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A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

UNIVERSITY COLLEGE HOSPITAL.SUPPURATION OF THE KNEE-JOINT, WITH SUBSEQUENT CARIES

OF THE HEAD OF THE TIBIA; PRESERVATION OF THE LIMB.

(Under the care of Mr. ERICHSEN.)

N’ulla est alia pro certo noacendi vin, nisi quam plurimas et morbornm etdissectionum histories, tam aliorum proprias, éollectas habere et inter se com-paMi’e.—MonQAajfi. De Sed. et Caus. Morb. lib. H. Yroamium.

A BLOW from an iron hoop, in a strumous boy, was sufficientnot only to produce active inflammation of the knee, but actuallyto give rise to suppuration in the course of ten days. Theformation of an abscess in such large joints as the knee andhip necessarily renders the prognosis serious, and we thoughtat one time the boy’s leg would have been taken off. The freeevacuation of the matter, however, was followed by goodresults, bnt with the drawback of necrosis of the head of thetibia, which was removed by the gouge to the extent of ahandful of fragments. This condition of the tibia seemed torelieve the disease of the joint, and was followed by anchylosis.The boy is still an out-patient, the wound is not completelyhealed, and seems to have become indolent; the probe doesnot detect any further dead bone, and a back splint is still

applied. Now, although anchylosis may become complete, thestate of the tibia is by no means promising, in such a diathesisas is present in this patient. Excision of the joint, unfor-tunately, can never be entertained, if active measures shouldhereafter be required, as the state of the tibia will prove anobstacle to the operation. We avail ourselves of the followingabstract from the notes of Mr. W. E. Allen, the dresser of thepatient

William C-, aged fourteen, of strumous appearance, wasadmitted on the 8th of April. Ten days previous to his ad-mission he trod on an iron hoop, which rebounded and hit theinner side of his left knee. The joint became swollen andpainful. Fomentations and cupping were used.On admission (April 8th) the boy complained of throbbing

pain in the joint, which was considerably swollen and red;iluctuation was perceptible below and on the inner side of thepatella. There was considerable constitutional disturbance.

April 13th. -Mr. Teevan, the house-surgeon, made an in-cision along the inner border of the patella, whereby a largequantity of pus was evacuated.17th.-On pressing the inner side of the joint, Mr. Erichsen

found that pus welled up. The ligaments were very lax, andthe bones, when rubbed against.one another, imparted a sensa-tion like that produced by rubbing the knuckles together;they did not give the usual sensation of bones deprived ofcartilage.21st.-Mr. Erichsen enlarged the wound which had been

made to evacuate the pus. A grating of articular surfacesvery distinct. -27th.-Hectic appearance of patient very marked. He feels

better, however, and his appetite is good.May 23rd.-The wound has completely healed, with the

exception of one or two fistulous openings, through whichthere is a constant discharge of pus. On passing a probethrough one of these iistuice, Mr. Erichsen found dead bone inthe head of the tibia.

27th. —The patient was placed under the influence of chloro-form, and the requisite incisions being made, Mr. Erichsen, bymeans of the gouge, removed a handful of carious bone fromthe head of the tibia, leaving but a very thin shell of bone nextthe joint.June 2nd.-The cavity in the head of the tibia is filling up

rapidly.30th.-The cavity is almost filled up; the wound has been

slightly affected by sloughing phagedsna, which was arrestedby the application of nitric acid, and healthy action restored.A splint was placed along the back of the limb, and a starchbandage to fix the joint.From this time the patient rapidlyimprovecl, and on the 9th

of August he was discharged as an out-patient, the woundbeing a,]1 but t-.i)tiinlofolx7 hfntfrh

ST. MARY’S HOSPITAL.NECROSIS OF THE TIBIA IN A BOY, EXTENDING TO THE HEAD AND

EPIPHYSIS; AMPUTATION AT THE KNEE-JOINT; RECOVERY.

(Under the care of Mr. LANE.)WE noticed in an earlier part of this year (p. 215, voL i.)

the performance of amputation at the knee-joint, by Mr. Fer-gusson, at King’s College Hospital, on a young lad with necrosiof the tibia, which ended in the most complete success, withthe possession of a firm, strong, and excellent stump. We

t again had the opportunity of seeing this operation performed,- at St. Mary’s Hospital, on the 16th September, by Mr. Lane,

upon a boy about eight years of age, who had disease of thehead of the tibia, extending into the knee-joint. It most pro.bably commenced as true necrosis, with the formation of an

; abscess in the head of the bone, matter from which now exudedfrom a fistulous opening below the tuberosity of the tibia, notunlike the case above recorded, in University College Hospital.The integuments around were quite sound; Mr. Lane, there.

; fore, determined, when the boy was on the operating table, to,

amputate at the joint, which was effected by first making agood covering to the condyles of the femur from a long anterior

liap, then a short posterior flap to draw the former backwards;; this was the more important, because the patella was retained,, it being found, together with the condyles of the femur, per.

fectly healthy, the articulating cartilages of each not being inthe slightest degree impaired. The disease, as was anticipated,was confined solely to the tibia, the head of which, with theepiphysis, being extensively destroyed, the diseased action ex-tending to the shaft of the bone lower down. The ulcerationof the cartilages was very extensive, with erosion of the osseousstructures, but not as yet extending to any other part of thejoint. The operation, therefore, was j ndiuious and well-timed,and when the parts were brought together and sutures appliedthere was promise of an excellent stump.We have seen Mr. Fergusson, when performing this opera-

tion, not only remove the patella, but also a slice from thearticulating surface of the condyles,-a feature most essentialin any articulation, as especially influencing the ultimate resultof the operation. It will be very interesting, however, towatch the termination of Mr. Lane’s case, because if a usefulstump is obtained, without any inflammatory complica-tion, it will be encouraging under similar circumstances toleave two articulating surfaces in contact. Plenty of integu-ment is required to cover such broad surfaces as the condyles,and we were under the impression that the anterior flap wouldhardly prove sufficient, more especially as great stress is laid,by both Mr. Syme and Mr. Fergusson, upon making a goodlong flap. Mr. Syme goes so far as to say it should be to thefull extent of the fleshy part of the gastrocnemii muscles,-apoint in which Mr. Fergusson fully concurs; but as the prin-cipal flap was the anterior, Mr. Lane could depend only uponintegument for covering, which would be quite proper to coverthe patella, itself no mean support in the stump. Althoughwe have no doubt this boy will do well, we will acquaint ourreaders with his condition at a future period. This form ofamputation is so uncommon in our London hospitals, that wethink it right thus early to draw attention to it, through thiscase.

CLINICAL RECORDS.

INCURABLE DISEASE OF THE KNEE, AND EPILEPSY.

THE subject of this case was an elderly man, with an oldbroken-down constitution from hard living in early life. Hesuffered years ago from disease of the liver, had haematemesis ayear ago, and diarrhoea lately in hospital hardly controlled byremedies. He had been an inmate of St. Bartholomew’s Hos-pital some months with extensive disease of the knee-joint,with suppuration in various directions, and an utter impos-sibility, Mr. Paget remarked, of saving the articulation. Mr.Paget amputated the thigh on the 5th September by thecircular operation, and so eiiectually was the circulation com-manded by Mr. Wormald, that not more than a couple ofteaspoonfuls of blood were lost. Mr. Paget observed that thelimb would have been removed some months ago, but the stateof the man’s health was so low that it could not be done. Itis now done, he said, to give him a chance, as under other cir.cumstances he was not likely to live a couple of months, thesystem was so enfeebled and low from the disorganization ofthe joint, conjointly with constitutional defects of long stand-ing. When we saw this patient, a fortnight after, we foundthat he was not doing well. It appears he formerly suffered

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from epilepsy, a fact not known to Mr. Paget, and since theoperation he has had several convulsive attacks, which havegreatly enfeebled him, His condition is such at this momentthat we look upon his recovery as hopeless.

CANCER OF THE LIP IN A WOMAN.

ABOUT a week ago a case of large cancerous ulcer on thelower lip of a woman was operated on by Mr. Hutchinson atthe Metropolitan Free Hospital. The patient was eighty-oneyears old, but tolerably vigorous. She had for years beenaccustomed to smoke, and had held her pipe on the side whichhad now become affected. There was no hereditary history ofmalignant diseases. It had existed for about six months, andhad involved half the lip. It had been very painful. The

-shaped incision was practised, and the wound healed well.Mr. Hutchinson adverted to the great rarity of cancer of thelip in women, and stated his belief that it was due almostsolely to the comparatively small extent to which smokingprevailed amongst them. Still it was by no means infrequentto meet with cancer of the lip in men who had not smoked.In this instance, as in one or two others which he had exa-mined, the structure under the microscope showed a much lessabundance both of epithelial and of the compound cells thanare usually met with in similar ulcers from the lips of men.Indeed in some parts the ulcer seemed rather of the rodentcharacter than of the true epithelial; yet before excision nothingcould have been better characterised than the condition of thesore, and, indeed, with the microscope, some, though but few,of the elements of undoubted cancer were seen. Mr. Paget,we believe, has made a similar observation.

ANOTHER RESECTION OF THE ELBOW.

IN the present instance the patient was a boy whose leftelbow has been subject to repeated attacks of inflammation forthe last eighteen months, with suppuration and the formationof sinuses leading to its interior, in which can be detected bare

’ bone. He came under the care of Mr. Ure, at St. Mary’s, whodetermined, in consultation, to remove the articulation byresection. This was done on the 3rd of September, by a longincision, and the ends of the bones excised with forceps, all ofwhich were denuded of cartilage from erosion, the entire jointbeing surrounded with a great quantity of that thick, gelatinousmaterial, which of itself alone will destroy any joint. Thiswas carefully removed, and the edges of the long wound werebrought together by several sutures. Mr. Ure thought theoperation was somewhat longer through the form of incisionemployed to remove the joint; but we did not think so, andthe advantages of this one line of wound are so great in relationto the ultimate results of the operation, that they should notbe lost sight of. If the incision is long enough, and the jointbent, it is completely extruded through the wound. On the16th we saw the wound all but healed up, and so far every-thing had progressed well.

DEFORMITY FROM CANCRUM ORIS.

IN the chapter devoted to the consideration of Cancrum Oris,in Dr. Churchill’s work on Diseases of Children, wherein thisaffection is most fully treated of, he observes, "As may besupposed, the great majority of cases terminate fatally, butsome few cases do recover, mainly those in whom the diseaseis primary, the constitution good, and which remain free fromcomplications." p. 406. The truth of this we find confirmedby experience, but more especially in meeting with cases ofdeformity later in life, which have been the result of sloughingfrom this terrible affection in childhood, with the barest escapefrom a fatal result. In most of the cases, also, which comeunder our notice in the hospitals, the disease has supervenedupon an attack of either scarlet fever or typhus fever, mostgenerally the former. We remember well two cases of thekind, in girls, which were treated by plastic operation, by Mr.Fergusson, at King’s College Hospital, two years ago. Wesaw another case, at Guy’s, on the 15th September, of a youngwoman aged nineteen, whose right cheek had sloughed awaynear the angle of the mouth when three years old, completelydestroying the latter, and exposing the teeth and gums, thedeformity being increased by the presence of a supernumerarycanine tooth projecting obliquely outwards. This was theresult of cancrum oris after an attack of fever. The latelamented Dr. Marshall Hall thought at one time that thisaffection was more common in female children than in males;most certainly we see more females suffering from the efects of

it than males, although statistics do not bear out that one sexis more affected by it than the other. Mr. Cock treated thisdeformity by paring the edges of the cicatrized tissues, de-taching the old adhesions, and bringing the parts together bystitches; but this was not accomplished till a long incision wasmade over the margin of the lower jaw towards the chin,which permitted of approximation. The projecting tooth waspulled out. The patient was fully under chloroform at thefirst part of the operation, and bore it tolerably well.

PROLAPSUS OF THE UTERUS AND RUPTURE OF THE PERINÆUM.

THE two following cases were of long standing, and thepatients miserable sufferers. Both were perfectly relieved byoperation, and. left the hospital cured. They are quite distinctfrom the cases recently published by Mr. Brown in this journal.

A. H--, aged thirty-three, was delivered of her first childabout three years ago. Nothing particular occurred in herlabour, but she got up very early and pursued her usual avoca.tions. She soon began to suffer from pain in the back andbearing down, which gradually increased, and the uterus

began to protrude. She applied at another hospital, and,three months ago, was there operated upon without success.

The uterus protruded through the external parts to the size ofa full-period foetal head. Mr. Baker Brown performed hisusual operation at St. Mary’s Hospital on the 10th June, 1857.The deep sutures were removed on the third day, and the partsare very firmly united.M. H-----, aged twenty-seven, four years ago was delivered

of her first child. The labour was very natural, and onlylasted one night. The midwife who attencied her, however, wasvery impatient, and drew away the chil’.l without waiting forthe pains, and thus tore through the perineum. She has sincebeen delivered of another child. She has had no control overher bowels since the first labour. The periuceum was entirelytorn through the septum. Mr. Brown performed his usualoperation on the 1st July. There was rather more haemorrhagethan usual, and one small artery required torsion. The sphinc-

ters were well divided. The deep sutures were removed onthe third day, and the parts were well united.

THREE SERIOUSLY IMPAIRED ANKLES.

WHEN the entire ankle is involved in disease, it is useless toattempt any other measure than removal of the leg; for ifSyme’s operation be performed, with the surrounding struc-tures much implicated, with even a moderately diseased stateof the lower end of the tibia, no actual good can result from it.A case of this kind we observed at Uny’s Hospital on the

15th inst., in a man aged fifty-five, whose left ankle had beenthe subject of disease for the last eleven months, during twoof which he had been an inmate of the hospital. The wholeankle was swollen and filled with pus, and the surroundingtissues appeared much diseased. What with the man’s ageand the existing state of things, amputation of the leg wasdeemed the most suitable measure, and this was performed, bymeans of the lateral flaps, by Mr. Bryant.A similar operation was done by Mr. Paget at St. Bartho-

lomew’s, on the 19th inst., for disease of the os calcis of sevenyears’ duration, in a man whose age was fifty-five, but wholooked very much older. Four different operations had beenperformed upon this patient’s foot at St. George’s Hospital atvarious times, and twice in St. Bartholomew’s by Mr. Pagettwo years ago; and although the diseased portions of bonewere removed each time, the carious condition reappeared.Mr. Paget considered the bone too much diseased to removeentire; the man’s age was, moreover, he thought, unsuited tothat proceeding, and at any rate hs could not afford to waitthe process of cure afterwards, so that amputation appeared tobe the most reasonable measure; this was done by the antero-posterior flap.A third case, at the last-named hospital, allied to the fore-

going, we saw on the 5th inst., of apparently very severe dis-ease of the ankle-joint, under Mr. Coote’s care. The limblooked as if most serious miscief were present, the result of aninjury but three months before. The patient was a man ofnervous aspect, twenty-six years of age. Disease of the bone

i was anticipated, and on cutting down over the internal mal-leolus an abscess was found to exist within it, forming a dis-

! tinct cavity ; this was opened, and the most marked relief was: obtained within two weeks. It is, however, a matter of doubt! whether, in the event of a cure being established, the patient; will ever possess a strong, useful foot, from the presence of sof much sympathetic irritation in the adjacent parts.