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moi." Some surgeons have even the coolness to eulogize as CONSERVATIVE SURGERY" that treatment which sends cripples into the streets and scores of victims to the grave. As a consequence, the man opposing this sort of treatment, which speaks volumes of self-condemnation, becomes

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the object of derision, and is characterized as a "most dangerous, revolutionary, and daring innovator." Truly, more moral courage is required to shape a new course of any human pursuit, or to assume an independent position, than the mere acceptance of established or traditional doctrines; and, perhaps, forbearance is the least that such a man should expect from his co-laborers in the service of science and suffering humanity. One of the first axioms in the treatment of morb. cox. is rest, and

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the next is insuring a good position to the affected extremity. earlier this is done, the better. The whole antiphlogistic apparatus, combined with the best constitutional treatment and nursing, are not to be compared with the therapeutical effects of simple rest and proper position, and, to use the words of a young medical friend, "they act like charms." It is very evident that the recumbent position in bed is not the thing. It leaves the patient subject to accidental move

ments of his limb, and does not prevent malposition. In order to accomplish both, various means have been devised. Physick used his carved wooden splints, Brodie leather, Alden March cloth impregnated with glue, Bonnet his so-called "great apparatus." With the exception of the last, we have tried them all, and, in addition, Hagedorn and Dzondi's machine; but their inefficiency has induced us to construct another, which a waggish medical confrére has christened the "wire breeches." It consists, as you perceive, gentlemen, of a frame of stout wire, filled with wire cloth. In order to solder one to the other, they should be galvanized with tin. An opening is left for the anus. At the lower end two foot-boards are movably fixed, so as to change the length of the apparatus and exercise any amount of extension, the counterextension being procured by the healthy extremity and in part by the tuber ischii. The whole should be varnished for the purpose of protecting it against rusting. The apparatus being well filled with cotton, the patient is placed within and fastened by bandages. extension should be decided upon, you may surround the leg with a loose stocking, or fasten it directly to the footboard by adhesive straps, as in fracture of the thigh, for which itself, particularly that of infants, it is the most useful and commendable contrivance, satisfactorily tested by ourself and medical friends. Thus securely placed, the patient enjoys the most perfect repose of his joint. He may be carried from one place to the other, or his alvine evacuation may be attended to, without disturbing his comfort or position.

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In the first stage of the malady this will be amply sufficient to check the disease and to prevent further mischief.

In the succeeding period, the therapeutical indications are more diversified. We have to contend:

1. With a higher grade of inflammation, having already terminated in effusion of various kinds.

2. With malposition, opposing more or less the proper placing of the affected extremity.

3. With most violent nocturnal pains, threatening to annihilate the patient in the shortest possible time.

As to the existing inflammation, it is but natural that the antiphlogistic method should have been employed, but, we apprehend, without avail or benefit. We have fairly and repeatedly tried its efficacy, without the desired result. All we have retained of it is local depletion, by means of leeching or cupping behind the joint. But even on them you cannot count with any degree of certainty, nor will their benefits last more than perhaps forty-eight hours.

Next in order comes the derivation in its various forms of blister, seton, issue, moxa, actual and potential cautery, etc. The use of these means is certainly calculated to render the poor patient still more wretched. You inflict additional pain, you interfere still more with his comfort, and you increase the drain upon his system. They, moreover, constantly require cleaning and daily dressing, which again interferes with the quietude of the joint. And, in fine, their efficacy is, to say the least, questionable. At any rate, we have never derived the least benefit from their faithful and systematic use, nor has it come to our knowledge that other surgeons have been more successful. Nélaton, Syme, and Bonnet, advocate still the so-called linear application of hot iron over affected joints, yet they have not asserted that that remedy is so indispensable either, nor that they chiefly rely on it. We have dispensed with the entire class of derivatory appliances, and we firmly believe that our patients have fared the better for it.

But what shall we do with the effusion in the joint? If it is of a plastic character and small amount, we may leave it to resorption; and if it should organize and cause fibrous adhesions between the corresponding articular surfaces, it would matter but little, since we have it in our power to break them up again and to reëstablish mobility. Occasional motion of the joint in the process of their formation may even prevent them effectually; this should be done, however, with great discretion, and not before the inflammation has abated in some degree. A considerable quantity of effused material is not only a great impediment to the

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restoration of the position of the extremity, but it is in some respects the means of continuing inflammation by keeping up the distension of inflamed tissues. With the quantity of exudation the degree of malposition and the violence of symptoms correspond. In order to relieve both, we have to withdraw it. We may do this in two ways, with knife or trocar. A straight and pointed tenotome is flatly inserted behind the joint, then so turned as to penetrate the capsular ligament. The wound of the latter should be at least a quarter of an inch long, so as to facilitate the escape of the fluid. Whilst this is being done, the extremity should be inverted so as to diminish the size of the articular cavity, which has the effect of driving all liquid out. The punctured wound should, in fine, be carefully closed with adhesive straps, and the limb fastened in the wire appaWe should proceed in a similar manner with the trocar, with this difference, however, that the canula remains in the joint until the limb has been inverted. The limb should be kept in this position until the canula has been removed, the wound closed, and itself fastened down in the wire breeches, otherwise the formation of a vacuum would invite the air to rush in and cause mischief. The exact place to enter is to be determined by the fluctuation, mostly an inch posterior and superior to the large trochanter, where the joint is but little covered with adipose tissue and fascia. We prefer a fine trocar of about a line thick to the knife, as you are more certain in its handling and as you can see the contents withdrawn, which will not only perfect your diagnosis in reference to the actual condition of the joint, but will also guide you in determining the plan of treatment afterwards to be pursued.

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If the retraction of muscles oppose the proper placement of the extremity, they should be divided previous to the puncture of the joint. We mostly find the tensor fascia latæ, and only occasionally the adductors involved. The operation is but trifling. The pelvis of the patient should be firmly fixed and the limb well extended by assistants. This In pressing the knife raises the muscles from the subjacent parts. through from without to within, we are certain that all fibres are divided, The tensor we divide about an and that no important parts are injured. inch below the sup. ant. spin. process of ilium, and the adductors at about the same distance from the pubic arch.

We have performed puncture of the hip-joint about fifty times, mostly with signal relief, and at no time with disagreeable consequences to the respective patients, whereas the subcutaneous division of those muscles has been very frequently resorted to. We do not pretend, gentlemen, that puncture or myotomy, by themselves, cure hip-joint disease, or have any direct influence upon the disintegrating process of the bones; but our

daily observation teaches us that they are the most valuable and indispensable remedies in its treatment. What no other therapeutical agent can do, they will accomplish. In the first place, they render the quietude of the articulation and proper position of the extremity possible; they not only alleviate the pain of the joint itself, but remove in almost all instances that characteristic nocturnal pain which rapidly consumes the strength of the patient. It improves the form, and if the disease has not proceeded too far, having caused already ulceration and caries, it will even check its progress. Our confidence in myotomy is so unbounded as to decline the charge of any articular disease with the exclusion of that remedy, and in no disease is it more reliable than in those of the hip and knee-joint.

The rest and painlessness thus attained, the patient begins to improve, to increase his weight, to look better, and to become cheerful. The wire apparatus is indispensable to his comfort, and he solicits to be replaced, if it should have been deemed necessary, for the sake of cleanliness, to remove it. The apparatus must remain applied until the joint has become almost painless, when the patient may be permitted cautious locomotion, upon crutches, supported by a framework moving upon four wheels. That the patient should receive the best of air, of food, and of such remedies as his case may otherwise require, is a matter of course.

The objection has been raised against this treatment, that the confinement was highly prejudicial to the general health of the patient. This is, however, not the case, as you will readily observe in the blooming appearance of our little patients in the hospital.

And if it is even in a certain measure detrimental to the system, which we do not at all admit, it would certainly be the lesser of two evils. The same argument might as well be applied to fracture of the leg, and yet nobody can treat such injuries without the inconvenience of confinement of the patient.

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In a few instances, myotomy not only failed in relieving, but rather seemed to aggravate the sufferings. This was found to be due to imperfect division. But in one case, that of Richard Trottman, the division of all contracted muscles did not give the desired relief. Anodynes and narcotics of every description were tried in vain. Morphine, in pretty large doses, neither allayed the pain nor secured rest. with strychnine, however, it had instantaneous effect.

In combination

The course of gradual improvement is occasionally, though rarely, interrupted by new inflammatory attacks. A few leeches or cups will generally suffice to meet the case.

But, gentlemen, if suppuration of the joint has been made out, the

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