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of those who have had large experience in this frightful diseaseas to the local application of iodine. Its effects in external

erysipelas are sometimes wonderful, and it would be worthtrying in the prevalent inflammatory sore-throat.March, 1859

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

UNIVERSITY COLLEGE HOSPITAL.

STRUMOUS DISEASE OF THE KNEE-JOINT, WITH DEPOSITIONOF TUBERCLE IN THE OSSEOUS STRUCTURES; EXCISION ;

DEATH FROM ERYSIPELAS.

(Under the care of Mr. ERICHSEN.)

Nulla est alia pro certo noseendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliornm proprias, collectas habere et inter se com.parare.-MORGAGNI. De Sed. et Caua. Morb., lib. 14. Proaemium.

FROM the state of the patient on admission, as related inthe case which follows, it is evident that in a little while thelimb would have become so extensively involved as to hold outno other mode of relief than that of amputation of the thigh,with the risk at the same time of active disease in the lungs.As various plans of treatment had hitherto proved unavailing,and as circumstances were favourable, excision of the articula-tion was practised, with fair prospects of success. Unfor-

tunately, however, erysipelas, which was prevailing in thewards, attacked the limb on the nineteenth day, up to whichtime everything was going on favourably. It did not yield toremedial measures, and the patient sank on the twenty-thirdday after the operation. For the notes of the case we are in-debted to Mr. J. S. Wilkinson, house-surgeon to the hospital.Mary Ann B-, aged thirty, single ; parents are alive,

and, with exception of her father, who is subject to rheu-matism, her family enjoy good health. She was born andbrought up in the country. She entered service as a servant,and has knelt a good deal on stone steps. Six years since shehad pneumonia, which invalided her for twelve months. Fouryears and a half ago she had a catching pain in the left kneeunder the cap, accompanied with a crampy stiffness whilstwalking, especially whilst going up and down stairs. This didnot prevent her performing her ordinary work. Two yearsafter, the joint inflamed and swelled much, occasioning con-tinuous and excessive pain; this was relieved by leeching, rest,and subsequent blistering, and the swelling decreased some-what, so that she returned to her duties. Twelve months latershe had another attack; the inflammation was less marked,although there was a good deal of pain and swelling, for whichshe was treated with benefit at Winchester Hospital. Twelvemonths since, startings at night began, and blisters were ap-plied with advantage. She then continued under surgical treat-ment up to the time of admission. Until within the last eightmonths the patient has not felt pain in the knee, except whilstexercising it, since then it has prevented her walking, and ifshe stood for any time the joint became puffy, as also the legand foot ; this subsided on reclining. During the night shewould awake with pain, and if the foot were knocked, the painwas excruciating. She has been losing flesh fast, especially oflate.On admission, December 29th, 1858, the patient seems care-

worn, much emaciated, and has altogether a tuberculous aspect;has a bad appetite and a slight cough, but the chest reveals nophysical signs of disease. The diseased knee is semi-flexed,rounded, and full, the outlines of the various points being barelyperceptible to the eye or touch; it measures fourteen inchesand a half in circumference over patella (sound knee eleven anda half), and the skin and tissues are thickened, cedematous,and resisting, and convey a semi-elastic feeling. Manipulationcauses much pain, especially when gliding the opposed articularsurfaces of the femur and tibia over one another, which is

readily permitted from the laxity of the ligaments and capsule;this elicits no grating. There is great pain when pressure isapplied over the tuberosity of the tibia, and the outer boundaryof the joint is tender and inflamed. The thigh is emaciated,and the leg and foot oedematous, contrasting much with themeagre limb of the opposite side. The knee was fixed in leathersplints, and the patient was put on a tonic of quinine and iron.

Jan. 5th, 1859.-Her general health is much better; appetiteimproved, and there is no pain in the knee, except when thesplints are taken off, or towards night when she drops off tosleep. Mr. Erichsen has decided upon resecting the joint.

Operation.-The patient being put under the influence ofchloroform, and placed on the operating-table, the knee waswell flexed to stretch the tissues in front of it. A transverseincision was made from condyle to condyle over the lower partof the patella, which was dissected out; in so doing aquantity of liquid, softened-down, pultaceous d6bris escaped.The articular cartilages were ulcerated to a great extent, andthe ends of the bones exhibited cavities containing softeningtubercle. The lower end of the femur was removed just abovethe condyles, as was also the upper end of the tibia tothe depth of half an inch. The freshly-sawn surface of thefemur was healthy, but that of the tibia presented three orfour largish spots of tubercular deposit, which were gougedout. Three vessels required ligaturing, and the edges of thewound were brought together by three sutures. The woundwas kept well covered with water-dressing. On recoveringfrom the effects of the chloroform, she had thirty minims oflaudanum. The pain continuing, twenty more were adminis.tered at ten r.M. Pulse 95.

After the operation, the patient went on well up to the 24th,when she unfortunately caught erysipelas, that affection beingvery rife at the time. This subsided, leaving her weak andunable to bear the pain of having her splints changed (whichwas absolutely necessary) without chloroform. On anaesthesia-

passing away, the patient was very sick, and continued retchingup to the afternoon of the 28th, in spite of all the remediestried. She had now small quantities of brandy at short in-tervals, and a brandy-and-egg enema, with beef-tea, in hopesof rallying her, but she gradually sank, and died at eight P.M.The following were the means adopted in order to ensure the

highly essential points of keeping the cut ends of the bones inclose apposition, and preventing their movement :-Immediately after the operation, the limb was bandaged to

a well-padded straight splint, running up the back of the legand thigh as high as the tuber ischii, with a foot-piece at rightangles.When the sutures were removed (10th), the edges of the

wound, which were for the most part united, were supportedby three strips of plaster.l2th.-The apparatus having become loose, it was re-applied,

with the addition of two broad pieces of gutta percha, linedwith a thin layer of cotton wool, arched, the one over the frontof the leg, and the other over the front of the thigh, and furthersupport was given by a strip of gutta percha on either side ofthe knee; but although this answered admirably at first, inthe course of a few days the gutta percha yielded to the heatof the limb, and allowed displacement of the bones.20th.-To obviate this, the following alterations were made

in the splint :-The gutta percha was used as on the last occa-sion, but in addition it was embraced by a pair of wooden flaps(2 in. by 13 in.), hinged on to the back splint on either side ofthe leg, and a similar pair (3 in. by 9 in.) on either side of thethigh, thus affording an unyielding support to the limb, keepingthe ends of the bones in perfect apposition, and preventing theslightest movement of them.To facilitate dressing the wound, and allow free exit to the

discharges without disturbing or soiling the apparatus, a pieceof gutta percha, about fifteen inches long, was bandaged oneither side of the knee, external to the general splint.

bandaged,

CHARING-CROSS HOSPITAL.

EXCISION OF THE ANKLE-JOINT, IN A CHILD, FOR EX-TENSIVE DISEASE ; RECOVERY, WITH A USEFUL FOOT.

(Under the care of Mr. HANCOCK.)g i WHILST the knee and the hip in the lower, and the elbowI and the wrist in the upper, extremity have been excised for

disease on numerous occasions, the ankle and the shoulder

r would seem to be remarkably exempt from this proceeding.s That this should be so with regard to the shoulder need not

366

excite any surprise when it is remembered that this articu-lation is comparatively very seldom diseased. Far otherwiseis it with the ankle, which appears to us to be more frequentlyaffected than the knee, yet resection of the former has not beenattempted, so far as we can learn, at any other hospital thanCharing-cross. Mr. Hancock has performed it four times. In

one only did it not succeed. His fourth case we have the

pleasure of placing upon record to-day. The three othershave been noticed in former " Mirrors," the last in the firstvolume of this journal for 1858, p. 36, to which we wouldrefer the reader. The boy who was the first person to undergoexcision of the ankle in this country, at the hands of Mr.

Hancock, in 1851 (see THE LANCET, vol. i., 1851, p. 355), isalive and well, and possesses considerable motion in his newankle-joint. The risks of excision of the ankle are not lessthan those attending this operation on other joints, inasmuchas the former is surrounded by vessels and nerves, upon the in-tegrity of which the surgeon mainly relies for a successful

issue. The success which has attended excision of the anklein Mr. Hancock’s hands is most encouraging, and we hope itwill receive a fair trial by other hospital surgeons when suit-able cases come under their notice.

J. T-, aged six years, residing at Hounslow, was sent tothis hospital, under the care of Mr. Hancock, in Sept., 185S,by Mr. Chapman, of Hounslow. In the preceding April hefirst complained of pain in his left ankle-joint, unaccompaniedhowever by swelling, discoloration, or lameness. On the 26thof August he leaped from the top of a wall about five feet

high, and so injured the ankle that he had to be carried intothe house. Great swelling ensued in a few days, followed byprofuse suppuration. When admitted he was very weak andfeverish, his countenance anxious and indicative of great suffer-ing. There was an unhealthy wound in front of the internalmalleolus, discharging a large quantity of offensive matter;and a probe readily penetrated the joint, which was found ex-tensively diseased, the cartilage being much destroyed. Ashis health and strength were rapidly declining, it was proposedto remove the diseased parts, and to endeavour to preserve thefoot. This having been acceded to by his friends, he was, onthe 9th of October, placed under the influence of chloroform,and Mr. Hancock commenced the operation for excision of theankle-joint, by carrying an incision from about an inch and ahalf above the extremity of, and behind, the internal mal-leolus, across the front of the joint, and to a similar extent be-hind the external malleolus, merely dividing the skin, whichwas dissected back; the external lateral ligaments were thendivided, and the peronei tendons dissected from their groovebehind the fibula, which was next cut through by bone nip-pers about half an inch above its articulation with the horizon-tal tarsal articulating surface of the fibula; this portion wasthen removed, the tibio.fibular ligament being cut through bya knife introduced between the bones. The leg was now turnedon its outer side, and the internal lateral ligament of the anklenext divided, the edge of the knife being carried close to themalleolus, thus avoiding the posterior tibial artery; and, thefoot being displaced towards the fibula, the end of the tibiawas projected through the wound, and the inner malleolusand lower end of the tibia removed by a saw, at about half aninch above its horizontal articular surface. The astragaluswas next examined, when it was found that the disease ex-tended through and beneath that bone, involving the os calcisto a considerable extent. The convex tibial articular surface,and the whole of the body of the astragalus behind the inter-osseous calcaneo-astragaloid ligament, were removed, as werethe remains of the corresponding articular surface on the upperpart of the os calcis; whilst the interior of that bone behindthe interosseous notch was carefully gouged out before thewhole of the disease could be got rid of, so that little morethan the shell of the bone remained in that situation. The

parts being replaced ira sitg, the wound was closed, excepting atits outer part, and the leg laid upon its outer side on a splint,having a hole corresponding to the unclosed portion of thewound, so as to present no obstacle to the free escape ofmatter. No arteries were tied.The boy suffered very little constitutional disturbance; his

general health and appetite having been uniformly good andhis progress satisfactory.March 10th, 1859.-He is now cured. He can stand upon

his foot and walk without pain. The wound is entirely healed.

CLINICAL RECORDS.

RUPTURE INTO THE DUODENUM OF AN ANEU.RISMAL TUMOUR OF THE ABDOMINAL AORTA.

WHEN an abdominal tumour is clearly made out to be ananeurism, the physician at once becomes aware of the extremehazard to which the patient is exposed from rupture of the sacinto one of the internal cavities. Usually this terminates thepatient’s life, unless he has already succumbed, worn out byexcruciating suffering. The sac may sometimes rupture at anearly stage of the disease. We recollect a case of the kindunder Mr. Solly’s care at St. Thomas’s Hospital, in 1856, inwhich the aneurism burst into the abdomen-an event mainlyattributable, we believe, to the occurrence of epileptic fits, towhich the patient was subject. More recently, a man, agedthirty-seven, a patient under Dr. Johnson’s care at King’s Col.lege Hospital, had a large aneurism of the abdominal aorta, inan advanced stage, which burst into the duodenum on the 6thof February, whilst he was sitting up drinking a cup of tea.The symptoms were at first obscure, but ultimately the truenature of the case was distinctly made out. After death theliver was found to be pale and flattened from above downwards"and possessed the microscopic characters of tubercle. Thestomach and small intestines were filled with coagula and san-guineous fluid, as far as the ileum. A small orifice at the lowerend of the duodenum was found to communicate with the sacof a very large aneurism which sprang from the centre of theabdominal aorta, extending forwards, and pressing the inter-mediate viscera towards the abdominal walls. Several layers’of fibrine had become deposited within the tumour, whose com-munication with the aorta was by an oval opening, three incheslong. A second aneurismal tumour projected on the left sideof the aorta, and had denuded the bodies of the second andthird lumbar vertebrae. The duration of the aneurism wasabout fourteen months, as we gather from the notes of Mr. C.Parsons, the house physician; it was, however, only seven weeksbefore his admission into the hospital, on Dec. 31st, 1858, thathe perceived a swelling beneath the margin of the left falseribs, which rapidly increased in size.

VESICAL CALCULI.

As we have often stated before, the operation for stone iachildren is almost invariably successful. The two cases brieflynoticed in our number of 26th March, turned out well. Anotherchild, eight years of age, was submitted to lithotomy on the.22nd ult., at Guy’s Hospital by Mr. Birkett. The little patienthad been long subject to symptoms of stone, and on this occa-sion one was removed nearly an inch long, but in shape like anabruptly-broken piece of lead pencil, its diameter measuring,about five lines. The same operation was performed by Mr.Mitchell Henry, at the Middlesex Hospital, on the 23rd ult.,upon a child, ten years old, who had not been so long labouringunder symptoms of stone, but from whose bladder a calculuswas removed, the size of a hickory nut, the surface being irre-gularly lamellated, as if some portions of the layers had beeneither dissolved by the urine, or were incompletely deposited..There was free heamorrhage in this case, which was controlledby a couple of ligatures. Both of these patients are going on.well. A third case, in a lad aged twelve, was submitted tolithotomy, on the 26th ultimo, at King’s College Hospital, byMr. Fergusson, who extracted a calculus, the size of a pullet’segg. In this instance there was some difficulty experienced inpassing either an ordinary curved sound or a catheter intothe bladder. This patient had been sent up from the countryfor some supposed disease of the bladder. He is doing verywell.On the 2nd of April, a case of stone in the bladder, of more

than ordinary interest, was operated upon by Mr. Fergusson.The patient was a man, sixty-five years old, long subject tosymptoms of stone; he had besides a stricture of the bulbous

! portion of the urethra, and very recently an abscess had formedin the perineum. When the stone was laid hold of by theforceps, it was so soft that it broke into several pieces, which

’ were taken out by the scoop. Two distinct calculi were pre-sent, and the bladder was found to be sacculated in severalplaces, the pouches not being larger than would admit the end

. of the finger. In the operation, Mr. Fergusson deviated fromhis usual plan, and commenced his incision to the right of theraphe, in the perinseum. No untoward symptom has occurredup to the present time, and a good recovery may be looked for.