impede their osseous union, and favour anchylosis, when it did occur in some awkward position. The ample experience obtained from excision of the elbow-jointwhich he had himself performed little short of a hundred times-showed that many months, or years, or even a whole lifetime, might elapse before the wound was so completely consolidated as not to suffer occasionally from small collections of matter in and about the cicatrix, which interfered little with the patient's comfort, as they did not affect the usefulness of the hand or the strength of the arm, but would entirely unfit the inferior extremity from being employed as a support for the body. In children the danger of the operation would be probably less than in adults, and the chance of consolidation greater. But, on the other hand, there was reason to fear that the limb would not grow proportionally, and remain in the shrivelled condition usually consequent upon spontaneous anchylosis. The results already obtained were confirmatory of these theoretical considerations. Although the operation had been limited to cases favourable for recovery, a large portion of the patients, whose fate could be regarded as decided, had perished. In some cases there had been no osseous union; and in others, anchylosis with miserable deformity. Thus in Sir P. Crampton's only successful case—the famous one of Ann Lynch, who “could walk the length of a day”—it appeared from the bones which were in the Lincoln's-Inn-Fields Museum, that the tibia and os femoris were united at a right angle so that the progressive motion must have been of a very rare and remarkable kind; while the subject of Mr. Park's never to be too frequently quoted case probably made a better appearance, climbing up the rigging of his ship like the quadrumanous inhabitant of a tropical forest, than he would have done as a biped on terra firma. He therefore did nct feel warranted to substitute this operation for amputation, which, when properly performed, relieved the patient with little risk, and enabled him to obtain an adequate support far more useful to a poor man and ornamental to a rich one, than could be procured through all the suffering, prolonged treatment, and risk of life attendant upon removal of the articulation. But in saying this, he begged it might be distinctly understood, not as an attack upon any other person, but simply as a defence for himself, for declining an experiment which did not in his mind possess the proper requisites of an experientia erudita.-Monthly Journal of Medical Science, July, 1853, p. 89.

66.-ON EXCISION OF THE KNEE-JOINT.

By HENRY SMITH, Esq., Surgeon to the Westminster General Infirmary.

[The success which has attended this operation since 1850, seems now to be in a fair way to set the question of its value at rest. Out of the three cases operated on in London during the last two years, two have died. The following are the parti culars of the last case:-Emma Saville, aged 28, unmarried, noticed eleven years ago, that her left knee became swollen and painful, and, though it got well, yet it very often became affected in the same way. She had been admitted into King's College Hospital on various occasions for its relief. The last time she applied its appearance was as follows:]

Left knee much larger than the right, the chief difference being over the head of the tibia. The joint is bent outwards, as though there had been a partial dislocation. Considerable pain is experienced through the joint, and is much aggravated in the night. On rubbing the bones together, a very distinct grating is experienced; any attempt at motion on the part of the patient gives intense pain. There is no disease whatsoever of the soft parts, and the swelling is not great, and there does not appear to be any, or at least any quantity of, fluid within the joint. Her general health is weak; she has lost much flesh, and the countenance is of a sallow and unhealthy appearance; sleep is prevented at night by the pain.

The patient was placed under the treatment ordinarily adopted in such cases; the limb was bandaged from the toes, and was placed upon a splint, and perfect rest was enjoined. Under this treatment the patient experienced relief from pain, but permanent benefit did not result; the patient continued in her weak state of health, and became most anxious to have some operation performed, but refused to undergo amputation. It was therefore determined upon to perform excision.

Saturday, April 2, 1853, 2 P.M.-Excision of the knee-joint was performed by Mr. Fergusson. He did not remove any of the skin, as in the instance next related; but more of the femur was taken away, in consequence of the periosteum being stripped off from the bone for some inches. There was a considerable amount of disease in the joint; the cartilages had entirely disappeared, and it contained a quantity of cheesy strumous material. The head of the tibia was more implicated than any other portion. There was only slight bleeding during the operation. The wound was united by sutures; wet lint was placed over it, and the limb was enclosed in a proper apparatus, and suspended on the swing splint; and the patient was ordered half a drachm of laudanum.

3rd. Has had much pain and starting in the limb at night; pulse 160; had only slept one hour.

[Up to the 5th she took beef-tea and brandy every few hours. On the 7th she fainted, and on the 8th looked pale and coughed much. On the 11th the tongue became brown and dry. Pulse 130, and countenance anxious. On the 17th much worse; a severe rigor set in, and all the symptoms of purulent absorption were manifest, and she died on the 18th, evidently from purulent infection.

Unfortunate, however, as has been the result in London, in other parts the operation has been much more successful. Mr. Jones of Jersey, and Dr. Mackenzie of Edinburgh, have given it a fair trial. The former gentleman has operated five times, four of which were successful. Mr. Smith observes:]

It is to Mr. Jones, of Jersey, most undoubtedly, that the Profession is chiefly indebted for having furnished the most numerous, most important, and most satisfactory data respecting this operation. While I am writing this, I have received another communication from this gentleman, containing the details of a sixth instance in which he has excised the knee-joint. It may, with truth, be affirmed, that in all his cases, six in number, he has succeeded,-for dysentery, not the surgeon, destroyed the only one of his patients who is now in her grave. It is useless to attempt concealing the fact, that she did die of this disease, and not of anything else. Mr. Jones, in a letter to me, states, that everything connected with the operation was progressing most satisfactorily, and that "scores of persons died in the neighbourhood" of dysentery.

According to Dr. Mackenzie, there are two other authenticated cases in which this operation has been performed with success within the last two years,-one by Dr. Stewart, of Belfast, the other by Mr. Page, of Carlisle; so that, in fact, the entire number of operations of excision of the knee-joint has been thirteen since the proceeding was first revived by Mr. Fergusson; of these three have turned out badly, the remaining ten are alive; and if we take away Mr. Jones's single unsuccessful case, we have only two fairly attributable to the interference of the surgeon,-a proportion of deaths by no means great when compared with ordinary amputation through the thigh. There is still one point of great importance, in reference to this particular operation, which is to be considered.—viz., the utility of the limb as a means of progression after the joint has been excised, and a cure has been effected. The evidence on this subject, so far as it can be obtained at present, is on the one hand of a nature highly satisfactory, while on the other it is the reverse. In the remarkable case where Park first operated so successfully, the man returned to his occupation of a sailor, and "was enabled to go aloft with considerable agility, and to perform all the duties of a seaman;" surely this is more than could be reasonably expected. Mr. Jones wrote to me some time ago as follows concerning one of his cases :-" He walked without the assistance of crutch, stick, or any appliance whatever to the limb, up and down the largest room in the hospital, quite as fast as I could." On the other hand, Mr. Syme's patient did not, I believe, have much use of his limb eventually. Although the exact particulars of the condition and aptitude of the member have not lately been obtained, there is reason, however, to believe, that it is not satisfactory, as Mr. Syme has evinced great opposition to the operation.

However, there is no doubt that strong union of the parts in the site of operation does take place, and that, by careful attention to position, a very useful substitute for a sound limb may be effected. In some instances the union is only ligamentous, but in others it is bony, as was the case in Sir Philip Crampton's patient.

Here, however, the limb was not of very much use; and any gentlemen who will take the trouble to walk into the pathological department of the Hunterian Museum,

and examine the large glass case on the basement floor, will at once see the reason of this; for he will there find the preparation of the parts, and will observe, that the divided bones had become joined by strong bony anchylosis, almost exactly at right angles. Sir Philip Crampton informed a friend of mine, that the limb had not been kept steadily in the extended position after the operation; thus arose the awkward anchylosis. But this case, instead of proving anything against the operation, speaks much for it, as the parts are firmly knit together by bony junction. And doubtless this union might have been effected in a straight position.

In concluding these observations on the cases above detailed, I cannot avoid expressing my conviction, that excision of the knee-joint, as a substitute for amputation, may worthily occupy the attention of surgeons; and I doubt not that the merits of the operation will in time be fairly tested, as such enterprising men as Mr. Fergusson, Mr. Jones of Jersey, and Dr. Richard Mackenzie, have taken the subject up. We can hardly expect to meet with such success as obtains in the proceeding on the elbow-joint; but there is not any reason why the excision of the knee-joint should not prove to be less fatal than the amputation through the thigh, in which procedure large nerves and vessels are divided, and a considerable portion is suddenly taken away from the rest of the body. If time proves such to be the case, and if, also, it be found that the limb is as useful to the patient as an artificial leg, surgeons will feel bound to adopt the operation. If, on the contrary, a greater mortality attends the removal of the joint than the amputation, and if the limb which is preserved becomes inferior to an artificial substitute, they will be bound to reject it altogether. The experience which has been obtained within the last two years, inclines to the belief, that it may ultimately be an operation recognised among surgeous. Med. Times and Gazelle, Aug. 27, p. 213.

67.-CASE OF EXCISION OF THE KNEE-JOINT.

By GEORGE M. JONES, Esq., Surgeon to the Jersey Hospital.

[Mr. Jones is induced to publish the particulars of this case, owing to the conflict of medical opinion as to the merits of the operation, and because the operation was performed after a different manner to that commonly adopted. The patient, in the case, was a boy aged 12. He was admitted on the 12th October last, on account of a disease in the knee, of a year's standing. There had been inflammation, followed, it was suspected, by extensive ulceration of the cartilages. All the usual means tried to preserve the joint failed, and it was, therefore, determined to excise the joint.]

The operation was performed on the 17th of April last. A longitudinal incision was made on each side of the knee-joint, midway between the vasti and flexors of the leg, full five inches in extent; rather more than half the length was over the femur, and rather less than half over the tibia. These two cuts were down to the bones; they were connected by a transverse one just over the prominence of the tubercle of the tibia, care being taken to avoid cutting the ligamentum patellæ by this incision; the flap thus defined was reflected upwards, the patella, its ligament, and the joint, thereby exposed. The synovial capsule was cut through as far as it could be seen; the patella and its ligament were now drawn over the internal condyle, while the joint was kept extended. It was next forcibly flexed; the crucial ligaments, almost breaking in the act, only required a slight touch of the knife to divide them completely; the articular surfaces of both bones were thus completely brought to view, and nearly two inches of the femur and half an inch of the tibia were sawn off, the soft parts being drawn aside by assistants. The external condyle of the femur was found hollowed out by a large abscess, and it was necessary to saw off a portion of the carious bone, and to gouge the remainder, until healthy cancellous tissue was reached. The entire synovial membrane was in a state of pulpy degeneration, and was carefully dissected off. The hemorrhage had been rather great, but had now almost ceased, and no vessel required deligation. The blood was sponged out of the wound, the patella (after the diseased portion had been gouged out) and its ligament were replaced, as nearly as possible, in their natural state, the bones brought in apposition, the flap brought down and held by sutures, the limb bandaged

on a slight under-splint and laid in a box, the wound covered with moist lint, and the boy put to bed yet asleep. The operation occupied full twenty minutes, and was performed while the patient was under the influence of chloroform.

Opiates had, for some time, to be freely administered every night; and the boy's appetite, always excessively small, having entirely failed, the stimulating plan of treatment was followed out more rigorously than I had pursued it in other cases. The seventh day after the operation, a slough of some extent was perceived on the lower part and sides of the flap. This went on increasing for some days; the ligamentum patella was, however, never bared. Mild, stimulating applications arrested its progress; healthy granulations sprang up; and soon the suppuration, which was at one time very considerable, lessened in quantity. At present it amounts to a mere nothing, the wounds being now all but healed.

Not seven weeks have yet elapsed since this operation was performed, and it is most satisfactory to witness its favourable and rapid progress. The little patient never experiences the slightest pain in any part of the limb; he turns it from side to side easily and quickly, and without either assistance or appliance of any kind, can, while lying on his back, raise the leg from the hip upwards. The knee bows slightly inwards; but my previous experience in these cases leads me to believe, that a very slight mechanical contrivance will entirely remedy this. The patella is adhesive to the femur and tibia, and its ligament preserves its integrity.

The integuments covering the joint had been so much deteriorated by the disease itself, and perhaps also by the remedies used, as, together with the length of the flap, to account naturally for the slough. Probably two smaller flaps, reflected upwards and downwards from the centre of the patella, might have answered better.

I am very unwilling to be supposed to recommend this plan of operation, as one adapted to all cases of knee excision,-very far from it; there are cases in which it is altogether inadmissible; and I feel persuaded, that whoever adheres to one mode only, will often find himself wofully disappointed in the result. The general rule of acting according to the features the case presents, is quite as applicable to these particular cases as to others generally.

Preserving the patella, and not dividing its ligament, makes the operation more tedious and difficult; but this is a very secondary consideration, where it results in obtaining a more favourable issue. That it proved so in this instance is abundantly established by the fact already mentioned, that, in less than seven weeks after the operation, this patient is able to raise his foot without any assistance; while a young man who occupies the next bed, and in whose case everything has gone on favourably, was only able to do so in as many months.-Med. Times and Gazette, July 2, 1853, p. 11.

68.-PRACTICAL OBSERVATIONS ON AMPUTATION AT THE TARSO. METATARSAL ARTICULATIONS.

By DR. CHARLES EDWARDS, Cheltenham.

Supposing the single or double flap formation at the option of the operator, in order, first, to get the line of cicatrix near the upper margin of the stump, and secondly, to avoid the painful and unnecessary dissecting-up of an anterior flap, I think it best to make but one flap-a plantar one.

To reach the line of articulations, and have a precisely adapted flap, ink the following lines-First, a line near the roots of the toes, a, b. g, close by their commissures. Precisely parallel with this dotted guidance-line draw another arched line, commencing at the projection of the fifth metatarsal bone, or an eighth of an inch below it. This parallelism will prove an equal, if not superior guide to the articulation between the first metatarsal and internal cuneiform than any conjectural measurement from the projection of the navicular, which itself, in certain diseased states, is not easily felt. This arched line will be the course for the dorsal incision; the structures retracted, not reflected, will correspond to the joints.

Unite across the plantar surface the cornua of this irregular arc by a right line : this chord, e, g, will be the base-line of the plantar flap to which the knife should be fully carried.

It now only remains to mark its periphery, which will be determined by inking, if thought necessary, another arched line on the plantar surface, precisely bounding the roots of the toes, l, m, n (as a, b, g, on the dorsal surface).

D

n

E

a, b, g, commissure guidance-line.

C, D, E, line of dorsal incision.

1, m, n, periphery of plantar-flap.
c, g, base line of ditto.

Having thus accurately defined the measurements, I would conclude with a few observations on the plantar flap, the dorsal incision, and finally the management of the second metatarsal bone.

As to the plantar flap, commence with a strong scalpel at, or slightly beyond, either extremity of base-line, and deeply groove out the whole circuit of the flap from without, carrying your incision round by the plantar arched line till it meet correspondingly the other extremity of base-line. Finish this flap, not with a scalpel or bistoury, but with a small, straight-edged amputating knife, one stroke of which will smoothly reach the base by reason of its greater breadth. Thus, in addition to a more perfect outline of the flap than can be obtained from within after the disarticulation, by cutting from without no tendons are left projecting to be clipped. Some authors say, "Koep close to the metatarsal bones." If, however, you have, and leave too much muscle in this plantar flap, you will incur difficulty in bending it up over the stump, and much pressure and many sutures to keep it there: I speak to operators on the living body.

Secondly, as to the dorsal incision, see that the assistant who has charge of the arterial pressure presses perpendicularly to the surface, and does not disturb the parallelism, while the dorsal incision is being made, by unequal or, indeed, any tegumentary retraction.

Finally, with respect to the disarticulation, when from disease you cannot save the head of the first metatarsal bone, or leave behind that of the second with impunity, have in an instant disarticulated the latter, without previously removing any projection of the first cuneiform, by the following method:-The plantar flap being formed as directed, and the union of its base extremity and the corner of dorsal incision clearly made, disarticulate the first metatarsal, then press the metatarsus, not downwards, but rather directly outwards (this manipulation admits of easier demonstration than description). The point of a scalpel, applied laterally, by a person knowing where to expect the articulation, will most readily penetrate it, and so the chief difficulty of the whole operation will be readily overcome by any dexterous hand.-Lancet, April 30, 1853, p. 405.

69.-PURULENT INFECTION, AND ITS EFFECTS ON JOINTS.

[In a paper read before the Medical Society of London, MR. BULLOCK divided the subject into the following heads: 1st, secondary affections, not fatal; 2nd, those proving fatal; 3rd, the pathology and treatment. The first head was subdivided into-secondary affections following certain diseases, and those after operations. Examples of the former of these are mild cases of puerperal fever and gonorrhoeal rheumatism.]