P A R T III .

H A L F - Y E A R L Y R E P O R T S .

R E P O R T ON S U R G E R Y .

By WILLIAM THOMSON, M.A., ~F.R.C.S.; Surgeon to the Rich- mond Hospital, Dublin ; Examiner, Royal College of Surgeons.

E X C I S I O N O F T H E K N E E .

T w o papers which will prove of much interest to operating surgeons have recently appeared upon the subject of resection of the knee- joint. The first is by Ollier of Lyons (Revue de Chirurgie, Nos. 4 and 5, 1883, and Lond. Med. Record, October 15, 1883), and the second by P. Vogt of Griefswald (Centralbl. far Chirurflie, No. 24, 1883, and .Lond. Med. Record, August 15, 1883). The former author gives a general review of the operation and its results, and points out the cases in which it appears to him to be a successful procedure. One is surprised to find that his first cases were attended by a mortality of from 75 to 80 per cent., a result which for a time caused him to abandon the operation altogether. Anti- septic dressings have, however, reduced this frightful death-rate to 14. Even this, however, is far beyond what is met with by Irish surgeons. In his own cases and in a large number operated upon by his colleagues the reporter cannot recall a fatal result. The operation has failed in some few instances to secure a useful limb, and amputation has been performed, but the mortality has been nil.

M. Oilier states : - -

"Tha t formerly he was opposed to this operation, and, on account of the high mortality--75 to 80 per cent.--which followed his first attempts~ he thought it preferable in cases not amenable to treatment by rest~ drainage, and incision of abscesses, to have recourse to amputation in the thigh, the mortality of which operation in such eases was about 40 per cent. At the present day, however, owing to antiseptic dressings~ the proportion is completely changed. Of seven cases in which resection of the knee has been recently performed by Ollier, one only was fatal ; and in this death occurred very soon after the operation. and was due to shock. The mortality of resection of the knee has thus

Report on Surgery. 479

been reduced from 80 to 14 per cent., and the motives which formerly induced the surgeon to abstain from performing this operation no longer exist. The use of Lister's dressings, with which M. Oilier associates iodoform~ have completely changed the conditions of operative surgery in the clinique at Lyons. As an example of this, M. Oilier states that, during the six months just previous to the date of his paper, he had performed twenty-two major operations (resections of large joints, ampu- tation in the thigh and leg) without having had a single bad result through infection. Resection of the knee, which now, in M. Ollier's opinion, claims a place in the first rank of conservative operations, is applicable to three principal conditions--osteo-arthritis, or suppurative fungous arthritis, comminuted fracture, or gun-shot wounds involving the joint ; ankylosis in a bad position. Thus the resection may be patho- logical, traumatic, or orthopaedic.

"M. Ollier does not approve of performing resection of the knee on children in whom osteo-arthritis usually yields to the expectant treat- merit, and the limb after the resection i s likely to become very much reduced in length. He would not, therefore, practise the operation on any subject under the agd of eight years and a half. In older patients, the indication for resection of the knee exists not only when the removal of the osseous extremities is absolutely necessary for th 0 preser- vation of life, but is presented also when it is desirable to remove the source of a suppuration which though not threatening to become immediately fatal, may prove so at any time, and which condemns the patient to long confinement in bed, and causes all the bad results of a chronic discharge. Formerly, it would have been more prudent under these conditions to undertake a natural cure; but now, M. Ollier holds, it would be blameable not to resect. The operation, when performed at a proper time, will prevent the dangers of articular suppuration, and enable the patient in the course of three or four months to leave his bed and to move about.

" I n performing resection of the knee, it has been M. Ollier's aim to place the parts in the best conditions for favouring osseous ankylosis, or obtaining an useful new joint in cases where solid union has not been established. Division of the ligaments and ablation of the capsule, as practised in the operations of Park and Moreau, is attended with the dis- advantage of destroying the close relations of the osseous surfaces~ and leaves the extremities of the bones quite loose in the wound, and deprived of such supporting soft structure as might assist very much in their ulterior union. By preserving the periosteo-eapsular sheath~ and maintaining the lateral and posterior continuity of this sheath, the surgeon may retain the ligamento-muscular girdle which surrounds the bones~ and would keep them together after the operation. M. Oilier advocates the subperiosteal method of resecting the knee D but points out that this is not

480 Report on Surge~ T.

done with the view of forming a new joint. A solid limb is needed to support the weight of the body, and osseous union is the best guarantee against any relapse of the local disease. An H-shaped incision is made, which, however, is smaller than that which was formed by ]~loreau; on each side of the joint, is made an incision for free discharge and for the insertion of drainage-tubes. The outer incision is made just in front of the tendon of the biceps, and the inner one just behind the tendon of the sartorius. In making the tranverse incision, the ligamentum patellm is cut through and the joint opened; the lateral ligaments of the knee are not divided. The superior flap is then raised together with the patella. I f this bone be found diseased it is removed, its anterior covering of periosteum, together with the continuation of the tendon of the extensor muscles, being carefully preserved. The crucial ligaments having next been divided, the inferior extremity of the femur is projected through the wound and stripped of its periosteum, and the insertions of the ligaments, as far as the line to which it is thought necessary to apply the saw. The extremity of this bone having been removed in the usual way, the end of the tibia is dealt with in a like manner. All masses of thickened synovial membrane are scraped away, and the sawn surfaces of the bone brought together and fixed by two wire sutures. After the application of sutures to the edges of the skin flaps, the ends of the divided ligamentum being also brought together by suture, antiseptic dressings are applied, and the whole limb secured in a splint. This proceeding, Ollier asserts, not only seems to realise all the conditions required for total resection, but is applicable in its primary stage to exploratory arthrotomy, to articular scraping, and to superficial (intra-epiphysal), and partial resections of the knee-joint. Under these circumstances, it is important to preserve the lateral ligaments and to re-establish the con- tinuity of the quadrieeps by suturing the ligamentum patellae. The tendino-ligamentous girdle having been left intact, the elements of resistance and motility are preserved, and the joint is subjected but to the minimum of disturbance. M. Oilier, however, would not at the present day compare these partial operations with total resection of the knee. The former are, in certain cases, rational operations, the dangers of which are much diminished by :Lister's dressings and iodoform, but they are attended by the disadvantages of all operations that are too conservative--they expose the patient to the risk of relapse. The patella has always been removed by M. Oilier ; and it is considered prudent not to leave this bone in resection of the knee in the adult, when it is deprived of its cartilage and more or less diseased internally. This practice is a guarantee against relapse of osteitis and of fungous disease of synovial membrane. M. Oilier would not, however, adhere strictly to this rule, and thinks that the patella might woll be left in cases of trau- matic arthritis, particularly in infants. Whoa this is done, it is necessary

Report on Surgery. 48 l

to increase the number of drainage-tubes. In preserving the patella when sound, in cases of some other lesion of the joint than osseous or synovial tuberculosis, the surgeon might gain the same advantages which he seeks to obtain by preserving the lateral ligaments and the capsule--- that is to say, around the line of reunion of the bones there is an addition to the tissues, serving to augment the solidity of the limb. I f firm union fail to be established between the bones, the presence of the patella would probably favour the compatibility of articular motility with usefulness of the limb.

" I n dealing with enlarged granular masses of synovial membrane in resection of the knee, the surgeon's practice should vary according to the nature of the arthritis. In articular disease of traumatic or rheumatic origin, these granular masses are converted into stable cicatricial tissue after the removal of their superficial layer, but in tubercular arthritis it is necessary to remove all the diseased synovial membrane and to apply the actual cautery to the raw surface. In cases where well-marked grey granulations exist, and where large masses are observed of caseous material, or of pale and slightly vascular granulations extending under the periosteum, amputation is preferable to resection. Since the intro- duction of antiscptic dressings, the prospects of treating severe open injuries of the knee by resection have much improved ; and, at the same time, these dressings, by preventing those bad results which resection is intended to remedy, are likely to diminish considerably the number of cases of resection, and to widen the field of non-operative conservative surgery. There will, however, always remain a certain number of cases of comminuted fracture of the epiphyses which should be treated by resection--as, for example, when the condyles are broken up into numerous fragments and a projectile or some other foreign body is present in the midst of the splinters. In a case of this kind, IV[. Oilier would perform the following operation, which he has not yet tried on the living subject, but which seems to possess several advantages on account of its sim- plicity and of its favourable anatomical conditions with regard to ulterior renewal of the joint if ankylosis should fail. This consists in a single straight median incision carried longitudinally over the patella and through the tendon of the quadriceps and the ligamentum patellae, dividing these latter structures into two equal parts. The patella having been divided by a saw into lateral halves, the two lips of the wound are separated, the interior of the joint is exposed, and the extent and situation of the injury fully revealed. The surgeon is then able to do what is neeessary~ whether simply to remove splinters or foreign bodies, or to perform resection.

" I n two of the seven cases of resection of the knee recorded in this memoir, the operation was performed for osseous ankylosis. This con- dition has been the result in one of these instances of extension of inflammation from the juxta-epiphysal region; in the. second, of acute

2 I

48~ Report on Surgery.

traumatic arthritis. In dealing with ankylosis of the knee by operatlon~ the surgeon has hitherto had the choice of two methods of procedure; cuneiform excision of the femur above the articulation ; resection of the osseous extremities which formerly constituted the joint. The second~ M. Ollier statess is that most frequently indicated~ and is the only operation applicable in cases where the extremities of the bones are stil l diseased; where there are patches of osteo-myelitis in the condyles of the femur; and where open sinuses still exist and lead down between the bones. The operation of cuneiform excision of the femur may doubtless be often applied~ but iu cases where i t is not necessary to interfere with the old joint s and where there is no diseased tissue to be removed s this cuneiform resection s in Ollier's opinion s should be replaced by a simple supracondyloid osteotomy~ or better still by a bloodless opera t ion-- tha t is to say~ by femoral osteoclasis. This supracondyloid fracture is with Ollier the ~method of election~' whenever such operation is applicable and especially in ankylosis of traumatic or rheumatic origin. In such casess he would not hesitate to have recourse to osteoclasis~ if the amount of flexion at the freed knee did not pass beyond a right angle. Osteotomy s it is allowed~ has no great danger if performed antiseptically~ but still it is not so harmless a proceeding as osteoclasis. That method should be chosen which enables the surgeon to obtain the same orthopaedic result without a wound and yet with equal precision.

" T h i s memoir concludes with the following summary : - -1 . Antlseptlc dressings have completely changed the indications and prognosis of resection of the knee. As formerly it was accounted wise and prudent to reject this operation~ or at least to limit its indications in hospital practice, so now it would be considered unreasonable to continue to amputate the thigh in cases where resection is applicable. 2. In young subjects s on account of the dangers of resection with regard to ulterior lengthening of the bone~ it is still necessary to insist on a methodical expectant treatment in suppuration of the knee~ and on the employment of such relatively simple means as arthrotomy~ articular scraping s drainage s &c. The surgeon might have recourse in the first place to these means at any ag% but he should always prefer resection to amputa- tion~ except in dealing with severe forms of tubercular arthritis~ for which the latter is the proper operation. 3. The gravity of resection of the knee is not greater at the present day than that of amputation through the thigh. The cases recorded in this memoir show that in resection of the knee success is now the rule where formerly it was the exception~ and that the surgeon must be gnided by other motives than the gravity of the operation in deciding between amputation and resection. 4, Endeavou'r should always be made to obtain osseous ankylosis after resection of the knee; but i t is necessary in this operation to ensure a strong articula- tion~ in case~ for some reason or other~ ankylosis might fail. 5. The

Report on Surgery. 483

subperiosteal method allows the surgeon to attain this result. The sawn surfaces of the bones are thus left surrounded by abundant ossifiabte tissue; and in cases where osseous union does not result~ a complete ligamento-muscular girdle is preserved around the new joint. 6. F rom the scarcity of the observations that have hitherto been recorded, it is yet impossible to estimate the value of resection of the knee in military surgery. I t may be presumed, however, that in future campaigns results may be obtained as good as those of modern civil surgery~ if only the wounded can be treated with ordinary care. 7. In resection a transverse incision is recommended~ together with two lateral vertical incisions. These incisions should not be so extensive as those that were made in 1)arke's operation~ and the lateral ligaments of the knee should be left intact. On each side of the joint, far back and near the posterior margins of the condyles, a deep vertical incision is made for the purpose of drainage. 8. In cases of chronic intra-art icular suppuration~ it is usually found necessary to remove the patella, its anterior covering of periosteum being preserved. The continuity of the ligameutum patel la should be re-established by nature. 9. In the operative treatment of comminuted fracture of the articular extremities of the bones, a longitudinal incision is to be preferred to transverse incisions. A median longitudinal incision in front of the knee, dividing the patella into two lateral halves~ facilitates the operation~ and preserves all the constituent elements of a new joint, and at the same time favours aukylosis, if this result be intended. 10. In osseous ankylosis of the knee, supracondyloid osteo- elasis should be the method of election. This operation is especially applicable in cases of ankylosis of traumatic or rheumatic origin, when flexion does not reach or exceed a right angle~ and when there are not any deep-seated and multiple cicatrieial bands in the popliteal spaces. 11. Whenever there is a risk of lacerating any of the popliteal vessels or nerves enclosed in cicatricial tissue, it would be better to have recourse to supracondyloid osteotomy or to resection. I t would be necessary in such ease always to practise total resection of the condyloid expansions of the femur, if the cicatricial adhesions be deep-seated and multiple, and if the leg be flexed beyond a right angle. 12. Resection of the condyloid expansions is the only operation to be proposed when signs of inflamma- tion of bone are presented. In a case of flexion of the leg passing beyond a right angle, the surgeon must remove not merely a wedge-shaped boney but must take away some thickness of the posterior portion of the femur. This is the sole means of bringing the surfaces of section into contact~ without exciting painful tension in the popliteal region, and interfering with the circulation of the limb.

" D r . P. Vogt, of Griefswald, states that~ with our very imperfect knowledge of the pr imary conditions of fatal absorption of fat after injuries of bone. it might be of interest to direct attention to one point

484 Report on Surgemj.

which, in his opinion, is likely to favour extensive fat-embolism after resection of -the knee, and the neglect of which is more frequently fol- lowed than is generally thought by a fatal result from the operation. The following case is reported, of speedy death after resection of the knee performed under apparently favourable conditions : - -The patient was a girl, aged twelve years, on whom resection of the knee was per- formed for fungous disease, with extreme and long-standing contraction of the flexor muscles. On opening the joint, the extremities of the femur and tibia were found to be so far free from tubercular deposit that it was possible to save the epiphysal cartilages. The whole of the osseous elements of the joint were in a condition of extreme fatty degenera- tion, so that the removal of the articular surfaces could be readily effected by the use of a knife. This condition seemed a likely result of the prolonged inactivity of the limb, and did not decidedly contra- indicate subsequent union of the sawn surfaces. The lower limb could now be readily straightened, and in this position of full extension the opposed osseous surfaces came into direct contact. Although the patient had taken but little chloroform, and there had not been excessive bleed- ing, and carbolic acid had not been used for disinfection, she, after the influence of the anmsthetic had passed off, remained extremely prostrate. The countenance was pallid, the respiration shallow, sensibility much reduced, the pulse scarcely perceptible, the heart's action very slow, and the extremities cold. Notwithstanding the use of stimulating remedial agents, there was no improvement in the condition of the patient, who became more and more drowsy, and died after an interval of twenty- four hours. On post mortem examination, appearances of very extensive fat-embolism Of the lungs were presented.

" A f t e r careful consideration of the symptoms presented in this case, and of the post mortem appearances, Vogt felt obliged to exclude all other conditions as causes of the collapse, and to attribute the fatal result to fat-embolism, indicated by diffused infarction in the lung, containing large and small globules of oil. As has been shown by the experiments and clinical observations of Czerny, Recklinghausen, and others, only very extensive fat-embolism of the lungs can cause death, whilst the slight fatty infarctions of the pulmonary vessels, frequently occurring after injury to bone, do not result in serious lesions. The necessary conditions for the production of fat-embolism are--sufficiently large normal or pathological orifices in the walls of the vessels; the presence of free oil near the vessels ; and, lastly, a vis ~t tergo, usually the pressure of extravasated blood. All these conditions are frequently present in cases of fracture; but fat-embolism rarely occurs after amputation and resection, sinc% on account of the free discharge of the secretions of the wound, there is not sufficient pressure to favour absorption. The only other case of fat-embolism after resection known to the author is one

Report on Surgery. 485

that occurred in Professor Liicke's practice after resection of the hip. In Vogt's case, as is pointed out, the conditions for the absorption of fat by the surfaces of exposed bone were extremely favourable. When the limb was straightened after the ends of the bones had been removed, the sawn surfaces came into very close contact, and were pressed together. The bones were kept in this close contact by two wire sutures, so that there was no possibility of the secretion from the sawn osseous surfaces and of the abundant oil flowing away into the soft parts of the thigh and leg. Vogt holds that the rapid absorption of oil from the sawn surfaces of the degenerated bones is thus fully explained. Under no circum- stances, it is stated, should osseous surfaces found in a similar condition in future cases of resection of the knee be placed in close contact. The enfeebled cardiac action in the anaemic subject of Dr. Vogt is pointed out as having been a favourable condition for the arrest and accumulation of oil in the hmgs. Dr. Vogt has been led by a consideration of this case to suggest that, in dealing with similar cases of disease of the knee, with extreme flexion of the leg, and fatty degeneration of the marrow of the femur and tibia, it would be well, if the limb in resection cannot be straightened without close contact of the sawn surfaces of bone, or without removal of the epiphysal cartilage, to have recourse to amputa- tion.

"Allusion is made to an interesting point in this case, that, in the interval between the operation and the death of the patient, the tem- perature remained low, and showed no tendency to rise. This fact indicates that lowered temperature is pathognomonic of uncomplicated fat-embolism, and that the increase of temperature associated with pneu- monic symptoms recorded by some observers in cases of such embolism was due to some complicating infective condition."

RESECTION OF H A L F OF A V E R T E B R A L BODY.

Israel of Berlin (Berliner klinische Wochenschrift, No. 146, 1882) reports a case in which a patient with curvature of the spine suffered from abscess and paraplegia. Supposing that the last-named was due to compression of the spinal cord by a purulent collection, Israel resected the twelfth rib and half of the twelfth dorsal vertebra, and was thus able to evacuate the abscess. The paraplegia was not at all modified by this interference, and the patient died at the end of thirty-seven days, after having presented symptoms of purulent pleuritis.

T E A R I N G OF T H E VENA CAVA W I T H O U T HIEMORRHAGE.

Liicke (Deutsche Zeitschrift fi~r Chirurgie, X V . , fas. 5 and 6, p. 578) reports a case in whidh sarcoma of the kidney having been

486 Report on Su~,gery.

diagnosed, extirpation of the gland was proposed and accepted. The capsule of the turnout having been opened it was enueleated. While it was being thus detached it suddenly appeared to view and rolled into the room. A t the same moment a flood of dark blood filled the abdomen. Compression was made with sponges and gauze upon the point from which the blood appeared to come. The bleeding ceased, and the abdominal wound was closed. The patient did well for a day; then followed symptoms of ur~emia, small pulse, vomiting, diarrhoea, and absolute suppression of urine. Death followed on the fourth day from urmmia. The post mortem, which was made by V. Recklinghausen, showed primary carcinoma of the kidney, carcinomatous thrombosis of the renal veins, lacera- tion of the principal renal vein and of the inferior vena cava, closed by a large thrombus 15 mm. long.

T H E TREATMENT OF F R A C T U R E D P A T E L L A .

Mr. Lister, in an address before the Clinical Society of London (Brit. Med. Jour., :Nov. 3, 1883), has made a most important contri- bution to surgery in regard to the treatment of fracture of the patella. The distinguished surgeon was able to show six out of seven cases on which he had operated successfully; and all showed that very free use of the joint was maintained. The question, in spite of this success, however, is a very debatable one. I t has been the fortune of the reporter to meet with a case in which the most disastrous results followed this operation, and it may not be out of place to repeat some of the particulars in connexion with Mr. Lister's most interesting communication. The operation has been done very frequently not only for want of union, but in cases of recent fracture. Mr. Lister says that these latter can be treated so as to restore " t h e joint to practically a perfectly natural condition, provided only that no disaster occurs ; " and he admits the danger by observing " tha t , however, is a tremendous proviso, and no one is more conscious of it than myself." The question which presents itself to one's mind is th i sm" Is the end attained by success worth the risk ? "

Mr. Lister's address deserves careful study. I t is unnecessary to give details of the cases, but the directions for operating may be quoted here : - -

" I should like now to say a few words as to the method of operating. The wire employed should be, as I have said, pretty stout, about one- sixteenth of an inch in diameter. I have not found it needful to use

Report on Surgery. 487

more than a single suture of such wire. I t is applied in the vertical plane, in the course of the longitudinal incision over the middle of the bone ; and in recent cases no dissection of the soft parts from the patella is necessary. I t seems important that the cartilaginous surface of the hone should be left quite smooth, or, in other words, that the fragments should be exactly at the same level at their lower part. We cannot be perfectly sure, when we drill, that the bradawl will come out exactly at a correspondifig point on the two surfaces. Supposing that on one side the instrument should have come out too far down, it may be into the cartilage instead o~ a little above it. We do not regard that at first, but pass the wire through each drill-hole the moment the drill is with- drawn, and then on that side oa which the hole has come too far down, by means of the bradawl, we simply chip away a little of the material that is above the wire until the wire comes to be in a position exactly opposite to the hole on the other side, leaving a gap below. This is a perfectly simple matter ; at the same time~ it might possibly not occur to anyone during the operation. Here we have the wire represented twisted, and the twist hammered down. The twist always goes to one side, and, being on the other side in this instance, is not shown in the section re- presented by the diagram.

~' I think it must be admitted that these eases show that the mode of treatment which i have recommended, when applied to recent transverse fractures of the patella, affords a means of ~s to r ing the joint to, practically, a perfectly natural condition, provided only that no disaster occurs. That, however, is a tremendous proviso, and no one is more conscious of it than myself. Before I made the incision in the first case that I have recorded to-night, I remarked to those who were assembled in the theatre that I considered no man justified in perform- ing such an operation unless he could say, with a clear conscience, that he considered himself morally certain of avoiding the entrance of any septic mischief into the wound. Supposing, on the other hand, that a man can say that with a good conscience, then I conceive that he is not only justified, but bound to give his patient the advantages that we see are to be derived from this method of procedure."

T h e repor te r ' s case was read before the Br i t i sh Medica l Associa- t ion a t W o r c e s t e r (Brit. Med. Journal, A u g u s t 26, 1882), and, as i t th rows l igh t on a possible r esu l t of" su ture of the pate l la , i t is here summar i sed : - -

" I was sent for to my hospital, late one evening, to see a man who had just been brought in, and who was the subject of a very remarkable accident. He was aged about thirty-six, and had filled the position of first officer in a large foreign-going ship. I found him lying in bed, Suffering from an extensive rupture of the knee-joint. Thex~ was a

488 Report on Surgery.

great gaping wound running directly across the knee, extending from condyle to condyle of the femur, with edges as sharply defined as if they had been made by a surgeon's knife. The patella was broken trans- versely; and, as the patient could not extend the limb, and the thigh ~nd the leg lay at about r ight angles to each other, the condyles of the femur and the articular surface of the t ibia were fully exposed.

" T h e patient had been operated upon by the late Mr. Amphlet t , of Charing Cross Hospital, London, about a year previously. The frag- ments were sutured with wire.

" T h e patient stated that, after he left Greenwich, he gradually improved ; but the joint had hardly any motion. I t was slightly flexed, so as to cause him to walk on the anterior part of the foot~ and he was unable to pursue his occupation. On the evening of the accident he was leaving a shop, and when stepping down to the pavement his toe caught in some obstacle; the limb was violently flexed as he tried to save himself from falling. He at once felt something snap, and an examination showed what terrible mischief had been done.

" A f t e r a full consideration of the case, we believed that excision offered a fair chance of success. This was accordingly at once per- formed, and the patient recovered with a useful limb.

" T h e patella itself is in two fragments. The fracture has taken place nearly in the line of the old in jury ; but there can be no doubt that osseous union existed in the bone after the original operation. Four holes remain (two above and two below the line of fracture) to indicate the position of the wire sutures. Union had taken place for about two- thirds of the distance across. Beyond that is a separation between the portions of the patella amounting to one-third of an inch. The fracture was almost extra-articular, only encroaching on the line of cartilage to the extent of half a line. The carti lage has nearly altogether dis- appeared, except round the margins.

'~ Is a fractured patella, united by ligamentous bonds, which after- wards stretch~ so great a misfortune after all ? I have never seen a case of osseous union in a l iving subject, and I have never seen a case in which a patient was disabled to any great degree by his fractured patella. Every surgeon has met with cases which get on very well without bony union, and without any special apparatus. I do not mean to say that in no instance ought this operation to be done, but I think i t ought only to be recommended where the injury has become an absolute impediment to the patient 's progression. In the present case, at all events, the man's position was not improved. He had a too flexible joint before the operation, and a stiff flexed one after i t - - a condition which might have been practically secured by a properly adjusted knee- cap. Moreover, I think we render these persons so operated upon often liable to such an accident as is here reported ; for we may have~ instead

Report on Surgery. 489

of movement~ a spurious insecure ankylosis, with a joint covered by cicatrised and tightened integuments, liable to rupture o~a very slight provocation.

" I f , however, the operation in such cases should be rarely resorted tOy it seems to me that it cannot be justified in recent accidents. Experience shows us every day the admirable results which may be attained by simple methods, and the facility with which persons with broken pateUm may pursue their avocations. Is it to be laid down as a rule that we are to wipe out such probabilities altogether, and to lay open a man's joint at once ? If we could be assured of perfect motion with perfect union the justification would be strong, but who can assure us ? Passive motion is always late and limited, because we cannot disturb the uniting fragments; and, meanwhile, changes are being effected in the synovial membrane~ the cartilages, and the ligaments generally, which may end in giving us a much worse joint than if we had left it alone. I am quite conscious of the great advances in operative work which the Listerian method has allowed to be made; but, thorough believer as I am in its efficacy and its complete safety where accurately carried out, there are risks which will always surround it, as they surround every scientific method. I t has enabled us to do great things, but even with its help I cannot believe that we are justified in attempting to do what is unneces- sary, when that proceeding is attended not only with danger to limb but to life also."

V E R A T R I N E AS A. REMEDY FOR TREMOR.

M. F~RIS, of Brest (Progr~s mddical, July 14, 1883), has come to the conclusion that veratrine will control the tremor of alcoholism, of various nervous affections, and of the state folloycing pyrexia. I t is to be given in half-milligramme pills, four of which should be taken daily. The action is apparent almost immediately after the first doses are taken. I f the remedy is continued for a sufficient length of time, its influence remains for a long period after the use of the drug is suspended. This persistence has been observed for almost two months. The treatment should be continued at least ten days in order to produce permanent results. M. Dubois (Gaz. hebdom, de m~d. et de chir., July 27, 1883)~ in reviewing the conclusions of M. F~ris, observes that most of the active principles, administered during the state of alcoholic intoxication, from the time the tremor is of the greatest intensity (the patient having abruptly stopped the alcohol), will act like veratrine to check the t remor.--N. Y. Med. ,Tour.