BOOKS RECEIVED.

From Evans and Hastings

Annual Report of the Vancouver Board of Trade, 1903-4. From Cassell and Co.

The Student's Handbook of Surgical Operations. TREVES. New Edition.

Serums, Vaccines, and Toxines in Treatment and Diagnosis. BOSANQUET.

From George Standring-

The State Remedy for Poverty.

From Elliott Stock

Municipal Shortcomings. SMALLCROSS.

From H. K. Lewis

Enlargement of the Prostate. MANSELL MOULLIN. New Edition.

Deaths in Childbed--A Preventable Mortality. WILLIAMS. From Young J. Pentland

The Nervous Affections of the Heart. G. A. GIBSON. From Cornish Bros.

On the Sterilisation of the Hands. LEEDHAM-GREEN.

OPERATIVE METHODS-NEW AND OLD-IN TUBERCULOSIS OF THE KNEE JOINT. *

BY SIR WILLIAM THOMSON, C.B., F.R.C.S., Surgeon to the Richmond Hospital, Dublin; Hon. Surgeon to the King in Ireland.

MR. PRESIDENT AND GENTLEMEN,

I have to thank the Committee of this Society for the honour they have done me in inviting me to address you at this opening meeting of your session. I feel that you have paid a flattering courtesy not only to myself, but to the country from which I come, and I wish most cordially to acknowledge it.

When I first put to myself the question, "What shall be the subject of my address?" it occurred to me that I might find you sated with the whole range of problems in what I may call the transcendental surgery of to-day's fashion, and that you might for a change be inclined to go with me along some paths more prosaic, but not less interesting and important. So discussing the matter in my mind, I came at last to the decision to ask you to consider with me the treatment of tuberculosis of the knee joint. I think you will admit that it is not in a quite satisfactory position-and the variety of methods points to the fact that there is great difference in the views of surgeons as to what is best to be done. The disease is common enough—but if it is common, it is not commonplace. It influences severely the life-history of the poor, among whom almost every individual must be a breadwinner; it mars many a career, which otherwise might be so successful, among those with the best social surroundings. It is, then, of great importance among the things that form the activities of a surgeon's life; and in dealing with it he may worthily exercise his best qualities, for not only does it

*An Address delivered before the Midland Medical Society at Birmingham,

October 27, 1904.

demand high powers of brain and hand, but it will test his skill and patience to the utmost. And to my younger confreres may I say that they will meet tubercular arthritis far more frequently than abdominal mysteries, with all their fascinating perplexities? So it seems to me that I am justified in trying to lay before you shortly the claims of competing methods, and to arrive at a fair appreciation of them.

I start with the admission that by far the greater number of cases, if seen early, are amenable to a certain degree to treatment by mechanical methods. Some appliance, such as Thomas's splint, which gives rest to the joint, and enables the patient to take exercise in the open air, supplemented by generous constitutional treatment, will frequently stay the progress of the disease, and leave the patient with a joint which may be damaged, but useful. It is for this reason that we seldom find it necessary to interfere actively with children of the better class. The watchful care which they enjoy leads to an early recognition of symptoms, and medical aid is sought. But unhappily that is not so with the children of the poor, whom we see in such numbers in the outpatient departments and hospitals of large towns. Their condition is not recognised by parents who are too often unobservant or neglectful; or their complaints are attributed to some passing strain, or to "growing pains." When we see these cases, many of them have far advanced on the road which leads not only to permanent damage, but to the imperilling of the joint or limb altogether. What is to be done for them? Our hospitals have too many demands upon their space to give shelter to all these poor creatures. They cannot provide themselves with suitable splints and crutches, for they cost money. So we treat the less urgent of them as extern patients. We put up the limbs in plaster of Paris, and send their owners back to their wretched dwellings to every hostile condition that we can conceive-bad air, bad food, bad clothing. And with what result? There are some who appear to think that joints will in such circumstances get well in time. I envy them their optimism. In my experience they do not get well. The poor live their uncared-for,

happy-go-lucky lives as usual-perhaps they only appear at long intervals at the out-patient department, or not at all. But very surely the trouble goes on, and in the end, sooner or later, they come to us with a joint whose treatment has passed out of the region of simpler non-operative remedieswith greatly thickened synovial membrane, often with sinuses, sometimes permanently flexed and deformed.

Up to fifty years ago it may be said that all such joints had a uniform fate at the surgeon's hands. The thigh was promptly amputated, if only the patient would consent, and the sufferer was submitted to the risk of a 30 per cent. operative mortality. It came about, however, that limbs as well as life had an increasing value; and there arose among surgeons, influenced by the wonderful development of their art, in response to the lessons of science, a desire to preserve what it had been the habit to condemn.

But long before this period-in 1782-Park, of Liverpool, had the honour of trying to place the treatment of these cases on a rational basis. He successfully excised the knee joint, and seven years later he did the operation a second time with a fatal result. Filkin, of Northwich, had, however, anticipated Park by just twenty years, although he modestly withheld publication, and to him belongs the distinction of having performed the first operation of this kind. Up to 1816 only six cases are recorded. Then came a couple of Irish cases operated upon by Sir Philip Crampton. The procedure was one of the surgical curiosities of the time. No British surgeon other than Filkin and Park had ventured upon it, and naturally in Dublin, where Crampton operated in 1823, there was intense excitement in the profession. The theatre of the Meath Hospital was crowded by medical men and students. I have already put on record an account of the proceedings as described in the Lancet of 1825, but the story will bear repetition now. The writer says: It was the first time, we believe, that the removal of the knee joint was attempted here. We earnestly hope it will be the last. The operator, of course, accomplished his purpose with his usual dexterity. But could he have beheld, as we did, the contorted countenances of the spectators, the knife would have

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fallen from his hand, never to be used where it was not more imperiously indicated. To be present was indeed a torture. One man vented his feelings in a wink; a second in a "hem"; a third overcame his sympathies in a forced fit of laughter. All, to be sure, admired, but all disapproved. We saw this poor creature a long time afterwards endeavouring to drag her limb with her by means of sundry wooden contrivances. Let it be called by whatever name the sanguinary desperadoes of the profession choose, we shall never be cheated out of our judgment, or fear to expose such practice when it falls under our observation." Ninety-four years after (1856) Filkin's operation, Syme is to be found protesting against the vehement and persevering efforts which have lately been made to force into fashion two operations (excision of the knee and of the hip) which are bloody and formidable." The denunciation reminds me of the statement of a writer in one of the Scotch medical journals, who declared that Mr. Lizars having twice operated for the removal of ovarian tumours and failed to save the patients, he was sure no one else would have the hardihood to repeat the experiment.

But as to knee joint excision, the experiment was repeated in spite of much hostility. Butcher, in Dublin, and Heron Watson, in Edinburgh, laboured on, and Butcher-although his cases were few compared with present-day statistics-did succeed in establishing the operation in his own country. In England, however, the operation has never been a popular one. It takes a long time to overcome the opposition of men of accepted eminence; but in Ireland we have not been so reverent to authority, and the results we have obtained justify our position.

It is a sound principle that we should take the easiest and the simplest road to attain a good result in our treatment. But it must be clear beyond dispute that the plan we adopt is as effective as any rival one in regard to efficiency of the limb; that it has less risk to life; and that it occupies less time in reaching the final stage of success. Experiment in surgery has led us to very remarkable achievements, and it is essential to progress that all legitimate efforts in this line