On Subcutaneous Orthopaedy versus Knee Excision for Ankylosis
BMJ (Clinical Research Edition)
Nov. 30, 1872.] THE BRITISH MEDICAL _7OURNAL. 605 to be difficult. I-Ie must sternly exclude all broken drunkards from the immaculate array. An inquiry on this basis, however, though commended as likely to be instructive to myself, can convey no information to the writer of the article, since his far reaching knowledge enables him to forecast the resuLits. Liberal with what has cost him nothing, he gives them to us. He has " no hesitation in declaring that they would show such a large
... h a large preponderance of albuminuria amongst the tipplers, as would lead to the irresistible conclusion that alcohol in excess is a most powerful agent in the production of kidney-disease". He is among the prophets. Happy he to whom the results of an investigation are so manifest before it is begun that he has no hesitation in cleclaring them !-an economy of labour desirable in busy times. The writer objects to mechanical principles. In considering the organs in relation to stomach-absorption, I had to take them in some order. I might have placed them alphabetically, or according to their distance from the centre of the earth, but it seemed more natural to refer to them according to their position in the path of the influence in question. I argue nothing from this. It is sufficiently obvious that, if any alcoliol be altered in the liver, it cannot get unaltered to the lung, and that what escapes with the breath does not afterwards enter the general circulation. These simple considerations, mechanical though they be, are enough to guide arrangement, and have been thus used by Trousseau. My statemnents, howvever, were not based upon any considerations whbatever beyond simple inspection. I vent by what was seen, not by what might have been expected. If the liver displayed a more unequal distribution of disease than the kidney, the matter was one not of theory but of observation. I necessarily excluded all considerations connected with physiologJy as apart from the design and basis of the inquiry. I limited my business to the exposures of the post mortem knife-appearances rather than theories, results rather than modes of action; not that I ignored the uses of physiological inquiry, but because I kept to the results of (lissection, which it was the sole object of my paper to dlisplay. " The patho!ogist", says the article, "who ignores physiological considerations......is not likely to throw much light upon renal pathology." I will rather say, the pathologist who in matters of simple observation does not ignore everything else, is likely to allow what he sees to be warped by what be expects, and to fall into (rrievous error. I will refer to one other criticism-not that it needs an answer, but in evidence of the animus of the article. In the paper, the portal and hepatic veins, the vena cava, and the pulmonary artery, were not considered, for the obvious reason that they were not examined. The paper was avowedIly based upon post mod)-em examinations made without special object, anid, it is scarcely necessary to add, without habitual exanmination of these structures; yet the eager critic affects to infer that, because no disease of these vessels was described, therefore none existed; and proceeds to argue accordingly against wlhat he calls my theory. How often, let me ask him, has he seen, in a post mzortem examination made without special object, the vena cava, the veins of the liver, and the arteries of the lung, opened up? Considering the basis of the paper, the criticism is inappropriate, and, like the general style of the article, captious rather than judicial. The whole article, indeed, savours of the bar rather than the bench, and speaks witlh the impassioned voice of a combatant, rather than in the balanced tones which should proceed from the serene sky of editorial wisdom. Formerly Physician to the London Hospital, etc. IN the JOURNAL of October 26th last, Mr. James Adams, surgeon to the London IHospital, has done me the honour of quoting my opinion, expressed in an article on Orthopaedic Surgery in Holmes's System of Surgery, respecting the value of subcutaneous osteotomy applied to the relief of rectangular knee ankylosis, in the manner since described by my son, L. S. Little, in the AMedico-C7zirzurgical 7ransactionls, vol. liv, I 87 I, compared with resection at the knee in the manner in which it has been, in my opinion, too frequently practised. Mr. J. Adams's neat and successful operation has two great drawbacks-viz., the subsequent occurrence of several weeks' suppuration, and the loss of two inches in length of the limb, owing to removal of a wedge-shaped piece of bone. Subcutaneous osteotomy at the knee, as practised by my son in the only recorded case of the kind, was, on the contrary, followed by no suppuration and by no similar shortening of the limb, inasmuch as no removal of bone takes place in subcutaneous osteotomy. Notwithstanding my personal regard for MIr. Adams, and his having been one of my pupils, I cannot avoid characterising the removal of a wedge-shaped piece of bone, and consequent resort to a considerable open wound, as a retrograde step in surgery-a proceeding stigmatised years ago by me, when performed on less defensible grounds by Meyer, for the relief of severe knock-knee. It is a practice opposed to the " conservative" surgery of the present day, one of the greatest triumphs of which has been the substitution of subcutaneous operations whenever practicable, without after-stuppuration, for operation with a large wound, ablation of bone, and almost certain after-suppuration. Mr. J. Adams has in this case slhown himself a good operator, but apparently wanting in confidence as a pathoo logist in one of the restorative processes of the economy. I entertain no doubt that, when selecting the method of partial resection rather than adopting subcutaneous osteotomy, he was apprehensive that by the latter method he might have greater difficulty in keeping the severed bones in suitable apposition for the purposes of future use of the limb. But experience of ankylosed joints shows that in the reparative processes wvhich ensue when periosteal and bonstructures are involved, an abundance of plastic materials, prone to bony consolidation, is thrown out, owinig to which the limb, wlhether it be straightened without wound, with the help of anesthesia and manual gentle violence, or whether subcutaneous osteotomy be resorted to, a continuous stable, more or less straight, more or less firmly united and normally shaped, femur and tibia is the result. CLINICAL MEMORANDA. TIHE TREATAIENT OF STRICTURE. IN the JOURNAL of November 9th, MIr. Fairneaux Jordta describes a newn method of treating retention of urine and impassable stricture, apropos of which I would make a few remarks. I have no intention of claiminig a priority for any one else in the operation described, nor yet of disparaging the new method. which, if it can be performed as easily and safely as the description leads onie to imagiine, deserves tlle name of " improved" in addition to new. Aty reason for writing" is simply to put in a claim for trial for an -old method, before any operatlve proceedings are thought of, whether bistoury or trocar be the instrument used. A glance at the diagrams given witl ir. Jordan's lectuire will showv that the difficulty in passing a catheter fromii before backwards, througIh such a stricture as is there figured, arises from the certainity of the end of the instrument catclhiing in the poucth wvhiclh surrounds the stricture ; or, to use Mr. Jord.an's apt simile, its getting under, over or at the sides of-in fact, outside-the narrow end of the funnel. Now the prevention of this is easily effecte(d by what is generally known ar " Hutton's railway catheter", or, rather, by a slight modification thereof. That commonily use(d consists of a No. 2 flexible catheter, cut off at the eye, and a piece of catgut instead of stylet, whiclh, on the end of the catheter reaching the stricture, is pushed on into the bladder, and then serves as a railway for the catheter to run on. If, instead of a No.