv Prof. Volkmann, 

 of Halle,^ that in cases like this, in which the knee remains for a long time in 

 a bent position, the lower end of the femur, no longer supported as usual by the 

 articular surface of the tibia, may experience disproportionate growth in the 

 downward direction, often to a very considerable extent. Meanwhile the 



* See a translation of Prof. Volkmann's paper in the Edinburgh Medical Journal, vol. xx, p. 794. i) 



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