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was now divided by subcutaneous incision, and two days later the needles were removed. After three or four more days the parts usually had the appearance of having united by the first intention, and the patient was allowed to go about his usual occupation. In his first attempts to perform this operation, he could not say that his success had been quite such as he could have wished, and indeed expected. One case in particular had some severe local and constitutional symptoms; and he had reason to believe that an abscess had formed in the vein, where it had been traversed by one of the needles. Reflecting subsequently on the cause of this, he became convinced that the origin of the mischief was, that the needle had pierced the vein instead of being made to pass fairly under it. In subsequent operations this point was attended to, and performed with due precaution, as it has now been by Mr. Erichsen, and various other surgeons, a great number of times, and it has not, so far as Mr. Lee was aware, been attended with danger. During the last twelve months a further improvement, as he conceived, had been effected in regard to this operation. The vein is divided as soon as the needles have been placed under it. The subcutaneous incision heals in about the same time as in the other operation, and the confinement of two days previous to the section of the vein is avoided. In this operation the blood which the vein contains between the two needles is allowed to flow out of the incision; and thus any tendency that there might be for stagnant or effused blood to decompose is avoided. In performing the operation in the manner now described, the blood contained in the veins between two needles escapes; the sides of the vein necessarily fall together, and are maintained in apposition. The sides of the vein compressed by the needles and ligature suffer no violence or injury. The subcutaneous incision is pretty sure to heal by first intention, and even should it not, the vein being closed above and below, no diseased secretion can find its way along its channel. Various cases were given to illustrate the different modes of producing obliteration of veins by subcutaneous division.

ART. 116.-Chronic Hydrarthrosis of the Knee-Joint treated by Iodine Injections. By Dr. MCDONNELL, Surgeon to St. Patrick's Hospital, Montreal.

(Montreal Med. Chronicle. Nov., 1857.)

This is the seventh case which Mr. McDonnell has treated in this manner with perfect success, and without the slightest unpleasant result.

CASE.-J. W, æt. 13, was sent from a town in Vermont, to consult Dr. Howard, the oculist, for an affection of the eyes; he was admitted into St. Patrick's Hospital, where it was observed that in addition to the disease of the eyes he also labored under a chronic hydrarthrosis of the left knee-joint, which had caused lameness, and was attended with much pain at the inner side of the joint and at the insertion of the ligamentum patella; the joint was swollen, and globular in appearance; the increase in size amounted to nearly two inches more than the healthy articulation; the swelling was soft, fluctuated on pressure, and the fluid could be forced from the lower part to above the patella, on the front of the femur; a crepitating sensation was experienced when the joint was minutely examined. There was no heat of the joint nor discoloration. He was placed under a mild mercurial course, combined with blistering, stimulating liniments, rest in the recumbent posture, starch bandages, strapping with the mercurial plaster, and the mercury was followed by a course of hydriodate of potash. After a lapse of nearly two months no improvement was perceptible, and I resolved to puncture the joint and inject with iodine; accordingly this operation was performed, in the manner already described, on the 1st of July; no pain followed the operation. About four ounces of fluid was drawn off; it was transparent, of a light straw color, and coagulated slightly on cooling; the opening was closed with adhesive plaster, a wet roller was carried round the limb from the toes to above the knee-joint, and a padded splint was applied to the back of the leg and thigh. No uneasiness or pain followed the operation, and the joint quickly regained its natural appearance; the pain vanished, and at the end of ten days he was able to walk about; but as a measure of precaution I still kept the joint supported by a starched bandage. This

patient was seen by some American surgeons during their visit to the scientific association held here last August, as well as by some practitioners of this city. The above makes the seventh case in which I have employed, in chronic hydrarthrosis of the knee-joint, injections of iodine, and I have not in a single instance witnessed the least unpleasant result follow the practice, and in all it has been eminently successful. Before concluding, I would direct attention to the following points :

1st. The necessity of a careful diagnosis. It is in chronic hydrarthrosis alone that I recommend iodine injections.

2d. Puncture the sac above the level of the patella and on the front of the femur, having first made the tumor tense by a bandage carried round its lower portion.

3d. Inject two drachms of tincture of iodine with two drachms of lukewarm

water.

4th. Having injected that amount of the fluid, manipulate the joint, so as to bring all its surface into contact with the fluid, which is then to be allowed to remain.

5th. Close the external wound, and surround the joint with a wet bandage, which should be carried upwards from the ankle to above the knee.

6th. Keep the limb in a straight position on a padded splint.

7th. Do not allow any motion to take place for at least a week after the operation.

8th. When the patient is allowed to leave his bed, take off the wet bandage and surround the joint with a starched bandage.

ART. 117.-On Excision of the Knee-Joint.

By Mr. HUMPHREY, Surgeon to

Addenbroke Hospital, Cambridge.

(Proceedings of the Royal Med. and Chir. Soc., March 9, 1858.)

The paper contains an abstract of the thirteen cases operated upon by the author. Of these, one (a little child, in whom the operation was performed on account of acute suppuration of the joint) died; in four amputation was required, the patients all recovering; and the remaining eight did well, retaining, or with the prospect of retaining, a useful limb in each case. In none were any severe constitutional symptoms excited by the operation, from which it might be inferred that the operation is not in itself one of much danger. Nevertheless, the processes of reparation are more difficult than after amputation; there is likely to be protracted discharge and recurrence of abscesses, &c., and therefore, when the patient is of strumous temperament, or in a very reduced state, amputation is to be preferred to resection. The results of excision are likely to be favorable in proportion as the disease for which it is performed is slight and not acute. Amongst the most suitable cases are those in which the severe stages of disease have passed by, and left the joint crippled, and the limb, consequently, useless. The cases, also, in which simple inflammatory disease, commencing in the synovial membrane, involves the cartilage and bones, destroying the former to such an extent as to leave little hope of a useful joint, are well suited to excision. But where the disease remains fong confined to the synovial membrane, inducing great thickening and various other changes in it, the prospects of excision are less good, because the subjects of this form of disease are generally of strumous temperament, and some portions of the morbid structure are liable to be left, and so become sources of irritation and suppuration. Nevertheless, the author would not altogether decline to perform the operation in this latter class of cases, inasmuch as the remaining fragments of the diseased membrane may fall into a quiescent state and disappear, and the cases do well, provided the bones become firmly united to one another; and if the health begins to fail, the limb can still be removed. The operation is also well suited to some other cases of rarer occurrence, such as certain cases of chronic rheumatic arthritis, knock-knee in the adult, unreduced dislocation, compound fracture of the patella, &c. In performing the operation, Mr. Humphrey makes a crucial external incision, takes away the patella, and dissects the soft parts away from the bones no more than is absolutely necessary for

the removal of their articular ends, is careful to tie the bleeding vessels, and to secure good apposition to the cut surfaces of the bones and of the skin. The straight position and quiescence of the limb are secured by splints and bandages, which should be changed no oftener than is necessary for cleanliness. The after-treatment was very simple in all the cases related; opiates were very rarely given, and stimulants were generally avoided.

ART. 118.-Excision of the Os Calcis by a New Method. By Mr. ERICHSEN, Surgeon to University College Hospital.

(Lancet, Jan. 30, 1858.)

Excision of the os calcis is usually practised by making an incision across the sole of the foot, from one malleolus to the other, turning back the heel-flap thus formed, making another incision forwards over the calcaneo-cuboid articulation, and then dissecting out the bone. In such an operation as this, the sole is extensively incised, and there is the after-disadvantage of cicatrices being left along the line of most pressure. In order to obviate this the operation was modified, as described in the following case, drawn up by my dresser, Mr. James. The modification consists in carrying a horseshoe incision from a little in front of the calcaneo-cuboid articulation round and behind the heel, to a corresponding point on the opposite side of the foot. The semicircular flap thus formed is dissected up by carrying the bistoury close to the os calcis, the under surface of which is exposed. A perpendicular incision is then made, about two inches in length, over the middle of the tendo-Achillis, falling into the horizontal one. The tendon is then detached, and the two lateral flaps dissected up, the knife being kept close to the bone. The blade is then carried over the upper and posterior part of the os calcis, the articulation with the astragalus opened, the ligaments divided, and the bone turned out. The articular surfaces of the astragalus and cuboid should be examined, and, if carious, gouged out. When the flaps are brought together, there is no line of incision in the sole, the horizontal one running round the sides of the foot, and the perpendicular one being above this, and behind the heel. M. Guérin describes an operation similar to this as having been practised by him on the dead subject, but he states that he has had no experience of it on the living. Judging by the case in which Mr. Erichsen has recently performed it, it is easy of execution, and leaves an excellent result.

CASE. Frederic C, æt. 45, a man of the ordinary stature, having a rather dusky appearance of the skin. By occupation he is a plumber, which he has always followed. He has always enjoyed good general health. He states that he has never had any colic or wrist-drop; but he has now a blue line along the edges of the gums. When about the age of twenty, he had a severe blow on the inner left ankle, or a little above it; after a time this "gathered," and was opened. About five years ago he fell and injured his left foot; his comrade pulled it forcibly, with the intention of reducing a supposed luxation, with no good result. About two years ago an abscess formed at the back part of the heel; the abscess was opened, and the patient states that he was told that a bone was diseased. Last April, having caught a severe cold, his right leg became very painful, red, and swollen. There had been a brownish-red line along the integument over the tibia for two years previously. He was ordered to use hot fomentations and poultices. An abscess was opened over the head of the tibia about two months afterwards. He was then admitted into one of the London hospitals; some diseased bone was removed (patient states) from the head of the right tibia, also from the right os calcis.

Present state. The patient is in good health, appetite good, bowels open, &c. He cannot walk, though he can bear on his left foot to a slight extent; the right limb is of more use to him, but even that is not very strong. The integu ments over the left ankle and its vicinity are tense and shining, looking somewhat like cicatricial tissue. About six inches above the heel a small aperture is observed, and, on introducing a long probe, it is found to communicate with the os calcis by means of a sinus; the bone was found to be bared, the crepitus was easily felt. There was also an open sinus near the anterior part of the

astragalus on the outer side of the foot; grating was here felt on introducing a probe. There was a pretty fair amount of movement admitted of in the ankle-joint, hence it was diagnosed to be disease of the os calcis, superiorly and posteriorly, and near its articulation anteriorly with the cuboid, but the astragalus was considered to be sound, since its movement on the bones of the leg was good. The upper part of the right leg has also the appearance of cicatricial tissue on its anterior surface, especially over the head of the tibia, and the red line over the course of the tibia is still present. On introducing a probe, grating is felt. A poultice was applied to the ankle, and the patient was placed on a good diet.

December 11th.-Appetite being rather deficient, he was ordered two grains of quinine three times a day.

15th.-Appetite improved, bowels regular.

16th. The patient being placed under the influence of chloroform, Mr. Erichsen commenced operating by making a longitudinal incision over the head of the right tibia. The edges of the wound being drawn aside, a good deal of necrosed bone was removed by means of the gouge and Mr. Marshall's osteotrite. The cavity thus formed extended upwards very nearly to the kneejoint. It was plugged with lint. While still under the influence of chloroform, the patient was turned on his left side, or nearly on his face, to facilitate the removal of the os calcis. An incision was made just above the sole of the foot, extending from the cuboid on the outer side to the scaphoid on the inner side of the foot, passing round the point of the heel. The posterior part of the sole was then separated from the os calcis, and reflected forwards, the calcaneocuboid articulation being opened. The tendo-Achillis was next divided, and the soft parts dissected up on either side, and in doing this a small abscess seemed to have been opened, for a little pus suddenly gushed out, apparently from the cavity in the os calcis. A longitudinal incision about an inch in length was then made over the tendo-Achillis, so as to allow of the lateral soft parts being reflected upwards whilst the calcaneum was being excised. Some difficulty was met with in removing the os calcis, and it was soon found to be anchylosed to the astragalus; it was then sawn off by means of Butcher's saw along the line of articulation, and some small portions of the bone which were left attached to the astragalus, also necrosed, were removed by means of the gouge and bone-forceps. A good many arteries were tied. The flap (consisting of the sole) was replaced, and retained by the aid of a few sutures and a strip of plaster. A suture was also put into the lips of the longitudinal incision above the tendo-Achillis. Water-dressing was applied.

On examination after its removal, the os calcis was found to be considerably excavated. The cavity, large enough to admit a finger, commenced between the tendo-Achillis and the calcaneo-astragaloid articulation; it extended in an arched direction downwards and forwards, then upwards to the astragalus at its articulation with the os calcis. The shell of bone surrounding it was much condensed in structure. A small piece of necrosed bone was found at the bottom of the cavity.

Since the operation the patient has gone on favorably, no bad symptom of any kind having occurred, and the wound in the foot being in a great measure healed.

ART. 119.-On the Treatment of in-growing Toe-nails.

By Mr. JAMES LONG, Surgeon to the Liverpool Royal Infirmary.

(Liverpool Medico-Chirurgical Journal, Jan., 1858.)

Speaking of this plan of treatment, which he has practised for nearly thirty years, Mr. Long says: "I first wash the toe in tepid water, and make the parts as dry as possible with cotton wool. I then, with the flat end of a very fine probe, insinuate between the nail and the granulations a little cotton wool, which I extend backwards along the groove between the base of the nail and cuticle. I next freely rub the nail with nitrate of silver, close to the cotton, not allowing the caustic to touch the granulations; and, lastly, place a thin layer of cotton wool around the toe.

"If examined in two days or so, the state of the parts will be found as follows: The nail will be perfectly black, and detached from the parts underneath to a greater or less extent; the cotton wool, by its imbibition of the caustic and secretions, will have become converted into a hard bluish substance; the granulations will have receded from the nail, and their extreme sensitiveness will have disappeared. The dead piece of nail can then be easily removed by a fine pair of scissors introduced underneath it, and a little cotton wool, carefully introduced into the gap, will, in a simple case, complete the cure.

"Should the nail be very thick, it will be necessary, after the first application of the caustic, to scrape off the dead and blackened surface, and apply it a second time before the nail becomes so permeated by it as to lose its connection with the parts beneath. A third application is rarely required. By applying the caustic over the whole nail, and around its base and borders, and pushing the skin back by means of cotton wool introduced between it and the nail, after each application, the whole nail may be removed without pain. The recurrence of the growth may be prevented by scraping the middle of the body of the nail from time to time, so as to keep it thin, introducing at the same time a little cotton wool along its border.

"Dr. Nevins has directed my attention to the following remarks on the above subject in his Translation of the Pharmacopoeia,' in the article on Nitrate of Silver: Previous to the removal of the nail, the moistened nail ought to be freely rubbed with this caustic, and in two or three hours a poultice should be applied; this makes the nail soft, and the next day, if the nail be again washed in hot water, it can be dissected with ease from the adjacent tissues, as far as the caustic has been applied. By this means the horrible and barbarous operation of tearing out the nail, or a portion of it, by force, may be entirely dispensed with. I can speak of this with confidence, having applied it thus in several instances.'

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