The value of repeated leucocyte counts should not be lost sight of as one means of determining the presence of an acute epiphysitis or medullary abscess accompanied by a sterile effusion into the neighboring joint. Bloodgood believes there cannot be a leucocytosis, especially an increasing one, without a pyogenic infection of the joint or bone. Ironclad rules are not applicable to the treatment of disease, yet in general I believe the following statements with reference to aspiration and arthrotomy of the knee-joint are warranted: I. If smear preparations reveal no microorganisms in the aspirated fluid, arthrotomy may be postponed for twentyfour hours. If after the lapse of that period the fluid has not re-accumulated and the culture remains sterile radical measures should be superseded by conservative treatment. On the other hand, if after the lapse of twenty-four hours it is found that the fluid has re-accumulated it should be removed a second time for examination, and if still found sterile without amelioration of constitutional symptoms a disease of the bone in close proximity to the joint should be anticipated. 2. If in place of a sterile fluid an infected one be obtained immediate arthrotomy and irrigation should be done. 3. If no organisms are demonstrated by means of the cover-glass preparations, but a positive culture is obtained at the end of twenty-four hours, arthrotomy should then be done, unless the general symptoms are much improved and there has been no re-accumulation of the exudate. In such a case one is justified in awaiting further developments. Bloodgood says that whenever the presence of the staphylococcus aureus or albus is demonstrable, immediate and strenuous measures are demanded. An infection of the streptococcus, gonococcus, pneumococcus, or typhoid germ permits of delay, yet even in these infections he feels that early arthrotomy is the safer treatment. The various methods of arthrotomy, drainage, and irrigation have not been considered since the time allotted is not sufficient to give this part of the subject the attention it well deserves. London Lancet, Nov. 18, 1900. Progressive Medicine, December, 1900. Progressive Medicine, December, 1899. British Medical Journal, January 13, 1903. London Lancet, January 24, 1903. · New York Medical Journal, September 15, 1900. Journal of the A. M. A., March 30, 1901. Centralbl. f. Chir., No. 16, 1897. Boston Medical Journal, October 18, 19c0. Park's "Surgery." Annals of Surgery, Vol. 21, 1895. DISCUSSION DR. C. H. MAYO (Rochester): I don't like to see this excellent paper go by without discussion. It is always a timely subject, especially when the paper is to be published, and we can look up these cases. I think there is nothing that appeals to us so seriously as an infection of the knee-joint when it comes into our own hands. I remember I read a paper some ten or twelve years ago upon late infection, after it has passed the period the doctor has described, while the doctor has confined himself to watching only the acute stage; but in those cases where a penetrating wound has inoculated the knee-joint, or in one of those extreme cases where the capsule has been ruptured by accumulated pus-in that kind of cases the old treatment was an amputation, and in most cases it was considered comparatively hard work to save the patient's life. One of the first operations I ever did was to amputate such a leg following a draw-shave injury. Some two weeks after the infection was received the amputation was done to save life. Having seen such cases later, and having a chance to treat them in a hospital, I made a section across the knee, cutting the patella in two, resulting in as much exposure as an amputation would give. I have done that on three children, packing the wound full of gauze, getting free drainage, relieving the tension of the blood vessels, amounting almost practically to an amputation, but leaving all the structures that are important to the leg and that lie behind the joint. Three-fourths of an encircling incision of the knee-joint will still leave the very important structures for the preservation of the leg below, and in all those cases-some of them have gone eight to ten years—they have from one-quarter to three-quarters motion; and in that type of cases where we have inflammation of the capsule following an infection of the blood, or where we have a penetrating wound, such an opening of the joint will serve every purpose of amputation, and save the leg, even if it does become stiff, because a stiff leg is better than an artificial one. Recently that same surgeon who has done so many original things. Dr. Ferguson, has devised a flap covering for opening the side of the joint in such infected injuries by dislocation of the patella and absolute exposure of the whole joint, and it is possible that this operation will be used with the one which I brought forth some years ago and to which Gerster applied the name of the "Mayo" operation. DR. A: MACLAREN (St. Paul): In these acute cases which Dr. Goodrich so well describes where we have in the past frequently lost the use of the leg, an amputation is not always necessary, as Dr. Mayo has suggested. Early aspiration of the joint and examination of fluid is a wise procedure to follow in every serious case, and is the means of saving many useful limbs. My own experience in this direction is limited to one case, where in an acute osteomyelitis of the tibia, the inflammation of the knee-joint seemed to be the first symptom of infection. The child's temperature ranged from 105° to 107°. Forty-eight hours after the first chill I found a very sick child and a very acutely inflamed joint which was red, fixed, and greatly distended. It seemed as though the child's life would be lost from the severity of the infection, so the joint was freely opened and drained, and we found that it contained turbid fluid and that the joint had been infected from the head of the tibia. The tibia was guttered from end to end, eventually the child recovered, and to-day has as perfect a leg as the other, with absolute free motion. Now, with the more conservative lines of treatment such as we used to follow, in this case we should undoubtedly have lost the use of the joint, if we had not lost the leg. I wish to congratulate the doctor upon his timely paper. DR. H. B. SWEETSER (Minneapolis): I would like to emphasize the importance of early operation in these cases of epiphysitis before they break in the joint cavity. If they are not operated upon, and they go on to inflammation of the joint, there will be a very marked loss of function, if not requiring amputation. If you operate upon the cases early, you may prevent the loss of the joint and get good results, as Dr. MacLaren has indicated. I think the old plan of letting it alone, and trusting to the Lord, is bad treatment in acute infections of any kind. DR. A. E. BENJAMIN (Minneapolis): I want to mention a case along this line which is very important in showing the complications which may arise. A man I treated four years ago had been sick three or four days or a week previous to my first visit, with inflammation of the knee-joint. He gave a history of having had osteomyelitis when a boy. It was in the tibia, I think. I ordered him to the hospital, and the second day after he went there I received a telephone message to come immediately. When I arrived I found that the popliteal artery had ruptured. It was necessary to do an immediate operation. The man was in a very bad condition. We amputated above the middle third of the thigh. I think this is one of the most extreme cases I have seen of these inflammations of the knee-joint. I thought this might be of interest in connection with the paper that has been read. THE EFFECT OF THE OPERATIONS FOR SUBSEQUENT PREGNANCY H. P. RITCHIE, M. D. St. Paul The numerous methods of surgical relief for displacement of the uterus resolve themselves into three types of operation, viz. : First, suspension of the uterus by artificial attachments. Third, suspension of the cervix by use of the deep pelvic fascia known as the utero-sacral ligaments. Included in the first division are the suspension or fixation operations, either by the vaginal or abdominal route. When performed through the vagina an attachment is made between the anterior face of the uterus and the mucous membrane of the vagina or the wall of the bladder. By laparotomy the fundus is held upright by stitching it to the abdominal peritoneum, the use of the urachus, a strip of the peritoneum or fixation by scarification. Suspension by stitching and the consequent formation of a ligament as suggested synchronously by Kelly and Oldhausen has been most popular in my list of cases. The round ligaments may be reached by the inguinal canal, vagina, or through the abdomen. Alexander is the name associated with the first operation, although there have been many suggestions as to technique. Procedure through the vagina is typified by Goffe's operation. Intra-abdominally the methods are numerous, such as folding upon themselves (Wylie), bringing up through the abdominal wall and stitching to the fascia (Ferguson), perforating the broad |