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Cation of pain has, in the great majority of instances, ensuedin rather an extensive use of this powerful agent.As a rule, however, the tooth should not be stopped on th<

same day as the electric cautery has been employed, unless irthe exceptional instances just mentioned-the removal of thEcarious portion not being followed by sensibility. ExperiencEand practice teach us to know the proper cases which can b(plugged immediately.By waiting a day or two, I have found by experience also,

that any sensibility remaining after the destruction of thEdental pulp, and removal of the carious parts of the affectedtooth, is sure to disappear, assisted by the solution of morphineand mastich, or mastich and camphor, which occupies thE

cavity. By this time the cavity will bear the pressure of aninstrument within it, and an examination will show that thedestroyed pulp has receded considerably inwards; this is apparent by noticing the black discoloration from the previous carbonization of the affected part, and as it is deeply situated, itis either out of the way of being pressed upon by the stoppingof the tooth, or becomes a matter of the smallest possible im-portance, so far as my experience permits me to judge in thisrespect. I must, however, warn others not to mistake theblack speck here referred to for actual caries.Under the various circumstances which have been men-

tioned, the results of the operation are completely successful,and the teeth are serviceable for years. If, however, a toothshould remain tender after the use of the cautery, it is alwaysbetter to wait for its complete disappearance before proceedingto stopping. I cannot call to mind any single instance in whichthe pain was at all persistent after its use, but it will be sureto become so, if the tooth is one not fairly suitable for preserva-tion, from being either loose or diseased at the termination ofa fang, such as a small fungous growth, or some similar cause.In such cases, as I will shortly show, the destruction of thetooth-pulp, accomplished no matter by what method, will

prove unavailing and unsatisfactory, ultimate extraction insuch instances proving the only resource. Should there beassociated inflammation of the gums with a carious tooth, inwhich/the pulp has been destroyed in the manner which hasbeen recommended, then the usual means for combating itmust be resorted to, such as a leech or two to the gum, andrepeated fomentations with warm water alone, as I am in thehabit of recommending, or with warm milk-and-water, or apoultice. For the pain in the tooth itself, morphine and mastichwill be found quite sufficient.Some patients express the receipt of immediate relief after

the use of the cautery, others, again, not for an hour or two, buteventually they are quite relieved; the pain, however, is, Irepeat, extremely slight.

’

In the large number of instances in which I have used theelectric cautery to destroy the sensitive’tooth:pulp, I have notknown an accident, in the true sense of the word, to happen,unless I should except the case in which the dental pulp wassuddenly drawn out attached to the platinum wire, which Ihave preserved for illustration, and depending upon, as hasbeen said, the wire being at a red instead of a white heat.Such a circumstance might occur again in the hands of others.To avoid injury or accidents to the teeth or gums, it is nieces-sary to keep the hand quiet, firm, and steady; the heatedwires, if suddenly dislodged, would assuredly burn the cheekor gums, the tongue or palate, especially if steadiness was notparticularly observed on the part of the patient. It was,I may say, only the other day, that au accident of this kindhappened to a lady, in whose tooth I was applying the cautery;she suddenly turned her head, from some cause, when theheated wire touched the internal surface of the* cheek. It maybe observed, however, that so rapidly can the disconnexion ofthe wires be accomplished by removal of the finger from thehandle of the instrument which is held in the hand, that anaccident can really very seldom occur from the heated wire.Having thus considered the history of the use of the electric

cautery in general surgery, its application to dentistry, thenature of the apparatus employed, and the general features ofthe operation, together with its effects and results, I shall inthe next place make a few observations upon the cases whichare suitable, and upon those which are unfitted for its use; andwill then draw a comparison between the use of the cauteryand other methods of destroying the pulp.

(To be concluded.)

APPOINTMENT--The Lord-Lieutenant of Ireland hasappointed J. S. Hughes, Esq., F.R. C.S.I., to the office of sur-geon to his Excellency’s household, vacant by the promotion ofDr. Hatchell to the Inspector-Generalship of Lunatic Asylums.

A Mirror

OF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

KING’S COLLEGE HOSPITAL.

EXCISION OF THE KNEE-JOINT IN A MAN AGED THIRTY-FOUR,WHO HAD HAD A STIFF KNEE SINCE THE AGE OF SIXTEEN,FOLLOWED LATELY BY DESTRUCTION OF THE CARTILAGESAND DISEASE OF THE BONES; PATELLA PARTLY RETAINED;THE PATIENT WALKING SIX WEEKS AFTER THE OPERATION.

(Under the care of Mr. FERGUSSON.)

Nulla est alia pro certo nosceudi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter se com-parare.-MORGAGNI. De Sed. et Caus. Morb. lib. 14. Prooemium.

AT the present moment the student has the opportunity oseeing thirty cases or more in the London hospitals, in whichexcision of the knee-, the hip-, or the elbow-joint, has been prac-tised. Of these, King’s College Hospital alone contains fiveexcisions of the knee, two of the hip, and two of the elbow,which have been performed since the 1st of May last. Atthe same time it may be truly said that, with scarcely a singleexception, all are doing well in the strictest sense of the word.We contemplated giving these resections in the form of a series,such as were presented to our readers about this period of lastyear in our "lTirror," (see THE LANCET, vol. ii. 1856, pp. 251,279, 304, 380, 406, and 430;) but their number entirely pre-cludes our doing so. Our object has, however, been attained,in drawing the attention of the profession to the subjectin the pages of this journal, and the result has been that,with the knee especially, it is a rare circumstance nowto see amputation performed when there is the slightestchance of saving the limb by excision. We shall continue,however, to give short records of the cases as they occur,several of which appear to-day;’ also placing upon recordfrom time to time instances which will, serve as good illus-trations of the operation and its effects generally. On thisoccasion we present one of excision of the knee in a man agedthirty-four, which was followed by such a rapid cure that hewas enabled to go about the ward on crutches in the shortspace of six weeks. He walked into the theatre of the hospitalon the 13th June, and we again saw him in the same place onthe 18th instant. This case is remarkable for the great im-provement which took place in the patient’s health almostimmediately after the operation, and also for the short timeduring which he was confined to bed, scarcely six weeks.Another peculiarity was, that there was no change of splint orpads throughout the treatment-a point of some importance.The suppuration was of trifling amount, the result no doubt ofthe careful adaptation of the cut surfaces of the bones. We are indebted for the notes of the case to Mr. Christopher

Heath, house-surgeon to the hospital.Edward O----, aged thirty-four, admitted into London ward

February 7th, 1857, with disease of the knee-joint. He is anative of London, a French-polisher by trade, and has livedfreely. When sixteen years of age he fell and struck the knee,which swelled considerably, but subsided under the use ofleeches and blisters. The joint, however, remained weak, andhe walked with a stiff knee. Six- months ago it became verypainful, so that he could not put his foot to the ground. The

joint:has since been leeched and blistered again, but withoutany good results. On admission, the knee was slightly en-larged, there being some effusion into. the joint. There was’

great pain in the joint when pressure was made on the patella,’or the tibia pressed against the end of the femur. He wasunable to sleep from the violent startings of the limb at night,.arid is in consequence much reduced in health, and of a pale,weakly appearance.

Feb. 10th.&mdash;Blisters were applied to the knee without relief.15th.-The limb was placed on a splint, and suspended in

Salter’s swing, which, together with fomentations, relieved thestartings.

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March 4th.-Knee less painful, and startings less frequent.31st.-Mr. Fergusson made a puncture with a grooved needle

into the joint, and gave exit to some purulent fluid.April 23rd.--Mr. Fergusson made a free incision into the

anterior part of the joint, and a probe passed into the wounddetected dead bone in the head of the tibia.

, May 2nd. -The man being much reduced by the constantpain, and the joint being very seriously implicated, Mr. Fer-gusson determined to excise the joint this day, amylene havingbeen administered. The usual H -incision was made, and thestructures in front of the joint having been divided, the patellawas found to be displaced, being quite on the outer side of thejoint, fitting in a grooved depression on the corresponding por-tion of the tibia. A slice was removed from the inner condyle,the outer having apparently been absorbed to a great degree.A slice was then removed from the tibia, as also some of thethickened semi-cartilaginous tissue around the joint. Thepatient was removed to bed, and in about two hours, all oozinghaving ceased, chloroform was administered, and the limb putup in the apparatus in common use for resections of the knee-joint in the hospital,* great care being taken accurately toadjust the cut surfaces of the bones by means of the finger in-troduced through the sides of the incision. Half an ounce ofbrandy was given every two hours, and half a drachm of tinc-ture of opium at night.3rd.-Patient passed a tolerably good night; pulse 120;

tongue furred; knee starts occasionally.5th.-Progressing favourably ; pulse 120 ; bowels open ;

wound healthy; granulation commencing.8th.-Pulse 100; wound discharges freely, and pale granula-

tions springing up; stitches removed. Ordered red lotion towound.14th.-Granulations healthy and abundant; appetite and

general health good; limb in capital position.17th. -Very little discharge from wound; granulations filling

up rapidly; the inner portion of the transverse incision nearlycicatrized.. 28th.&mdash;The incisions are in great part cicatrized; thereseems to be considerable firmness in the knee; health verygood.June 2nd.-Cicatrization still advancing; limb in excellent

position; no pain in the joint. 10th.&mdash;The splints were removed to-day for the first time

- Since the operation; union between the bones very firm; thelimb is perfectly straight, and there is shortening to two inches.and a half. Gutta-percha splint applied. Incisions healingrapidly. 13th.-To-day (being exactly six weeks after the operation)

the patient walked into the theatre upon crutches, and stoodon his feet without any support. The limb is entirely freefrom pain.

July 8th.-Wound entirely healed, with the exception of asmall sinus by the patella; anchylosis become firm; leg per-fectly straight; is able to rest upon the limb when gutta-perchasplint is applied, without any pain. Will be sent to a conva-lescent institution next week.

CANCER HOSPITAL.

CANCER OF THE BREAST, EXTENDING TO THE RIBS AND NEIGH-BOURING TISSUES; CANCEROUS DEPOSITS IN THE LUNGS,PLEURA, PERICARDIUM, LIVER, AND STOMACH, WITH

THORACIC EFFUSION AND CARDIAC DISPLACEMENT; RENALCALCULI.

(Under the care of Mr. WEEDEN COOKE.)IN a recent "Mirror," (THE LANCET, vol. i. 1857, p. 553,)

we placed upon record an example of the co-existence of thevarious forms of cancer in one individual, which we statedamongst other things proved the common origin of the varietiesof cancer as originally pointed out by that distinguished patho-logist the late Sir Robert Carswell. On the present occasion,we present an instance of cancer of the breast which provedfatal, the disease being disseminated throughout various organsin a wonderful manner, and too truly proving the constitutionalcharacter of this dire disease, and the utter impossibility of- eradicating it by mere local measures. There was, however,in this case, a tendency to aggravation by any slight cause,such as a cold, depending upon the vices to which the patientwas subject, which tended in a great measure to general dis-semination of the disease. As the report shows, all the im-portant organs of the body were infiltrated, and we have nodoubt the microscope would have shown the spleen and pancreas I

* An engraving of this appears at page 85 of the previous volume.

equally the seat of the cancerous germ, as well as the otherviscera. The tendency of old age, as every physiologist isaware, is to produce ossific deposit in the costal cartilages, afact which every student soon finds out who performs autopsieson the aged. Now, this condition was reversed, in the fol-lowing case, in the ribs, for they were converted into cartilagenear the seat of the diseased breast-that is, there was amolecular destruction or absorption of the osseous tissue, whichgives the bone the appearance as if macerated in a mineralacid; this is called carnification of bone by some pathologists.The subjoined abstract we have taken from the hospital case-book. A case resembling this in many respects was broughtbefore the Pathological Society by Dr. Habershon in February,1855, and is recorded in the sixth volume of the Society’s" Transactions," p. 321; the bones were more extensivelydiseaseo.Mary Y-, aged sixty-two, of Dartford, admitted March

3rd, 1856. Has had cancer of the left breast for four years.The whole breast is now ulcerated deeply, and bleeds fre-quently ; she is very ansemic and emaciated. She has alwaysrefused operation, although proposed to her by many surgeons.Some months ago the breast spontaneously sloughed, and sub-sequently showed a disposition to heal; but the occurrence ofa cold or any trifling ailment aggravated the disease, and sheis now in a deplorable condition. Unfortunately she has notbeen temperate either in spirits or opium, and the great dys-crasia is no doubt to be attributed to that cause more thanto the disease. The perchloride of iron always checked thehaemorrhage, and a lotion of chlorate of potash and hydrochlo-ric acid, with the carrot poultice, kept the ulcer clean and freefrom unpleasant odour. She sank on the 17th of March, four-teen days after admission, and exhibited the following post-mortem appearances ten hours after death: Body not greatlyemaciated, and some eedema of the legs. In the position of theleft mamma there was the large flat ulceration with thickenededges, the cancerous induration extending down to and be-tween the ribs, so that it was impossible to separate, as usual,the integuments from the rib; and in order to raise the ster-num it was necessary to cut through the sessile cancer and ribsat the same time. This act, by the ease with which the knifecut through the ribs, showed that the cancerous degenerationhad extended itself to these bones; they were gradually assum-ing the same cartilaginous appearance as the outer edges of thecancerous ulcer external to them. The lung of this side (theleft) was greatly atrophied, and had several patches of scirrhusin its substance. Dotted about the pleura costalis were manyscirrhous tubercles the size of a pea; and filling the cavity ofthe pleura there was serum to the extent of two or three pints:thus the heart was pushed over to the right side. Upon thepericardium there was a large crop of scirrhous tubercles alreadymentioned. The right lung was tolerably healthy, having onlysome slight emphysema, and two very small patches of scirrhus.The heart was dilated and hypertrophied; both cavities werefilled with dark clots. The mitral valve contained severalportions of osseous deposit, and the cordae tendinas were short-ened. The aortic valves were so thickened, that they couldhave had very little power during life to resist the regurgitantaction. The liver was greatly enlarged, and bad two consider-able cancerous deposits, one on the upper surface of the leftlobe, and the other on the under surface, to the left of the gall-bladder ; they were white scirrhus, and resembled puckeredcicatrices. The stomach was diminished in size, and in thepyloric orifice:there was scirrhous deposit, reducing the apertureto the size of a goose-quill. The spleen and pancreas were un-usually hard, but not altered in structure. The right kidneywas healthy, but the pelvis of the left contained twelve smallcalculi, and one the size of a nutmeg. The intestines werehealthy. The bladder and uterus normal, but the ovaries wereconverted into cysts, each the size of a large orange.

CLINICAL RECORDS.

CASE OF EXCISION OF THE KNEE IN A VERY YOUNG PATIENT.

THIS was upon a little boy aged four years and eight months,in the Westminster Hospital, whose knee had been injured inScotland while travelling with his mother, which injury wasfollowed by inflammation and abscesses in various places aroundthe joint, with subsequent fistulous openings. Mr. Holtlooked upon excision of the joint here as the only course likelyto prove of service, and performed the operation on the 30th ofJune, saving the patella in the anterior flap. A slice was

, taken off the lower end of the femur, which, when detached.