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written and rightly used or their influence is pernicious. It is a dangerous thing to teach the student to acquire his knowledge through a quiz-compend, a yearbook or an abstract. His training should be in the study of the original and in the making of his own abstract. Thus he will acquire the judgment, the laboratory knowledge, if you please, that will enable him to “size up" the abstract of another and to rate it at its correct value, and to know at a glance whether a given abstract contains what he desires to know or whether the article should be consulted in the original. Rightly used, these abstract columns of our journals become much more to us than catalogues or indices. But they ought not to be allowed to supplant the solid articles as the substantial niental pabulum.
If writers were to follow more closely the advice given by Virchow a short time ago in his strictures on present methods of medical composition; if they would condense, say what they have to say and stop, there would be less excuse than there is for the physician to read the abstract because he finds it impossible to read the long, wearisome articles with their bewildering mass of superfluous details.
It is, perhaps, objected that the older writings are obsolete and entirely out of date; that a ten years old text-book on a progressive science is behind the times and should be replaced by a more recent one. But the literature to which I refer is not text-book literature, not mere compilation, but monographs, the results of original work in research or clinical observation, literature that has been creative and epochmaking. Laennec's treatise on “Mediate Auscultation,” Virchow's “Cellular Pathology" or "Tumors,” Bright's original articles on the Kidney, koch on "Tuberculosis," may serve as illustrations of this kind of writing, as far removed from the transitory magazine article or the made-to-order compilation called a text-book as is Handel's Messiah from the catchy street song of the day. There is a certain solidity
a , to such writings that is difficult to define. But there are truths there announced that are imperishable, though modified as time goes on and new knowledge is acquired. Many of the facts first announced by Laennec are bound to be true for all time. Morgagné's morbid anatomy is, much of it, classic today and will remain so. The old Diener in the Vienna dead-house, who worked with the great Rokitansky, declares that little new is found at autopsies except microbes. Our fathers in medicine, with trained senses that were untaught to rely upon the aid afforded by instruments of precision, observed the phenomena of disease with a shrewd keenness that is not surpassed today. The facts as they observed them are as true now as then. We do well to turn occasionally to their pages to learn that all of diagnosis is not in the test-tube, the microscope or the incubator ; that the eye, ear or finger if properly trained can detect much, and that in many cases the findings of the clinical or pathological laboratory must be combined with those of the educated but naked five senses and the whole interpreted by a logical mind, before the proper diagnosis or prognosis is reached.
One errs greatly if one imagines that it is impossible to learn from a writer of fifty years ago. Take the matter of disease of the heart for instance. Read Skoda, Bamberger, Flint, Walshe, with Laennec first, of course, and see if you do not learn as much as, or more than, from any modern text-book. Nearly all is there save bacteriology and, perhaps, the importance of the myocardium in a consideration of cardiac disease, and you merely have to change your point of view a little so that the new light strikes the picture right, and the old facts so clearly painted by these masters shine out all the more distinctly. When wishing to pass a quiet hour with profit and pleasure read some of Trousseau's clinical lectures, or try Charcot. You will be surprised to see how much you can learn from these sharp-eyed clinicians with the Frenchman's proverbial ability in expression, his power of “putting things.” And there is a delight in coming upon something good in unexpected places that is like suddenly running across a bubbling spring in a wood. You will often find your own vague thought crystallized or some hint thrown out by the writer that clears up a point that has long been foggy in your mind. This fact was brought home to me the other day in reading some of Latham's writing on medical education. I had put together some thoughts on methods of teaching with special reference to the ward clinic. I had spoken my piece, had done my “stunt.” Yet, in Latham I came across the whole subject discussed nearly three-quarters of a century ago, the place of didactic lectures, large clinics, ward clinics all considered and with splendid ideas, well put. And I had missed it. It is discursive, but I must quote from him now, for I lost the opportunity before my other audience. And it illustrates my point. I quote only a few sentences:
"I have always thought that hospitals are not converted to half the good they are calculated to serve as schools of medicine; and I think SO still.”
"I have always thought that, in hospitals, knowledge is perpetually running to waste for want of labourers to gather it; and I think so still.
“I have always thought that, in our schools, every mode of lecturing has been unduly exalted above clinical lecturing; and every place where knowledge is to be had, or is supposed to be had, has been unduly preferred to the bedside; and I continue to think so.
"Clinical lecturing * * * has been separated too much from the wards and the bedside, and has deviated into a discussion of abstract pathology and therapeutics."*
Surely there are medical teachers who might profit by reading these words of Latham, even though the bool: be out of date.
By the reading of these older writings there is obtained a knowledge of the history of medicine. I need not dwell upon the fact that this is of value. How inspiring to read the lives of many of the famous medical men of the past. One is enthused with the spirit of Boerhaave, the father of clinical medicine, whose labors made him so popular that when he recovered from a severe illness the houses were decorated and
* Loco citato, page 19.
the town illuminated. To see what Leeuwenhoek accomplished with slender means arouses one to renewed effort to do much with the advantage of better instruments and opportunities. And to think of what Laennec did and that he left an imperishable name though dying at forty-six!
One learns of the state of medical knowledge in earlier times and can trace step by step the advances that have been made down to the present. Knowledge is not of its full value until one knows how it has been acquired and at just what stage in the advancement of knowledge we have arrived.
And another point. It is often difficult to make the exact distinction between what is fact and what is theory. Text-book writers and lecturers too often make dogmatic statements as to facts when in reality they are merely voicing theories that they firinly believe to be true. When the student, a few years later, finds that the supposed fact is false, he grows skeptical and cynical as regards the science of medicine. Much of this can be avoided by a study of earlier history, thus tracing the development of theories, che gradual growth of knowledge and the establishment of facts. Fact and theory are thus clearly differentiated.
The history of medicine teaches how great results may follow apparently trifling causes. We see how no truly scientific observation, be it at the bedside or in the laboratory, is to be ignored, no matter how insignificant it may at the time appear to be. Its results may be farreaching. Read the story of myxedema. It is interesting as a romance and it teaches a lesson as to the wonderful interdependence of the various branches of medical science and as to the value of the search for truth for the truth's sake, though the immediate results are not foreseen. For the knowledge of myxedema, as you know, came as the result of work by physiologists, surgeons, pathologists, clinicians, chemists, men working in many lands and with different objects in view, but their results fitting in so nicely with each other as to make a complete whole and to give help in the solution of the vexed question of the diseases and functions of the thyroid gland and to impart an impetus to the study of the whole subject of internal secretions. No physician can read such a story without feeling inspired and stimulated to work himself. When he reads Addison's description of disease of the suprarenal capsules, or Bright's account of the renal changes associated with dropsy and albuminuria, he rises with the renewed determination to be more careful in his clinical observation and his recording of facts concerning all of his patients.
To my mind this subject of the value of the older medical writings is an important one and should not be overlooked. I have dared present it to you this evening rather than a more technical or strictly medical paper, because I believe it worthy of serious consideration. I would have a place for it in the medical school. It may be, in fact should be, an elective study. I have taught it for two years as a seminary course. It might be better to have it entirely as a side issue, not strictly speaking a part of the curriculum, but the subject for consideration by a students' medical society or historical club. But in some way the attention of the student should be drawn occasionally to the beginnings of medical things. At least he can be taught in his routine of work to refer back to many of these original articles, so that he may learn to use a litrary, to look up references and cross-references, to see how medical books and medical articles are made. This can easily be done in connection with any branch of medicine. And I am sure if the incentive is thus early given, our graduates will later, even though busy in practice, find time for an occasional delightful and profitable excursion into old medical lore, though by so doing they may become hunters of curios or even bibliomaniacs—but surely they might have some worse hobby or weakness than that of collecting old medical books and learning about their authors. When men like Osler advise the young physician to buy Laennec and to read Hippocrates; when Benjamin Ward Richardson said that he read Laennec every two years, there is something more to all this than a hobby.
EXCISION OF THE KNEE FOR CHRONIC RHEUMATISM.*
BY THEODORE A. MCGRAW, A. M., M. D., DETROIT, MICHIGAN. PRESIDENT OF THE FACULTY AND PROFESSOR OF SURGERY IN THE DETROIT COLLEGE OF MEDICINE,
In discussing the therapeutics of chronic incurable rheumatism of the knee-joint, in which function has been either totally lost or so far impaired as to render life miserable, there are two questions to consider. First, whether the case is incurable, or in other words, whether the joint by any kind of treatment other than operative can be rendered serviceable; and second, whether in case of hopeless disease, with loss of function, the limb can be rendered useful by operative procedures.
As regards the first question, it becomes in each individual case a matter of diagnosis. It is, however, usually correct to assume that when a knee-joint has been for years the subject of some form of rheumatic disease, when for one, two or three years it has practically lost its function and when the patient has tried every known form of internal and external treatment, including change of climate, the use of mineral baths, massage, passive motion, electricity and the x-ray, without getting relief from pain and disability, that a rational hope of cure cannot be indulged in. The period in the course of the disease at which physician and patient come to this sad conclusion will vary with their temperaments. The painful experiences of many years will not suffice with persons of certain disposition to deprive them of the expectation that sooner or later some remedy will be found to meet their malady; others learn more quickly to recognize the hopelessness of their condition.
To the practical surgeon the methods of dealing with these joints will present themselves in a variety of ways. If he entertains the hope of restoring the motion of the joints with a certain usefulness, he may think best to forcibly break up all adhesions under an anesthetic and,
* Read at the Mount Clemens meeting NORTHEASTERN DISTRICT MEDICAL SOCIETY OF MICHIGAN.
afterward, treat the knee with daily massage, passive motion and moist or dry heat. My own experience has been limited for the most part to chronic cases in which this method of action has already been tried without avail.
In the few cases in which I have practiced it the results have been disheartening. The joint has become greatly swollen and very painful. Subsequent passive motion has caused an agony which made its continued practice impossible, and the outcome has been a condition as bad as or worse than that for which the operation was performed. This, indeed, was to be expected from the known pathology of those advanced cases, in which we find invariably one of two conditions.
In the majority of cases, the ligaments have become thickened from a fibrous deposit, the neighboring bones have developed rings of osteophytes. The synovial membrane has nearly all disappeared and the cartilages have become eroded. The tibia is often connected with the femur by a new formation consisting of a connective tissue band which attaches itself to the crucial ligaments and contains minute spicula of new bone. The motion of the joint rarely wholly disappears. Just enough remains to cause pain by the stretching of the inflammatory deposit.
If the knee were left extended and complete anchylosis should take place, the leg would again become useful, but unluckily this rarely occurs. In most cases the joint becomes bent and the flexion becomes associated with a partial dislocation backward, and the patient is forced to go on crutches.
The other much rarer variety of rheumatic disorder shows little or no thickening of the ligaments and no formation of osteophytes. The joint may be freely movable, but whenever the patient begins to bear his weight on it he is seized with most severe pain. If the knee is opened it will be found to contain some serum. The seat of disease in this variety may be confined to the cartilages, which are thinned, eroded, and in some places entirely destroyed.
Such patients are to be seen everywhere in the land, moving painfully on crutches or wheeled around in chairs. Many of them might be put on their feet, relieved of pain and restored to active life, by the excision of the diseased joints—and it is of the indications for and the indications agair.st the operation that I now wish to speak.
If I am consulted by a patient who has an incurable rheumatic affection such as I have described, confined to one knee, and who has no other serious trouble such as Bright's disease or general tuberculosis, I do not hesitate to advise a resection of the knee-joint. The cperation, if properly done on an otherwise healthy subject, has extremely little danger, and the bones will usually heal by first intention. The patient will be able to sit up at the end of a month. At the end of two months, with the leg and thigh supported by a plaster bandage, he will be able to walk on crutches, bearing some weight on the injured leg, and at the end of three months will be able to discard his crutches. Splints should, however, be applied in some form until the end of the third or fourth month.