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A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

KING’S COLLEGE HOSPITAL.

A SECOND EXCISION AT THE KNEE-JOINT, WITH WOUNDOF THE POPLITEAL ARTERY ; AMPUTATION THROUGH

THE JOINT ; RECOVERY.

(Under the care of Mr. FERGUSSON.)

Nulla est alia pro certo noscendi via, nisi qusm plurimas et morbornm ttdissectionum historias, tam aliorum ptoprias, collectas habere et inter se com-parare.-MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proaemiutn.

IN the cases of excision of the knee which follow, it will benoticed that the operation is practised at hospitals in which, afew years ago, it was tried and abandoned because of its then

proving a failure. It is a proceeding that is now much betterunderstood than formerly, and has come into general use innearly all our metropolitan hospitals. The two instances inwhich it was practised at St. Bartholomew’s Hospital, and theone at St. George’s, have turned out remarkably well thus far,and the operators will continue to give excision the preferenceover any other measure in such cases of disease as shall admitof it.

If it were possible for anyone at the present time to favourthe profession with statistics of excision of the knee, as hasbeen already so admirably done by Mr Butcher, of Dublin, ontwo occasions, it would be seen that the per-ceutage of recoveries is far larger than it has been heretofore. Considerable

difficulty, however, would be experienced in obtaining thedetails of the cases, as many patients are now beneficially sub-mitted to the operation without any special record beingpreserved, in consequence of its not being any longer considered a proceeding of much novelty.We are glad to observe, also, that the same operation has

extended to the colonies. We learn by a recent paper thatthe knee-joint of a girl was excised, for painful strumous disease,at St. Patrick’s Hospital, Montreal, by Dr. Hingston, in thepresence of a large number of military and civil surgeons.This is the first operation upon this joint that has been prac-tised in the Canadas.The patient who is the subject of the following case under-

went excision some five years before with such satisfactoryresults that she was frequently exhibited at the hospital as anexcellent illustration of its practical value. The limb was in

every way perfect for progression. About a year ago she sus-tained an injury which revived the old disease, and a secondtime she was being submitted to excision, when, owing to somealteration in the relative posirion of the soft parts, consequentupon the former operation, the popliteal artery was wounded,and the limb was accordingly removed at the knee-joint. A

good recovery has been made. For the notes of the case weare indebted to Mr. I. Barr Brown, house-surgeon to the hos-pital.Ann T-, aged twenty-five, single, readmitted into King’s

College Hospital Nov. 1st, 1861. About five years ago Mr.Fergusson performed exoisio’i of the riht knee joint in this

hospital, for scrofulous disease, then of ten years’ standing.She was under treatment five months and a fortnight, andmade use of a stick for four months after her discharge. Fromthat time till Nov. 1860 she could use the limb very well with-out artificial support. At that date she fell down stairs, andinjured the excised knee. She was admitted into the hospital,and was under treatment for some months, with abscesses andsinuses about the joint. The joint was not perfectly anchy-losed ; the leg was shorter than the other by about an inch anda half. She left the hospital for the country July 23rd, 1861.On her readmission, Nov. 1st, there was a longitudinal open-

ing on each side of the upper part of the tibia, correspondingwo the lower parts of the H incision at the original operation.

The transverse cicatrix was scarcely visible. Dead bone couldbe felt through both these openings. A poultice was applied.On Nov. 9t.h, the patient being placed under the influence of

chloroform, Mr. Fergusson explored the sinuses, with the in-tention of re-excising or amputating, as the state of the partsmight seem to require. He then made an incision across thefront of the joint, and, bending the limb at right angles, ex-posed the ends of the fmnr and tibia, which had not united,but were covered with a pnlpy material answering the pur-pose of cartilage. The surfaces of both bones were diseased,especially the tibia. A slice of bone about three-quarters ofan inch thick was removed from the tibia with the saw; butas this did not include the whole of the disease, and moreoveran artery of considerable size was wounded, amputation wasdecided upon. The knife was carried behind the tibia, and aflap made, about nine inches long, from the calf of the leg; thesoft parts on the front of the femur were then dissected upfrom the bone, a thin slice. of which was removed by the saw.Several arteries having been secured by ligature, the flaps wereunited by silk suturps, and the stump was dressed with wetlint and bandage. The slice of the femur was found diseasedonly superficially and to a small extent, but the tibia wasaffected to a much greater depth. The patient was very sickafter the operation, and scarcely slept at all during the night.

10th.-I’Latlier better. A good deal of discharge, whichsmells very offensively, has oozed through the dressings. Pulse130 ; face flushed. Slept at night after a draught of morphia.12th.-Stump dressed. Edges of incision swollen and in-

flltmed ; yet a good deal of adhesion has formed between theflaps. A large quantity of discharge.14th.-Stump looks healthy; plenty of discharge of healthy

pus from the corners of the wound. The under flap is supportedby strapping under the dressings. Pulse 120 ; tongue clean;appetite good. Comulains of pain in the limb.18th.-The posterior flap has considerable tendency to drag

downwards; the middle part of the anterior flap, where it isstretched over the femur, is inclined to ulcerate; otherwisedoing very well.21st.-The outer corner has healed well; the rest of the in-

cision presents a granulating surface half an inch wide.25th.-The ligatures have all come away; the corners of the

wound are healed, and the rest is closing up. The patch overthe end of the femur how ulcerated, and is protected from pres-sure by a pad of lint. The patient is remarkably well in healthand appetite.

Dec. 5th.-The ulcerated patch is still open, but is healing.An abscess which had formed near the inner corner has been

opened, with great relief.11th.-The wound is healing rapidly. Patient had a slight

attack of diarrhoea, which, however, was stopped by opiumand sulphuric acid.23rd.-There remains a very small part not healed; the

ulcerated patch is not quite healed.Jan. 4th, 1862. -A slight discharge has formed at the corners

of the incision.She left the hospital Feb. 7th, to go to Walton Convalescent

Hospital. Returned March 5th, much improved; but thecorners of the wound were still slightly open.

ST. BARTHOLOMEW’S HOSPITAL.

EXCISION OF THE KNEE-JOINT AFTER FIFTEEN MONTHS’UNAVAILING TREATMENT FOR DISEASE, THE RESULT OF

INJURY; RECOVERY WITH A GOOD LIMB.

(Under the care of Mr. SKEY.)

THOMAS M-, aged three years and a half, was admittedinto the above hospital on July 12th, 1860, with disease of theleft knee. He was reported to have sustained some injury tothe joint in consequence of a fall, which had occurred somemonths previously. At the date of his admission the joint wasconsiderably swollen, and its movements impaired both asregards entire flexion and extension. The child was in bad

health, and somewhat emaciated. At the expiration of someweeks, under the influence of good hospital diet, his healthimproved; but the joint, except that its movements becamesomewhat more limited, remained unchanged. The knee wasthen subjected to pressure by the application of plaster, theeffect of which was some reduction of its size.

In November, the flexor tendons were divided, and the limb

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was straightened and placed in splints. In this condition itremained many weeks, with the occasional removal of the

splints. A succession of abscesses then formed on the innerside of the joint, which greatly retarded the progress of thecase. At length they healed, and the leg was placed in anapparatus, and subjected o extension by means of a screw.This principle of treatment was varied from time to time bythe change of the local agents, but without success. Althoughthe boy’s health continued good, the permanent extension ofthe knee yielded to the gradual and increasing influence of theflexor muscles.In August last these tendons were again divided, and the

limb extended and placed on a back splint, and the limb wassimply rolled. In this position it was retained during twomonths, at the expiration of which, when the splint was re-moved, the knee again contracted as before. It was obviousthat no alternative remained but that of the removal of thejoint. The recognised resources of art had been exhaustedwithout benefit. Fifteen months had been devoted to their

application without success. Rest, improved health, mercurialinunctions, iodine, pressure, division of the tendons, one andall proved unavailing for any permanent good, and on Dec.17th the joint was excised by Mr. Skey.The operation itself presents no novel or remarkable feature.

A horse-shoe incision in front divided the ligamentum patellæ,and exposed the very reduced cavity of the joint. About threequarters of an inch of the femur was removed by the saw, andless than half an inch of the tibia; and the patella was dis-sected out. The opposing surfaces, when brought into contact,fitted with sufficient exactness; the edges of the wound wereunited by silver sutures, and the knee rolled in cotton-wool.The limb was placed in the back splint, with lateral supportsmoving on hinges as improved by Messrs. Lawson and Price,and the boy was then carried to bed.

In the subsequent history there is little to record beyond theappearance of a slight attack of erysipelas, which occurred onthe thigh about a fortnight after the operation, and which ledto the formation of an abscess near the popliteal space. Theformer malady yielded readily under the influence of a grain ofquinine given thrice daily, and the latter early ceased to provethe cause of disquietude, as it obviously did not communicatewith the bone within. At the termination of the eighth weekthe union of the bones appeared firm ; and at the expiration ofthe tenth week the apparatus was finally removed, and a backsplint applied as a precautionary measure to protect the limb against the liability to injury from the incessant activity of theboy, who yet remains an inmate of the hospital in consequenceof the difficulty of finding the whereabouts of his parents. Hewalks about the ward wiLh great ease and freedom, and witha limb which appears to have sustained but a very slightabridgment of its length from the operation.

SUPPURATION OF THE KNEE-JOINT, WITH AN ABSCESS IN THEHEAD OF THE TIBIA; EXCISION; RECOVERY.

(Under the care of Mr. PAGET.)

The following abstract we have condensed from the notes ofthe case furnished us by Mr. E. Ludlow, the dresser of thepatient.Joseph B-, aged fourteen years, was admitted Oct. 3rd,

1861, for a swelling of the left knee. The swelling extendedone-third of the distance up the thigh, and was evidently dueto the presence of a very large collection of fluid within theknee-joint. It was tense, painless, and tolerant of pressure;both tibiae were bent. Four years ago he had a swelling of theright knee, which confined him to bed for some time; but fromthat he completely recovered. The swelling of the left kneefirst appeared three months ago. He was placed under treat-ment, and his general health improved under the use of quinineand iron. On the 2nd of December the joint was punctured onthe outer side with a small trocar, but no fluid was evacuated.This operation was repeated on the 21st of January last, asfluctuation was again felt, but with a similar result.On the 1st of February, Mr. Paget proceeded to excise the

joint. A semilunar incision was made through the skin fromthe outer to the inner side of the joint; and, in dissecting upthe flap, an abscess was discovered in contact with the outercondyle. Slices of the condyles of the femur and of the headof the tibia were now sawn through; in the latter was foundan abscess which had communicated with the knee-joint. Thewound was closed by silver sutures, and placed on an ironsplint, the limb being covered with cotton-wool, and bandaged.On the night of the operation the patient slept well; but he

was very sick all the next day.

, Feb. 3rd.-Had slept well; the pain in the knee decreased,but the slightest shaking of the bed caused pain. From thistime the improvement continued uninterrupted. By the 15thof March the external wound had entirely healed, and theunion of the tibia and femur appeared to be strong. The lowerend of the femur projects beyond the tibia forwards and out-wards, so that an obtuse angle is formed at the seat of union.The limb was firmly bandaged upon a back splint, and thepatient was directed to get up out of his bed for a short timeevery day. The affected limb is two inches and a half shorterthan the other.

[The reports from the Hospital for Sick Children, the Londonand St. George’s Hospitals, are unavoidably postponed untilnext week.]

Medical Societies.MEDICAL SOCIETY OF LONDON.

MR. COULSON, PRESIDENT.

DR. RICHARDSON read a paper entitled

FURTHER RESEARCHES ON THE THERAPEUTIC PROPERTIES

OF THE PEROXIDE OF HYDROGEN. ’

The author first drew attention to the subject of the manufac-ture of the peroxide, and reported that after repeated and long-continued experiments in reference to the different processesfor making the solution, his opinion ultimately was that noplan is so good as the original one invented by Thenard, inwhich the peroxide of barium is used as the agent for supply-ing the oxygen, with hydrochloric acid as the displacing body.The strength of the solution was next discussed, and it wasshown that a solution charged with ten volumes of oxygen wasthe best and most applicable. The dose of this solution for anadult was from one drachm to half an ounce in a liberal quan-tity of water. The compatibility of the peroxide solution withother medicines was next considered, and it was intimated that,as a general rule, the solution should be given separately, or,if mixed with another remedy, should be so admixed at theperiod of administration.From the narration of these particulars Dr. Richardson passed

in review the results of his experience in disease. He had usedthe remedy now in 223 instances-viz., in simple diabetes, 3;in diabetes complicated with phthisis, 2; in chronic rheumatism,1; in subacute rheumatism, the continuation of an acute attack,2; in mitral disease with great pulmonary congestion, 4; inirregularity of the heart, with cardiac apncea, 3 ; in struma,with enlargement of the cervical glands, 2 ; in struma, withformation of purulent matter constantly recurring, 1 ; in me-senteric disease, 1 ; in simple jaundice, 1 ; in jaundice compli-cated with cardiac and hepatic disease and ascites, 1 ; in canceraffecting the glands of the nock, 1 ; in pertussis, 9 ; in chronicbronchitis, 9; in bronchitis complicated with mesenteric dis-ease, 1 ; in chronic laryngitis, 3 ; in anasmia, 44; in phthisis,first stage, 66 ; phthisis, in the second stage, 31 ; phthisis, inthe third stage, 13; in phthisis, first stage, complicated withbronchial disease, 6 ; in phthisis, second stage, with bronchialdisease, 3 ; phthisis, with valvular disease of the heart, 2 ; andalso in a few cases of dyspepsia.

Analyzing these cases, the author came to the following con-clusions:-That in the treatment of diabetes, the peroxide,while it reduced the specific gravity of the renal secretion, in-creased the quantity; so that its value in this disease was in-appreciable. In chronic and subacute rheumatism it was ofgreat value. In valvular disease of the heart, attended withpulmonary congestion, it largely relieved the attendant apnoea.In struma it removed glandular swelling, like iodine. Inmesenteric disease it improved the digestion, and favoured thetolerance of cod-liver oil and iron. In jaundice it exercised anexcellent effect, by improving the digestion and causing a freesecretion. In cancer it seemed to exert no influence. In per-tussis its value was very remarkable; it cut short the paroxysms,and removed the disorder altogether, quicker than any otherremedy, except change of air. In old-standing bronchitis,during attacks of suffocative dyspnoea, it afforded rapid relief.In chronic laryngitis, its caustic character rendered its admi-nistration painful. In anasmia, while it exerted no specificinfluence per se, yet combined with iron it increased the acti-vity of that drug. In phthisis pulmonalis, in the first stages,it greatly improved digestion and increased the activity of iron;while in the last stages it afforded unquestionable and wonder-

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