William Thornley Stoker

On the operative treatment of trifacial neuralgia

1. That in cases of trifacial neuralgia demanding operative treatment neurotomy is not usually a satisfactory or efficient operation. 2. That in purely sensory nerves stretching is at best but a temporary expedient, and either should not be undertaken, or having once been performed and followed by a return of pain, should not be repeated. 3. That the reasonable treatment in trifacial neuralgia of an extreme character is neurectomy, and that while the operation on divisions of the 5th nerve external to the cranial cavity may be regarded as an established procedure, the ultimate operation of removing the Gasserian ganglion must still be considered as on its trial. 4. That avulsion should only be practised as a part of an open operation, and that, as originally proposed by Professor Thiersch, it should be regarded as a blindfold and unscientific proceeding, to be undertaken only when an open operation is for sufficient reasons impossible or inexpedient.

On some Elements of Success in Excision of the Knee-Joint

Tim surgery of to-day is a scieRce of great principles, but an art of small details. In view of the latter part of this postulate, I think it not without interest to relate a few of the practical conclusions I have come to with regard to certain methods to be followed in excision of the knee-joint, which, although small in themselves, help to grealter ends. I do not purpose going into the subject generally, but stating some opinions I have formed as a result of my own practice, and my observation of that of others. It is manifestly of interest that surgeons should state their views broadly; we have too much in our current literature of details of cases, and too little of the general ideas arrived at by men of experience. My strong sense of the value of communications of this class is my reason for wishing to state the conclusions I have formed on two or three points connected with excision of the knee, for my operative material has been at least sufficiently large and extended to justify me in pUttiDg forward what it has taught me. Besides, in a city so well supplied with hospitals as Dablin, and where they are so close together, surgeons see an amount of the practice of each other which magnifies their opportunities. While I would not say a word to disparage the operation of kneeexcision in suitable cases, I think its results have been too favourably stated, and that many instaDces recorded early in their history as ones of cure have later on shown a return of disease. In Ireland iur experience should naturally be less favourable, as the bulk of our cases occur amoiig tuberculous subjects. Age has been over-estimated as an influence for goo(d or evil in this operation. Two of the best results I hitve had in my own practice were in patients who were aged 5 and 39 years respectively. The first, a scrofulous suibject operated on niore than a year ago, is in active health, and able to walk with any ordinary child of her age ; the second, a farmer whose right knee I excise(d seven years ago when he was dying of pain and hectic, leads an active life, and can walk vigorously all day long. It is not correct to teac-h that removal of an entire epiphysis from a young bone of necessity involves a short limb. The child above referred to had such extensive disease that the entire epiphysis of her femur was removed, but only the upper surface of that of the tibia. She has grown rapi(dly since the operation, but the limb on which I operated is not an eighth of an inch shorter than its fellow. Nature is a bountiful mother, and a compensatory growth often takes place in those epiphyses which are not removed, so as to preserve activitv and syminetry. The im-mature human being seems to have certain qualities of free and exceptional growth, which are perhaps an approach to the conditions of those lowei creatures to whom the human embryo is related more closely than the developed adult. Given a case of disease of the knee-joint well selected for operation, there are three factors of superlative importance in its prospect of successL. Complete removal of all diseased structures. 2. Relative permanence of dressings. 3. Thorough fixation of parts. 1. As regards the first of these I agree with Professor Humphry that prolonged scrofulous suippuration is the most common cause of failure in this operation. It is of paramount importance to remove thoroughly not only diseased bone, but any soft structures which are engaged. The tissue which is at once the most rich in tubercular foci, and the most diffi-ult to remove owingf to its complex involutions, is the synovial membrane. I have latterly made it a general practice to divide