there is no need of opening the joint, but, if we have so extensive a laceration that we have no control of extension then it seems to me that the advisability of wiring is to be seriously considered. The time of confinement in ordinary cases of fracture of the patella should be six months. It has been shown in the ordinary non-operative methods of the treatment of frac ture of the patella that they recur if the patient walks in six months. I should say that we are no longer to be influenced by the bad results which follow the too early use of the limb. The results in non-operative cases with extensive separation are ex tremely good. I have seen a sea captain who had extensive comminution of the patella and who can now walk perfectly well although the accident occurred three months before he got into port.

It is not necessary to repeat the good results which have followed bad cases, for we have all seen them. The question is whether we can predict a bad result,

As to the separation of the fragments, at the Massachusetts Hospital between 1888 and 1898 the records show that there were 128 cases of fracture of the patella treated there, of which 113 were simple fractures. Of this 113, fifteen were wired, and of the wired cases two suppurated. I think one of the wired cases was my own as I know in one of them there was a wide separation. This means to say that in fifteen cases of simple fracture infection only occurred in two. I am convinced from my own experience that no wounds can be assuredly aseptic, for I believe that all cases are infected and especially wounds that are opened for any length of time. The so-called aseptic healing is because the infection is not successful and in my experience a wound of the knee joint is especially liable to infection so that it is hard to prevent serious results. I consider therefore that this operation of opening the knee joint is a very serious. one and may be followed by the loss of the limb or death. I have opened the joint for foreign bodies but have never felt the security that I should feel in an amputation or a removal of the breast. Perhaps the knee joint is not infected any more than other parts of the body but it is less able to withstand the attacks of micro-organisms and we must therefore consider interference with more deliberation.

The best time to wire the patella is when we have demonstrated the failure of conservative methods and we should watch for the absorption of effused blood. It seems clear that effused blood is the best field for infection and, as has been shown by Halsted, the most aseptic operations are those which are bloodless. We should wait a certain length of time to know just how bad the result is to be before going into the joint.

Dr. James F. Moore, Minneapolis, said: I believe this paper represents the opinion of American surgeons today, that is, of those who are conservative, and by conservatism I do not mean that we shall refrain from operations. I think Dr. Powers' personally collected opinions from a good index in a certain way and they come from surgeons who have ample hospital facilities at their command. They report favorably on the operation but they do not advocate it as a universal practice and very few say that they always perform open arthrectomy. The argument therefore is in favor of a good surgeon with proper surroundings. The mortality in selected cases is less than one per cent. which is as small as you can get from any operation. There is only three per cent. of unsatisfactory results, which is infinitely better than the best results reported by treating fracture of the patella by non operative means. It is of interest to notice that in reported cases operations have increased in number within the past few years and that the increase is in the hands of men who have done the most work in this line. Men who have operated upon these cases under favorable circumstance have been well pleased with the results, and it would be of interest to know why those who are opposed to operative interference take that stand. I know an eminent surgeon who is opposed to operative treatment under any circumstances, and happen to know that his experience is one case in which the man died of septic arthritis. This is an unfair conclusion.

I agree with the author of the paper and with the most of those who have written and spoken upon this subject that the operation of open arthrotomy is more dangerous than a simple laparotomy as the lymphatic system cannot be compared with that of the peritoneum. The peritoneum is able to take care of infections while the knee joint cannot do so, and Dr. Powers' conclusions are therefore justifiable, that open arthrotomy with the proper environment is proper. I do not be

lieve, however, that this should be accepted as a general practice as every tyro will be making open arthrotomies and the grave yards will be filled by men who have had simple fractures of the patella. A man in general practice who is not sure of his asepsis has no right to open the knee joint, but if we do operate upon the knee joint open arthrotomy is the only thing to be considered as any other method savors of homopathic surgery. Dr. Powers' results show that there is less than one per cent. of mortality which is practically nothing and there is no question which will give better results.

Dr. Powers does not commit himself as to time operation should be performed, but Dr. Richardson touches upon this point. I must differ from him as I do not see why he should prefer late operation as we can be just as successful by operating immediately. The trouble often is to approximate the fragments, and we have to cut right and left in order to do this. We have to stir things up about as badly as they were stirred at the time of the fracture, and I do not see therefore what can be gained by waiting, so that I advocate immediate operation.

One point in the technique. I do not advocate drainage of wounds in general but I am in favor of the principle that when you are in doubt as to whether you should drain, do not do it. In open arthrotomy I think you should drain because if you open a large joint there will be an excessive amount of discharge which will cause a mechanical distension and interference with circulation. I think therefore that you would get the best results by temporary drainage. I have had some experience in making a cutting operation for congenital dislocation of the hip and have been driven to drainage sometimes in those cases.

A point of considerable interest is recurrence after operative procedures, and on this we have little information at present, but it is a good point upon which to make notes in the future. Should patients who have been subjected to open arthrotomy expect a recurrence? I believe not.

One point made by Dr. Richardson is interesting, i. e., that the amount of separation is an index as to what should be done. All of us who have treated these cases know that the amount of seperation is not a sure index of the amount of usefulness of the jimb. In one of my best cases there is a separation of four

inches and yet the man walks better than patients with only twe inches separation.

Dr. W. S. Halsted, of Baltimore, said: I will confine myself to one of the most important points, and that is drainage. We do not drain the knee joint in order to get rid of micro-organisms, If the tissues are in such shape that they can take care of the micro-organisms they will do better than they would if hampered by drainage. I think one who operates should wear gloves and use strictest precaution.

In closing the discussion Dr. Powers said he thought if a surgeon felt competent to undertake this operation he should feel safe in dispensing with drainage.

UTERINE FIBROID.*

BY J. GARLAND SHERRILL, M. D., Lecturer on Surgery in the Hospital College of Medicine, etc., Louisville, Kentucky.

I

HAVE here a tumor which was removed September 14th, from a lady aged forty-four years who came to see me on August 27th. Her family physician had made an exami. nation some time previously and made the diagnosis of "abdomi nal tumor." She had been suffering for two years from some remote abdominal trouble, but had not been examined until two months before I saw her.

An examination when she came to see me revealed an abdomen considerably enlarged, the umbilicus was about level with the abdominal wall, there was a tendency to hernia at that point, but the umbilicus did not protude much if any beyond the surrounding skin. Further inspection revealed a growth of some kind within the abdomen. Examination per vaginam revealed an os uteri very high up; I could just reach it with the tip of my index finger, and it was situated far to the left side. On the right side, through the vagina, I could detect a large hard lump, and in the abdomen above the tumor extended a little further than the umbilicus. I was unable to determine the connection between the growth and the uterus, and the diagnosis rested *Reported to the Louisville Surgical Society.

between a tumor of the ovary and an intraligamentous fibroid

tumor.

Ar operation was performed with the assistance of doctor James B. Bullitt; a very large incision was made; we found that the broad ligament was lifted up nearly to a level with the umbilicus if not above that point; the caput coli and the appendix had been also lifted up with the omentum which was extensively adherent over the mass; the bladder was pushed forward and upward, and I made an incision across the front separating the bladder from the tumor, tearing into the bladder as I did so probably half an inch; I then dissected down one side separating the omental adhesions, and dissected down upon the other side. The fundus of the uterus appeared to be normal. A peculiar feature of the case was the position of the right ureter. In dissecting on the right side we found the ureter had dipped under the lower lobe of the tumor and was considerably out of its normal position. We made a complete dissection of the ureter and isolated it before tying the artery on that side. Having ligated upon both sides the tumor was brought out of the cavity; a noeud was thrown around the pedicle and the operation completed in that way. The operation was rather tedious because of the careful dissection necessary to free the tumor from its attachments without injury to the ureter which was included in the growth. The tumor seems to have grown entirely out of the side and front of the uterus, the fundus not being involved. The rent in the bladder was sutured with three layers of silk, and the abdominal wound closed except at one point where a strip of gauze was inserted to take care of any oozing that might occur. The gauze was removed the following day. The patient voided her urine from the first without trouble: her temperature rose to 102 F. on the third day after the operation, quickly falling to normal after the use of purgatives, and she has returned to her home perfectly well. The only part of the wound which granulated was at the site of the stump.

Dr. James B. Bullitt: I was present and assisted Dr. Sherill in the operation to which he has referred, and he is to be congratulated upon his success in removing such a large tumor. The relation which the ureter bore to this lobulated mass in the pelvis was singular. A complete dissection was made, the ureter had to be dissected away from the lobule before the