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which for the last few days has spread laterally; and Mr.Bryant intends putting a ligature on the femoral artery.

July 6th.-He was put under the influence of chloroform,and the femoral artery tied quite at the lower part of Scarpa’striangle. Ordered, ten grains of Dover’s powder at bed-time.

7th.—Passed a good night, and complains of no particularpain.

12th. -Progressing very favourably; the wound has unitedby first intention, except the part in the immediate vicinity ojthe’ligature, from which there is a healthy discharge. Aneurismis firm, and becoming smaller.

18th.—The discharge is slightly tinged with blood.Aug. 1st.—A very slight discharge, which is healthy.3rd.-Ligature came away to-day, being the twenty-eightl

day after the operation; and it has evidently been resting orthe wound, as it was not thought necessary to apply any forclto hasten its removal.The patient is now convalescent.

CHARING-CROSS HOSPITAL.

FORCIBLE SEPARATION OF THE SHAFT OF THE FEMUR

FROM ITS LOWER EPIPHYSIS ; EXCISION OF THE

KNEE-JOINT ; RECOVERY.

(Under the care of Mr. CANTON.)WITHIN a short period we have witnessed several cases of

excision of joints, four of which we briefly notice in our " Cli-nical Records" of to-day. But there has been an instance verylately at this hospital which possesses features of such novelinterest, as necessitating the operation, and differing from anythat have hitherto been recorded in our "Mirror," that wewould request the attention of our readers to it.

Excision of the knee-joint has now been performed for allthe varieties of disease, and for deformities resulting there-from. But among all the examples collected together in Mr.Butcher’s excellent memoirs on the subject, we do not findone in which the operation was done as the result of an injuryunder such peculiar circumstances as were present in thefollowing case. The patient, a boy, met with an injury tohis knee, which, at first sight, was supposed by the house-surgeon to be a dislocation of the knee. There were severalconditions, however, which went to show that it might not bethat accident; in addition to which, the accident itself is ofvery rare occurrence. On this point the late Mr. SamuelCooper observes, in his " First Lines of Surgery," when speak-ing of dislocations of the knee: " All varieties of these are

exceedingly rare, yet we occasionally read of them; and per-haps in the course of twenty years there may be one casebrought into a large hospital." p. 716. We think this is the

experience of most surgeons. But cases do now and then comeunder our notice; as for example, a partial dislocation of bothknees in a female aged twenty-two, at St. Bartholomew’s Hos-pital, under Mr. Coote’s care; and a dislocation of one knee ina man aged fifty-four, under Mr. Gant’s care, at the RoyalFree Hospital, both given in our " Clinical Records" of lastyear. (THE LANCET, vol. i. 1857, pages 30, and 553).Then again, when we come to compare the security of the

knee-joint-due to the number and strength of its ligaments,and the fibrous involucra derived from the expansion of theneighbouring tendons-with the means of union between theshaft of the bone and,its epiphysis at this period of life, weshall find that great violence applied to this joint will be moreliable to cause the quasi-fracture noticed in the case than adirect luxation. It is easy to comprehend, therefore, why inthe young an injury will detach an epiphysis in other jointsbesides the knee. Nevertheless, this very important point isoverlooked by many surgeons; and on reference to Mr. R. W.Smith’s work on " On Fractures in the Vicinity of Joints," wefind that he makes no mention even of this form of accident.The records of excision of joints in our " Mirror" furnish us

with a good example, in which a severe laceration of the elbow—a joint analogous to that of the knee-was treated by exci-sion of the ends of all the bones, also by Mr. Canton, (THELANCET, vol. ii, 1855, p. 324.) In that case a good cure waseffected, and the patient has ever since followed his employ-ment of a printer, with some degree of motion in his newly-formed joint.The injury to the knee, treated in a similar manner by the

same surgeon, forms an interesting addition to the series ofcases of excisions of that joint especially, which has been sofully illustrated in our " Mirror," and we believe it is the first t

instance of the kind in which this operation has been performedfor such an unusual accident.A boy, aged eight years, was admitted into the hospital,

having suffered the above-mentioned injury, and received alsoan extensive wound of the scalp at the back part of the head,from which a large quantity of blood had been lost. Theexact mode of production of the mischief could not be ascer-tained. It was known, however, that the boy whilst ridingbehind a cart had fallen to the ground, and it was believedthat his knee had become entangled between the spokes of oneof the wheels as he fell. On first view, the knee presented theappearance of a dislocation of the femur outwards, the defor-mity, of course, being very great. Manual examination, how-ever, soon proved that the movements of the joint were intact,and on the employment of slight extension and counter-exten-sion in a bent position of the limb, the form of the part wasreadily restored by pressing the lower portion of the thigh in-wards at the same time that the upper part of the leg with thef directed outwards There r"

but that the shaft of the femur had been fractured, or rathertorn from its yet cartilaginous epiphysis. Adjustment beingaccomplished, the limb was placed in a slightly flexed positionon a well-padded splint, with one on either side of the thigh,the whole being secured by a bandage. The night was passedin great restlessness, though an opiate had beeu administered.The next day severe pain was complained of in the knee, andwhich arose from mal-position of the fragments consequent onthe patient’s inquietude. In effecting re-ac2juatment, the softparts, against which the lower end of the femoral shaft hadbeen driven, were seen to be much ecchymosed, and in a fewdays-a slough having formed there and separated—the boneprotruded, showing at its lower surface that appearance whichcharacterizes the part for attachment with the articular extre-mity. Various means were adopted with the view of keepingthe parts properly set; but in consequence of the severe natureand painful state of the scalp wound, the boy, besides his gene-ral restless state, was continually throwing his body towardsthe opposite side of the injury, so that his head might reclinesideways on the pillow: hence the femur was proportionatelydirected outwards, protruding through and irritating the wound,by which it had so lately found egress. Suppuration soon tookplace, and threatened to become profuse; constitutional irrita-tion ran high; the appetite had failed; sleep could hardly beprocured; indeed it became evident that, unless some decisivemeasure were speedily instituted, the patient would die.Under these circumstances, Mr. Canton, in pursuance of the

conservative surgery of the present day, determined to excisethe knee-joint. The incisions formed together an H, the

opening already described being included in the outer one.After the joint ends of the femur and tibia, together with thepatella, had been removed, a very thin piece was sawn fromthe free end of the thigh-bone, so that more even adaptationwith the tibia might be ensured. The patient during theoperation was under the influence of chloroform. No attemptat primary union took place. The continual restlessness of thepatient defied all the means adopted to quiet his system andmaintain the limb at rest. About an inch of the femur pro-jected, and could in no manner be kept reduced; and it 1e-coming evident that this part tendecl greatly to the main-tenance of irritation, at the same time that it was quicklypassing into a state of necrosis, Mr. Canton removed it with asmall hand-saw. The edges of the wound could now be againbrought together, and were so maintained, whilst an openingwas preserved on the outer side, so as to allow freedom of exitfor the discharge, which shortly began to assume a more

healthy character. Since this period the little patient hasprogressed most favourably, and the wound has now nearlyhealed up.

CLINICAL RECORDS.

CONGENITAL VESICAL CALCULUS.

WE have often heard the question asked, is stone in thebladder ever found as a congenital affection ? This has par-ticularly occurred when a very young child, under three yearsof age, who has had irritability of the bladder and other symp-toms more or less indicative of stone, from, we may say, the

! hour of its birth. The records :f surgery, however, scarcelyrefer to the subject; and very few examples indeed, if any,of congenital calculus, have been placed upon record. Theurine of infants has occasionally been observed copiously ab-

232

normal with actual deposits of uric acid, partaking sometimesof the character of gravel, which would lead to the conclusionthat a stone may form before birth. Mr. Coulson remarks,in his work " On Diseases of the Bladder," "It is cer-

tain that uric acid gravel is very frequent in children undersome circumstances; and it is known that calculi have beenfound in the bladder even at the time of birth." He, how-ever, does not mention any specific instances in any of hiswritings. But that stone is found to exist in the bladder ofthe newly-born infant, cœteris paribus, we think few will beiuclined to deny at the present day, although there are so fewpublished instances.At Guy’s Hospital, on the lOth instant, Mr. Cooper Foster

cut two children for stone in the bladder; one of these was alittle boy, two years and a half old, from whose bladder heremoved a small, flat calculus, the size of a French bean; theother was a male child, four years and a half old, with distinctsymptoms of calculus, clearly traceable to the period of hisbirth. The stone removed from the latter was pretty large,being fully the size of a pigeon’s egg, and no doubt had takena long time to form. From what was stated by Mr. Foster,we are disposed to believe with him, that a small stone waspresent in this child’s bladder at birth, and this accounted forthe irritability of the bladder, and acid urine at that time,’which has continued uninterrupted to the present time.At the Royal Infirmary for Sick Children, during the lastyear, Mr. Foster performed lithotomy on seven young children;in one of these, a child five years old, he could distinctly tracethe symptoms of stone from birth, and he believes it quite pro-bable that the stone may have existed before birth, as in thechild four years and a half old just operated upon.As relating to this subject, we may here refer to an example

of infarction of the tubuli uriniferi of the kidney of an infantwith uric acid salts, which was exhibited before the MedicalSociety of London in October, 1856, (THE LANCET, vol. ii.,1856, p. 434,) by Dr. Willshire. The kidney was taken froma child who died in partu, after having breathed. If renal in-farction would thus commence before the child’s separationfrom the mother, even although it had breathed, there is noreason against its occurrence before birth, although it was notobserved in 113 dead-born children, as mentioned by Dr.Willshire.

EXCISION OF TWO KNEE-JOINTS.

As the operation of excision of the knee-joint has to someextent replaced amputation of the thigh, we have not thoughtit necessary to report all the cases in which this operationis now performed. At King’s College Hospital it is statedthat amputation has become a rare proceeding, excision ofthe joints being preferred to removal of the limbs. On the14th instant we saw two knees and one hip-joint excised byMr. Fergusson. The first of the knee cases was the right jointof a young man who had suffered from disease of this articula-tion for the last four or five years. The symptoms were notvery acute in the earlier stages; but within the last twelvemonths the pain had been extreme, and the suffering of thespatient were so severe that he was induced to seek relief. Itdid not appear to Mr. Fergusson at first to be an urgent case,but subsequently the pain in the joint increased, and consider-able effusion took place into the articulation, which indicatedsevere inflammation. Acute oedema, of the leg also occurred.A few days before the operation he had made a puncture intothe joint without any good effect. Excision was therefore re-sorted to, and a slice of the tibia and condyles of the femurremoved. The patella was at the same time taken away. Thedisease was found to be even greater than there was any ex-ternal indication of, but was limited to the surfaces of thefemur and tibia, slightly affecting the patella; in all probabi-lity it had at first commenced in the synovial membrane, andthence spread to the cartilages. In these cases Mr. Fergussonnow considers it best to take away the patella, as he does notbelieve that the retention of that bone adds strength to thejoint, and the cure in many cases has perhaps been more pro-tracted from its having been left, as was particularly illus-trated in a case lately under our observation, in which whenthat bone was subsequently removed the cure became veryrapid. The limb was carefully adjusted in a splint beforeremoval of the patient to the wards, the flaps of the woundhaving been first brought together by means of silver-wiresutures.The second case was that of a little boy whose knee-joint

was much enlarged, associated with disease of the synovial

membrane and articular cartilages, which had existed uninter-ruptedly since his birth; having undergone various methods oftreatment, with no good result. A modification of the usual

operation was adopted in this case, the diseased surfaces. of thejoint, together with the affected patella, being removed throughthe opening formed by a single line of incision right across thejoint, thus avoiding an H incision, as in the first case. Rathermore of the femur was taken away in this instance. Therewere the remains of an abscess in the upper part of the tibia,which had pointed into the calf of the leg. Silver-wire sutureswere also applied in this case to bring the lips of the wound

together, and the limb was placed upon a splint.On enquiry, we learn that both cases are going on favourably.

EXCISION OF THE HIP-JOINT.

A FEW weeks ago we recorded three recent instances of exci-sion of the hip-joint, and we will now merely refer to a fourth.A little boy was admitted into King’s College Hospital withextensive and old-standing disease of his left hip-joint, with theremains of numerous old sinuses and abscesses which had appa-rently healed, leaving several cicatrices which had becomeblended into one very large one. The disease had been exist-ing between three and four years, and he was seen by Mr. Fer-gusson about ten months ago, at which time he recommendedresection of the joint, but the parents would not consent. Thechild’s health, however, got very bad, his joint was quite stiff,the knee drawn up, and his condition very precarious, and hisparents therefore consented to the operation, which was per-formed under the influence of chloroform, on the 14th inst.,on the same occasion as the two knee-joints already described.The parts around the joint were found to be very rigid ; thehead of the bone was in the natural position, but the greaterpart of it was absorbed, the remains resting upon the cotyloidcavity, which had become filled with new material, and had noevidence of disease affecting it. The lips of the wound, whichconsisted of a single longitudinal incision, were brought togetherwith silver-wire sutures, and the leg and thigh placed in aninterrupted splint. The little patient has been doing wellsince the operation, and will probably recover with a usefullimb. It is possible, in such a case as this, that the patientmight have completely recovered without resection, but itwould have been with a permanently stiff joint, and after along course of illness.

There is a little girl at present in the Royal Free Hospital,under Mr. Cooke’s care, with disease of the left hip-joint andthe formation of an abscess over it, which has not yet burst,which, if submitted to excision in time, promises to be asuccessful case.

EXCISION OF THE ELBOW.

ONE of the most typical cases of disease of the elbow for thejudicious employment of resection presented itself to noticelately at Guy’s Hospital. The left elbow of a lad betweensixteen and seventeen years of age had become swollen by theinfiltration of the tissues with that gelatinous substance socommonly met with in certain diseased joints, causing it to re-semble in shape a small leg of mutton. This appearance is,however, more indicative of strumous disease. The diseasehere had commenced about eighteen months ago, and had involved the cartilages and synovial membrane, extending in twoor three places to the osseous structures, especially in one partof the shaft of the ulna, which was found to contain, during theperformance of resection by Mr. Birkett, on the 17th ofAusust, a small cavity filled with strumous deposit. Therewere three openings in the vicinity of the joint-one above,one to the inner side, and one to the outer side, the last beingupwards of an inch in diameter. Excision was performed bymeans of a single longitudinal incision, which is now foundvery much to facilitate the process of healing. The quantityof plastic matter around the joint was very great, extendingeven within the articulation. Mr. Birkett removed the endsof all the affected bones, taking away a second piece of theulna., and the flaps were well brought together by means ofstrips of wet lint. Not a vessel required ligature, and we learnthat up to the present moment the lad is doing well.

Of all the joints, the elbow is perhaps the most frequentlysubmitted to resection, and, as a rule, is followed by success,which is very gratifying to the surgeon. Good motion is usually

obtained if a sufficiency of the joint is taken away.