CASE OF DIAPHRAGMATIC HERNIA; PERFORATION OF THE STOMACH WITHIN THE PLEURAL CAVITY
1095 cases are, no doubt, very difficult to diagnose in the early stage, but I feel sure that if they are looked for a considerable number, especially of the osseous deposits, will be found and recognised. I have now operated on some half a dozen cases of this kind-not nearly so many as I could wish,-and I can recall others which came under observation before I thoroughly understood the importance of the matter in which I would now intervene by operation. Of the cases which I have had affecting
... have had affecting the ankle, tarsus, elbow, and knee, I have only had recurrence in one instance. Of cases seen at a later stage of the disease, where suppuration has not yet occurred, we have three great classes-viz., those where diffuse synovial thickening is accompanied by, and usually secondary to, an osseous deposit, those where there is diffuse synovial thickening alone, and those where either of the above conditions is accompanied by marked deformity. As regards the first of these conditions, I may say that, as far as I have had the opportunity of investigating the matter, I believe that, while in the case of disease of the synovial membrane complete cure, with disappearance of all the tubercular tissue, is not an uncommon occurrence after expectant treatment, this is much less frequently the result in cases where there is an osseous deposit. In these cases the apparent recovery is too often merely a period of quiegcence, rather than a cure of the disease, and therefore in these instances the trouble is apt to break out again ; sometimes, after a comparatively slight injury. Hence, in cases where there is undoubtedly an osseous deposit I believe that the best thing for the patient is to interfere by operation, in the case of children by removal of the deposit and the thickened synovial membrane (arthrectomy), in adults by excision, if possible. The cases which are most likely to do well under expectant treatment are those where the disease is limited in the first instance to the synovial membrane, and more especially those where the thickening is not very marked and is pretty firm; and in children I should employ expectant treatment in the first instance in all cases of diffuse and pure synovial disease, and persevere in it so long as matters were steadily improving, or, at any rate, not becoming worse. If, in spite of treatment, the thickening steadily increases and becomes softer and other parts of the joint become involved, the question of operative treatment must, of course, be taken into consideration. Where in addition to the disease of the joint deformity has occurred which can only be remedied by operation, then the age and general condition of the patient play an important part in the decision as to whether operation should be performed at once or whether it may be delayed for a time. I think that in most cases in children where there are no other circumstances which demand operation-that is to say, where, were it not for the deformity, expectant treatment would be employed, and where excision would be necessary to remedy the malposition-it is better to leave it alone till the patient has attained adult life; of course, employing apparatus to prevent further deformity, and perhaps remedy, or at least improve, what exists. The deficiency of growth due to disuse will be less than that following excision. The last point which I shall touch on is what form of treatment should be employed when septic sinuses are already present. Shall we simply dress the wounds and go on with expectant treatment as if there were no sinuses present, or shall we adopt some form of operative treatment? Of course, when the sinuses lead to osseous deposits outside the joint there can be no doubt that the proper treatment is to clear out these dep@sits and remove the wall of the sinus. Where in children the sinuses lead to thickened synovial membrane or into the interior of the joint absolute immobilisation and pressure may be employed for a time, provided that there is not much discharge and nothing in the general condition to contraindicate delay. Although in some cases great improvement follows this treatment, I cannot say that I have been favourably impressed by my experience of it or by what I have read, and I think that in most cases where septic sinuses are present some form of operative interference is desirable. Of twenty-one cases in my statistics which were,.admitted with septic sinuses, and in which expectant treatment was employed, only two completely healed, and most of them were discharged from the hospital in much the same condition as when they were admitted. A septic state of the part aids the spread of the tubercular virus by weakening the vitality of the tissues, and therefore the thorough removal of the disease seems more desirable than where there is no sepsis. At first I was inclined to think that the presence of septic sinuses contraindicated arthrectomy, but of late I have several times performed complete arthrectomy in children under these circumstances, sponging the parts afterwards with undiluted carbolic acid, and with very good results. To sum up. Operative interference is desirable in the following cases : where chronic suppuration has occurred ; at an early stage, where the disease is localised to one part of the synovial membrane or bone ; in many cases, at a later stage, where there is a deposit in the bone along with general synovial thickening ; in cases of diffuse synovial thickening, where expectant treatment has failed to arrest the progress of the disease; in cases where a better functional result can be obtained by operation; in cases, in adults, where deformities are present which can only be remedied by operation; in many cases where there are septic sinuses; in certain cases where phthisis is present, or the general condition such as to require removal of the disease ; in adults more frequently than in children; in the poor more frequently than in the rich Expectant treatment should be employed in the first instance in cases of diffuse synovial disease without suppuration provided that there are no other reasons requiring operative interference, and it should be persevered in so long as improvement follows ; also at first in cases in children where osseous deposits are present in parts where they cannot be reached without excision or in cases where the presence of deposits in the bone is doubtful; also in some instances where septic sinuses are present. In any case it should be persevered in longer in children than in adults. It will thus be seen that I limit the sphere of expectant treatment considerably, and this. limitation is mainly due to the fact that under aseptic precautions we can now cut into joints at an early stage, while they are as yet comparatively healthy, and remove, portions of synovial membrane or bone without fear of doing. harm by our operation and with a good chance of ridding the patient of his disease and getting a useful joint. The cures. by expectant treatment when it is carried to excess are. often obtained only at a great expenditure of time and after great endurance of pain and at a certain risk to the patient s . and it by no means follows because a good result is obtained in any given case by expectant treatment that it would not have been wiser, and that in a number of similar cases the results would not have been on the whole better, had operative measures been employed. In thus attempting to indicate the limits of expectant and operative treatment, I am well aware how far I have come short of what is wanted; but in these diseases, perhaps more than in any other, so many points have to b& taken into consideration, and so much depends on the, circumstances of each individual case, that it is quite impossible to lay down rules which are universally applicable, and one cannot do more than indicate some of the chief. points which must be taken into consideration in coming to. a decision. I hope, however, that I have introduced a sufficient amount of contentious matter to enable us ta. have a good discussion.