which are in a doubtful condition, can nevertheless be operated upon with success after careful preliminary antiseptic and astringent treatment for days or weeks. 4. Under such conditions, however, naturally, the percentage of failure rises sharply. 5. But the measure of success attained amply justifies the additional risk. 6. Previous iritis has a particularly prejudicial effect on the results. 7. The omission of iridectomy, while producing excellent results in the majority of cases, does undoubtedly increase the risk of prolapse of the iris and also of occlusion. On the other hand, the danger of vitreous loss is diminished. 8. The attempt to extract the lens in its capsule is so frequently attended with vitreous loss that it should be restricted to cases where the lens nucleus is small. 9. As an all-round operation, von Graefe's linear extraction with iridectomy is the most suitable, and in the long run gives the best average results. New York Medical Journal.

Chronic Suppurations of the Middle Ear.

E. Schmiegelow describes ninety-six cases he has operated and gives tabulated details, in the Nordiskt Med. Arkiv, 1898, No. 17. He has operated over three hundred in all. In twentythree cases the affection had lasted eleven to twenty years; in seventeen, from one to five years, and in one case between forty and fifty years. The mastoid apophysis was alone opened in twenty cases, with fifty-five per cent cured; in the rest the otitis was not arrested. The attic was opened in fourteen cases; seven were cured, three improved; one relapsed, and in two the result is unknown. In fifty-three cases the entire middle ear was opened and seventy per cent cured. In seven cases the operation was not completed. In nine cases there was improvement; three cases died-miliary tuberculosis, or meningitis. The transverse sinus was opened once. In four cases the operation was followed by traumatic facial paralysis. He states that the patient must be prepared for the tediousness of the after-treatment. one of his cases it required a year and

In

a half; in several six to nine months, but the average limit was from two to four. In fifty-eight cases nothing could be learned as to the etiology. In ten it commenced as an acute suppuration after influenza. It three it was evidently a carious process due to the presence of adenoid vegetations. In four cases the suppuration was tuberculous. In two it was the result of whooping-cough, in eleven of scarlet fever, in two of measles, in five of trauma, and in one case there was a carcinomatous growth. The hearing was unaltered after the complete operation in eight; more or less improved in twenty-seven.-Journal of the American Medical Association.

Ringworm of the Scalp Treated by Sodium Chlorid.

Dr. Perkins writes to the London Lancet that for fifteen years he has treated every case of ringworm which has come under his care with chlorid of sodium, and with complete success in every case. The first case in which he used this treatment was a chronic one of five years' standing.

of five years' standing. The child was well in three weeks and had no return. Many of the cases which have been attended since have been of chronic character. His method is the follow

ing: Have some chlorid of sodium finely powdered and then mix with a little vaselin to make an ointment. The affected part having been shaved, rub this ointment in well night and morning until the place is sore; this takes from two to four days. Then use some simple application to aid the healing of the part. When well from the soreness, the hairs will be found growing healthily and the tinea trichophyton destroyed.

The Symptomatology of Urethritis.

S. Rona (Archiv fur Dermatologie und Syphilis, 1898, p. 141; Gazette hebdomadaire de medecine et de chirurgie) arrives, as the result of his investigations, at the following conclusions: 1. Of one hundred and sixty patients attacked with acute urethritis and examined by the author, twenty-six had

anterior urethritis, twenty-two posterior urethritis, and one hundred and twelve total urethritis. 2. Vesical tenesmus with frequent micturition was observed in six out of the twenty-six cases of anterior urethritis. 3. Out of the twenty-two cases of posterior urethritis, vesical tenesmus with frequent micturition was observed seven times, and in ten cases there were frequent pollutions. 4. In total urethritis, even when complicated by prostatitis, gonecystitis, or epididymitis, vesical tenesmus was never observed, nor were pollutions, or pains in the posterior urethra. In thirteen out of the hundred and twelve cases of this group there was a little blood at the end of micturition. 5. The terminal hematuria would seem to in

dicate that the internal orifice of the bladder is profoundly affected by the inflammatory process which, in this case, occupies the fold of the vesico

urethral orifice.- New York Medical Journal.

has only been observed in the secondary stage. This pseudo-rheumatism differs from ordinary rheumatism by very marked characteristics; its appearance in subjects free from any hereditary or personal arthritic taint; the habitual co-existence of secondary manifestations; lesser intensity of the inflammatory phenomena; greater fixity of the articular determination; and nocturnal exacerbations of painful symptoms. It yields rapidly to specific treatment, but the pains are often assuaged by local applications of salicylate of methyl.— New York Medical Journal.

Alcohologenic Cardiac Epilepsy.

A. Smith applies this term to an epileptoid condition accompanied or preceded by dilatation of the heart. As the state of the heart improves, the epilepsy disappears also. The dilatation of the heart is purely alcohologenic, and subsides completely with abstinence from alcohol in some cases, or partially in others, with slight recurrences for a while. In the first group, a slight excess of alcohol above very moderate amounts will induce the attack. In the second group the intolerance to alcohol is not so pronounced. Complete abstinence is the only cure, combined with medication to strengthen the musculature of the heart.-Munich Med. Woch.

Sero-therapeutics of Tuberculosis.

Maksutow has obtained a serum from the juice extracted from a tuberculous abscess on a cow, chopped fine, in an jected after filtering, into guinea-pigs aqueous alcohol-glycerin solution. Inand goats, it prevented infection and arrested lesions already under way. Every test was successful.-St. Petersb. Med. Woch.

Orthoform for the Larynx.

Kassel prevents the coughing that usually follows the insufflation of the dry powder, in anesthetizing the larynx, by injecting it in an emulsion of 25 parts orthoform to 100 parts olive oil, with the ordinary larnygeal syringe. -Munich Med. Woch.

VOLUME 5.

NUMBER 27.

Original.

Exsections of the Knee-Joint.*

BY AUGUST SCHACHNER, M. D., Professor of Principles and Practice of Surgery, Louisville Medical College.

It is not the intention of the essayist to present in a complete and systematic form the subject of exsection of the knee-joint, nor to indiscriminately recommend this procedure for the relief of pathological conditions of this joint. The intention of the essayist is to emphasize a few practical features relating to exsection of the knee, and to present a summary of the clinical status of the question, from which it is hoped that useful deductions may be drawn.

The indications for the operation are almost entirely covered by two conditions, namely, tuberculosis and ankylosis. Occasionally an exsection is undertaken for the repair of an injury recent or remote, but in general the first named conditions practically represent the prime indications for the performance of the operation. While tuberculosis is responsible for more exsections than all the other conditions combined, it is by no means to be inferred that every tubercular knee-joint is to be excised. Far from this; suitable orthopedic measures, such as "high shoe" fixation of the diseased joint with plaster dressing, coupled with a Thomas splint, together with the proper hygienic and constitutional measures, offer much success and encouragement. Such measures, however, yield the desired success, provided they are carried out in the proper way and for the proper length of time. To any one who has had but a slight experience with orthopedic measures, it has become painfully evident that outside of an institution the fulfillment of these wants is not

*Read before the Louisville Clinical Society.

always an easy matter. Such patients may begin in good faith, but frequently long before the end is reached the enthusiasm fails or they grow careless, which means either the sudden or gradual abandonment of the treatment. In either of these events we may be driven to operative measures, or we may foresee such an end and be justified in "taking time by the forelock" without any previous treatment with more conservative measures. When the conditions demand exsections, thoroughness should be the key-note of our action. The sooner that we reduce tubercular processes to the level of carcinomatous processes and deal with them accordingly, the sooner will our action be rewarded with brilliant and lasting success. Either procrastination or deficiency lurks in the overwhelming majority of the unsuccessful operations for tuberculosis; either they have applied too late, or the operation was not of sufficiently radical nature to fulfill the need.

In the knee the conditions are peculiarly favorable for the removal of any tubercular process unless unusually advanced or uncommonly extensive in its nature. As to whether the tubercular processes in the knee are primarily osseous or synovial in their character, there is as yet some lack of unanimity. The operation of exsecting the kneejoint is already too well known to require a detailed description in this paper. In its performance the majority of operators resort to the bloodless. method as facilitating the rapidity as well as the thoroughness of the procedure; others, however, prefer its omission, using the arteries as landmarks. Where elastic constriction is resorted to, it should never be applied over the joint lest some of the tubercular material be driven into the circulation. Various incisions have been employed, the Textor or semilunar infra

patellar incision being the most popular. Hahn, of Berlin, recommends semilunar suprapatellar, owing to the easy access it affords to the large synovial sac located above the patella and behind the quadriceps tendon. The transpatellar of Von Volkmann is as a rule rarely employed unless the operation be one of arthrectomy rather than complete exsection.

In making the Textor incision the knife is more advantageously used in an oblique rather than a vertical manner, since this affords the broadest and best opposition in the final coaptation of the divided surfaces. The patella is usually removed whether it is affected or not, for with the disappearance of the joint the existence of this bone as a fulcrum to the quadriceps becomes superfluous, and its presence only adds annoyance during the operation. Helferich, I believe, recommended the freshening of its posterior surface as well as a freshening of the anterior surfaces of the femur and tibia and the transplantation of the patella in this position with the view of obviating the tendency to subsequent flexion.

Shortening has always been the the bete noire of this operation, especially if carried out in the young subject. One has but to examine closely into the matter to become satisfied that while there is such a danger, this danger has always been accorded more gravity than it has deserved. It is true that the femur receives a large proportion of its growth in length from its lower epiphysis and the tibia from its upper epiphysis, and in this operation we are endangering more or less the future length of the limb by operating in the proximity of these epiphyses. If we examine closely we will find that these epiphyses are situated remotely enough from the seat of operation to allow the removal of a fair amount of bone without practically compromising the future length of the extremity. So that if we are able to do an intra-epiphyseal operation, and generally we can, we need have no fear of any appreciable shortening in the undeveloped subject. König has formulated the rule to saw off inside the extent of the cartilage. In fact, there may actually be a lengthening occasioned

by a congestion and an increased development of the blood-vessels in the epiphyses as the result of the process or of the removal of the capsule so near the epiphyses.

The desire to obviate all shortening as well as the preservation of motion is responsible for the existence of arthrectomy, an operation credited alike to Dr. G. A. Wright, of Manchester, and Von Volkmann, of Halle. The operation of arthrectomy is, in a few words, a mild compromise upon exsection; consisting as it does of the removal of the diseased capsular ligament or the synovia, with perhaps a curettement of the bone. In selected cases it has its field of usefulness, but in general it lacks thoroughness which attends exsection and which is so necessary to supply permanency to the result. After the removal of the dressing a posterior splint should be worn for some time to avoid the tendency to subsequent flexion which attends exsections that have not been properly supported for a sufficient length of time. The limb should furthermore be protected from bearing any weight for some time after the operation, lest the concussion from walking may excite a new process before repair has been perfectly established.

When exsection is performed for the relief of an ankylosis, it is advisable to reduce by means of weight and pulley as much of the angle of deformity as possible before the operation. This rule applies especially to those cases attended with considerable deformity. Ankyloses of long standing are not infrequently complicated with changes in the normal relation and condition of the soft parts in the popliteal space, such as adhesions, shortening of the vessels and nerves, and the occurrence of osteophytes on the posterior border of the tibia. This must be borne in mind by the operator, and should as much as possible be corrected before the operation, lest the sudden correction of the deformity occasion a stretching and compression of nerves and vessels that may lead to serious consequences.

The following transcriptions, copied almost verbatim from sources indicated, fairly represent the clinical side of the question.

The final results of knee-joint resections in von Esmarch's clinic :

The former mortality of fifty per cent was reduced through antisepsis to twenty per cent, then to thirteen per cent, and since the use of permanent dressings so far that fatal cases are the exceptions.

Of these one hundred and fifteen resections, one hundred and two were typical, four partial, and nine cuneiform (for angular ankylosis). The trouble was, in one hundred and two chronic gonitis, in nine ankylosis from previous chronic gonitis; in one each osteomyelitis, shot injury, rheumatic polyarthritis and purulent gonitis. As to etiology, in the one hundred and eleven cases of tubercular gonitis, seventy-nine were spontaneous, twenty-three from fall or blow, two each from stab, overstrain, and tibial ostitis, one each from scarlatina, distortion, and throwing stone. Hereditary disposition proven in fortythree, absent in thirty-nine, questionable in seventeen, unstated in twelve. There were sixty-two males and fiftythree females. All but four were under thirty years. The result was in eightyfour (73 per cent) a cure-eleven of these after secondary amputation; in twenty-five (21.8 per cent) an imperfect cure, that is, a fistula remaining-one of these after secondary, amputation; in six (5.2 per cent) death in hospital. The twenty-one from the time of the typical Lister dressing show 14.3 per cent of fatal cases, while the ninetyfour since the use of permanent dressings show only 3.2 per cent.

In this region the synovial form exceeds the ossal. Somewhat at variance with Volkmann, he finds that in youth, up to seventeen years, the primary synovial exceeds the ossal (thirty-six to twenty-four), while in those older the reverse occurred (fourteen to eighteen). The duration of treatment in the seventy-three cured cases averaged eighty-five days.

As to the later results of the operation, he has hunted up sixty-three of the cases-some discharged as cured, others as not cured-in all of which at least two years had passed since the operation, the average being five and one half years. In these subsequent

years four have died, two from tuberculosis after eight and two years; one from acute fatty liver; one from sarcoma. There were eight relapses requiring further operation, all in children of from three to fourteen years at first treatment. These occurred after one half to six years, three falling in the second subsequent year.

The usefulness of the resected limb was good to excellent in fifty (91 per cent), poor in five. The general health was undisturbed in forty-eight; one suffered from epilepsy, one presented dulness at apex of one lung, two had fistulæ. In three mobility of the joint was stated, one of these having been only a partial resection. In thirtyfour of sixty-one (56 per cent) the limb remained straight; in nineteen, slightly flexed; in three, more flexed; in two, varus; in three, valgus. Of the twentytwo more or less flexed, sixteen were at an angle before the resection. Of the nineteen slightly flexed, two were so when discharged.

A subsequent lengthening of the resected extremity was observed in only one. Slight shortening is the rule in patients from one to ten and from eighteen to fifty years old; moderate shortening (6 to 16 cm.) in those from eleven to seventeen years old. (Mittheilungen a. d. Chirurg., Klinik zu Kiel, IV, 1888; Loc. Cit. Annals Surgery, Vol. x, p. 152.)

Dr. Neugebauer, of Strassburg, tabulated one hundred and one cases of resection of the knee-joint occurring in the clinic of Prof. Lücke.

The so-called "typical" resection has, according to the author, not been carried out in this clinic for some years past. Typical resections in this article include those cases in which cartilage or sections of bone have been removed from both articular extremities of the bones of the joints. Partial resections include those in which either the capsule of the joint has been removed or simple curettement resorted to.

Chronic gonitis, ninety cases; acute gonitis, six cases, and ankylosis, five cases, were the diseases for which the resection was resorted to. There were forty-two males, twenty-nine females treated, and the resections (partial) were