300

But however this may be, the time has arrived at which itappears necessary, for the good of the public service, that thedepartment for treatment of disease and the department forthe prevention of disease should be separated. This divisionof labour is called for by the urgent wants of the army. Thesanitary and medical wants of the forces have need of thehighest science.

20. Referring to the medical corps generally, it has beensuggested by some persons that it should be regarded and.treated altogether as a civil body; and, as matter of mere

plausible theory, it would seem at first sight not unreasonablethat the military surgeon should be held to be a man of purescience only, devoted to the service of the hospitals.

But such views, to be equitably treated in practice, must becarried out to their legitimate ends; and the surgeon, if

stripped of his uniform, and classed with the clergyman andthe commissary, must in fairness be placed on an equal footingof security and ease with those functionaries, quoad the march,the siege, and the battle.A practical trial, however, of but one day during an active

campaign, would settle the value of such vain imaginings, andreplace the surgeon in his natural military position, along withthe engineer, as belonging to one of the " scientific corps"-aposition which must be held to be as justly and necessarilymilitary as any in the army-so long as the term may haveany really separate or distinctive significance.

21. It has long been matter of regret in the profession thatthe qualifications, moral and intellectual, of the medical officersof the public services, and the important nature of the dutiesrequired of them, have not been duly estimated in this country- circumstances which I believe to have proved highly detri-mental to the best interests of both army and navy.A high military authority, Sir De Lacy Evans, has said-

For the sake of the efficiency of the army before the enemy,it is important that the utmost attention should be paid to thestate of the medical department." By "attention" is heremeant the countenance and support of the government of thecountry—privileges and attributes depending greatly, and atall times, on the qualities to be found at the head ; and I ven-ture to say that no measures of improvement can prove gene-rally or permanently useful which do not begin with the headof medical administration and government.

Grosvenor-street, Jan. 1st, 1857. J. R. MARTIN.J. R. MARTIN.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY

TUESDAY, MARCH 9TH, 1858.

SIR CHARLES LOCOCK, BART., PRESIDENT, IN THE CHAIR.

ON EXCISION OF THE KNEE.

BY GEORGE MURRAY HUMPHRY, M.B. CANTAB.,SURGEON TO ADDENBROOKE’S HOSPITAL, CAMBEID&E.

THE paper contained an abstract of thirteen cases operatedupon by the author. Of these, one (a little child in whom theoperation was performed on account of acute suppuration ojthe joint) died; in four amputation was required, the patientsall recovering; and the remaining eight did well, retaining, 01with the prospect of retaining, a useful limb in each case. Innone were any severe constitutional symptoms excited by theoperation, from which it might be inferred that the operationis not in itself one of much danger. Nevertheless, the processesof reparation are more difficult than after amputation ; there islikely to be protracted discharge and recurrence of abscesses,&c., and therefore, when the patient is of strumous tempera-ment, or in a very reduced state, amputation is to be preferredto resection. The results of excision are likely to be favourablein proportion as the disease for which it is performed is slightand not acute. Amongst the most suitable cases are those inwhich the severe stages of disease have passed by, and left thejoint crippled, and the limb, consequently, useless. The casesalso in which simple inflammatory disease, commencing in thesynovial membrane, involves the cartilage and bones, destroy.ing the former to such an extent as to leave little hope of auseful joint, are well suited to excision. But where the diseaseremains long confined to the synovial membrane, inducinggreat thickening and various other changes in it, the prospect,of excision are less good, because the subjects of this form oidisease are generally of stramons temperament, and some por

tions of the morbid structure are liable to be left, and so be-comes sources of irritation and suppuration. Nevertheless, theauthor would not altogether decline to perform the operationin this latter class of cases, inasmuch as the remaining frag.ments of the diseased membrane may fall into a quiescentstate and disappear, and the cases do well, provided thebones become firmly united to one another; and if thehealth begins to fail, the limb can still be removed. The

operation is also well suited to some other cases of rareroccurrence, such as certain cases of chronic rheumatic arthritis,knock-knee in the adult, unreduced dislocation, compoundfracture of the patella, &c. In performing the operation, Mr.Humphry makes a crucial external incision, takes away thepatella, and dissects the soft parts away from the bones nomore than is absolutely necessary for the removal of their arti.cular ends, is careful to tie the bleeding vessels, and to securegood apposition of the cut surfaces of the bones and of the skin.The straight position and quiescence of the limb are secured bysplints and bandages, which should be changed no oftener thanis necessary for cleanliness. The after-treatment was verysimple in all the cases related ; opiates were very rarely given,and stimulants were generally avoided.Mr. Hor.nzES CooTE did not agree in the conclusion at which

the author had arrived. Of thirteen cases of resection detailed,six had been followed by amputation or death. Mr. Humphryhad said that resection should be resorted to only in slightcases, and amongst these was knock-knee in the adult, andcontraction in the joints. Now, at St. Bartholomew’s Hospitalin London, having 642 beds, and of which 389 were for surgicalcases, there had been admitted a vast number of patientssuffering from diseases of the joints in every possible form.During the last twelve months there had been but ten cases ofamputation, and not a single case of resection. Now he wouldventure to say, in the presence of his senior colleagues, thatnot one case of diseased knee presented itself, in which anyman could conscientiously have ventured to perform the opera-tion of resection. Resection should be regarded in two distinctaspects: in its relation to the young and to the old. In youngpersons the result of the proceeding was often surprising; whilstin older patients the various internal diseases to which theywere subjected, rendered the operation far more formidable.Three only of the ten amputations of which he had spoken hadbeen upon young subjects. One of these was a pallid littleIrish boy. In this instance there was not sufficient disease todemand amputation under ordinary circumstances, but the boy’shealth had suffered so much, and the lungs were so diseased,that the limb was removed for the purpose of restoring thegeneral health. Had there been no disease of the chest in thiscase, he (Mr. Coote) felt assured that the knee would haveultimately recovered. The second case was that of a child,who had met with an accident. In the third, a young girl hadsuffered from necrosis of the femur, and she died after removalof the limb. In no instance had the operation of resection beendeemed necessary. It might be urged that some patients haddied in consequence of the non-performance of the operation,but he carefully inspected the list of deaths, with a view of de-termining this point, and he found that during the past yearthere was but one recorded case in which death had occurredfrom diseased knee, and this was in a child, who died fromphthisis. Why no operation had been performed he was unableto say. In children, then, it was fair to conclude that diseaseof the knee-joint, in the absence of any great cause of excite-ment, would, if properly treated, in time do well. Even inadults only two deaths had occurred in the hospital from dis-eased knee-joints during the past year, and in both these in-stances the men refused amputation. At the Orthopaedic Hos-pital, cases of joint disease, in every form, were constantlybrought, many of them having been condemned by other hos-pitals, and the patients declining amputation. During the year1851, between 300 and 400 cases came under the care of Mr.Tamplin, and in no one instance was the idea of amputation orof resection entertained, though most of the cases had been re-lieved. Between the 10th of December last and the 10th ofJanuary he recollected six cases of children who came to thehospital with joint disease. In every one of these instances itwas stated that they had been in other hospitals, and refusingto submit to amputation or resection, had been discharged.Now he (Mr. Coote) felt confident that a few months of treat-ment at the Orthopaedic Hospital would restore them to such acondition as would enable them to walk far better than theycould with a wooden leg or an excised joint. Why was it, hewould ask, that resection was not resorted to in the upperranks of society : if good for the poor, it was equally good forthe rich ?

301

Mr. SKEY had paid much attention to details of the variouscases recorded by the author, who he had fully expectedwould have come to the conclusion, from the evidence he had Iadduced, that he ought not to recommend the operation of re-section to the Society. The cases were thirteen in number,and there were five amputations ! Had the author calculatedthat five amputations out of thirteen cases of resection amountedto something like thirty per cent. of failures ? Was any opera-tion to be recommended, in which such an enormous amount offailures was exhibited ? He considered, however, that theauthor of the operation of resection had great claims upon theacknowledgments of the profession, because he considered theoperation to be a great invention-a discovery, indeed, whichmight be subservient to the most important uses in the restora-tion of limbs. But the question before them was not whetherby sawing off the extremities of a bone, and bringing the twosurfaces into contact, a useful limb might be retained; the realquestion was, who should determine where such an operationshould be performed ? The author had referred to a " judiciousselection of cases," but how was it that in St. Bartholomew’sHospital, in the course of the last five years, no aggregate equalto that of the author alone had been produced ? It was a

striking fact, also, that these remarkable cases of excision camefrom comparatively a few quarters, and were not spread overthe whole of the profession. It was not one practitioner havingthree cases, and another five, but twelve cases came from onesurgeon, fifteen from another, and fourteen from a third. Itwould appear from this that resection of a diseased joint wasthe rule, rather than the exception. It was incumbent on theauthorities of the profession to stand forward and declare wherethe line should be drawn. He knew of no disease which re-quired more patience, more knowledge, more perseverance,more anxious watching day by day before the end was accom-plished, than disease of the joints. Mr. Abernethy was in thehabit of carefully watching cases of this kind week after weekand month after month, and rarely failed to restore themwithout having recourse to resection, which he regarded as asubstitute for amputation, and which ought only to be resortedto as a pis aller, and when, in fact, all other methods of treat-ment had been unavailing.Mr. CURLEW thought Mr. Holmes Coote had been too cre-

dulous in believing the statements of patients coming to theOrthopfedic Hospital, to the effect that their limbs had beencondemned elsewhere. If correct, his own hospital, St. Bar-tholomew’s, being the largest, would incur the greatest oppro-brium. It was rare, he believed, that amputation was requiredfor disease of the joints in children.Mr. HUMPHRY remarked that the position he had advanced

was, that excision of the joint should be resorted to in those in-stances in which the articulation was not likely to be restoredto usefulness. Such diseases rarely terminated fatally, and hedid not therefore propose the operation as the means of savinglife, but of restoring a useful limb to the patient. Amputationmight not be required to save the life of the patient; but thequestion was, what kind of joint had been left in those caseswhich had been treated in the ordinary way. He contendedthat in most of those cases an useful joint was not preserved tothe patient, whereas by excision the use of the limb was in agreat measure preserved, and that without danger to life.Mr. TAMPLIN spoke at some length against the operation,

which he contended was rarely, if ever, required. Diseases ofjoints, if properly treated, would get well. He passed a higheulogium on the practice pursued at the Orthopaedic Hospital incases of the kind.

Correspondence.

ON THE IDENTITY OF FEVER POISONS.[LETTER FROM DR. R. H. BAKEWELL.]

II Audialteram partem."

To the Editor of THE LANCET.SlE,—I have read with great interest the report of Dr. T. K.

Chambers’s Clinical Lecture on Fever. I am delighted to seethat a physician of his standing and reputation has had, mayI call it, the moral courage to advocate the almost forsakendoctrine of the unity of the fever poison. For some yearspast the views promulgated by Dr. Jenner, and supportedby many other men of note, have reigned almost supreme; andthose who have held the older opinion have been considered

either as prejudiced adherents to the opinions of the past, orelse as deficient in the power, the opportunities, or the will forproper clinical observations.As I was educated in the views of the new school, will you

permit me a few lines to explain how facts compelled me tobecome a convert to the opinion that typhus and typhoid areessentially one and the same disease.

After leaving London, I was appointed house-surgeon to theStaffordshire General Infirmary and Fever Hospital. In thisinstitution there are separate male and female fever wards,into which, if I remember aright, all cases of fever occurring inthe workhouse are sent. A considerable number are annuallyadmitted from the town and neighbourhood. When I firsttook office, I was much embarrassed by the anomalous charac-ter of the cases. I attempted, as a matter of course, to dividethem into typhus and typhoid; but I found, to my surprise,that obstinate and unmistakable purple petechiss (non-elevated)would persist in showing themselves in cases where there wasdiarrhoea, and that rose-coloured spots and constipation wereexceedingly common. And not only was this the case, butcases not unfrequently occurred in which both eruptions were

visible together. I gave up the attempt in despair, and wasreduced to what I thought the ignominious result of writing" Febris " on the cards, and putting down the symptoms. Inthis state of mind, I was conversing one day with one of thesurgeons, then recently appointed, and who had been educatedat King’s College, and was the most distinguished student ofhis day, also a gold medalist of the University of London(whose name I do not like to mention without his consent),who stated that he had felt the same difficulty as myself, andkindly offered me permission to see some of his patients out ofdoors. This I did, and found the cases exactly of the samekind as those in the infirmary.

Tranferred from Stafford to Scutari, I found no essentialdifference in the fever there. I never could make out clearlyany spots, for the men were so covered with vermin bites thatthere was a universal eruption; but I believe it is acknowledgedby all that there was no distinguishing eruption in these cases.

Since my return from the East I have seen comparativelylittle fever-not above twenty cases, and these all in the

country. I have examined these cases with the most scru-pulous care, both as to the state of the skin and as to othersymptoms, and not in one have I been able to say positivelythat it belonged to typhus or typhoid. In some there hasbeen no eruption at all, or only one or two rose spots, in thecourse of the whole attack; in others, there have been purplespots with abdominal symptoms; in others, there have beenrose spots, followed by purple spots; in one there was a copiouseruption of rose-coloured, elevated, lenticular discs, togetherwith a purple mottling of the skin, leaving a yellow stain likethat of a bruise. In this case the constipation was mosttroublesome.The general character of the disease was the same in all e

chills and hot flushes; hot skin; quickened pulse, varyingmuch in strength; dry and sometimes brown tongue; completeanorexia; thirst; restlessness, and sometimes delirium, espe-cially at night; generally some inflammatory or congestiveaffection of the posterior parts and bases of one or both lungs,mostly only detected by auscultation; either diarrhaea or con-stipation, and often tenderness in the right iliac fossa. Gurglingthere I believe to be a sign of no value, having so often foundit in a state of health.The cases have generally been rather troublesome and linger-

ing, but under the treatment I have adopted I have never lostone. I have given salines-the nitrate of potash and sulphateof magnesia when the bowels were constipated, with or with-out tartarized antimony, according to the state of the patient; ysmall doses of mercury with chalk, and carbonate of soda, everyfour or six hours, and low diet, with abundance of coolingdrinks. If there has been delirium, I have had the headshaved and cold lotions applied, and have given a dose of

opium at night. Under this kind of treatment the pyrexialstate generally disappears in about a week or ten days, and Ithen give tonics, wine, &c. I always give beef-tea from thevery first, believing that that sustains without stimulating.

I should not have ventured thus to intrude upon your spacewith a detail of treatment, but that, although my experienceof fever in England has been but small, I have seen very muchof it in the East. I pursued the same line of treatment there,and with, I believe, uniformly successful results. I do notremember losing a single patient from fever alone, either atScutari or in the Crimea.

I should add, that latterly I have kept up a constant thoughslight smell of chlorine gas in the Datient’s bed-room. bv